Deaths Among Ambulance Patients Released from the Emergency Department Within the First 24 Hours With Nonspecific Diagnoses - Expected or Not?

BACKGROUND: Emergency patients are frequently assigned nonspecific diagnoses. Nonspecific diagnoses describe observations or symptoms and are found in chapters R and Z of the International Classification of Diseases, 10th edition (ICD-10). Patients with such diagnoses have relatively low mortality, but due to patient volume, the absolute number of deaths is substantial. However, information on cause of short-term mortality is limited. OBJECTIVES: To investigate whether death could be expected for ambulance patients brought to the emergency department (ED) after a 1-1-2 call, released with a nonspecific ICD-10 diagnosis within 24 h, and who subsequently died within 30 days. METHODS: Retrospective medical record review of adult 1-1-2 emergency ambulance patients brought to an ED in the North Denmark Region during 2017-2021. Patients were divided into three categories: unexpected death, expected death (terminal illness), and miscellaneous. Charlson Comorbidity Index (CCI) was assessed. RESULTS: We included 492 patients. Mortality was distributed as follows: Unexpected death 59.2% (n = 291), expected death (terminal illness) 25.8% (n = 127), and miscellaneous 15.0% (n = 74). Patients who died unexpectedly were old (median age of 82 years) and had CCI 1-2 (58.1%); 43.0% used at least five daily prescription drugs, and they were severely acutely ill upon arrival (24.7% with red triage, 60.1% died within 24 h). CONCLUSIONS: More than half of ambulance patients released within 24 h from the ED with nonspecific diagnoses, and who subsequently died within 30 days, died unexpectedly. One-fourth died from a pre-existing terminal illness. Patients dying unexpectedly were old, treated with polypharmacy, and often life-threateningly sick at arrival.

Associations between emergency call stroke triage and pre-hospital delay, primary hospital admission, and acute reperfusion treatment among early comers with acute ischemic stroke.

To investigate the association between the Emergency Medical Service dispatcher's initial stroke triage and prehospital stroke management, primary admission to hospitals offering revascularization treatment, prehospital time delay, and rate of acute revascularization. In an observational cohort study, patients with acute ischemic stroke (AIS) in Denmark (2017-2018) were included if the emergency call to the Emergency Medical Dispatch Center (EMDC) was made within three hours after symptom onset. Among 3546 included AIS patients, the EMS dispatcher identified 74.6% (95% confidence interval (CI) 73.1-76.0) correctly as stroke. EMS dispatcher stroke recognition was associated with a higher rate of primary admission to a hospital offering revascularization treatment (85.8 versus 74.5%); producing an adjusted risk difference (RD) of 11.1% (95% CI 7.8; 14.3) and a higher rate of revascularization treatment (49.6 versus 41.6%) with an adjusted RD of 8.4% (95% CI 4.6; 12.2). We adjusted for sex, age, previous stroke or transient ischemic attack, and stroke severity. EMDC stroke recognition was associated with shorter prehospital delay. For all AIS patients, the adjusted difference was - 33.2 min (95% CI - 44.4; - 22.0). Among patients receiving acute revascularization treatment (n = 1687), the adjusted difference was -12.6 min (95% CI - 18.9; - 6.3). Stroke recognition by the EMS dispatcher was associated with a higher probability of primary admission to a hospital offering acute stroke treatment, and subsequently with a higher rate of acute revascularization treatment, and with an overall reduction in prehospital delay.

Assessed and discharged - diagnosis, mortality and revisits in short-term emergency department contacts.

BACKGROUND: Emergency departments (EDs) experience an increasing number of patients. High patient flow are incentives for short duration of ED stay which may pose a challenge for patient diagnostics and care implying risk of ED revisits or increased mortality. Four hours are often used as a target time to decide whether to admit or discharge a patient. OBJECTIVE: To investigate and compare the diagnostic pattern, risk of revisits and short-term mortality for ED patients with a length of stay of less than 4 h (visits) with 4-24 h stay (short stay visits). METHODS: Population-based cohort study of patients contacting three EDs in the North Denmark Region during 2014-2016, excluding injured patients. Main diagnoses, number of revisits within 72 h of the initial contact and mortality were outcomes. Data on age, sex, mortality, time of admission and ICD-10 diagnostic chapter were obtained from the Danish Civil Registration System and the regional patient administrative system. Descriptive statistics were applied and Kaplan Meier mortality estimates with 95% CI were calculated. RESULTS: Seventy-nine thousand three hundred forty-one short-term ED contacts were included, visits constituted 60%. Non-specific diagnoses (i.e. symptoms and signs and other factors) were the most frequent diagnoses among both visits and short stay visits groups (67% vs 49%). Revisits were more frequent for visits compared to short stay visits (5.8% vs 4.2%). Circulatory diseases displayed the highest 0-48-h mortality within the visits and infections in the short stay visits (11.8% (95%CI: 10.4-13.5) and (3.5% (95%CI: 2.6-4.7)). 30-day mortality were 1.3% (95%CI: 1.2-1.5) for visits and 1.8% (95%CI: 1.7-2.0) for short stay visits. The 30-day mortality of the ED revisits with an initial visit was 1.0% (0.8-1.3), vs 0.7% (0.7-0.8) for no revisits, while 30-day mortality nearly doubled for ED revisits with an initial short stay visit (2.5% (1.9-3.2)). CONCLUSIONS: Most patients were within the visit group. Non-specific diagnoses constituted the majority of diagnoses given. Mortality was higher among patients with short stay visits but increased for both groups with ED revisits. This suggest that diagnostics are challenged by short time targets.

Pediatric Emergencies in Helicopter Emergency Medical Services: A National Population-Based Cohort Study From Denmark.

STUDY OBJECTIVE: To examine the diagnostic pattern, level of severity of illness or injuries, and mortality among children for whom a physician-staffed helicopter emergency medical service (HEMS) was dispatched. METHODS: Population-based cohort study including patients aged less than 16 years treated by the Danish national HEMS from October 1, 2014, to September 30, 2018. Diagnoses were retrieved from inhospital medical records, and the severity of illness or injuries was assessed by a severity score on scene, administration of advanced out-of-hospital care, need for intensive care in a hospital, and mortality. RESULTS: In total, 651 HEMS missions included pediatric patients aged less than 1 year (9.2%), 1 to 2 years (29.0%), 3 to 7 years (28.3%), and 8 to 15 years (33.5%). A third of the patients had critical emergencies (29.6%), and for 20.1% of the patients, 1 or more out-of-hospital interventions were performed: intubation, mechanical chest compressions, intraosseous vascular access, blood transfusion, chest tube insertion, and/or ultrasound examination. Among the 525 patients with hospital follow-up, the most frequent hospital diagnoses were injuries (32.2%), burns (11.2%), and respiratory diseases (7.8%). Within 24 hours of the mission, 18.1% of patients required intensive care. Twenty-nine patients (5.1%, 95% confidence interval [CI] 3.6 to 7.3) died either on or within 1 day of the mission, and the cumulative 30-day mortality was 35 of 565 (6.2%, 95% CI 4.5 to 8.5) (N=565 first-time missions). CONCLUSION: On Danish physician-staffed HEMS missions, 1 in 5 pediatric patients required advanced out-of-hospital care. Among hospitalized patients, nearly one-fifth of the patients required immediate intensive care and 6.2% died within 30 days of the mission.