[Patient reported outcomes measures (PROMs): definitions and perspectives for their use as quality indicators in emergency rooms.] / Patient-reported outcomes measures (PROM): definizioni e prospettive per il loro impiego quali indicatori di qualità nei Pronto Soccorso.

There is a growing emphasis on including patients' perspectives on outcomes as a measure of quality care. This recent interest has spawned the rapid development and testing of patient-reported outcome measures (PROMs), through which patients report on their perception of the outcomes of the care they received. Their use has moved significantly from medical research toward applications in the clinical setting, quality measurement, and system accountability. While the use of as measures of clinical or treatment effectiveness, especially in chronic conditions, is widespread, their use in the emergency department (ED) setting is currently limited. In ED care, PROMs could offer promise since 80% of patients are discharged without any other way to track outcome. We explore the development and use of PROMs in publications on benchmarks and patient-centered care.

Patients with isolated pulmonary embolism in comparison to those with deep venous thrombosis. Differences in characteristics and clinical evolution.

BACKGROUND: Patients with acute pulmonary embolism (PE) often have leg deep vein thrombosis (DVT); sometimes, however, a DVT is not detected (isolated PE, I-PE). We aimed at assessing the proportion of patients with I-PE, and their characteristics and clinical evolution compared to those with DVT with/without PE (DVT/PE). METHODS: Among 3573 patients included in the START2-Register for a venous thromboembolic event, 2880 (80.6%) had DVT/PE, the remaining I-PE (19.4%). RESULTS: Patients with I-PE were older [(≥75 years, OR 1.4 (95%CI 1.13-1.69)], and more frequently females [OR 1.4 (1.19-1.67)]. Young females (aged ≤ 50 years) with an index event occurring during hormonal contraception (HC), were more prevalent in I-PE [OR 1.96 (1.26-3.03)]. At multivariate analysis, age > 75 years, female sex, heart failure, cancer and use of HC were risk factors significantly associated with I-PE, whereas thrombophilic alterations were associated with DVT/PE. During a follow-up of 4504 years (during anticoagulation), the rate of bleeding events was 1.1% patient/years and 1.0% patient/years in I-PE and DVT/PE, respectively. Venous thromboembolic events were equally prevalent in DVT/PE or I-PE (1.94% vs 0.86%, ns), whereas arterial complications were more prevalent in the latter group (1.01% vs 0.28%, p = 0.008). CONCLUSION: I-PE and DVT/PE have important differences. Older age, female sex, heart failure and cancer, were risk factors for I-PE; thrombophilic alterations were associated with DVT/PE. HC use was more frequent in the I-PE group. The prevalence of arterial complications was higher in patients with I-PE. Further studies, specifically designed on this issue, are warranted.

Emergency Department Non-Urgent Visits and Hospital Readmissions Are Associated with Different Socio-Economic Variables in Italy.

OBJECTIVE: The aim of this paper was to evaluate socio-economic factors associated to poor primary care utilization by studying two specific subjects: the hospital readmission rate, and the use of the Emergency Department (ED) for non-urgent visits. METHODS: The study was carried out by the analysis of administrative database for hospital readmission and with a specific survey for non-urgent ED use. RESULTS: Among the 416,698 sampled admissions, 6.39% (95% CI, 6.32-6.47) of re-admissions have been registered; the distribution shows a high frequency of events in the age 65-84 years group, and in the intermediate care hospitals (51.97%; 95%CI 51.37-52.57). The regression model has shown the significant role played by age, type of structure (geriatric acute care), and deprivation index of the area of residence on the readmission, however, after adjusting for the intensity of primary care, the role of deprivation was no more significant. Non-urgent ED visits accounted for the 12.10%, (95%CI 9.38-15.27) of the total number of respondents to the questionnaire (N = 504). The likelihood of performing a non-urgent ED visit was higher among patients aged <65 years (OR 3.2, 95%CI 1.3-7.8 p = 0.008), while it was lower among those perceiving as urgent their health problem (OR 0.50, 95%CI 0.30-0.90). CONCLUSIONS: In the Italian context repeated readmissions and ED utilization are linked to different trajectories, besides the increasing age and comorbidity of patients are the factors that are related to repeated admissions, the self-perceived trust in diagnostic technologies is an important risk factor in determining ED visits. Better use of public national health care service is mandatory, since its correct utilization is associated to increasing equity and better health care utilization.

[The nursing approach to pre-hospital pediatric emergencies: cognitive study in 2 cohorts of nurses]. / L'approccio infermieristico all'emergenza pediatrica pre-ospedaliera: indagine conoscitiva in due coorti di infermieri.

Pediatric emergencies have a relatively low incidence compared to the total number of pre-hospital events. The quality of emergency care for pediatric patients can be improved by specific training, a dedicated team and uniformity of pediatric protocols. The aim of this study is to assess how nurses perceive pediatric emergencies in a non-hospital environment by means of two questionnaires issued to two cohorts of nurses working on ambulances. The results of the study show that nursing care of pediatric patients in critical situations seems to depend on adequate training, not only formal but also with simulations, paying particular attention to the emotional situation nurses have to face, and complete equipment of the ambulance and emergency personnel.

A management of blunt thoracic trauma in an emergency department observation unit: pre-post observational study.

BACKGROUND: The best management of patients with isolated blunt thoracic trauma at high risk of pulmonary complications (HRPC-BTT: ≥3 isolated rib fractures, sternal fracture, single or few pulmonary contusions or minimal pneumothorax) is still unclear. We compared efficacy and cost-effectiveness of a new clinical pathway involving an Emergency Department Observation Unit (EDOU) with routine care. DESIGN: Retrospective before-after study. SETTING: Level II Trauma Center within a Regional Teaching Hospital. PARTICIPANTS: A consecutive series of patients with HRPC-BTT. INTERVENTIONS: a new clinical pathway involving EDOU was implemented. MAIN OUTCOMES: Death rate, tube thoracostomy, and re-admission of discharged patients. Hospital admission rate, length of hospital occupancy, overall costs, and cost-effectiveness were also compared in pre- and post-EDOU period. RESULTS: Two hundred forty patients were eligible for the study: 110 patients in the pre-EDOU period and 130 in the post-EDOU period. Thirteen (12%) of the treated patients were re-admitted to the ED in the pre-EDOU period compared with only five (4%) when the EDOU was available (p = 0.03). The rate of tube thoracostomy performed in admitted patients significantly increased after EDOU implementation: 1 of 54 (1.9%) versus 4 of 32 (12.5%; p < 0.05). The rate of hospitalization decreased from 49% in the pre-EDOU period to 24% in the post-EDOU period (p < 0,005) and the length of stay in hospital in the pre-EDOU period was longer than in the EDOU period: mean 94.7 ± 79.6 versus 65.7 ± 60.6, respectively (p < 0.02). Cost analysis revealed no relevant change in cost-effectiveness per patient (median; interquartile range): €487; €103 to 1959 versus €616; €124 to 1455, respectively, in the pre- and post-EDOU period. CONCLUSIONS: In managing patients affected by HRPC-BTT, a clinical pathway involving the EDOU seems to be more effective than routine care with little impact on cost.

Hernia of Morgagni and mediastinal lipoma: a case report.

A hernia of Morgagni (also called hernia of Morgagni-Larrey) is a congenital herniation of abdominal contents into the thoracic cavity through a retrosternal diaphragmatic defect. The Morgagni hernia can create uncertainty in its diagnosis and difficulty for subsequent treatment. If after clinical examination and x-ray we suspect the hernia, computed tomography imaging should be the desired imaging method to confirm the diagnosis. Surgery is the only definitive treatment. When a patient presents signs and symptoms of incarceration or strangulation, emergency surgery is required. We report the first life-threatening case of an association between a hernia of Morgagni and a mediastinal lipoma. We present an adult patient with mediastinal lipoma and a right incarcerated hernia of Morgagni with engagement of the stomach, the duodenum and the transverse colon, successfully treated without complications. To our knowledge, this is the first report of an association between those two rare entities in an acute setting. We discuss the differential diagnosis and physiopathology of the condition, referring to published reports.

Metaphylaxis of urolithiasis.

The urolithiasis is a growing disease because of the changes in dietary habits and in he general life style. Urolithiasis is characterized by the recurrent clinical manifestation and possible effect of structural damage of the kidneys and of the urinary tract ast well as the potential increase in systemic blood pressure. Moreover, frequent need for medical cure and invasive urological treatment exposes the patient to the complications of such procedures. The lithogenic process involves a wide number of systemic pathologies that are often undiagnosed. However, once identified they can be treated more precisely having an impact on the stone's forming process. For these reasons, prevention of new urolithiasis in patients, and in particular in those with high risk, appears to be clinically important. Metaphylaxis can be differentiated in two ways: "general metaphylaxis" in patients with lithiasis of the urinary tract, and "specific metaphylaxis" meant for patients with risk factors for recurrent calculosis. The aim of this narrative review is to present an algorithm for clinical practice for patients that have undergone one or more attacks of renal/ureteral colic from lithiasis in order to prevent further attacks. As such, this review deals with a method of secondary prevention (prophylaxis) that aims at identifying and correcting metabolic disorders (from which the term metaphylaxis comes) that favor and support the lithogenic process in the urinary tract.