Quality in emergency departments: a study on 3,285,440 admissions

INTRODUCTION

A multi-centre study has been conducted, during 2005, by means of a questionnaire posted on the Italian Society of Emergency Medicine (SIMEU) web page. Our intention was to carry out an organisational and functional analysis of Italian Emergency Departments (ED) in order to pick out some macro-indicators of the activities performed. Participation was good, in that 69 ED (3,285,440 admissions to emergency services) responded to the questionnaire.

METHODS

The study was based on 18 questions: 3 regarding the personnel of the ED, 2 regarding organisational and functional aspects, 5 on the activity of the ED, 7 on triage and 1 on the assessment of the quality perceived by the users of the ED.

RESULTS AND CONCLUSION

The replies revealed that 91.30% of the ED were equipped with data-processing software, which, in 96.83% of cases, tracked the entire itinerary of the patient. About 48,000 patients/year used the ED: 76.72% were discharged and 18.31% were hospitalised. Observation Units were active in 81.16% of the ED examined. Triage programmes were in place in 92.75% of ED: in 75.81% of these, triage was performed throughout the entire itinerary of the patient; in 16.13% it was performed only symptom-based, and in 8.06% only on-call. Of the patients arriving at the ED, 24.19% were assigned a non-urgent triage code, 60.01% a urgent code, 14.30% a emergent code and 1.49% a life-threatening code. Waiting times were: 52.39 min for non-urgent patients, 40.26 min for urgent, 12.08 for emergent, and 1.19 for life-threatening patients.

Comprehensive drug screening in decision making of patients attending the emergency department for suspected drug overdose

OBJECTIVES

This study aimed to evaluate the usefulness of a comprehensive drug screening method as a first line diagnostic tool on clinical decision making in patients attending an emergency department for suspected drug overdose in terms of agreement between physicians on patients' disposal.

METHODS

Five emergency physicians retrospectively evaluated the records of 142 adult patients, admitted to the emergency department of a community hospital for suspected drug overdose. They were asked for an expert opinion on patients' disposal at the end of the observation period, based on paired records, with/without the results of a comprehensive drug screening.

RESULTS

In the absence of the drug screening, a very poor agreement (kappa statistics) was observed between physicians. When the drug screening was available, the interobserver agreement for decision on patients' disposal increased to the fair to good range (global agreement: from 0.238 (0.019) to 0.461 (0.020) (mean(SE)); p<0.001). The agreement also increased when admission to an intensive care unit, to a general ward, and discharge from hospital were separately analysed. The availability of drug screening would have saved 21.7% of hospital admissions and 53.3% of high dependency and/or intensive care unit admissions.

CONCLUSION

Comprehensive drug screening adds to decision making for patients attending an emergency department for suspected drug overdose, improving agreement among physicians on patients' disposal and potentially saving hospital resources.

Galactose elimination capacity and liver volume in aging man

The galactose elimination capacity, a measure of the functional liver cell mass, and liver volume were measured in 50 normal subjects of five different age groups (less than 50, 51 to 60, 61 to 70, 71 to 80 and greater than 81 years). The volume of the liver was evaluated by ultrasonography. All subjects had normal routine liver function tests and no history of liver disease. Galactose elimination progressively decreased from 3.05 +/- 0.58 (S.D.) mmoles per min in younger subjects to 1.83 +/- 0.24 mmoles per min in subjects over 81 (p less than 0.00003), without any change in the apparent volume of distribution of the sugar. Similarly, the estimated volume of the liver decreased from 110 +/- 14 units to 75 +/- 13 units with increasing age (p less than 0.0002). Both galactose elimination capacity and the estimated liver volume inversely correlated with age (r = -0.728 and r = -0.579, respectively) whereas a positive correlation was observed between galactose elimination and the estimated liver volume (r = 0.520). Part correlation analysis confirmed that age, when entered in a multiple regression already containing body weight and estimated liver volume as independent variables, had a significant effect on liver function, whereas no significant independent effect of liver volume was present. Both age and body weight had a significant independent effect on the estimated liver volume. The maximum functional capacity of the liver, measured by galactose elimination, is reduced in the elderly. Although several factors may play a role, our data suggest that aging is associated with a slight decline in the intrinsic metabolic activity of the hepatic parenchyma.

Insulin resistance in aged man: relationship between impaired glucose tolerance and decreased insulin activity on branched-chain amino acids

The effects of glucose-induced hyperinsulinemia on plasma amino acid levels were measured in 50 subjects divided into five age groups. Following an oral glucose load the plasma levels of most amino acids decreased, the decline being more pronounced for the three branched-chain amino acids (valine, isoleucine, and leucine). A progressive insulin resistance was proved on the basis of an age-related impaired glucose tolerance and a normal or increased insulin response. The plasma disappearance of branched-chain amino acids significantly correlated with age (r = -.514). The effects of the prevailing plasma insulin on branched-chain amino acids, measured by the ratio of amino acid changes per total insulin response, progressively declined in older subjects (P = .0005), and strictly correlated with age (r = .652). Insulin resistance in the elderly similarly affects glucose and branched-chain amino acid metabolism, with possible relevant effects on whole-body protein turnover.

Plasma amino acid response to protein ingestion in patients with liver cirrhosis

The metabolic effects of a protein-rich meal were studied for 3 h in 10 controls and in 20 cirrhotic patients. After protein ingestion, blood glucose did not vary significantly. Insulin and glucagon levels rose in controls and, more markedly, in cirrhotics. Aromatic amino acids and tryptophan increased more in cirrhotics as a result of their decreased liver function. Similarly, branched-chain amino acids increased by 153 +/- 14 nmol/ml X min (mean +/- SE) in controls and by 259 +/- 27 nmol/ml X min in cirrhotics (p less than 0.02), in the presence of a markedly increased insulin response. Branched-chain amino acid metabolism mainly occurs in skeletal muscle under insulin control; in cirrhosis, it might be reduced as a consequence of insulin resistance. To support this hypothesis, the effects of the protein meal were compared with those of an oral glucose load in 15 cirrhotic patients. Branched-chain amino acid response to protein ingestion significantly correlated with blood glucose response to oral glucose (r = 0.714), and with insulin resistance during the glucose tolerance test, when assessed by the insulinogenic index (r = 0.628). Similarly, in 8 patients, increased branched-chain amino acid response also correlated with the index of tissue sensitivity to insulin obtained by means of the glucose clamp technique during continuous insulin infusion (r = -0.809). We conclude that liver cirrhosis is characterized by an abnormal branched-chain amino acid response to protein ingestion, which matches the well-known intolerance to oral glucose. Both alterations are possibly due to decreased peripheral insulin activity on substrates.

Effect of euglycemic insulin infusion on plasma levels of branched-chain amino acids in cirrhosis

To test the hypothesis that hyperinsulinism is responsible for reduced branched-chain amino acids in cirrhotics, plasma amino acids were sequentially determined in 8 controls and 8 matched cirrhotics during continuous i.v. insulin infusion. An artificial endocrine pancreas which infused glucose was used to sustain euglycemia. Basal plasma insulin levels were high and branched-chain amino acids were reduced in cirrhotics. Insulin infusion raised insulin levels to 3 to 4 times basal values. During the test, the decline in branched-chain amino acids was markedly higher in controls who had similar steady-state insulin levels. Not only did the level of branched-chain amino acids in controls reach the values seen in cirrhotics after 60 min, but the levels continued to fall at a significantly higher rate throughout the second hour. Glucose consumption and the ratio of glucose infused/steady-state insulin--a measure of tissue sensitivity to insulin--were markedly reduced in cirrhotics and positively correlated with the decline in branched-chain amino acids. In cirrhotics, insulin effects on carbohydrate and branched-chain amino acid metabolism were reduced. Low branched-chain amino acid levels in cirrhotics are not likely to depend only on hyperinsulinism.