Management of acute pyelonephritis in the emergency department observation unit

INTRODUCTION@#This study aimed to assess the effectiveness of the emergency department observation unit (EDOU) for patients with acute pyelonephritis in a Singapore tertiary academic medical centre.@*METHODS@#We reviewed the clinical records of consecutive patients who presented with pyelonephritis between 1 July 2012 and 31 October 2014 to collect information on demographics, symptoms, signs, laboratory and radiological results, treatment, and clinical outcomes.@*RESULTS@#Of 459 emergency department (ED) patients who were identified as having pyelonephritis, 164 (35.7%) were managed in the EDOU. Successful management in the EDOU was achieved in 100 (61.0%) patients. Escherichia coli was the predominant (64.6%) micro-organism in urine cultures and was positive in 106 patients. Patients diagnosed with acute pyelonephritis who were successfully managed in the EDOU had a lower incidence of nausea (32.0% vs. 60.9%, p < 0.001) and vomiting (15.0% vs. 50.0%, p < 0.001) compared to those who were not successful.@*CONCLUSION@#EDOU is useful for both observation and treatment of patients with acute pyelonephritis. Urine cultures are sufficient for the identification of the culprit micro-organism. Patients who present with prominent symptoms of vomiting should have routine administration of antiemetics, while consideration for second-line antiemetics is recommended for those with persistent symptoms.

Improving Primary Care Management of Time Sensitive Emergencies

Ischemic heart disease, pneumonia, cerebrovascular accidents and chronic obstructive pulmonary disease rank among the top 10 causes of hospitalisation in Singapore1. For optimum patient outcomes, acute presentations of each of these spectrum of diseases requires a continuum of care involving crucial steps at primary healthcare, pre-hospital transport, emergency care at the emergency department, hospitalisation and sometimes, rehabilitation at step-down facilities. For patients with suspected ACS, a resting 12-lead electrocardiogram (ECG) should be obtained as soon as possible: do not rule out acute coronary syndrome (ACS) because of a normal resting 12-lead ECG; administer a loading dose of 300mg aspirin, preferably chewed; do not offer other antiplatelet agents in primary care; and if aspirin is given before arrival at hospital, send a written record with the patient. For patients with suspected stroke, attempt to ascertain exact time of onset of stroke - when the patient was last seen at his or her neurologic baseline, rather than the time at which the symptoms were first noticed; immediate assessment using a standardised tool (CPSS, or FAST, or LAPSS) is indicated for patients with new or developing stroke-like symptoms. The therapeutic window for thrombolsis is 3 hours for intravenous tPA and 6 hours for intra-arterial tPA. For patients presenting with acute onset dyspnea, assess emergently for signs and symptoms suggestive of airway obstruction; administer high flow oxygen in sitting position/ position of comfort; without delaying transfer, obtain CXR, ECG, capillary blood glucose.

Improving Primary Care Management of Time Sensitive Emergencies

Ischemic heart disease, pneumonia, cerebrovascular accidents and chronic obstructive pulmonary disease rank among the top 10 causes of hospitalisation in Singapore1. For optimum patient outcomes, acute presentations of each of these spectrum of diseases requires a continuum of care involving crucial steps at primary healthcare, pre-hospital transport, emergency care at the emergency department, hospitalisation and sometimes, rehabilitation at step-down facilities. For patients with suspected ACS, a resting 12-lead electrocardiogram (ECG) should be obtained as soon as possible: do not rule out acute coronary syndrome (ACS) because of a normal resting 12-lead ECG; administer a loading dose of 300mg aspirin, preferably chewed; do not offer other antiplatelet agents in primary care; and if aspirin is given before arrival at hospital, send a written record with the patient. For patients with suspected stroke, attempt to ascertain exact time of onset of stroke - when the patient was last seen at his or her neurologic baseline, rather than the time at which the symptoms were first noticed; immediate assessment using a standardised tool (CPSS, or FAST, or LAPSS) is indicated for patients with new or developing stroke-like symptoms. The therapeutic window for thrombolsis is 3 hours for intravenous tPA and 6 hours for intra-arterial tPA. For patients presenting with acute onset dyspnea, assess emergently for signs and symptoms suggestive of airway obstruction; administer high flow oxygen in sitting position/ position of comfort; without delaying transfer, obtain CXR, ECG, capillary blood glucose.

Emergency department headache admissions in an acute care hospital:why do they occur and what can we do about it?

<p><b>INTRODUCTION</b>Many patients present to the Emergency Department (ED) complaining of headache and a significant proportion of these visits would result in hospital admissions. This study analyses the demographics, presentation, work-up, reasons for admission, diagnoses and outcomes of patients admitted with the chief complaint of headache--to identify possible ways of reducing such admissions.</p><p><b>MATERIALS AND METHODS</b>A retrospective analysis was done of the electronic medical records/discharge summaries of all adult patients admitted during a 1-year period from January to December 2006 with the diagnosis of primary headaches or secondary headaches not related to trauma, intracranial infection, inflammation, mass lesion, raised intracranial pressure or a serious systemic illness from the ED of the National University Hospital of Singapore.</p><p><b>RESULTS</b>One thousand two hundred and seventy-six patients presented to the adult ED with primary headaches or secondary headaches not related to serious conditions in 2006. This represented 2% of the ED attendances in the period. Two hundred and twenty-three patients were admitted for various reasons--diagnostic uncertainty: 110 (49%), pain control: 73 (33%), social/patient request: 60 (27%) and others: 4 (2%). Sixty-six per cent of the patients had either computed tomography (CT) or magnetic resonance (MR) head imaging. Eighteen patients (8%) were eventually diagnosed with a "potentially serious" diagnosis (intracranial haemorrhage, brain metastasis, stroke, meningitis, cerebral inflammation, cysticercosis, cervical osteomyelitis, hydrocephalus, seizure and malignant hypertension).</p><p><b>CONCLUSION</b>Specific strategies addressing the various reasons for admission including physician training, use of evaluation protocols, imaging to exclude secondary pathology, a longer duration of treatment and evaluation in the ED, effective pain control and patient education may help reduce headache admissions.</p>