Seven-year evolution of discharge diagnoses of emergency department users

Frequency and predictors of unspecific medical diagnoses in the emergency department: a prospective observational study

Background

Misdiagnosis is a major public health problem, causing increased morbidity and mortality. In the busy setting of an emergency department (ED) patients are diagnosed under difficult circumstances. As a consequence, the ED diagnosis at hospital admittance may often be a descriptive diagnosis, such as “decreased general condition”. Our objective was to determine in how far patients with such an unspecific ED diagnosis differ from patients with a specific ED diagnosis and whether they experience a worse outcome.

Methods

We conducted a prospective observational study in Bern university hospital in Switzerland for all adult non-trauma patients admitted to any internal medicine ward from August 15th 2015 to December 7th 2015. Unspecific ED diagnoses were defined through the clinical classification software for ICD-10 by two outcome assessors. As outcome parameters, we assessed in-hospital mortality and length of hospital stay.

Results

Six hundred eighty six consecutive patients were included. Unspecific diagnoses were identified in 100 (14.6%) of all consultations.

Patients receiving an unspecific diagnosis at ED discharge were significantly more often women (56.0% vs. 43.9%, p = 0.024), presented more often with a non-specific complaint (34% vs. 21%, p = 0.004), were less often demonstrating an abnormal heart rate (5.0% vs. 12.5%, p = 0.03), and less often on antibiotics (32.0% vs. 49.0%, p = 0.002). Apart from these, no studied drug intake, laboratory or clinical data including change in diagnosis was associated significantly with an unspecific diagnosis. Unspecific diagnoses were neither associated with in-hospital mortality in multivariable analysis (OR = 1.74, 95% CI: 0.60–5.04; p = 0.305) adjusted for relevant confounders nor with length of hospital stay (GMR = 0.87, 95% CI: 0.23–3.32; p = 0.840).

Conclusions

Women and patients with non-specific presenting complaints and no abnormal heart rate are at risk of receiving unspecific ED diagnoses that do not allow for targeted treatment, discharge and prognosis. This study did not find an effect of such diagnoses on length of hospital stay nor in-hospital mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00665-x.

Patient experience of severe acute dyspnoea and relief during treatment in ambulances: a prospective observational study

Background

Acute dyspnoea is common among ambulance patients, but little is known of the patients’ experience of symptom. We aimed to investigate ambulance patients initial perceived intensity of acute dyspnoea, and whether they experienced relief during prehospital treatment. Furthermore, to investigate the validity and feasibility of using a subjective dyspnoea score in the ambulance, and its association with objectively measured vital signs.

Methods

We performed a prospective observational study in the North Denmark Region from 1. July 2017 to 30. March 2019. We studied patients over the age of 18 to whom an ambulance was dispatched. Patients with acute dyspnoea assessed either at the emergency call or by ambulance professionals on scene were included. Patients were asked to assess dyspnoea on a 0 to 10 verbal numeric rating scale at the primary contact with the ambulance personnel and immediately before release at the scene or arrival at the hospital. Patients received usual prehospital medical treatment. We used visual inspection and Wilcoxon matched-pairs signed-ranks test, to assess dyspnoea scores and change hereof. Scatterplots and linear regression analyses were used to assess associations between the dyspnoea score and vital signs.

Results

We included 3199 patients with at least one dyspnoea score. Of these, 2219 (69%) had two registered dyspnoea scores. The initial median dyspnoea score for all patients was median 8 (interquartile range 6–10). In 1676 (76%) of patients with two scores, the first score decreased from 8 (6–9) to 4 (2–5) during prehospital treatment. The score was unchanged for 370 (17%) and increased for 51 (2%) patients. Higher respiratory rate, blood pressure, and heart rate was seen with higher dyspnoea scores whereas blood oxygen saturation lowered.

Conclusions

We found that acute dyspnoea scored by ambulance patients, was high on a verbal numerical rating scale but decreased before arrival at hospital, suggesting relief of symptoms. The acute dyspnoea score was statistically associated with vital signs, but of limited clinical relevance; this stresses the importance of patients’ experience of symptoms. To this end, the dyspnoea scale appears feasible in the prehospital setting.

Diagnosis and mortality of emergency department patients in the North Denmark region

Background

Emergency departments handle a large proportion of acute patients. In 2007, it was recommended centralizing the Danish healthcare system and establishing emergency departments as the main common entrance for emergency patients. Since this reorganization, few studies describing the emergency patient population in this new setting have been carried out and none describing diagnoses and mortality. Hence, we aimed to investigate diagnoses and 1- and 30-day mortality of patients in the emergency departments in the North Denmark Region during 2014–2016.

Methods

Population-based historic cohort study in the North Denmark Region (580,000 inhabitants) of patients with contact to emergency departments during 2014–2016. The study included patients who were referred by general practitioners (daytime and out-of-hours), by emergency medical services or who were self-referred.

Primary diagnoses (ICD-10) were retrieved from the regional Patient Administrative System. For non-specific diagnoses (ICD-10 chapter ‘Symptoms and signs’ and ‘Other factors’), we searched the same hospital stay for a specific diagnosis and used this, if one was given. We performed descriptive analysis reporting distribution and frequency of diagnoses. Moreover, 1- and 30-day mortality rate estimates were performed using the Kaplan-Meier estimator.

Results

We included 290,590 patient contacts corresponding to 166 ED visits per 1000 inhabitants per year. The three most frequent ICD-10 chapters used were ‘Injuries and poisoning’ (38.3% n = 111,274), ‘Symptoms and signs’ (16.1% n = 46,852) and ‘Other factors’ (14.52% n = 42,195). Mortality at day 30 (95% confidence intervals) for these chapters were 0.86% (0.81–0.92), 3.95% (3.78–4.13) and 2.84% (2.69–3.00), respectively.

The highest 30-day mortality were within chapters ‘Neoplasms’ (14.22% (12.07–16.72)), ‘Endocrine diseases’ (8.95% (8.21–9.75)) and ‘Respiratory diseases’ (8.44% (8.02–8.88)).

Conclusions

Patients in contact with the emergency department receive a wide range of diagnoses within all chapters of ICD-10, and one third of the diagnoses given are non-specific. Within the non-specific chapters, we found a 30-day mortality, surpassing several of the more organ specific ICD-10 chapters.

Trial registration

Observational study - no trial registration was performed.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3361-x) contains supplementary material, which is available to authorized users.

Readmission and mortality in patients discharged with a diagnosis of medical observation and evaluation (Z03*-codes) from an acute admission unit in Denmark: a prospective cohort study

Background

We assessed the 30-day risk of readmission and mortality among patients receiving an International Classification of Diseases 10th edition diagnosis of medical observation and evaluation (Z03*) following admission to an acute medical admission unit (AMAU), stratified on any further specification of diagnosis during hospital stay.

Methods

We used Central Denmark’s (Midt)-Electronic Patient Journal to identify patients with a Z03*-diagnosis among patients admitted to the AMAU, Aarhus University Hospital Nørrebrogade from April 2012 to March 2013, and noted any specification of diagnosis. Patients were followed from hospital discharge until death, emigration, or completion of 30 days follow-up.

Results

Of 409 patients with an initial Z03* diagnosis at the AMAU, 55% (n = 226) received a more specific discharge diagnosis after transferral to other departments. Among patients discharged to home with a Z03*-diagnosis, 30% were readmitted within 30 days, while the corresponding figure was 23% for patients receiving a specific diagnosis (p = 0.06). In contrast, corresponding figures for 30-day mortality were 3% for Z03*-diagnosed patients and 10% for those who obtained a specific diagnosis (p = 0.003).

Conclusions

Patients diagnosed with Z03* at hospital discharge have a substantially lower 30-day mortality, but a higher readmission-rate, compared to patients who obtain a specific diagnosis during the entire hospital stay.

All-cause mortality and suicide within 8 days after emergency department discharge

AIM

The aim of the study was to evaluate the association of death within 8-30 days after discharge home from the emergency department with a non-causative diagnosis in a prospective cohort study.

METHODS

The 227,097 visits to the emergency department were filed by personal identification number and included information on gender, age, admission, discharge, and diagnosis. The visits were classified by main diagnosis at discharge into those with non-causative diagnosis and those with other diagnoses. Mortality per 100,000 within 8, 15 and 30 days and the corresponding hazard ratio (HR) and 95% confidence intervals (CI) were calculated for all causes of death and for selected causes of death in a time-dependent analysis.

RESULTS

The HRs of all causes of death for patients with a non-causative diagnosis were 0.64 (95% CI 0.41-1.01) within 8 days, 0.70 (95% CI 0.50-0.99) within 15 days, and 0.82 (95% CI 0.65-1.04) within 30 days as compared to those with a causative diagnosis. The HRs within 30 days among those with a non-causative diagnosis at discharge were 1.48 (95% CI 1.03-2.13) for malignant neoplasm, 3.72 (95% CI 1.44-9.60) for suicide, and 0.50 (95% CI 0.32-0.79) for diseases of the circulatory system.

CONCLUSION

Death within 8 days after discharge home from the ED is a rare event. Death of patients that occur shortly after discharge who had received a non-causative diagnosis as the main diagnosis may indicate a misjudgement of the patients' condition at that time.

Non-causative discharge diagnosis from the emergency department and risk of suicide

Approximately 20% of Emergency Department (ED) users discharged home receive a non-causative discharge diagnosis in the category of "Symptoms, signs, abnormal findings, and ill-defined causes," according to the International Classification of Diseases. The objective of this study was to evaluate the association of these non-causative discharge diagnoses with mortality in general and with violent death and suicide in particular. This is a prospective study; the primary source of data was computer records from the ED at Landspitali University Hospital, Hringbraut, Reykjavik, Iceland over the period 1995-2001. The main discharge diagnoses were recorded according to the International Classification of Diseases. Individuals with a non-causative discharge diagnosis were followed-up for cause-specific mortality through national registries by record linkage and were compared to national mortality rates and the rates of those with causative physical diagnoses. The standardized mortality ratios, hazard ratios, and 95% confidence intervals (CI) were calculated. The data on individuals with a non-causative discharge diagnosis from the ED revealed that the standardized mortality ratio for all causes was 1.57 (95% CI 1.39-1.77) among men and 1.83 (95% CI 1.61-2.08) among women. The hazard ratio for violent death was 1.64 (95% CI 1.07-2.52) and for suicide 2.08 (95% CI 1.02-4.24), adjusted for age and gender, among individuals with a non-causative discharge diagnosis compared to those having causative physical discharge diagnoses. Through analysis of the discharge diagnoses "Symptoms, signs, abnormal findings and ill-defined causes," this study has identified an association between the group of patients discharged from the ED with a non-causative diagnosis who are at high risk of suicide and who may, through further studies, become subjects for suicide prevention strategies.

Death within 8 days after discharge to home from the emergency department

BACKGROUND

Deaths within 8 days after discharge have, in previous studies, been evaluated retrospectively based on review of hospital records and the cause of death. The aim of the study was to evaluate the association of death within 8 days after discharge to home from the emergency department with a non-causative diagnosis in a prospective cohort study.

METHODS

The records from the emergency department were filed by personal identification number and included information on gender, age, admission, discharge and diagnosis. The cause of death was obtained from a nation-wide registry by record linkage. Mortality per 100,000 within 8 days and the hazard ratio and 95% confidence intervals (CIs) were calculated for all causes of death in a time-dependent analysis.

RESULTS

A non-causative diagnosis had been given to 11% of those who died within 8 days after discharge home. The mortality per 100,000 within 8 days was 208.5, within 15 days 347.4 and within 30 days 648.6. In the analysis of deaths within 8 days, the hazard ratio was higher for men than women and increasing age was significantly associated with high mortality. The hazard ratio for non-causative diagnosis was 0.44 (95% CI 0.20-0.96) as compared to causative diagnosis, adjusted for gender and age.

CONCLUSION

The mortality rate within 8 days of discharge found in the present study is considerably higher than findings in previous studies. Death shortly after discharge of patients with non-causative diagnosis may indicate a misjudgement of the patients' condition at the time of discharge.