Israel Medical Association Journal

Objectives: To determine the prevalence of abnormal coagulation studies in ED[1] patients evaluated for suspected ACS[2], and to investigate whether abnormal international normalized ratio/partial thromboplastin time testing resulted in changes in patient management and whether abnormal results could be predicted by history and physical examination.

Methods: In this retrospective observational study, hospital and ED records were obtained for all patients with a diagnosis of ACS seen in the ED during a 3 month period. ED records were reviewed to identify all patients in whom the cardiac laboratory panel was performed. Other data included demographics, diagnosis and disposition, historical risk factors for abnormalities of coagulation, ED and inpatient management, INR[3]/PTT[4], platelet count and cardiac enzymes. Descriptive statistical analyses were performed.

Results: Complete data were available for 223 of the 227 patients (98.7%). Of these, 175 (78.5%) patients were admitted. The mean age was 64.2 years. Thirteen patients (5.8%) were diagnosed with acute myocardial infarction. Of the 223 patients, 29 (13%) and 23 (10%) had INR and PTT results respectively beyond the reference range. Seventy percent of patients with abnormal coagulation test results had risk factors for coagulation disorders. The abnormal results of the remaining patients included only a mild elevation and therefore no change in management was initiated.

Conclusions: Abnormal coagulation test results in patients presenting with suspected ACS are rare, they can usually be predicted by history, and they rarely affect management. Routine coagulation studies are not indicated in these patients.

Background: The long-standing and ongoing controversy regarding administration of analgesia to patients with acute abdominal pain prior to final diagnosis has not yet been resolved, despite considerable research. Consequently, wide variations in clinical practice exist.

Objectives: To determine the motives, attitudes and practices of emergency physicians, internists and surgeons in Israeli emergency departments regarding the administration of analgesia before diagnosis in patients with acute abdominal pain.

Methods: Questionnaires were completed by 122 physicians in 21 EDs[1] throughout Israel and the replies were analyzed.

Results: Most EDs did not have a clear policy on analgesia for undifferentiated abdominal pain, according to 65% of the responders. More internists (75%) than surgeons (54%) (P = 0.02) and more emergency physicians (81%) than all other physicians (60%) (P = 0.05) held this opinion. Most respondents (64%) supported administration of analgesia pre-diagnostically. Support for analgesia was significantly stronger among internists (75%) compared to surgeons (52%) (P = 0.03). Despite this wide support, most respondents (68%) indicated that analgesia was rarely or never given pre‑diagnostically and, when it was, more surgeons (58%) than other physicians made that decision. Most internists (73%) and all surgeons reported that patients receive analgesia only after being examined by surgeons. Time allocated to the ED (part‑ or full‑time) significantly (P = 0.02) influenced decision-making, with 51% of part-time physicians vs. 25% of full-time opposing prompt administration of analgesia. Opinions on who should decide were divided according to medical specialty, with surgeons and internists almost opposed, as well as by physician age and percent of his/her time spent working in the ED. More surgeons than internists (P = 0.0005) reported that analgesia sometimes interfered with making a diagnosis. Most physicians (90%) stated that opiates impede diagnosis, to some extent. However, 58% of them supported the administration of opiates, more or less frequently. Intramuscular diclofenac was the most preferred analgesic, followed by intravenous morphine and pethidine; individual preferences extended beyond the list of actually administered drugs.

Conclusions: There is no consensus on the administration of analgesia for undiagnosed acute abdominal pain in EDs in Israel. Physicians’ attitudes are influenced by training, experience, and percent of personal time allocated to work in the ED.

The treatment of acute pain and anxiety in children undergoing therapeutic and diagnostic procedures in the emergency department has improved dramatically in recent years. The availability of non-invasive monitoring devices and the use of short-acting sedative and analgesic medications enable physicians to conduct safe and effective sedation and analgesia treatment. In today's practice of pediatric emergency medicine, sedation and analgesia has been considered as the standard of care for procedural pain. In most pediatric emergency departments throughout North America, "procedural sedation and analgesia" treatment is being performed by non-anesthesiologists (qualified emergency physicians and nurses). In 2003, the Israel Ministry of Health published formal guidelines for pediatric sedation by non-anesthesiologists; this important document recognizes for the first time the need for pediatric sedation and analgesia in the operating room. We describe the basic principles of procedural sedation and analgesia in children and urge physicians working in pediatric emergency rooms in Israel to expand their knowledge and be more involved in the treatment of pediatric procedural pain.

Background: Understanding discharge instructions is crucial to optimal healing but may be compromised in the hectic environment of the emergency department.

Objectives: To determine parents’ understanding of ED[1] discharge instructions and factors that may affect it.

Methods: A convenience sample of parents of children discharged home from the ED of an urban tertiary care pediatric facility (n=287) and a suburban level II general hospital (n=195) completed a 13-item questionnaire covering demographics, level of anxiety, and quality of physician’s explanation. Parents also described their child’s diagnosis and treatment instructions and indicated preferred auxiliary methods of delivery of information. Data were analyzed using the BMPD statistical package.

Results: Full understanding was found in 72% and 78% of the parents at the respective centers for the diagnosis, and in 82% and 87% for the treatment instructions (P  = NS between centers). There was no statistical correlation between level of understanding and parental age, gender, education, level of anxiety before or after the ED visit, or time of day. The most contributory factor to lack of understanding was staff use of medical terminology. Parents suggested further explanations by a special discharge nurse and written information as auxiliary methods.

Conclusions: Overall, parental understanding of ED discharge instructions is good. However, there remains a considerable number (about 20%) who fail to fully comprehend the diagnosis or treatment directives. This subset might benefit from the use of lay terminology by the staff, institution of a special discharge nurse, or use of diagnosis-specific information sheets.

Background: Patient feedback is increasingly being used to assess the quality of healthcare.

Objective: To identify modifiable independent determinants of patient dissatisfaction with hospital emergency care.

Methods: The study group comprised a random sample of 3,152 of the 65,966 adult Israeli citizens discharged during November 1999 from emergency departments in 17 of the 32 acute care hospitals in Israel. A total of 2,543 (81%) responded to a telephone survey tht used a structured questionnaire. The ndependent variables included: hospital characteristics, patient demographic variables, patient perception of care, self-rated health status, problem severity, and outcome of care. The dependent variable was dissatisfaction with overall ED[1] experience on a 1–5 Likert-type scale dichotomized into not satisfied (4 and 5) and satisfied (1,2 and 3).

Results: Eleven percent of the population reported being dissatisfied with their emergency room visit. Univariate analyses revealed that dissatisfaction was significantly related to ethnic group, patient education, hospital identity and geographic location, perceived comfort of ED facilities, registration expediency, waiting times, perceived competence and attitudes of caregivers, explanations provided, self-rated health status, and resolution of the problem that led to referral to the ED. Multivariate analyses using logistic regressions indicated that the four most powerful predictors of dissatisfaction were patient perception of doctor competence and attitudes, outcomes of care, ethnicity, and self-rated health status.

Conclusions: Attempts to reduce dissatisfaction with emergency care should focus on caregiver conduct and attitudes. It may also be useful to improve caregiver communication skills, specifically with ethnic minorities and with patients who rate their health status as poor.

Background: The emergency department is one of the hospital’s busiest facilities and is frequently described as a bottleneck. Management by constraint is a managerial methodology that helps to focus on the most critical issues by identifying such bottlenecks. Based on this theory, the benefit of adding medical staff may depend on whether or not physician availability is the bottleneck in the system.

Objective: To formulate a dynamic statistical model to forecast the need for allocating additional medical staff to improve the efficacy of work in the emergency department, taking into account patient volume.

Methods: The daily number of non-trauma admissions to the general ED[1] was assessed for the period 1 January 1992 to 1 December 1995 using the hospital computerized database. The marginal benefit to shortening patient length of stay in the ED by adding a physician during the evening shift was examined for different patient volumes. Data were analyzed with the SAS software package using a Gross Linear Model.

Results: The addition of a physician to the ED staff from noon to midnight significantly shortened patient LOS[2]: an average decrease of 6.61 minutes for 80–119 admissions (P<0.001). However, for less than 80 or more than 120 admissions, adding a physician did not have a significant effect on LOS in the ED.

Conclusions: The dynamic model formulated in this study shows that patient volume determines the effectiveness of investing manpower in the ED. Identifying bottleneck critical factors, as suggested by the theory of constraints, may be useful for planning and coordinating emergency services that operate under stressful and unpredictable conditions. Consideration of patient volume may also provide ED managers with a logical basis for staffing and resource allocation.

Background: Transfer to an emergency room and hospitalization of nursing home residents is a growing problem that is poorly defined and reported.

Objectives: To assess the clinical effectiveness of a pilot project involving hospitalization of nursing home residents directly to an acute-care geriatric department.

Methods: We retrospectively compared the hospitalization in an acute-care geriatric unit of 126 nursing home residents admitted directly to the unit and 80 residents admitted through the emergency room. The variables measured included length of stay, discharge disposition, mortality, cause of hospitalization, chronic medical condition, cognitive state, functional status at admission, and change of functional status during the hospital stay. Follow-up data were obtained from medical records during the 2 year study.

Results: No significant differences between the groups were found for length of stay, mortality, discharge disposition and most characteristics of the hospital stay. The only significant difference was in patients’ mean age, as emergency room patients were significantly older (86 vs. 82.9 years). The most common condition among nursing home patients admitted via the emergency room was febrile disease (36.9%) ,while functional decline was the most common in those coming directly from the nursing home (32.5%). The prevalence of functional dependence and dementia were similar in both groups. Functional status did not change throughout the hospital stay in most patients.

Conclusions: Treatment of selected nursing home residents admitted directly from the nursing home to an acute- care geriatric unit is feasible, medically effective, results in the safe discharge of almost all such patients and provides an alternative to transfer to an emergency room. This study suggests that quality gains and cost-effective measures may be achieved by such a project, although a randomized controlled trial is necessary to support this hypothesis.
 

Cancer is a multi-step disease involving a series of genetic alterations that result in the loss of control of cell proliferation and differentiation. Such genetic alterations could emerge from the activation of oncogenes and the loss or malfunctioning of tumor suppressor gene activity. Our understanding of cancer has greatly increased through the use of DNA tumor viruses and their transforming proteins as a biological tool to decipher a cascade of events that lead to deregulation of cell proliferation and subsequent tumor formation. For the past ten years our laboratory has focused on the molecular biology of the human neurotropic papovavirus, JCV. This virus causes progressive multifocal Ieukoencephalopathy, a fatal neuro­degenerative disease of the central nervous system in immunocompromised patients. JCV is a common human virus that infects more than 80% of humans but does not induce any obvious clinical symptoms. The increased incidence of acquired immune deficiency syndrome and the use of immunosuppressive chemotherapy have dramatically raised the incidence of PML. The coincidental occurrence of malignant astrocytes and oligodendrocytes in PML patients, coupled with the induction of glioblastoma in JCV-intected non­human primates, provides intriguing speculation on the association between JCV and CNS malignancies. In this report we discuss clinical data and laboratory observations pointing to the direct involvement of JCV in cancer.

Background: The outcome of cardiopulmonary arrest in children is poor, with many survivors suffering from severe neurological defects. There are few data on the survival rate following cardiopulmonary arrest in children who arrived at the emergency room without a palpable pulse.

Objective: To determine the survival rate and epidemiology of cardiopulmonary arrest in children who arrived without a palpable pulse at a pediatric ER in southern Israel.

Methods: We retrospectively reviewed the medical records of all patients with cardiopulmonary arrest who arrived at the ER of the Soroka University Medical Center during the period January 1995 to June 1997.

Results: The study group included 35 patients. Resuscitation efforts were attempted on 20, but the remaining 15 showed signs of death and were not resuscitated. None of the patients survived, although one patient survived the resuscitation but succumbed a few hours later. The statistics show that more cardiopulmonary arrests occurred among Bedouins than among Jews (32 vs. 3, P0.0001).

Conclusions: The probability of survival from cardiopulmonary arrest in children who arrive at the emergency room without palpable pulse is extremely low. Bedouin children have a much higher risk of suffering from out-of-hospital cardiopulmonary arrest than Jewish children.

Background: In Israel the pediatric emergency room functions as an urgent primary care clinic in addition to dealing with life-threatening situations. Due to health insurance stipulations, most patients come to the PER with a referral from the community clinic. The relationship between the referring physician’s expectations and the subsequent management of the referred patient in the PER is not well defined.

Objectives: To evaluate the relationship between the expectations of the primary care physician and the management of referred patients in the PER, assess the type of information provided by the referring physician, and examine the effect of additional information obtained from the referring physician on patient management in the PER.

Methods: We reviewed the records of patients presenting at the PER with referrals from primary care physicians as well as additional information obtained by telephone interviews with the referring physicians.     

Results: The expectations of the referring physicians were not fully documented in the referral form. The PER responded to the patient as if the PER was the initial contact. There was no significant difference in the response of PER physicians with or without additional information from the referring physicians.

Conclusions: The PER acts as an independent unit with no obligation to satisfy the expectations of the referring physicians. The relationship between the PER and the referring physicians needs to be clarified. Guidelines and structured PER referral forms should be implemented in all primary care clinics to improve patient management and communication between health providers. 

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PER= Pediatric Emergency Room