Emergency Medicine Journal最新文献

We approach emergency department delay-related harm as though it were a distinct condition and explore use of an explicit cost-effectiveness threshold as a guide to management. Based on the reported association of delayed emergency admission with short-term mortality, to prevent loss of one quality-adjusted life year per patient harmed in Ireland, annual resources equivalent to 70 additional bed years, or infrastructure funding for 90 new beds, could be considered cost-effective. The additional commitment represents under 1% of annual public acute hospital sector expenditure in Ireland, an OECD member country.

Background: The Psychiatric, Alcohol and Non-Prescription Drug Assessment (PANDA) Unit was opened at St Vincent's Hospital Sydney in 2020 to provide short-stay medical monitoring and care for people presenting to the emergency department with alcohol or other drug intoxication or behavioural disturbance with co-existing general medical, drug and alcohol and/or mental health issues. The aim of this study was to describe the activity of the PANDA Unit across the first 3 years of operation and explore patient experience.

Methods: A mixed methods design was used. A retrospective record review (2020-2023) captured patient demographics, admission characteristics and discharge disposition. Brief, structured interviews were conducted with PANDA patients to explore their admission experience, including the care provided. Interviews were analysed using an inductive approach to develop themes.

Results: 2473 patients had 4108 admissions to PANDA, median 333 (range, 296-396) admissions per quarter. Median patient age was 40 (range, 16-93) years, most (64.5%) were male and 11.2% had 'no-fixed abode' documented. Most admissions were associated with alcohol and stimulant intoxication and/or suicidality. Median PANDA length of stay was 21.2 hours (range, 0.5-883.1); 20% of admissions were >48 hours. Most patients (83.8%) were discharged from PANDA to their usual place of residence, 4.9% self-discharged and 15% were readmitted to PANDA within 28 days of discharge, 56 people were readmitted three or more times. The experiences of interview participants (n=14) regarding the PANDA Unit was described by three key themes: (1) patients receive non-judgemental, whole-person care from a large multidisciplinary team, (2) PANDA provides a transition point to further care and (3) PANDA is a comfortable and busy space.

Conclusions: PANDA provided tailored care in a short-stay context for people presenting to emergency department with complex comorbidities. Its unique model of care addressed barriers to healthcare access, such as stigma and siloed care.

Background: Older patients' attendances at EDs are rising. There are concerns that these individuals have prolonged stays, which have been shown to be associated with adverse clinical outcomes. We assessed the length of stay in older patients in a single ED in Singapore.

Methods: This was an observational retrospective study of ED attendances between 2017 and 2019 at the Singapore General Hospital (SGH) using the SGH ED database. The primary outcome was ED length of stay, with prolonged stay defined as 4 hours or more. The association between age (categorised into 18-44, 45-64, 65-84 and 85+) and length of stay was analysed using a mixed-effects logistic regression adjusting for variables like gender, ethnicity and triage acuity. Associations are expressed as adjusted ORs (AOR) with 95% CI. A subgroup analysis was performed for all considered variables.

Results: 391 171 patients qualified for analysis; median age 57 years (IQR 37-70) and 51.5% male. The median length of stay increased across age categories (age 18-44, 3.53 hours; 45-64, 4.04 hours; 65-84, 4.32 hours; and 85+, 4.46 hours). Using patients aged 18-44 as a reference, the AORs for prolonged length of stay by age group were 45-64 AOR 1.17 (95% CI 1.13 to 1.21), 65-84 AOR 1.26 (95% CI 1.21 to 1.30) and 85+ AOR 1.25 (95% CI 1.18 to 1.31). In the subgroup analysis, there was no association between age and length of stay for patients admitted, having multiple comorbidities, having blood tests or having high acuity scores.

Conclusion: In this Singaporean tertiary hospital, older patients had increased median stays and were more likely to stay in the ED for more than 4 hours. However, this did not apply in some subpopulations. This potentially suggests the need for systematic changes in discharge planning and triaging to reduce prolonged stays and their consequences for older patients.

Background: The widespread use of small and powerful neodymium magnets in consumer products has led to a significant rise in paediatric magnet ingestion. The ingestion of multiple magnets poses serious risks, including bowel obstruction and perforation. Evidence-based Clinical Practice Guidelines (CPGs) are necessary to inform clinicians of the safest and most effective management strategies across a range of healthcare settings.

Aim: This systematic review aims to summarise existing CPGs for diagnosing and managing paediatric magnet ingestion, evaluate the supporting evidence, highlight variation and consensus, and identify areas requiring further research.

Methods: MEDLINE, Scopus, the Cochrane Library, Web of Science and Embase were searched to identify CPGs. Study characteristics, investigation and management recommendations, and indications for conservative management, endoscopy, surgery and discharge with and without follow-up were extracted. Two reviewers independently assessed CPG quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

Results: 25 CPGs were included. Recommendations varied for diagnostic imaging, management of single and multiple magnet ingestion and the use of conservative, endoscopic or surgical interventions. However, there was consensus that: abdominal X-ray is the preferred first-line imaging modality, conservative management is recommended for asymptomatic single magnets, endoscopic removal is recommended for prepyloric asymptomatic multiple magnets and surgery for symptomatic multiple magnets. AGREE II appraisal revealed poor scores in CPG Applicability, Stakeholder Involvement and Rigour of Development, but strong scores for Editorial Independence. Existing CPGs for paediatric magnet ingestion are based on low-quality evidence or expert consensus.

Conclusions: This review highlights inconsistencies and areas of consensus in current CPGs for paediatric magnet ingestion. Variations underscore the need for standardised, evidence-based guidelines to optimise care for affected children. Future research should focus on addressing gaps in evidence and consensus to ensure consistent management across healthcare settings.