Emergency Department Operations II: Patient Flow.

Emergency departments have always been busy, but persistent annual increases in volume and rates of admission have led to high levels of boarding patients, adding additional risk to the situation. This article reviews specific areas of risk as patients progress through their care in the emergency department and methods by which to mitigate this risk. Beginning with an overview of the current state, commonly used throughput metrics are reviewed before proceeding to a discussion of best practice strategies to decrease risk exposure at input, throughput, and output phases of the patient visit.

Recognition and Management of Perioperative Stroke in Hospitalized Patients.

We sought to characterize stroke management and outcomes in a postoperative population. By using the electronic medical records, we identified 39 patients suffering perioperative stroke after noncardiac and nonneurosurgical procedures for whom documentation of management and outcomes was available. Thirty-three strokes occurred during admission, whereas 6 occurred after discharge and were recognized upon return to the hospital. Perioperative stroke was associated with delayed recognition, infrequent intervention, and significant rates of morbidity and mortality, suggesting the need for improved screening and more rapid treatment. There may be disparities in care and outcomes between in-hospital and out-of hospital stroke patients, though further study is warranted.

Perioperative metoprolol and risk of stroke after noncardiac surgery.

BACKGROUND: Numerous risk factors have been identified for perioperative stroke, but there are conflicting data regarding the role of ß adrenergic receptor blockade in general and metoprolol in particular. METHODS: The authors retrospectively screened 57,218 consecutive patients for radiologic evidence of stroke within 30 days after noncardiac procedures at a tertiary care university hospital. Incidence of perioperative stroke within 30 days of surgery and associated risk factors were assessed. Patients taking either metoprolol or atenolol were matched based on a number of risk factors for stroke. Parsimonious logistic regression was used to generate a preoperative risk model for perioperative stroke in the unmatched cohort. RESULTS: The incidence of perioperative stroke was 55 of 57,218 (0.09%). Preoperative metoprolol was associated with an approximately 4.2-fold increase in perioperative stroke (P < 0.001; 95% CI, 2.2-8.1). Analysis of matched cohorts revealed a significantly higher incidence of stroke in patients taking preoperative metoprolol compared with atenolol (P = 0.016). However, preoperative metoprolol was not an independent predictor of stroke in the entire cohort, which included patients who were not taking ß blockers. The use of intraoperative metoprolol was associated with a 3.3-fold increase in perioperative stroke (P = 0.003; 95% CI, 1.4-7.8); no association was found for intraoperative esmolol or labetalol. CONCLUSIONS: Routine use of preoperative metoprolol, but not atenolol, is associated with stroke after noncardiac surgery, even after adjusting for comorbidities. Intraoperative metoprolol but not esmolol or labetalol, is associated with increased risk of perioperative stroke. Drugs other than metoprolol should be considered during the perioperative period if ß blockade is required.