The AfJEM blog
Every quarter, the African Journal of Emergency Medicine, in partnership with several other regional emergency medicine journals, publishes abstracts from each respective journal. Abstracts are not necessarily linked to open access papers, but where green access is available it is linked to. Click 'Read More' to read further.
Patient-Identified Needs Related to Seeking a Diagnosis in the Emergency Department
From: Gerolamo AM, et al. Ann Emerg Med. 2018 Sep;72(3):282-288
Although diagnosis is a valuable tool for health care providers, and often the reason patients say they are seeking care, it may not serve the same needs for patients as for providers. The objective of this study is to explore what patients specifically want addressed when seeking a diagnosis at their emergency department (ED) visit. We propose that understanding these needs will facilitate a more patient-centered approach to acute care delivery.
This qualitative study uses semistructured telephone interviews with participants recently discharged from the ED of a large urban academic teaching hospital to explore their expectations of their ED visit and postdischarge experiences.
Thirty interviews were analyzed. Many participants reported wanting a diagnosis as a primary reason for seeking emergency care. When further asked to identify the functions of a diagnosis, they described wanting an explanation for their symptoms, treatment and guidance for symptoms, and clear communication about testing, treatment, and diagnosis. For many, a diagnosis was viewed as a necessary step toward achieving these goals.
Although diagnosis may not be a feasible outcome of every acute care visit, addressing the needs associated with seeking a diagnosis may be achievable. Reframing acute care encounters to focus on addressing specific patient needs, and not just identifying a diagnosis, may lead to more effective transitions home and improved patient outcomes.
Reproduced with permission
CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist
From: Stiell IG, et al. Canadian Journal of Emergency Medicine. 2018 May;20(3):334-42.
The attached CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist was created to assist emergency physicians in Canada and elsewhere manage patients who present to the emergency department (ED) with acute/recent-onset atrial fibrillation or flutter. The checklist focuses on symptomatic patients with acute atrial fibrillation (AAF) or flutter (AAFL), i.e. those with recent-onset episodes (either first detected, recurrent paroxysmal or recurrent persistent episodes) where the onset is generally less than 48 hours but may be as much as seven days. These are the most common acute arrhythmia cases requiring care in the ED.1;2 Canadian emergency physicians are known for publishing widely on this topic and for managing these patients quickly and efficiently in the ED.3-5
This project was funded by a research grant from the Canadian Arrhythmia Network and the resultant guidelines have been formally recommended by the Canadian Association of Emergency Physicians (CAEP). We chose to adapt, for use by emergency physicians, existing high-quality clinical practice guidelines (CPG) previously developed by the Canadian Cardiovascular Society (CCS).6-8 These CPGs were developed and revised using a rigorous process that is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system of evaluation.9;10 With the assistance of our PhD methodologist (IG), we used the recently developed Canadian CAN-IMPLEMENT© process adapted from the ADAPTE Collaboration.11-13 We created an Advisory Committee consisting of ten academic emergency physicians (one also expert in thrombosis medicine), four community emergency physicians, three cardiologists, one PhD methodologist, and two patients. Our focus was four key elements of ED care: assessment and risk stratification, rhythm and rate control, short-term and long-term stroke prevention, and disposition and follow-up. The Advisory Committee communicated by a two-day face-to-face meeting in March 2017, teleconferences, and email. The checklist was prepared and revised through a process of feedback and discussions on all issues by all panel members. These revisions went through ten iterations until consensus was achieved. We then circulated the draft checklist for comment to approximately 300 emergency medicine and cardiology colleagues; their email written feedback was further incorporated and the final version created and approved by the panel.
During the consensus and feedback processes, we addressed a number of issues and concerns, some of which required extensive discussion. We spent considerable time defining what is meant by “unstable” and highlighting the issue that many unstable patients are actually suffering from underlying medical problems rather than a primary arrhythmia. Where possible we chose to simplify the checklist, for example listing only procainamide for pharmacological cardioversion. Other drugs were considered including vernakalant, ibutilide, propafenone, flecainide, and amiodarone. We also tried to give specific drug dosage recommendations, recognizing that physicians are free to consult any number of excellent pharmaceutical references. The panel believes that, overall, a strategy of ED cardioversion and discharge home from the ED is preferable from both the patient and the healthcare system perspective, for most patients. One controversial recommendation is to consider rate control or transesophageal echocardiography (TEE)-guided CV if the duration of symptoms is 24-48 hours and the patient has two or more CHADS-65 criteria.This is based on some recent data from Finland.14;15 We emphasize the importance of evaluating long-term stroke risk by use of the CHADS-65 algorithm and encourage ED physicians to prescribe anticoagulants where indicated.
Our hope is that the CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist will standardize and improve care of AAF and AAFL in large and small EDs alike. We believe that these patients can be managed rapidly and safely, with early ED discharge and return to normal activities.
Reproduced with permission
Profile of older patients attended in the emergency department after falls: a FALL-ER registry study of the magnitude of the problem and opportunities for improving hospital emergency care
From: Miró Ò, et al. Emergencias. 2018;30(4):231-40.
To profile patients aged 65 years or older who are attended in a hospital emergency department after falls. To describe the falls, their severity, and factors relevant to recommended preventive measures.
The FALL-ER is a multipurpose, multicenter prospective registry of a systematically described cohort of patients aged 65 years or older attended in 5 hospital emergency departments on 52 days of the same year. We collected data on 68 independent variables. Patients were classified according to whether they had received recommendations related to preventing falls in any of the following categories: exercise, education on fall prevention, referral to a specialist or changes in medication.
A total of 1507 patients or carers were interviewed (93.6% of the 1610 patients in the registry). The cohort was of advanced age and had high rates of comorbidity, polypharmacy, and history of geriatric syndromes. The majority of falls occurred during the day and in the patients home. Half the falls were not witnessed. Forty-eight percent of the patients reported fear of falling, 22% had acute functional impairment, 16% were admitted, and 0.6% died in the hospital. Recommendations directed to preventing falls were received by 509 (33.8%) cases. Loss of hearing acuity, self-reported cognitive impairment, emergency first aid at the site of the fall, fear of falling again, acute functional impairment, and hospitalization were associated with a greater likelihood of receiving recommendations for preventing falls. Loss of visual acuity was associated with a lower likelihood of receiving recommendations.
Only a third of elderly patients attended in an emergency department after falls receive recommendations that target preventing further falls. Certain patient and fall characteristics are associated with a greater likelihood of receiving such recommendations.
Reproduced with permission
About the blog curator
Stevan Bruijns is the editor-in-chief for AfJEM. Providing access to resource appropriate research for those working in low and middle income settings is one of his passions. Others include keeping his four chickens out of the family veg patch.