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13th April 2022
A high proportion of cancer diagnoses occur through emergency care presentations and which are associated with a greater 12-month mortality compared to non-emergency care detected cancers. This was the main finding of a study by an international team of researchers.
There is some evidence to show that many patients with cancer are first diagnosed through an emergency presentation and which is associated with inferior clinical and patient-reported outcomes. Furthermore, one US study found that among patients with stage IV colon cancer, 34.6% presented as emergencies. The reasons for the high level of emergency care cancer diagnoses are complex and related to several different and interacting factors. For example, patients might experience no or only minimal symptoms prior to life-threatening complications requiring urgent medical or surgical attention. Secondly, patient-related factors e.g., knowledge, beliefs and attitudes, may also lead to ‘first presentation’ as an emergency diagnosis and thirdly, there could by any number of different and practical barriers that have prevented prior care.
For the present study, which formed part of the International Cancer Benchmarking Partnership, the researchers aimed to identify predictors and the consequences of cancer diagnoses made through an emergency presentation across 8 different cancer sites: stomach, colon, rectal, liver, pancreatic, lung and ovarian. For the purposes of the study, they defined an emergency presentation as one in which a cancer diagnosis was made within 30 days after an emergency hospital admission Countries for which data was collected included England, Norway, Denmark and several provinces such as Victoria (Australia) and Ontario (Canada).
Cancer diagnoses and emergency visits
A total of 857,068 patients with at least one of the 8 cancers mentioned above were included in the analysis. Across the different areas, the percentage of cancer diagnoses made through an emergency presentation ranged from 24% to 42.5%. The most commonly diagnosed cancer was pancreatic cancer, with an average of 46.1% but which ranged from 34.1% to 60.4%. The least commonly diagnosed cancer was rectal cancer, with an average of 12.1% and ranging from 9.1% to 19.8%.
Among factors associated with an emergency presentation cancer diagnosis were older age (85 years and older) and stomach and among stomach and colon cancer diagnoses, there was a J-shaped distribution by age, whereby patients aged 15 to 64, had the highest percentage of emergency presentation diagnoses.
The cancer stage adjusted odds ratios for 12-month mortality, compared with non-emergency presentations, were greater than 3.2 in all of the different areas studied, e.g. for Norway the odds ratio was 3.31 (95% CI 3.39 – 3.53).
Commenting on their findings, the authors suggested that the high level of emergency presentation diagnoses for pancreatic cancer probably reflected the low predictive value for symptoms such as abdominal or back pain. In contrast, rectal cancers were likely diagnosed less frequently due to the much clearer symptoms such as rectal bleeding.
The concluded that emergency presentations were frequent and associated with worse prognostic implications.
Mcphail S et al. Risk factors and prognostic implications of diagnosis of cancer within 30 days after an emergency hospital admission (emergency presentation): an International Cancer Benchmarking Partnership (ICBP) population-based study Lancet Oncol 2022
1st February 2022
Relevant vital sign cut off values used for the risk stratification and hence prognosis for patients attending an emergency department do not exist for some signs which has important implications for their use and interpretation. This was the conclusion of a large study by a team from the Emergency Department, Maxima Medical Centre, Veldhoven, The Netherlands.
An emergency department encounters a large number of sick patients who require quick evaluation to detect those who have serious medical problems and which might require hospital admission. This has led to the introduction of various triage tools such as the modified early warning score (MEWS) which serves as a rapid, simple triage method to identify medical patients in need of hospital admission and those at increased risk of in-hospital death. Other tools commonly used such as the quick sequential organ failure assessment (qSOFA) rely on the use of vital sign measurements and specify a cut-off for each vital sign to discriminate between a better or worse prognosis. However, the use of disease severity assessment tools may not be appropriate, particularly for elderly patients as revealed in one study of sepsis, which concluded that ‘prognostic and discriminative performance of the five most commonly used disease severity scores was poor and less useful for risk stratification of older ED sepsis patients.’
For the present study, the Dutch team looked to assess the association between vital signs and relevant clinical outcomes such as mortality and admission to an intensive care unit. In addition, they wanted to determine whether a single cut-off or threshold existed for each vital sign and the extent to which these were influenced by advancing age. They undertook an observational study at three EDs in the Netherlands and examined consecutive adult patients (18 years and older) where one or more of the following vital signs were measured: respiratory rate (RR), peripheral oxygen saturation (SpO2), systolic (SBP) and diastolic (DBP) blood pressure, mean arterial blood pressure (MAP), heart rate (HR) and temperature. Patients were stratified by age into three categories; 18 – 65, 66 – 80 and > 80 years and the primary outcome was whether there was a vital sign category that could be used as a cut-off to predict the outcome of in-hospital mortality or ICU admission.
A total of 101,416 patients with a mean age of 59.6 years (49.6% female) were included in their analysis. In many cases the vital sign values were outside of the usual range. For example, 23.4%, 79.1% and 14.2% of the total cohort had a RR, SBP and SP02 respectively, outside of the normal range. This proportion was also higher in older patients as seen for example with SBP for which 83.3% of patients aged > 80 had a reading outside of the normal range compared to 76.3% of those aged 18 to 65 years.
Among the cohort, a total of 2374 (2.3%) patients died. The adjusted odds ratios (aOR) for predicted mortality increased gradually with worsening values of SBP and SpO2 although there was no clear cut-off point for SBP, DBP, Sp02 and HR and mortality. In addition, for all vital signs, older adults had a larger increase in absolute mortality. For ICU admission, SBP had a relevant cut-off at 70mmHg and for MAP there was a threshold of < 60 mmHg.
In summarising their findings, the authors noted how in-hospital mortality increased gradually with decreasing SBP and SpO2 and there was no evidence of a specific cut-off for either vital sign. For DPB, MAP and HR, there was a quasi-U-shaped association with in-hospital mortality and while there was a single cut-off for MAP, RR and temperature, the authors argued that using a single cut-off value would ignore further increase of risk with more extreme values for these vital signs.
They concluded that the use of a single cut-off for each vital sign in acute care deserves scrutiny and that age-adjusted numerical scores would improve risk stratification since older patients have a larger increase in mortality with changing vital signs even after adjustment for confounds.
Candel BGJ et al. The association between vital signs and clinical outcomes in emergency department patients of different age categories Emerg Med J 2022
10th January 2022
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.
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.
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
8th November 2021
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.
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.
Simpson RM et al. Non-urgent emergency department attendances in children: a retrospective observational analysis. Emerg J Med 2021
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.
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.
Wiklund K et al. Amino acids predict prognosis in patients with acute dyspnea. BMC Emerg Med 2021
12th September 2021
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).
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.
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.