Validity of the classification of emergency service requests related to suicidal behavior / Validez de la clasificación de las demandas por conducta suicida a un servicio de emergencias

Abstract Introduction Suicide attempts are the most predictive risk factor for suicide deaths. Most people who attempt suicide receive care from out-of-hospital Emergency Services (OES), where these requests are managed and classified. Objective Validate the Emergency Coordination Center (ECC) classification for the detection of suicidal behavior requests. Method A descriptive, cross-sectional study of requests to the ECC of Málaga (Spain) during 2013 and 2014 was conducted. To classify the requests, the authors considered the ECC categorization when answering the call and the clinical assessment of the healthcare professional when attending the person who had made the call at the scene, which was considered the reference standard. To analyze the validity of the ECC classification system, sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated. Results The total number of requests for medical assistance analyzed was 112,599. The validity indicators of the classification system for suicidal behavior were sensitivity = 44.78%, specificity = 99.34%, PPV = 46.91% and NPV = 99.28%. Discussion and conclusion The ECC classification system has a lower capacity to detect the presence of suicidal behavior and a higher capacity to identify its absence in the requests received. OES provide key information on suicidal behavior requests as they can be one of the first places people with this problem go to. It would therefore be extremely useful to improve the classification systems for requests related to suicidal behavior.

Resumen Introducción Los intentos de suicidio constituyen el factor de riesgo más predictivo de todos los casos de suicidio consumado. La mayoría de las personas que intentan suicidarse reciben atención en los Servicios de Urgencias Extrahospitalarios (SUE) donde se gestionan y clasifican estas demandas. Objetivo Validar la clasificación del Centro Coordinador de Urgencias y Emergencias (CCUE) para detectar las demandas relacionadas con la conducta suicida. Método Se llevó a cabo un estudio descriptivo y transversal de las demandas al CCUE de Málaga (España) realizadas durante 2013 y 2014. Para su clasificación se tuvo en cuenta la categorización en el CCUE al responder la llamada y el juicio clínico del profesional sanitario cuando atiende al demandante in situ, considerando éste como patrón de referencia. Para evaluar la validez del sistema de clasificación se calcularon la sensibilidad, la especificidad y los valores predictivos positivo (VPP) y negativo (VPN). Resultados El total de demandas sanitarias analizadas fue de 112,599. Los indicadores de validez del sistema de clasificación para las demandas por conductas de suicidio fueron una sensibilidad = 44.78%, especificidad = 99.34%, VPP = 46.91% y VPN = 99.28%. Discusión y conclusión El sistema de clasificación del CCUE presenta una capacidad más baja para detectar presencia de conducta suicida comparada con una capacidad más alta para identificar su ausencia en las demandas recibidas. Los SUE aportan información relevante sobre las demandas por conducta suicida ya que pueden ser uno de los primeros lugares a los que acuden las personas con este problema. Por ello, sería de gran utilidad mejorar los sistemas de clasificación de las demandas por conducta suicida.

Médicos e hiperutilizadores de baixo risco em emergências: implicações éticas / Physicians and low-risk frequent users in emergency services: ethical implications / Médicos e hiperfrecuentadores de bajo riesgo en urgencias: implicaciones éticas

Resumo É crescente a demanda de usuários com problemas de baixa complexidade clínica que procuram serviços hospitalares de urgência e emergência frequentemente. Essa hiperutilização dos serviços impõe dilemas éticos aos médicos e demais profissionais. O presente estudo analisa as implicações éticas do encontro entre médicos e usuários hiperutilizadores em uma unidade universitária. Trata-se de pesquisa qualitativa desenvolvida por meio de entrevistas semiestruturadas com médicos e pacientes hiperutilizadores de baixo risco clínico e observação de campo etnográfica. Observou-se que os profissionais tendem a estigmatizar a demanda desses usuários. Já os usuários demonstram satisfação com os médicos, mas descontentamento com a atenção básica e especializada ambulatorial. Conclui-se que a hiperutilização gera conflitos ético-profissionais decorrentes sobretudo da estigmatização dos pacientes pelos médicos. Apesar disso, os hiperutilizadores se sentem satisfeitos com o atendimento, o que os motiva a continuar frequentando os serviços com frequência.

Abstract There is an increasing demand for Emergency Department (ED) services from frequent users with problems of low clinical complexity. The overuse of ED poses several ethical-professional dilemmas for physicians and other medical staff. The study analyzes the ethical implications that emerge from the relationship between physicians and low-risk frequent users in a university hospital. This is a qualitative research developed through semi-structured interviews with physicians and low-risk frequent users and ethnographic observation in the field. It was observed that medical staff tend to stigmatize the demand of frequent patients. They, on the other hand, are satisfied with the physicians but discontent with primary health care and specialized outpatient care. It is concluded that the overuse generates ethicalprofessional conflicts, especially due to the stigmatization of these users by physicians. Nevertheless, frequent users are satisfied with the service, which motivates them to continue using it often.

Resumen Existe una demanda creciente de usuarios con problemas de baja complejidad clínica que frecuentemente buscan servicios hospitalarios de urgencia y emergencia. El uso excesivo de SUH impone varios dilemas éticos a los servicios, médicos y otros profesionales. El estudio examina las implicaciones éticas que surgen del encuentro entre médicos y pacientes hiperfrecuentadores de bajo riesgo clínico en un SUH universitario. Es una investigación cualitativa desarrollada a través de entrevistas semiestructuradas con médicos y pacientes hiperfrecuentadores de bajo riesgo clínico y observación de campo del tipo etnográfico. Se observó que los médicos tienden a estigmatizar la demanda del hiperfrecuentador. Los pacientes, por otro lado, muestran satisfacción con los médicos y refuerzan el descontento con la atención básica de salud y los servicios ambulatorios especializados. Se concluye que el uso excesivo del SUH genera conflictos en el ejercicio ético-profesional, principalmente como resultado de la estigmatización de estos pacientes por parte de los médicos. A pesar de esto, los hiperfrecuentadores están satisfechos con el servicio, lo que los motiva a convertirse en grandes usuarios.

Working conditions and depression in hospital emergency service nurses / Condiciones de trabajo y depresión en enfermeras de servicio de urgencias hospitalarias / Condições de trabalho e depressão em enfermeiros de serviço hospitalar de emergência

ABSTRACT Objective: to analyze the presence, intensity and factors related to working conditions for depressive symptoms in hospital emergency nurses in the east of São Paulo. Methods: a descriptive, exploratory, quantitative and qualitative study, which applied psychometric scales and interview script. Results: nurses (95.24%) had depressive symptoms by the assessment scales by the observer, most with mild and moderate intensity. Inadequate working conditions led to suffering. Factors that trigger depressive symptoms were: disorganized work; harmful relationship with immediate management; inappropriate physician behavior; aggressions; lack of inputs, infrastructure and human resources; professional devaluation. Identified professionals with depressive symptoms who, because they were unaware of being affected by the disorder, did not seek treatment, continued to perform activities that compromised their physical and mental health, promoting damage to the assistance provided. Final considerations: high frequency of depressive symptoms. The precarious work environment negatively influenced the care and development of depressive symptoms.

RESUMEN Objetivo: analizar la presencia, intensidad y factores relacionados con las condiciones de trabajo para los síntomas depresivos en enfermeras de urgencias hospitalarias en el lado este de São Paulo. Métodos: estudio exploratorio descriptivo, enfoque cuantitativo y cualitativo mediante la aplicación de escalas psicométricas y guión de entrevista. Resultados: el 95,24% de las enfermeras tenían síntomas depresivos según las escalas de evaluación del observador, la mayoría con intensidad leve y moderada. Las condiciones de trabajo inadecuadas provocaron sufrimiento. Los factores desencadenantes de los síntomas depresivos fueron el trabajo desorganizado; relación perjudicial con la gestión inmediata; comportamiento inapropiado del médico; agresiones falta de insumos, infraestructura y recursos humanos; devaluación profesional. Profesionales identificados con síntomas depresivos que, debido a que no sabían ser afectados por el trastorno, no buscaron tratamiento, continuaron realizando actividades que comprometían su salud física y mental, promoviendo daños a la asistencia brindada. Consideraciones finales: alta frecuencia de síntomas depresivos. El ambiente de trabajo precario influyó negativamente en el cuidado y el desarrollo de los síntomas depresivos.

RESUMO Objetivo: analisar presença, intensidade e fatores relacionados às condições de trabalho para sintomatologia depressiva em enfermeiros de emergência intra-hospitalar da zona leste paulistana. Métodos: estudo descritivo exploratório, abordagem quantitativa e qualitativa por aplicação de escalas psicométricas e roteiro de entrevista. Resultados: 95,24% dos enfermeiros apresentaram sintomatologia depressiva pelas escalas de avaliação pelo observador, maioria com intensidade leve e moderada. Condições inadequadas de trabalho levaram ao sofrimento. Fatores desencadeantes da sintomatologia depressiva foram desorganização do trabalho; relacionamento prejudicial com chefia imediata; comportamento inadequado do médico; agressões; falta de insumos, infraestrutura e recursos humanos; desvalorização profissional. Identificados profissionais com sintomatologia depressiva que, por desconhecerem estar acometidos pelo transtorno, não procuraram por tratamento, continuaram a desempenhar atividades a comprometer sua saúde física e mental, promover prejuízo a assistência prestada. Considerações finais: alta frequência de sintomatologia depressiva. O ambiente de trabalho precarizado influenciou negativamente na assistência e desenvolvimento da sintomatologia depressiva.

Factors affecting the satisfaction of emergency medical services in capital and non-capital areas

OBJECTIVE: This study examined the factors affecting the satisfaction of emergency medical services in capital and non-capital areas. METHODS: Descriptive and logistic regression analysis was performed using the data from the 2014 Korea Health Panel Survey. RESULTS: Patients who resided in capital areas were likely to be more satisfied than those who resided in non-capital areas. In capital and non-capital areas, post-of-service action was an influential factor. Capital area patients, who were transferred to other hospitals instead of being admitted or returned to their homes, reported less satisfaction. In non-capital areas, delayed emergency room arrival that was self-perceived was also an influential factor. Moreover, patients who were transferred to other hospitals instead of being returned to their homes reported less satisfaction. CONCLUSION: In both capital and non-capital areas, the satisfaction of emergency medical services can be increased by avoiding transferring patients to other hospitals. For Koreans to be satisfied with emergency medical services, efficient and rapid emergency medical services will e needed to avoid delays in emergency room arrivals, particularly in non-capital areas.

Scorecard for early recognition of patients at high risk of delirium in emergency department

OBJECTIVE: This study was conducted to evaluate scorecards for early recognition of high-risk patients of delirium in the emergency department (ED). METHODS: Data from 399 consecutive patients aged 65 years or older between January 1, 2015 and December 31, 2015 were retrospectively analyzed. Delirium was identified by reviewing medical records and was confirmed by a psychiatrist. The study population was divided into a training and validation group. Predisposing factors were evaluated and validated by multivariate logistic regression analysis and a calibration plot, after which a scorecard was constructed using these factors and applying points to double odds to each regression coefficient. RESULTS: Dementia, transfer from a long-term care facility, acute acid-base imbalance, moderate pain, and stroke were independent predisposing factors for delirium in ED, with assigned scores in the scorecard of 3, 2, 2, 2, and 2, respectively. The total score of the scorecard for delirious patients was significantly higher than that for non-delirious patients in both the training and validation groups. The coefficient of determination (R²) of the calibration plot was 0.74 and 0.68 in the training and validation group, respectively. In the receiver operation characteristic curve, the cut-off point of the scorecard for delirium was 2.5 and the sensitivity, specificity, and accuracy were 75.0%, 87.8%, and 86.7% in training group, while they were 76.9%, 85.1%, and 84.2% in the validation group, respectively. CONCLUSION: The scorecard was a useful screening tool for early recognition of patients with a high-risk of developing delirium in the ED.

Risk factors for hospital admission in revisiting patients to the emergency department with abdominal pain

OBJECTIVE: The aim of this study was to identify the clinical characteristics and risk factors associated with the admission of patients in the emergency department (ED) within 30 days after discharge. METHODS: A retrospective, observational study was conducted on adult patients presenting with abdominal pain to the ED of a single, urban, university hospital, between January 2014 and December 2015, who revisited the ED within 30 days after discharge. Data was collected on the emergency severity index level, time to contact doctors, physical examination, laboratory tests, use of computed tomography (CT), and patient disposition on revisitation. The primary outcome was hospital admission following an ED revisit in the 30-day period after the first visit. RESULTS: During the study period, 19,480 patients visited the ED with the chief complaint of abdominal pain, and 13,577 were discharged. A total of 251 patients (1.29%) revisited the ED within 30 days, of which 89 were eligible for the study. The primary outcome was associated with not performing a CT scan on the initial visit and an increased C-reactive protein (CRP) value. Receiver operating characteristic curve analysis showed that a cut-off baseline CRP value of >0.35 mg/dL can predict the primary outcome with a sensitivity and specificity of 75% and 62.1%, respectively (area under the curve, 0.701; 95% confidence interval, 0.569–0.833; P=0.007). CONCLUSION: An increased CRP value and not performing abdominal CT were associated with a higher rate of admission following ED revisits of patients with abdominal pain. Future prospective studies on the role of abdominal CT imaging in patients presenting to the ED with abdominal pain will be needed.

Analysis of Differential factors for Detecting Surgical Acute Abdomen in Women of Childbearing Age Presenting to the Emergency Department with Non-traumatic Abdominal Pain in the Absence of Laboratory Abnormalities

PURPOSE: Acute abdomen in women of childbearing age has a broad differential diagnosis, often presenting a diagnostic challenge to an emergency physician. Computed tomography (CT) has been used for an accurate diagnosis and prompt treatment of acute abdomen. On the other hand, the increasing use of CT has been a subject of concern for patients, particularly women of childbearing age, due to the potential risk of radiation exposure. This study analyzed the efficacy of various physical examinations for detecting surgical acute abdomen in women of childbearing age who presented with non-traumatic abdominal pain in the absence of laboratory abnormalities. METHODS: The charts and CT reports of women, aged 15-35 years old, who visited our ED for non-traumatic abdominal pain between May 2011 and April 2017 were reviewed retrospectively. Patients with chronic abdominal disease, pregnancy, recent abdominal surgery within one month, and abnormal laboratory tests were excluded. RESULTS: In total, 121 patients were identified, of which 34 patients fell into a group that required surgical intervention (surgical acute abdomen group). The remaining 87 patients were managed conservatively without surgical intervention (non-surgical acute abdomen group). The maximal tenderness point (p=0.006), rebound tenderness (p=0.001), shorter duration of abdominal pain (p < 0.001), and absence of diarrhea (p=0.001) were statistically significant for predicting the need for surgical intervention. CONCLUSION: In the absence of abnormal laboratory studies, the hypogastrium tenderness point, rebound tenderness, duration of abdominal pain, and diarrhea were found to be independently valid factors for detecting surgical acute abdomen in women of childbearing age who presented with non-traumatic abdominal pain.

Análisis del perfil epidemiológico, demográfico y saturación ambulatoria de los consultantes a la unidad de emergencia adultos del hospital Carlos Van Buren durante el 2008 / Analysis of demographic and epidemiological profile of the consultants saturation out patient emergency unit adults at the hospital Carlos Van Buren in 2008

Objetivo: analizar el perfil epidemiológico, demográfico y saturación ambulatoria de los consultantes a la Unidad Emergencia Adultos (UEA) del Hospital Carlos Van Buren (HCB) durante el 2008. Materiales-métodos: es un estudio descriptivo-transversal, los datos se obtuvieron de la Unidad Administrativa Estadística HCVB. El criterio de inclusión fue hombres-mujeres mayores de 15 años atendidos en UEA HCVB durante el 2008; el criterio de exclusión fue pacientes de atención dental. Resultados: el número total de pacientes fue 175.562. Los meses de mayor consulta fueron Enero, Marzo, Abril y Octubre. Un 54,83 por ciento correspondieron a mujeres. Un 85,92 por ciento son menores de 65 años. Los hospitalizados correspondieron a 6,21 por ciento (10.919) del total. Los fallecidos fueron 360 pacientes (3 por ciento de los hospitalizados). El índice de Letalidad fue 3,5 por ciento. El nivel previsional fue 71 por ciento FONASA A y B. El indicador de saturación externa mensual fue de 0,5-0,6; pero al analizar el indicador de saturación externa horaria vemos que entre las 09:00-18:00hrs. los valores fluctúan sobre 0.8, llegando a 1 entre las 11.00-12:00hrs. Conclusión: a pesar de que la población consultante a nuestro servicio de urgencias se encuentra dentro de los límites establecidos para la población asignada, el análisis del indicador de saturación externa horaria nos permite evidenciar que existe un período importante del día en que la UEA se encuentra saturada para la atención ambulatoria y que el recurso médico no es suficiente para satisfacer la demanda externa.

Objective: to analyze the epidemiological, demographic and outpatient saturation of the consultants of the Adult Emergency Unit (AEU) of the Carlos Van Buren Hospital (CVBH) during 2008. Materials-methods: a descriptive 1 study, data were obtained from the Statistics Administrative Unit CVBH. Inclusion criteria were men-women over 15 years treated al CVBH AEU in 2008, the exclusion criteria was patients dental care. Results: the total number of patients was 175,562. The months of greater consultation were January, March, April and October. A 54.83 percent were women. A 85.92 percent are under 65 years. The admissions accounted for 6.21 percent (10,919) of the total. Dead patient were 360 (3 percent of inpatients). The case fatality rate was 3.5 percent. The health insurance level was 71 percent FONASA A and B. The monthly external saturation indicator was 0.5-0-6, but analyzing the external saturation indicator time, between 09:00-18:00hrs. the values fluctuate about 0.8, reaching1 between 11.00-12hrs. Conclusion: despite that the population received in our emergency department is within the limits for the assigned population, analyzing the external time saturation indicator we see that there is an important period of the day on which the AEU is saturated with outpatients and medical personal is not enough to satisfy it.

Exposure to Power Frequency Magnetic Fields in the Emergency Department

PURPOSE: We use many electronic devices for treating patients in our emergency department. Several studies have reported an association between electromagnetic field exposure and risk of cancer and other diseases. Our purpose was to measure the intensity of power-frequency magnetic fields in the emergency department and evaluate the conditions exceeded regulation guidelines for power-frequency magnetic fields. METHODS: Extremely low frequency magnetic fields were measured at 78 ordinary working spots in our tertiary hospital's emergency department (ED) and evaluated according to national regulatory guidelines and SWEDAC. Each spot was measured four times. During measurement, every electrical device in the emergency department was turned on. RESULTS: The average intensity of the magnetic fields in our emergency department was 0.99+/-1.27 mG. The maximum intensity was 8.3 mG, which was found in the pediatric section. CONCLUSION: The power-frequency magnetic field intensities of the various sections of our ED did not exceed national regulatory guidelines. However, pediatric and the minor emergency section showed magnetic fields intensities far above 2 mG. We found these high values outside the pediatric and waiting sections, where the electrical cabinet panel was located. We conclude that the electrical cabinet panel should be shielded and that similar studies are needed for other emergency departments.

The Benefit of Further Tests for Patients Presenting to the Emergency Department with Non-Specific Abdominal Pain

PURPOSE: Acute abdominal pain is the most common cause of visits to the emergency department (ED). Among these visits, 30% of patients have non-specific abdominal pain (NSAP). Although the actual number of such patients is large, there are few studies of NSAP. Our report is about the usefulness of results from additional diagnostic tests for patients who have NSAP. METHODS: Subjects in our study were patients who presented at our ED between January 1, 2007 and December 31,2008 with NSAP. We retrospectively investigated the relevance of several factors including general patient characteristic, associated symptoms, pain site, existence of tenderness, and whether additional diagnostic tests were done. RESULTS: A total of 470 patients visited our ED during the study period and 148 of them had additional tests. Among the 148 patients who had additional tests, 48 had an important change in their treatment plan. Abdominal-pelvic computed tomography scans were a most useful tool in plan change (in 37 patients). Diseases that changed the treatment plan included fatal diseases such as abdominal aortic dissection and pan-peritonitis. CONCLUSION: Among patients with NSAP, carrying out of additional diagnostic tests led to important changes in the treatment plan. Abdominal-pelvic CT scans were a useful diagnostic tool. Therefore, close observation of NSAP patients is necessary and it is clinically useful to carry out additional diagnostic tests to see if the patient's symptoms and signs are changing.

Effectiveness of a Specialized Emergency Department Unit for Cancer Patients in Management of Febrile Neutropenia

PURPOSE: Our medical institute developed an emergency department (ED) cancer unit that specialized in the management of oncologic emergencies; it was named the cancer emergency room (CER). The object of our study was to determine improvements in patient management, especially management of febrile neutropenia (FN). METHODS: This was a retrospective study of 137 febrile neutropenic episodes, including 70 episodes occurring between May 2008 and August 2008, and 67 episodes between May 2009 and August 2009. Episodes were grouped into two categories: those managed in the CER and those managed in the existing ED main treatment area of the main emergency room (MER). The time interval between presentation at the ED and first antibiotic administration, termed the door-to-needle time, clinical outcomes, and length of inpatient hospital stay were analyzed for those admitted. RESULTS: The median door-to-needle time in the CER was 2 hours (0.3-5.1), faster than the time, 3.5 hours (0.9-6.9) in the MER (p=0.000). The length of inpatient hospital stay in the CER was 4 days (1-16), shorter than that, 6 days (1-51), in the MER (p=0.034). Twelve episodes (26.1%) had adverse events in the CER and 42 (46.2%) in the MER (p=0.023). CONCLUSION: Management of FN in a unit specialized for oncologic emergencies showed faster antibiotic delivery time, more favorable outcomes and shorter duration of admission. This specialized cancer unit in the ED enables prompt and relevant management in oncologic emergencies, including events related to chemotherapy toxicity.