What is the risk of returning to the emergency department within 30 days for patients diagnosed with substance-induced psychosis?

OBJECTIVES: The primary objective of this study was to measure the risk of return Emergency Department (ED) visits in patients presenting to the ED with a diagnosis of substance-induced psychosis. Secondary objectives included: (1) describing the characteristics of patients returning within 30 days to the ED with substance-induced psychosis, and (2) identifying risk factors associated with such ED return. METHODS: At two urban sites from January 1, 2018 to December 31, 2019, we included consecutive patients presenting to the ED with substance-induced psychosis defined by their ED discharge diagnosis of psychosis and clinical evidence of substance use. We described ED resources utilized by this patient population including ED time and disposition then subsequently described return visits within 30 days and characteristics among those patients who returned. RESULTS: We identified 611 unique patients presenting with substance-induced psychosis, with 813 total ED visits. The median age was 35 years (IQR 28-45), 71.4% (n = 436) were male, and 44.8% (n = 274) were homeless. The median ED length of stay was 619 min (IQR 313-898), and 48.4% (n = 296) were admitted to hospital. Forty percent of patients (n = 237) returned to the ED within 30 days of the index substance-induced psychosis visit, 116 (18.9%) returning more than once. Of these return visits, 74 (31.2%) were for recurrent substance-induced psychosis. Younger age, female gender, no opioid use, and no prior history of bipolar disorder were identified as common characteristics among those returning to the ED with substance-induced psychosis. CONCLUSIONS: In ED patients with substance-induced psychosis, nearly half of all patients were admitted to hospital, 40% had a 30 days return ED visit, and one-third of those were for substance-induced psychosis. We identified clinically relevant factors common to those returning with recurrent substance-induced psychosis.

RéSUMé: OBJECTIFS: L'objectif principal de cette étude était de mesurer le risque de retour aux urgences chez les patients se présentant aux urgences avec un diagnostic de psychose induite par une substance. Les objectifs secondaires comprenaient : 1) décrire les caractéristiques des patients qui retournent aux urgences dans les 30 jours avec une psychose induite par la substance, et 2) déterminer les facteurs de risque associés à ce retour aux urgences. MéTHODES: Dans deux sites urbains, du 1er janvier 2018 au 31 décembre 2019, nous avons inclus des patients consécutifs se présentant aux urgences avec une psychose induite par une substance, définie par leur diagnostic de psychose à la sortie des urgences et des preuves cliniques de consommation de substances. Nous avons décrit les ressources des urgences utilisées par cette population de patients, notamment le temps passé aux urgences et les dispositions prises, puis nous avons décrit les visites de retour dans les 30 jours et les caractéristiques des patients qui sont revenus. RéSULTATS: Nous avons identifié 611 patients uniques présentant une psychose induite par une substance, avec un total de 813 visites aux urgences. L'âge médian était de 35 ans (IQR 28-45), 71,4 % (n = 436) étaient des hommes et 44,8 % (n = 274) étaient sans domicile fixe. La durée médiane du séjour aux urgences était de 619 minutes (IQR 313-898), et 48,4 % (n = 296) ont été hospitalisés. Quarante pour cent des patients (n = 237) sont retournés aux urgences dans les 30 jours suivant la visite de référence pour une psychose due à une substance, 116 (18,9 %) y étant retournés plus d'une fois. Parmi ces visites de retour, 74 (31,2 %) concernaient une psychose récurrente induite par une substance. Un âge plus jeune, le sexe féminin, l'absence de consommation d'opioïdes et d'antécédents de troubles bipolaires ont été identifiés comme des caractéristiques communes chez les personnes revenant aux urgences pour une psychose induite par une substance. CONCLUSIONS: Chez les patients des urgences souffrant de psychose due à une substance, près de la moitié des patients ont été hospitalisés, 40 % sont revenus aux urgences dans les 30 jours, dont un tiers pour une psychose due à une substance. Nous avons identifié des facteurs cliniquement pertinents communs à ceux qui reviennent avec une psychose récurrente induite par une substance.

One-year mortality of emergency department patients with substance-induced psychosis.

OBJECTIVES: Psychosis is a well established complication of non-prescription drug use. We sought to measure the 1-year mortality of emergency department patients with substance-induced psychosis (SIP). METHODS: This study was a multi-centre, retrospective electronic medical records review of patients presenting to the ED with substance-induced psychosis (SIP). We interrogated the hospital ED database from Jan 1, 2018 and Jan 1, 2019 to identify consecutive patients. All patients were followed for one year from index visit, and classified as alive/dead at that time. Patients were included in the study if they met the following criteria: 1) ED discharge diagnosis of psychosis NOS and a positive urine drugs of abuse screen (UDAS) or the patient verbally endorsed drug use, or 2) Mental disorder due to drug use and "disorganized thought", "bizarre behavior" or "delusional behavior" documented in the chart and one or more of the following criteria: a) arrival with police, b) mental health certification, c) physical restraints, d) chemical restraints. We excluded patients who were not British Columbia residents, since we were unable to ascertain if they were alive or dead at 1 year from their index ED visit. Primary statistical analysis was logistic regression for risk of death in 1 year, based on plausible risk factors, selected a priori. RESULTS: We identified 813 presentations for SIP (620 unique patients). The median age of the entire cohort was 35 years (IQR 28-44), and 69.5% (n = 565) were male. Thirty five patients (4.3%; 95% CI 3.2-5.9) had died one year after their initial presentation to the ED for SIP. Separate multivariable logistic regression analyses, controlling for age, demonstrated schizophrenia (OR 4.2, 95% CI 1.8-11.1) significantly associated with increased 1-year mortality. CONCLUSIONS: In our study of patients presenting to the ED with SIP, the 1-year mortality was 4.3%. Controlling for age, schizophrenia was a notable risk factor for increased 1-year mortality.

Rationale for withholding professional resuscitation in emergency medical system-attended out-of-hospital cardiac arrest.

BACKGROUND: Half of out-of-hospital cardiac arrests (OHCA) are deemed inappropriate for resuscitation by emergency medical services (EMS). We investigated patient characteristics and reasons for non-treatment of OHCAs, and determined the proportion involving illicit drug use. METHODS: We reviewed consecutive EMS-untreated OHCA from the British Columbia Cardiac Arrest Registry (2019-2020). We abstracted patient characteristics and categorized reasons for EMS non-treatment: (1) prolonged interval from the OHCA to EMS arrival ("non-recent OHCA") with or without signs of "obvious death"; (2) do-not-resuscitate (DNR) order; (3) terminal disease; (4) verbal directive; and (5) unspecified. We abstracted clinical details regarding a history of, or evidence at the scene of, illicit drug use. RESULTS: Of 13 331 cases, 5959 (45%) were not treated by EMS. The median age was 67 (IQR 54-81) and 1903 (32%) were female. EMS withheld resuscitation due to: non-recent OHCA, with and without signs of "obvious death" in 4749 (80%) and 108 (1.8%), respectively; DNR order in 952 (16%); terminal disease in 77 (1.3%); family directive in 41 (0.69%); and unspecified in 32 (0.54%). Overall and among those with non-recent OHCA, 695/5959 (12%) and 691/4857 (14%) had either a history of or evidence of recent illicit drug use, respectively. CONCLUSION: A prolonged interval from the OHCA until EMS assessment was the predominant reason for withholding treatment. Innovative solutions to decrease this interval may increase the proportion of OHCA that are treated by EMS and overall outcomes. Targeted interventions for illicit-drug use-related OHCAs may add additional benefit.

Awareness and knowledge among internal medicine house-staff for dose adjustment of commonly used medications in patients with CKD.

BACKGROUND: Drug dosing errors result in adverse patient outcomes and are more common in patients with chronic kidney disease (CKD). As internists treat the majority of patients with CKD, we study if Internal Medicine house-staff have awareness and knowledge about the correct dosage of commonly used medications for those with CKD. METHODS: A cross-sectional survey was performed and included 341 participants. The outcomes were the awareness of whether a medication needs dose adjustment in patients with CKD and whether there was knowledge for the level of glomerular filtration rate (GFR) a medication needs to be adjusted. RESULTS: The overall pattern for all post-graduate year (PGY) groups in all medication classes was a lack of awareness and knowledge. For awareness, there were statistically significant increased mean differences for PGY2 and PGY3 as compared to PGY1 for allergy, endocrine, gastrointestinal, and rheumatologic medication classes but not for analgesic, cardiovascular, and neuropsychotropic medication classes. For knowledge, there were statistically significant increased mean differences for PGY2 and PGY3 as compared to PGY1 for allergy, cardiovascular, endocrine, and gastrointestinal, medication classes but not for analgesic, neuropsychotropic, and rheumatologic medication classes. CONCLUSIONS: Internal Medicine house-staff across all levels of training demonstrated poor awareness and knowledge for many medication classes in CKD patients. Internal Medicine house-staff should receive more nephrology exposure and formal didactic educational training during residency to better manage complex treatment regimens and prevent medication dosing errors.