Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication.
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African journal of emergency medicine
The official journal of the African Federation for Emergency Medicine, the Emergency Medicine Association of Tanzania, the Emergency Medicine Society of South Africa, the Egyptian Society of Emergency Medicine, the Libyan Emergency Medicine Association, the Ethiopian Society of Emergency Medicine Professionals, the Sudanese Emergency Medicine Society, the Society of Emergency Medicine Practitioners of Nigeria and the Rwanda Emergency Care Association
The burden of acute coronary syndrome, heart failure, and stroke among emergency department admissions in Tanzania: A retrospective observational study
Hertz JT, Sakita FM, Limkakeng AT, Mmbaga BT, Appiah LT, Bartlett JA, Galson SW
Introduction: The prevalence of cardiovascular disease in sub-Saharan Africa is substantial and growing. Much remains to be learnt about the relative burden of acute coronary syndrome (ACS), heart failure, and stroke on emergency departments and hospital admissions.
Methods: A retrospective chart review of admissions from September 2017 through March 2018 was conducted at the emergency department of a tertiary care centre in northern Tanzania. Stroke admission volume was compared with previously published data from the same hospital and adjusted for population growth.
Results: Of 2418 adult admissions, heart failure and stroke were the two most common admission diagnoses, accounting for 294 (12.2%) and 204 (8.4%) admissions, respectively. ACS was uncommon, accounting for 9 (0.3%) admissions. Of patients admitted for heart failure, uncontrolled hypertension was the most commonly identified aetiology of heart failure, cited in 124 (42.2%) cases. Ischaemic heart disease was cited as the aetiology in only 1 (0.3%) case. Adjusting for population growth, the annual volume of stroke admissions increased 70-fold in 43 years, from 2.9 admissions per 100 000 population in 1974 to 202.2 admissions per 100 000 in 2017.
Conclusions: The burden of heart failure and stroke on hospital admissions in Tanzania is substantial, and the volume of stroke admissions is rising precipitously. ACS is a rare diagnosis, and the distribution of cardiovascular disease phenotypes in Tanzania differs from what has been observed outside of Africa. Further research is needed to ascertain the reasons for these differences.
Annals of emergency medicine
Official Journal of the American College of Emergency Physicians
Baseline performance of real world clinical practice within a statewide emergency medicine quality network: The Michigan Emergency Department Improvement Collaborative (MEDIC)
Keith E. Kocher, Rajan Arora, Benjamin S. Bassin, Lee S. Benjamin, Michaelina Bolton, Blaine J. Dennis, Jason J. Ham, Seth S. Krupp, Kelly A. Levasseur, Michelle L. Macy, Brian J. O’Neil, James M. Pribble, Robert L. Sherwin, Nicole S. Sroufe, Bradley J. Uren, Michele M. Nypaver
Study objective: Large-scale quality and performance measurement across unaffiliated hospitals is an important strategy to drive practice change. The Michigan Emergency Department Improvement Collaborative (MEDIC), established in 2015, has baseline performance data to identify practice variation across 15 diverse emergency departments (EDs) on key emergency care quality indicators.
Methods: MEDIC is a unique physician-led partnership supported by a major third-party payer. Member sites contribute electronic health record data and trained abstractors add supplementary data for eligible cases. Quality measures include CT appropriateness for minor head injury, using the Canadian CT Head Rule for adults and Paediatric Emergency Care Applied Network rules for children; chest radiograph use for children with asthma, bronchiolitis, and croup; and diagnostic yield of CTs for suspected pulmonary embolism. Baseline performance was established with statistical process control charts.
Results: From June 1, 2016, to October 31, 2017, the MEDIC registry contained 1 124 227 ED visits, 23.2% for children (<18 years). Overall baseline performance included the following: 40.9% of adult patients with minor head injury (n=11 857) had appropriate CTs (site range 24.3% to 58.6%), 10.3% of paediatric minor head injury cases (n=11 183) exhibited CT overuse (range 5.8% to 16.8%), 38.1% of paediatric patients with a respiratory condition (n=18 190) received a chest radiograph (range 9.0% to 62.1%), and 8.7% of pulmonary embolism CT results (n=16 205) were positive (range 7.5% to 14.3%).
Conclusion: Performance varied greatly, with demonstrated opportunity for improvement. MEDIC provides a robust platform for emergency physician engagement across ED practice settings to improve care and is a model for other states.
Canadian journal of emergency medicine
CJEM is the official publication of the Canadian Association of Emergency Physicians (CAEP)
Outcome of pediatric emergency mental health visits: incidence and timing of suicide
Joshua Lee, BA; Tyler Black, MD; Garth Meckler, MD, MSHS; Quynh Doan, MDCM, PhD
Objectives: To determine the incidence, risk, and timing of mortality (unnatural and natural causes) among youth seen in a paediatric emergency department (ED) for mental health concerns, compared with matched non–mental health ED controls.
Methods: This was a retrospective cohort study conducted at a quaternary paediatric ED in British Columbia. All visits for a mental health related condition between July first, 2005, and June 30th, 2015, were matched on age, sex, triage acuity, socioeconomic status, and year of visit to a non–mental health control visit. Mortality outcomes were obtained from vital statistics data through December 31st, 2016 (cumulative follow-up 74 390 person-years).
Results: Among all cases in our study, including 6210 youth seen for mental health concerns and 6210 matched controls, a total of 13 died of suicide (7.5/100 000 person-years) and 33 died of suicide or indeterminate causes (44/100 000 person-years). All-cause mortality was significantly lower among mental health presentations (121.3/100 000 vs 214.5/100 000 person-years; HR, 0.54; 95% CI, 0.37 to 0.78). The median time from initial emergency visit to suicide was 5.2 years (IQR, 4.2 to 7.3). Among mental health related visits, risk of death by suicide or indeterminate cause was three-fold that of matched controls (HR, 3.05 95% CI, 1.37 to 6.77).
Conclusion: While youth seeking emergency mental healthcare are at increased risk of death by unnatural causes, their overall mortality risk is lower than non–mental health controls. The protracted duration from initial presentation to suicide highlights the need for long-term surveillance and preventative care for youth seen in the ED for all mental health concerns.
Official Journal of the Spanish Society of Emergency Medicine (SEMES)
Nontraumatic chest pain and suspicion of acute coronary syndrome: associated clinical and electrocardiographic findings on initial evaluation
Òscar Miró, Gemma Martínez-Nadal, Sonia Jiménez, Elisenda Gómez-Angelats, Josep R. Alonso, Albert Antolín, Emilio Salgado, Rafel Perelló, Danielle M. Gualandro, Ivo Strebel, Pedro López-Ayala, Xavier Rosselló, Ernest Bragulat, Miquel Sánchez, Christian Müller, Beatriz López-Barbeito.
Objectives: To analyse clinical data and electrocardiographic (ECG) findings obtained during the initial evaluation of patients with nontraumatic chest pain (NTCP). To explore associations between these findings and the initial and final diagnoses of acute coronary syndrome (ACS). To assess which variables initially over- or underestimate risk ACS.
Methods: Consecutive patients with NTCP attended in a chest pain unit during the 10 year period of 2008–2017 were included if the suspected and discharge diagnoses of interest (ACS or non-ACS) had been recorded. Thirtythree independent variables (demographic, 2; cardiovascular, 5; chest pain, 22; ECG, 4). We included all variables in models to calculate crude and adjusted ORs between each independent variable and the initial and final diagnoses. The adjusted ORs were compared with determine whether the initial and final diagnoses of ACS differed significantly in relation to the variables.
Results: A total of 34 552 patient visits were attended. The ORs for the 33 variables were significantly associated with initial and final NTCP classification as ACS or non-ACS, and in many cases the association was confirmed by the adjusted ORs. The adjusted ORs for 19 variables were significantly different in their relation to the initial and final diagnoses of ACS: 10 overpredicted the probability of the diagnosis and nine underpredicted it.
Conclusions: The variables traditionally used to warn of ACS in emergency patients with NTCP identify individuals likely to be initially and finally diagnosed with ACS. However, some of these variables overestimate or underestimate the risk of a final ACS diagnosis. Emergency medicine physicians should be aware of variables associated with underestimation of risk.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.