Hospital Readmission Through the Emergency Department.

BACKGROUND: Hospital readmission places a high burden on both health care systems and patients. Most readmissions are thought to be related to the quality of the health care system. OBJECTIVES: The aim of this study was to examine the causes and rates of early readmission in emergency department in a Tehran hospital. PATIENTS AND METHODS: A cross-sectional investigation was performed to study readmission of inpatients at a large academic hospital in Tehran, Iran. Patients admitted to hospital from July 1, 2014 to December 30, 2014 via the emergency department were enrolled. Descriptive statistics were used to summarize the distribution demographics in the sample. Data was analyzed by chi2 test using SPSS 20 software. RESULTS: The main cause of readmission was complications related to surgical procedures (31.0%). Discharge from hospital based on patient request at the patient's own risk was a risk factor for emergency readmission in 8.5%, a very small number were readmitted after complete treatment (0.6%). The only direct complication of treatment was infection (17%). CONCLUSIONS: Postoperative complications increase the probability of patients returning to hospital. Physicians, nurses, etc., should focus on these specific patient populations to minimize the risk of postoperative complications. Future studies should assess the relative connections of various types of patient information (e.g., social and psychosocial factors) to readmission risk prediction by comparing the performance of models with and without this information in a specific population.

Intramuscular compared to intravenous midazolam for paediatric sedation: A study on cardiopulmonary safety and effectiveness.

BACKGROUND: Sedation in children remains a controversial issue in emergency departments (ED). Midazolam, as a benzodiazepine is widely used for procedural sedation among paediatrics. We compared the effectiveness and safety of two forms of midazolam prescription; intramuscular (IM) and intravenous (IV). PATIENTS AND METHODS: A cohort study was conducted on two matched groups of 30 children referred to our ED between 2010 and 2011. The first group received IM midazolam (0.3 mg/kg) and the second group received IV midazolam (0.15 mg/kg) for sedation. For evaluating effectiveness, sedation, irritation and cooperation score were followed every 15 min for 60 min and for safety assessment, vital signs and O 2 saturation were observed. RESULTS: Mean age was 6.18 ± 2.88 years and 31 patients (51.7%) were male. All patients were sedated completely after using first dose. There was an overall complication rate of 68.3%. 35 (58.3%) patients presented euphoria as the most common complication, but there was no statistical difference between the two groups (P = 0.396). Cases who received IV midazolam became sedated faster than those received IM midazolam (P > 0.001). The vital signs including heart rate, respiratory rate, systolic blood pressure and O 2 saturation changed significantly between and within groups during the sedation (P < 0.05). CONCLUSION: Both forms of midazolam, IM and IV, are effective and safe for paediatric sedation in ED. Although the sedative with IV form might appear sooner, IM form of midazolam can be effectively used in patient with limited IV access. Patients are better to observe closely for psychological side-effects.

Comparison between traction-countertraction and modified scapular manipulation for reduction of shoulder dislocation.

OBJECTIVE: One of the most common joint dislocations presented to the emergency department (ED) is anterior shoulder dislocation (ASD). Various techniques for the treatment of this abnormality have been suggested. In this study, we evaluated the efficacy and success rate of modified scapular manipulation (MSM) as a painless procedure compared to traction-countertraction (TCT) for reduction of ASD. METHODS: Patients with ASD who were presented to ED of Baqiyatallah Hospital, Tehran during 2011 were included. They were randomly divided into MSM group or TCT group and then pain at reduction, time of reduction, duration of hospitalization, and success rate were compared. In TCT group, reduction was performed using sedative and antipain medications. RESULTS: Ninety seven patients (81.6% male) with a mean age of 34.15 years±13.48 years were studied. The reduction time between both groups showed a significant difference (470.88 seconds±227.59 seconds for TCT group, 79.35 seconds±82.49 seconds for MSM group, P<0.001). The success rate in MSM group in the first and second effort were 89% and 97% whereas 73% and 100% in the TCT group respectively (P<0.001). CONCLUSION: It seems that the manipulation technique can be more successful than the TCT method at the first effort whilst the second effort has the opposite results. Also MSM can be safer, cheaper and more acceptable for patients than TCT as a standard traditional method.

Diagnostic value of "bedside ultrasonography" and the "water bath technique" in distal forearm, wrist, and hand bone fractures.

Bedside ultrasonography (BUS) has been widely used in many emergency evaluations, but the technique was not thoroughly evaluated for use in adult fractures. The water bath technique (WBT) is a modality which overcomes some important limitations of using BUS in extremity fractures. The study aims to evaluate and compare diagnostic values of BUS and WBT. The sensitivity, specificity, positive and negative predictive values (PPV and NPV), positive and negative likelihood ratios (LR+ and LR-), and accuracy of BUS and WBT were calculated and compared by the McNemar chi-square test. BUS had the highest sensitivity, specificity, PPV, and LR+ in the distal forearm. The highest NPV and LR- of BUS were seen in phalangeal and wrist injuries, respectively. The WBT examination had the highest sensitivity in phalangeal injuries and the highest specificity, PPV, and LR+ in the distal forearm. The highest NPV and LR- of the WBT examination were seen in phalangeal and wrist injuries, respectively. The McNemar χ (2) values for the comparison of BUS and WBT indicate that the two techniques provide statistically different results. The ultrasound revealed excellent diagnostic values which make it a favorable alternative in evaluating upper extremity fractures in adults. The WBT provides even better results.

Citrullus colocynthis as the Cause of Acute Rectorrhagia.

Introduction. Citrullus colocynthis Schrad. is a commonly used medicinal plant especially as a hypoglycemic agent. Case Presentation. Four patients with colocynth intoxication are presented. The main clinical feature was acute rectorrhagia preceeded by mucosal diarrhea with tenesmus, which gradually progressed to bloody diarrhea and overt rectorrhagia within 3 to 4 hours. The only colonoscopic observation was mucosal erosion which was completely resolved in follow-up colonoscopy after 14 days. Conclusion. The membranolytic activity of some C. colocynthis ingredients is responsible for the intestinal damage. Patients and herbalists should be acquainted with the proper use and side effects of the herb. Clinicians should also be aware of C. colocynthis as a probable cause of lower GI bleeding in patients with no other suggestive history, especially diabetics.

A recommended method in order to interpret chest x-rays for diagnosing small size pneumothorax.

BACKGROUND: Pneumothorax can be a both progressive and life threatening disorder. In this survey we evaluated the diagnostic accuracy of a recommended method for the interpretation of chest X-Rays (CXRs) compared to the common method in diagnosis of iatrogenic Pneumothorax in an emergency department. MATERIALS AND METHODS: We conducted a study on 100 CXRs (31 with the diagnosis of small size pneumothorax and 69 normal) of patients who have undergone the upper central venous catheterization. CXRs were interpreted by 5 Emergency Specialists (ESs) and 5 general practitioners (GPs) separately using the conventional and recommended method. Recommended method included a 90 degree rotation against the side of chateterization in addition to using a yellow shield as the background color. Presence of pneumothorax on the CXR was confirmed by a radiologist. RESULTS: 64.5% of the CXRs with pneumothorax were correctly diagnosed by GPs and 87.7% by ESs with reutine method and 83.2% and 97.4% by recommended method, respectively (P.value<0.001). 96.8% out of all CXRs were correctly diagnosed by GPs and 99.4% by ESs by conventional method and 97.9% by GP and 99.7% by ES was correctly diagnosed using recommended method(P.value<0.001). None of the underlying variables including sex, age, underlying diseases, the side of intervention did not affect on the diagnostic accuracy in either groups (P.value>0.05). CONCLUSION: A significant raise was obtained in the diagnostic accuracy of CXR using the recommended method. This study can be a preliminary study to conduct further investigations in order to enhance the diagnostic accuracy of CXRs.

Intramuscular midazolam for pediatric sedation in the emergency department: a short communication on clinical safety and effectiveness.

BACKGROUND: Procedural sedation in children continues to be a problem in the emergency department (ED). Midazolam is the first water-soluble benzodiazepine and it has been widely used for procedural sedation in pediatric patients. OBJECTIVES: The aim of this study was evaluation of clinical safety and effectiveness of intramuscular Midazolam for pediatric sedation in the ED setting. MATERIALS AND METHODS: We performed a self-controlled clinical trial on 30 children who referred to the Baqiyatallah Hospital ED between 2009 and 2010. They received intramuscular Midazolam 0.3 mg/kg for procedural sedation and then they were followed for sedative effectiveness and safety. Vital signs and O2 saturation were also observed. The findings were compared using SPSS ver. 16 software. RESULTS: The mean age was 5.50 ± 2.70 years, the mean weight was 19.50 ± 6.63 kilograms and 16 patients (53.3%) were females. The most common adverse effect was euphoria (66.66%) and vertigo (6.7%); 27.7% did not show any side effects. There was an overall complication rate of 72.3%. The vital signs including heart rate, respiratory rate, systolic and diastolic blood pressure and O2 saturation decreased significantly during sedation (P value < 0.05). CONCLUSIONS: Midazolam is an effective and relatively safe sedative for pediatric patients in the ED. The patient should be observed closely and monitored for psychological and hemodynamic side effects.

Time of admission, gender and age: challenging factors in emergency renal colic - a preliminary study.

BACKGROUND: Nephrolithiasis is a relatively common problem and a frequent Emergency Department (ED) diagnosis in patients who present with acute flank/abdominal pain. The pain management in these patients is often challenging. OBJECTIVES: To investigate the most effective dose of morphine with the least side effects in emergency renal colic patients. MATERIALS AND METHODS: 150 renal colic patients who experienced a pain level of 4 or greater, based on visual analog scale (VAS) at admission time were included. Pain was scored on a 100 mm VAS (0 = no pain, 100 = the worst pain imagined). When patients arrived at ED, a physician would examine the patients and assessed initial pain score, then filled a questionnaire according to the patient information. Patients were assigned to receive 2.5 mg morphine sulfate intravenously. We monitored patients' visual analog scale (VAS), and adverse events at different time points (every 15 minutes) for 90 minutes. Additional doses of intravenous morphine (2.5 mg) were administered if the patient still had pain. (Max dose: 10 mg). The cumulative dose of morphine, defined as the total amount of morphine prescribed to each patient during the 90 minutes of the study, was recorded. Patients were not permitted to use any nonsteroidal anti-inflammatory drugs as coadjuvant analgesics during the study period. Subjects with inadequate pain relief at 90 minutes received rescue morphine and were excluded from the study. The primary end point in this study was pain relief at 90 minutes, defined as either VAS<40 or decrease of 50% or more as compared to the initial VAS. The secondary objective was to detect the occurrence of adverse effects at any time points in ED. RESULTS: The studied patients consisted of 104 men and 46 women with the mean age of 43 ±14 years (range, 18 to 75 years). There was no statistically significant difference between the mean age and gender differences in pain response. Rescue analgesia at 30 minutes were given in 54.5% receiving morphine. The average time to painless was 35 minutes. But there were no statistically significant differences between the mean age and gender differences in pain response (P > 0.05). Older patients responded sooner to morphine than the young. Most of the patients had a pain score of 90 -100 (77.3 %) at the beginning that was reduced to 29.4% during the 30 minutes follow up. During the first hour, we found that 94.7% of the patients had no pain or significant pain reduction and only 2.1% of the patients still had pain. CONCLUSIONS: We conclude that there were no significant differences among the gender, time of admission and side - effects in renal colic patients in response to morphine.

Assigning residents of emergency medicine to screen patients before admission: a strategy to overcome overcrowding.

BACKGROUND: The overcrowded hospital is an unsafe one. Overcrowding the emergency department (ED) results in increased patient suffering, prolonged waiting time, deteriorating level of service, and on occasion, a worsened medical condition or even death. OBJECTIVES: This study proposes a strategy to overcome ED overcrowding. MATERIALS AND METHODS: The proportion of acute area admitted patients to screened patients (A/S), and the proportion of patients who were finally transferred to inpatient wards (W/A) to those admitted in ED acute area were investigated during 6 consecutive months. Emergency medicine residents were assigned to screen patients before ED admission and afterwards. RESULTS: The average A/S changed from 82.4% to 44.2% (P = 0.028), and the average W/A changed from 28.3% to 51.48% (P = 0.028) before and after screening patients respectively. The initiative resulted in 97 less patients in the acute area per day. CONCLUSIONS: Decreased number of acute area admitted patients, and increase W/A proportion showed that the initiative was successful in obviating ED overcrowding while provision of care to those most in need was not altered.