Traumatic intracranial hemorrhage in patients using warfarin or clopidogrel.

CLINICAL QUESTION: What is the prevalence of immediate and incidence of delayed intracranial hemorrhage in patients with blunt head trauma who use warfarin or clopidogrel? ARTICLE CHOSEN: Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 2012;59:460-8.e7. STUDY OBJECTIVE: To assess the prevalence of immediate and the cumulative incidence of delayed traumatic intracranial hemorrhage in patients using warfarin or clopidogrel.

Predictors of hospital admission for chronic obstructive pulmonary disease exacerbations in Canadian emergency departments.

OBJECTIVES: The objective was to examine predictors of hospital admission among adults presenting to Canadian emergency departments (EDs) for acute exacerbations of chronic obstructive pulmonary disease (COPD). Current acute treatment approaches and outcomes 2 weeks after the ED visit are also described. METHODS: Subjects, aged > or =35 years presenting with COPD exacerbations to 16 EDs across Canada, underwent a structured in-ED interview and a telephone interview 2 weeks later. RESULTS: Of 501 study patients, 247 (49.3%; 95% confidence interval [CI] = 44.9% to 53.6%) were admitted. Admitted patients were older, were more often former smokers, and had more admissions for COPD during the past 2 years. They also reported more days of activity limitation and use of inhaled beta(2)-agonists in the previous 24 hours. Canadian Triage and Acuity Scale (CTAS), respiratory rate (RR), and airflow obstruction were more severe in the hospitalized group. Most of the patients received inhaled beta(2)-agonists, anticholinergics, oral corticosteroids (CS), and antibiotics; hospitalized patients received more aggressive treatments. The median ED length of stay (LOS) of admitted patients was 13.1 hours (interquartile range [IQR] = 7.4-23.0) compared to 5.6 hours (IQR = 4.2-8.4) in discharged patients. Admission was associated with at least two COPD admissions in the past 2 years (odds ratio [OR] = 2.10; 95% CI = 1.24 to 3.56), receiving oral CS for COPD (OR = 1.72; 95% CI = 1.08 to 2.74), having a CTAS score of 1-2 (OR = 2.04; 95% CI = 1.33 to 3.12), and receiving adjunct ED treatments (OR = 3.95; 95% CI = 2.45 to 6.35). Use of EDs for usual COPD care was associated with a reduced risk of admission (OR = 0.43; 95% CI = 0.28 to 0.66). CONCLUSIONS: Exacerbations of COPD in Canadian EDs result in prolonged ED stays and approximately 50% hospitalization despite aggressive acute treatment approaches. Historical, severity, and treatment-related factors were strongly associated with hospital admission. Validation of these results should be completed prior to widespread use.

An emergency department-based nurse discharge coordinator for elder patients: does it make a difference?

OBJECTIVES: To evaluate the impact of an emergency department (ED)-based nurse discharge plan coordinator (NDPC) on unscheduled return visits within 14 days of discharge, satisfaction with discharge recommendations, adherence with discharge instructions, and perception of well-being of elder patients discharged from the ED. METHODS: Patients aged 75 years and older discharged from the ED of the Sir Mortimer B. Davis-Jewish General Hospital were recruited in a pre/post study. During the pre (control) phase, study patients (n = 905) received standard discharge care. Patients in the post (intervention) phase (n = 819) received the intervention of an ED-based NDPC. The intervention included patient education, coordination of appointments, patient education, telephone follow-up, and access to the NDPC for up to seven days following discharge. RESULTS: Patients in the two groups were similar with respect to gender and age. However, the patients managed by the ED NDPC appeared to be, at baseline, less autonomous, frailer, and sicker. The unadjusted relative risk for unscheduled return visits within 14 days of discharge was 0.79 (95% confidence interval [95% CI] = 0.62 to 1.02). A relative risk reduction of 27% (95% CI = 0% to 44%) for unscheduled return visits was observed for up to eight days postdischarge, and a relative risk reduction of 19% (95% CI = -2% to 36%) for unscheduled return visits was observed for up to 14 days postdischarge. Significant increases in satisfaction with the clarity of discharge information and perceived well-being were also noted. CONCLUSIONS: An ED-based NDPC, dedicated specifically to the discharge planning care of elder patients, reduces the proportion of unscheduled ED return visits and facilitates the transition from ED back home and into the community health care network.

Intervention to decrease emergency department crowding: does it have an effect on return visits and hospital readmissions?

STUDY OBJECTIVES: We evaluate the effect of a multifaceted intervention to decrease emergency department crowding on the incidence of return visits to the ED or a hospital ward. The intervention included increased emergency physician coverage, the designation of physician coordinators, and new hospital policies regarding laboratory, consultation, and admission procedures. METHODS: The incidence of return visits within 7 days of discharge was estimated in samples from 2 populations (ie, patients discharged from the ED and patients discharged from the hospital) and during a 12-month period before and a 12-month period after the implementation of the intervention. Return visits were categorized into the following groups: (1) scheduled or not and (2) related or not to initial visit. Logistic regression was used in subsamples to assess the effect of the intervention while controlling for potential confounders. By using information from the provincial medical services database, variation between the periods before and after implementation of the intervention in the incidence of return visits to any ED was compared between the study hospital and 2 external control hospitals. RESULTS: No difference was found in the incidence of return visits between the periods before and after implementation of the intervention, either for patients discharged from the ED (all returns: 11.0% versus 12.4%, 95% confidence interval on difference [CID] -1.5% to 4.3%; unscheduled-related returns: 6.5% versus 5.8%, 95% CID -2.8% to 1.6%) or the hospital (all returns: 6.8% versus 6.6%, 95% CID -2.5% to 2.1%; unscheduled-related returns: 4.2% versus 4.0%, 95% CID -2.0% to 1.7%). This lack of effect remained even after controlling for potential confounders. Variation between the periods before and after implementation of the intervention in the incidence of return to any ED was similar in the 3 hospitals examined. CONCLUSION: Our successful hospital intervention to decrease crowding reduced the mean length of stay for patients discharged from the ED from 13.8 to 5.9 hours, without resulting in increased return visits to the ED or hospital readmission.