First EDition: News for and about the practice of emergency medicine

Many ED Patients Triaged as “Nonurgent” Require Care Similar to That Provided to Urgent Cases

BY JEFF BAUER

FROM JAMA INTERN MED

A large study that compared ED visits of patients triaged as “nonurgent” to those triaged as urgent found that a considerable percentage of nonurgent patients receive diagnostic services, undergo procedures, and/or are admitted, including to critical care units.

Researchers evaluated data from the National Hospital Ambulatory Medical Care Survey on 240 million ED visits from 2009 through 2011 by adults ages 18 to 64 years. Triage scores were determined by a nurse’s assessment of a patient on arrival and were based on a 5-level score, with 1 = immediate, 2 = emergent, 3 = urgent, 4 = semi-urgent, and 5 = nonurgent. For the purpose of this study, visits with a score of 5 were categorized as nonurgent and visits with any other score were considered urgent.

Of the 240 million visits, 92.5% were triaged as urgent and 7.5% were triaged as nonurgent. In almost half of nonurgent visits (47.6%), patients received diagnostic services such as blood tests, electrocardiograms (ECG), and imaging tests. These diagnostic services were provided in 74.8% of urgent visits. Procedures such as administration of intravenous (IV) fluids, splinting, or casting were performed in 32.4% of nonurgent visits and 49.4% of urgent visits.

The symptoms reported by patients during urgent versus nonurgent visits were similar. Six of the top 10 symptoms reported during nonurgent visits (back symptoms, abdominal pain, sore throat, headache, chest pain, and low back pain) were also among the top 10 symptoms reported during urgent visits.

Approximately 4.4% of nonurgent visits resulted in admission, and of these, 16.2% were admissions to a critical care unit. By comparison, 12.8% of urgent visits resulted in admission, and 10.5% of these were to a critical care unit.

The study’s authors pointed out that “the original intention of triage—to predict the amount of time a patient could safely wait to be seen in the ED—was never intended to completely rule out the possibility of severe illness in a patient considered nonurgent.”

1.    Hsia RY, Friedman AB, Niedzwiecki M. Urgent care needs among nonurgent visits  to the emergency department. JAMA Intern Med. 2016 Apr 18. doi: 10.1001/jamainternmed.2016.0878. [Epub ahead of print]

Rapid Diagnostic Test Used to Detect Ebola

BY LORI LAUBACH

FROM MMWR

A new rapid diagnostic test for Ebola (RDT-Ebola) that can provide results in 30 minutes or less has been used to diagnose patients in Forécariah, Guinea. The National Ebola Coordination Cell implemented the test to enhance efforts to detect new Ebola cases and to ensure that such cases are not clinically misdiagnosed as malaria.

Huang et al found that among 13 sentinel sites during October 1 through November 23, 2015, 1,544 (73%) of 2,115 consultations were for evaluation of febrile illness. Of those 1,544 consultations, 1,553 RDT-Malaria tests were reported to have been conducted and 1,000 RDT-Ebola tests were conducted. A total of 1,112 patients tested positive for malaria by RDT (the range of percentage of positive malaria tests among 13 sentinel sites was 52.3%-85.7%); none tested positive for Ebola by RDT-Ebola.

The ratio of RDT-Ebola to RDT-Malaria tests used was 0.64 overall and ranged from 0.27 to 1.00, according to the researchers.

Reported barriers to RDT-Ebola use—inadequate stock of RDT-Ebola kits, lack of understanding of the CDC RDT-Ebola testing protocol, and patient refusal of RDT-Ebola testing—may have contributed to the differences in the numbers of malaria and Ebola tests conducted, the researchers wrote.

“Ongoing data collection from the sentinel sites can help to monitor the success of RDT-Ebola implementation, inform supply chain management, and identify and address barriers to RDT-Ebola use. RDT-Ebola implementation at the sentinel sites can also aid in screening for undetected Ebola cases to prevent establishment of new transmission chains,” the researchers concluded.

1.    Huang JY, Louis FJ, Dixon MG, et al. Notes from the field: Baseline assessment of the use of Ebola rapid diagnostic tests - Forécariah, Guinea, October-November 2015. MMWR Morb Mortal Wkly Rep. 2016;65(12):328-329.

ED Bedside Flu Test Accurate Across Flu Seasons

BY MARY ANN MOON

FROM DIAG MICROBIOL INFECT DIS

A rapid bedside diagnostic test for influenza showed consistent sensitivity and specificity across four consecutive flu seasons in a single pediatric ED in France, according to a report in Diagnostic Microbiology and Infectious Disease.

During flu seasons, it is difficult to distinguish young children who have the flu from those who have serious bacterial infections because clinical symptoms alone cannot differentiate the two conditions, and fever may be the only symptom during the onset of a bacterial infection. Rapid influenza diagnostic tests purport to help ED clinicians estimate the probability of influenza at the bedside, which in turn can reduce the need for further diagnostic testing, length of ED stay, inappropriate use of antibiotics, and the costs of care, said Dr Estelle Avril and colleagues in the pediatric ED at University Hospital in Nantes, France.