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Take a look at a selection of our recent media coverage:

Stroke risk after TIA higher in ED patients without follow-up compared with rapid-access TIA clinics

10th January 2022

The stroke risk after a TIA has been found to be higher among patients treated at an ED compared to those seen at a dedicated TIA clinic

The subsequent stroke risk among those who experience a transient ischaemic attack (TIA) is higher in patients seen at an emergency department compared to those seen at a rapid-access TIA clinic according to a meta-analysis by a team from the Neurology Department, Neuroscience Institute, Geisinger Health System, Pennsylvania, US.

After a TIA, the ischaemic stroke risk can range from 2.4% within 2 days to 4.7% within 90 days although the authors of this study hint that this risk may have reduced in the last two decades. Although patients with a suspected stroke might normally visit a hospital, the availability of 24-hour TIA clinics with immediate initiation of preventive treatment, have the potential to greatly reduce length of hospital stay.

Despite the presence of TIA clinics there is currently little is known about the outcomes for those experiencing a TIA who have been treated in different care settings. For the present study, the US team performed a meta-analysis to estimate and compare the risk of a subsequent ischaemic stroke in those with a TIA or minor ischaemic stroke (mIS) who received their care at either a rapid access TIA clinic, an inpatient unit, emergency departments (EDs) or other settings. The researchers focused on the subsequent stroke risk after 4 defined time periods; 2, 7, 30 and 90 days. Their literature search covered medline, Embase, CINAHL and clinical trial databases for studies that provided information on the occurrence of an ischaemic stroke after a TIA or mIS and included both retrospective and prospective studies. The primary outcome of the study was the proportion of early ischaemic strokes after the index TIA or mIS among patients receiving care in the four different settings and they focused their comparison on a TIA clinic vs inpatient facilities.

Findings

A total of 71 studies were included in the final analysis with 226,683 patients, 5636 from a TIA clinic, 130,136 inpatients, 3605 emergency department patient and 87,303 from a unspecified centre. The mean age of patients ranged from 65.7 to 78.3 years and proportion of male patients from 38.4% to 52.4%.

The stroke risk after a TIA or mIS at a TIA clinic was 0.3% within 2 days, 1% within 7 days, 1.3% after 30 days and 2.1% after 90 days. The highest risk was for patients treated at unspecified settings and which ranged from 2.2 % within 2 days to 6% within 90 days. When comparing the stroke risk between a TIA clinic or inpatient facility, there was no significant difference in any of the 4 time intervals. However, the risks were significantly higher among those receiving emergency department care compared to a TIA clinic within 2, 7 and 90 days.

The authors concluded that the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than among those hospitalised adding that patients treated in an emergency department without further follow-up had a higher risk of subsequent stroke.

Citation

Shahjouei S et al. Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis JAMA Netw Open 2022

Non-urgent attendances represent a substantial number of children’s emergency care visits

8th November 2021

Non-urgent attendances for younger children account for a fifth of all emergency care visits and which could be managed in other care setting.

A substantial number of emergency care (EC) visits for young children represent non-urgent attendance (NUA). This is the conclusion of a retrospective analysis of hospital database by a team from the School of Health and Related Research, The University of Sheffield, Sheffield, UK.

Data for the UK show that in 2018-19, there were 24.8 million attendances at accident and emergency (A&E) departments, which represents a 4% increase on the previous year and a 21% increase since 2009-10. While much attention has focused on adult attendance at A&E, visits by children and young people has been less well studied despite the fact that children make more frequent visits to A&E. For example, in 2015/16 there were 425 A&E attendances for every 1000 children and young people an 345 A&E attendances for every 1000 adults aged 25 and over.

Research suggests that non-urgent attendance to EC can vary between 20 and 40% and there is evidence that younger age is one of several associated factors, though specific data on characterising NUA in children is limited. For the present study, the Sheffield team sought to define the proportion of NUA by children which were amenable to treatment or management elsewhere, how these non-urgent attendances varied by patient age as well as the impact on waiting times in the EC department. Patient characteristics such as as age, gender, date of attendance, disposal, type of treatment etc were extracted from a hospital database containing information for more than a tenth of England’s population over a 3-year period. The team defined a non-urgent attendance as one in which there was no treatment/investigations or referrals that required the facilities of an EC department.

Findings

A total of 1,068,598 EC attendances from children aged 0 – 15 years were identified and included in the analysis. Overall, the proportion of visits deemed NUA was 21.4% (208,788). Compared to visits for children less than 1 years of age, the odds ratio for a NUA was much more likely in children aged 1 – 4 years (odds ratio, OR = 0.82, 95% CI 0.80 – 0.83). However, NUA decreased with increasing age, for example, among children aged 10 – 14 years, the proportion of NUA was 14.6% (OR = 0.40) compared with 20.5% (OR = 0.61) for those aged 5 – 9 years. The odds of a patient presenting with a NUA was also significantly higher (OR = 1.19, 95% CI 1.18 – 1.20) for those attending out of hours compared to in hours (i.e., 8 am to 6 pm, Monday to Friday).

The researchers also found that for a NUA, the mean waiting, treatment and department times were all lower compared with urgent cases. Extrapolating their findings, the authors estimated up to 1 million non-urgent attendance visits across England in 2018-19 for ages 14 years and under.

They concluded that targeting groups such as those age under 5 years, particularly in providing accessible, timely care outside of usual community care opening hours would be of benefit.

Citation

Simpson RM et al. Non-urgent emergency department attendances in children: a retrospective observational analysis. Emerg J Med 2021

Three amino acids predict 90-day mortality in patients admitted to ED with dyspnoea

Three amino acids, glycine, phenylalanine and valine were associated with the risk of 90-day mortality in ED patients admitted with dyspnoea.

Levels of three amino acids, glycine, phenylalanine and valine measured upon admission to an ED in patients admitted with dyspnoea are strongly predictive of 90-day mortality. This was the conclusion of a study by a team from the Department of Clinical Sciences, Lund University, Malmo, Sweden. Dyspnoea is a common presentation in an ED with one study of over 3,000 patients, finding that 5.2% of ED presentations, 11.4% of ward admissions and 19.9% of intensive care unit admissions were due to dyspnoea. There are a number of underlying conditions which can cause dyspnoea which presents as either an impaired ventilation or increased ventilatory demand, or some cases, both. Irrespective of the underlying cause, in patients with dyspnoea there is the release of stress hormones and metabolic changes, one of which is the induction of a catabolic state and insulin resistance.

Interestingly, some previous work has shown that the elevation of a combination of three amino acids could be used to successfully predict future diabetes. Based on these observations, the Lund University team hypothesised that the insulin resistance induced by stress in those with acute dyspnoea, would also alter levels of certain amino acids and that these alterations might be of valve in the assessment of dyspnoea severity and possibly even predictive of dyspnoea mortality.

In an effort to examine their hypothesis, the researchers retrospectively analysed patient data for those admitted to an ED with acute dyspnoea between 2013 and 2015. Plasma levels of nine amino acids were measured and Cox proportional hazard models used to explore the relationship between the level of these amino acids and the risk of 90-day mortality, which served as the primary endpoint for the study.

Findings

Data were analysed for a total of 663 patients with a mean age of 71.5 years (53.4% female), of whom 61% were admitted to a ward and 20.1% required intensive care treatment. Overall, 12% of patients died during the 90-day follow-up period. Only three amino acids of the original nine measured, demonstrated a significant association with 90-day mortality. These were glycine (hazard ratio, HR = 1.32, 95% CI 1.08 – 1.62, p < 0.001), phenylalanine (HR = 1.53) and valine (HR = 0.61).

Next, the researchers created an amino acid mortality risk score (AMRS) which was divided into quartiles and they found that in quartile 1, the 90-day mortality was 2.4% whereas it increased massively to 26.5% in quartile 4.

Commenting on these findings, the authors suggested that changes in the levels of these three amino acids, measured during presentation at the ED, were able to strongly predict 90-mortality in patients with acute dyspnoea, irrespective of the underlying cause. They concluded that a score using just these three amino acids could be used as a guide in risk assessment and to support decision-making to establish an appropriate level of care for patients presenting to an ED with acute dyspnoea.

Citation

Wiklund K et al. Amino acids predict prognosis in patients with acute dyspnea. BMC Emerg Med 2021

Large variation in laboratory tests for chest pain in emergency departments

12th September 2021

Laboratory tests requested by emergency care clinicians are often outside of guidelines and driven by both local and systemic factors.

Within an emergency care setting, the use of diagnostic tests helps with the detection or exclusion of a disease. Although diagnostic tests only account for a small proportion of a hospital’s budget, between 60 and 70% of all clinical decision-making is estimated to be based on the results of a diagnostic test. Despite this, in a review of studies, it was found that 45% of laboratory tests in healthcare are under-utilised compared to 21% which are over-utilised. In an effort to ensure both consistent and rational use of diagnostic and laboratory tests, the Sensible Test ordering Practice initiative was developed in Australia. However, in an analysis of tests ordered following the introduction of the initiative, it was found that just over a third (34.4%) of laboratory tests requested were unnecessary, i.e., generally not indicated. In trying to gain a better understanding of why such tests were being ordered, a team from the Australian Institute of Health Innovation, Sydney, Australia, undertook a qualitative study with clinicians. The team conducted semi-structured interviews and based on the themes identified developed targeted questions to be used with focus groups and focused on patients who presented with undifferentiated chest pain at an emergency department (ED).

Findings
While clinical staff were fully aware of the need to rationalise requests for laboratory tests, the adherence to sensible test ordering was affected by several local and systemic factors. For example, clinicians would order tests that were beyond the patient’s ED encounter often because of requests from other departmental specialists, e.g., can you also order this or that test. Furthermore, laboratory tests would be ordered in anticipation of the those required by the team admitting a patient, even though such tests were somewhat irrelevant within the ED setting. In other words, clinicians ordered tests beyond their remit to facilitate the entire patient’s hospital journey.

Another factor identified was the existence of conflicting guidelines. Although advice on the required tests were contained with the decision-support, electronic medical record (eMR), clinicians noted for example, that the clinical pathway on the eMR required additional tests to those in the order set for ischaemic chest pain, leading to an inconsistency. Moreover, with limited in-house speciality and diagnostic services in some hospitals, clinicians pre-emptively ordered tests for which they knew there would be a longer turnaround time after hours. Additional and unnecessary tests were also requested when patients were transferred to another centre, simply because clinicians were aware of the need for these tests to ensure acceptance at the receiving centre. Finally, while greater use of technology enabled laboratory testing requests much easier, the existence of multiple order screening within the eMR made it difficult to establish a common ordering process.

Summarising their findings, the authors noted that the variability in ordering of laboratory tests was influenced by requirements for admission, conflicting guidelines, availability of in-house resources and the features of of the eMR system. Given that the ED is perceived as the ‘front door’ it was not uncommon to see the ordering of laboratory tests which were beyond the scope of the ED but pertinent for other or later aspects of patient care. The authors concluded that beyond standardisation of laboratory and clinical decision-support systems, attempts to address the variation in laboratory tests need to address both local and systemic factors.

Citation
Li J et al. Why is there variation in test ordering practices for patients presenting to the emergency department with undifferentiated chest pain? A qualitative study. Emerg Med J 2021.