A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Abdominal/pelvic pain is one of the most common reasons that patients present to hospital emergency departments (ED). With 129.8 million emergency department visits per year nationally, efficient triage and admission of these patients from the ED is essential. At the New York Methodist Hospital (NYMH) ED, patients presenting with abdominal/pelvic pain are evaluated based on a series of factors such as pain scores, past medical history, physical exam, and laboratory tests. Depending on these factors, clinicians observe, evaluate, and treat their patients requiring varying lengths of stay in the emergency department before either being discharged or admitted to the hospital. Physicians must weigh the benefits and risks of each evaluation they perform knowing that their resources may be needed more urgently by other patients. Determine the quantitative factors correlated with an increased length of stay for adults presenting to the emergency department with abdominal or pelvic pain. Increases in factors such as age, pain, BMI, and vital signs will correlate with an increased length of stay in the emergency department as well as an increased rate of admission to the hospital. Data regarding the above factors were abstracted from a sample of adult patients (n=347) presenting to the New York Methodist hospital emergency department from June 1st, 2013 to May 31st, 2014. The review of patients presenting to the emergency department with abdominal/pelvic pain demonstrated that patients with lengths of stay greater than four hours had a significantly higher value for age, weight, BMI, and blood pressure compared to those with lengths of stay less than four hours. Additionally, patients that were admitted to the hospital had a statistically significantly higher value for age, pain scores, systolic blood pressure, and heart rate. The identification of factors associated with longer lengths of stay provides the first step in identifying how to improve patients’ access to care in a more time efficient manner. Understanding what factors account for delays in care and discharge will allow for more efficient allocation of time and resources to the patients that need it most.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Renal stones (or “calculi”) are a relatively common condition, affecting up to 12 percent of people during their lifetime. Typical presentation of renal calculi is acute, intermittent flank pain, termed “renal colic”, which may radiate to the groin. Pain may be accompanied by hematuria, nausea, or vomiting.1 Acute renal colic is a common cause for presentation to the Emergency Department, accounting for an estimated 1 million emergency room visits annually in the United States.2 The severe pain associated with renal calculi requires immediate analgesia, and effective analgesia is associated with improved functional capacity after drug administration.3 In this trial, we compare the efficacy of IV ketorolac vs. IV ibuprofen for pain control in patients with renal colic in a three‐armed double‐blind prospective trial. Patients were randomized to one of three treatment groups, receiving parenteral infusions of either IV ibuprofen + morphine, IV ketorolac + morphine, or morphine monotherapy. Outcome of drug administration was measured by patients’ self‐assessment of pain on a verbal scale at 15 mins, 30 mins, 60 min, and 120 min after drug administration. We hypothesized that IV ibuprofen would provide effective, non‐opioid pain relief in the emergency setting and might have a lower incidence of adverse effects than ketorolac. Need for rescue analgesia (with 4 mg morphine) was observed as an indirect measure of analgesic efficacy. A total of 11 patients completed the study. There was no significant difference in area under the curve of pain score in any of the three treatment arms (p>0.4). The ibuprofen group demonstrated consistent improvement in pain over the course of 120 min of study, with 100% of the patients in that arm demonstrating downtrending pain scores. Though the sample size was too small to identify a statistically significant difference in need for rescue medication, there was a trend toward increased opioid in the ibuprofen group, with 50% of those participants receiving rescue analgesia with morphine. The sample size of this pilot study is inadequate to fully assess the analgesic efficacy of IV ibuprofen for renal colic. A trend toward improved pain control in the ibuprofen group was observed, with 100% of the patients in the ibuprofen arm reporting decreased pain after 120 minutes (as compared to 66% in the ketorolac arm and 75% in the placebo arm). Further study of efficacy and need for rescue analgesia is warranted.

People who consume alcohol at risky levels are at an increased risk of presenting to the emergency department (ED). There are a variety of methods used for detection of alcohol-related ED presentations but little guidance about the relative strengths and weaknesses for each method. This research compared and contrasted multiple detection methods for alcohol-related ED presentations and also examined the characteristics of ED patients identified as risky drinkers on a brief self-report screen compared with those detected as having an alcohol-related ED presentation. The first study, a population health survey, found that high risk drinking, high psychological distress and current smoking were all significantly associated (both independently and when combined) with a greater likelihood of presenting to an ED in the last year. The second study involved electronically searching three years of ED nursing triage text data (N=263,937) for alcohol-related terms and found that over 5% of ED presentations were related to alcohol. The third study involved comparing a number of detection methods for alcohol-related ED presentations. It found that nearly a fifth (19%) of ED presentations were detected to be alcohol-related. The strongest method was a medical records audit (72%), followed by patient self-report (67%), nursing triage text (49%) then diagnostic codes (10%). Over a fourth of ED patients were identified as risky drinkers (28%), however, just over half (51%) of these did not present to the ED for an alcohol-related reason. Among alcohol-related ED presentations, nearly a third (31%) were not identified as risky drinkers. In a survey of ED staff, it was found that management of alcohol-related problems was not routine, and many staff appeared to lack the confidence to fully and appropriately manage ED patients with alcohol-related problems. In summary, not all patients who have an alcohol-related ED presentation usually drink at risky levels, nor do all risky drinkers present to the ED for an alcohol-related reason. Using a variety of detection methods for alcohol-related problems in the ED is recommended to enhance the impact of any intervention strategies. ED staff require additional training, resources and support to enhance their management of patients with alcohol-related problems.

Class of 2013 Abstract / Specific Aims: The objective of this study is to evaluate the effect of early blood glucose correction in the Emergency Department (ED) on hospital length of stay. Methods: This study has received institutional review board approval. This is a retrospective cohort study conducted in an academic medical institution. Diabetic patients with hyperglycemia in the ED between June 1st, 2011 and June 30th, 2012 were included. Patients were excluded if they were less than 18 or greater than 89 years of age, not admitted, had diabetic ketoacidosis or hyperglycemic hyperosmolar state, treated with insulin for hyperkalemia, trauma patients, or had an initial blood glucose value of 200 mg/dL or less. Patients were categorized into two groups based on blood glucose control achieved within the first 24 hours from triage. The primary outcome of this study was to compare hospital length of stay between the groups. Main Results: A total of 161 patients were included in this study. Baseline demographics between groups were statistically similar with the exception of gender (p=0.635), ethnicity (p = 0.149), and co-morbidities calculated by the Charlson Co-Morbidity Score (p = 0.112). Blood glucose values in the ED did not statistically correlate to hospital length of stay (p = 0.299), however, co-morbidities were predictive of hospital length of stay (p = 0.025). Conclusion: Early correction of blood glucose values in the ED are not associated with hospital length of stay.

Hundreds of Canadians die each year while awaiting a vital organ transplant. Consistent with several countries in the world, the demand for organs for transplantation outweighs the supply. In Canada, citizens must actively register to enlist themselves as organ donors after death occurs. The aim of this thesis was to examine and evaluate the acceptability of an emergency department-based organ donation registration strategy. Secondarily, we identified the proportion of emergency physicians, nurses and clerks who are personally registered as organ donors. We conducted three self-administered surveys as well as an a priori sub-study to evaluate the effect of a prenotification letter on postal surveys of physicians. We discovered that key stakeholders in emergency departments are engaged in organ donation and feel that the emergency department is an acceptable place to promote organ donation registration. In addition, we identified several barriers to such a potential intervention which largely revolve around time and resource limitations.

Elderly patients make up a disproportionately high proportion of emergency department visits and represent a high-risk sub group for urosepsis. As a component of the geriatric syndrome, acutely ill patients will often present to triage lacking the cardinal signs and symptoms of infection. Further research is necessary to describe geriatric urosepsis and provide a foundation for education for emergency department providers and triage staff. A retrospective, descriptive approach was utilized to examine geriatric patients age 50 years and over who presented to the emergency department with clinically validated urinary tract infection and sepsis. Geriatric age sub-groups as well as discharge mortality was used to compare the clinical and demographic features present with advancing age and urosepsis. Patients meeting urosepsis diagnosis criteria between June 2005 and June 2010 at a community hospital were queried and 270 of these met inclusion criteria. A significant difference in means between younger geriatric age groups (50-64 years) versus older groups (65-74, 75-84, and 85 and over) was observed with regard to presenting symptoms of acute change in mental status, dysuria, chills/ rigors, and nausea/ vomiting. Clinical variables also varied between age groups to include platelets, neutrophils, blood urea nitrogen, initial triage temperature, triage heart rate, highest obtained emergency department temperature and heart rate. On average there also existed significant difference in age, hospital length of stay, body mass index, blood urea nitrogen, creatinine, albumin, triage temperature, and highest temperature.

There is evidence that older Canadians have a higher incidence of presenting to the emergency department (ED) than any other age group. These visits may be made more complex if individuals are also cognitively impaired or have dementia. The purpose of this study was to explore ED nurses’ experiences of caring for adults with dementia in the ED. Using an interpretive descriptive approach, 12 registered nurses working in different EDs in an urban setting in Western Canada were interviewed about these experiences. Using the thematic analysis process described by Braun and Clarke, four themes were identified: 1) not a priority; 2) not the right place; 3) get them in, get them out; and 4) getting it wrong. The nurses identified that challenges in the care of persons with dementia in the ED are created by the fast-paced and chaotic environment of the ED, staffing, issues with disposition, and safety concerns. Suggestions for improving the care of persons with dementia were provided by the nurses. / October 2016

Patienter kommer till akutmottagningar med stora variationer av sjukdomar, skador, ålder och psykologiska tillstånd. Arbetet på akutmottagningen är ofta mer inriktat på de medicinska aspekterna av omvårdnad. Det är patientens upplevelser av omvårdnaden som fungerar som en bedömning av hur bra omvårdnaden utförs. Syftet med denna studie är att beskriva patientens upplevelser av omvårdnaden på akutmottagningen. Den metod som använts är en litteraturöversikt av tolv artiklar med kvalitativ eller kvantitativ metod. Studien resulterade i tre huvudkategorier som patienterna upplevde som omvårdnad. Huvudkategorierna var: Kommunikation mellan vårdgivare och vårdtagare, sjuksköterskans professionalism och vårdmiljön. Resultatet visar även att patienter har olika behov av omvårdnad, beroende på hur sjuka eller skadade de är. Det är dock viktigt att utgå från varje patients livsvärld för att kunna erbjuda en personligt anpassad omvårdnad vilket skapar en trygghet för patienten. Studien visar även att det i framtida studier finns ett behov av att klargöra hur patienters upplevelser av omvårdnaden på akutmottagningen relateras till hur skadade och sjuka patienterna är. / Patients arrive at emergency departments with large variations of diseases, injuries, age and psychological states. The work at the emergency department is often more focused on the medical aspects of nursing care. It is the patient´s experiences of the care that act as an estimation for how well the care is performed. The aim of this study is to investigate the patient’s experiences of care at the emergency department. The method used is a literature review of twelve articles which have a qualitative or quantitative approach. The study resulted in three major categories that patients experienced as caring. The categories were: communication between caregiver and caretaker, the nurse´s professionalism and the care environment. The results of this literature review also showed that patients have different needs of care depending on how sick or hurt they are. It is however important to build on each patient's life world to offer a personalized care which creates a sense of security for the patient. The study also shows that future studies needs to clarify how patients' experiences of care in emergency departments are related to the injured and sick patients are.

<p>Patienter kommer till akutmottagningar med stora variationer av sjukdomar, skador, ålder och psykologiska tillstånd. Arbetet på akutmottagningen är ofta mer inriktat på de medicinska aspekterna av omvårdnad. Det är patientens upplevelser av omvårdnaden som fungerar som en bedömning av hur bra omvårdnaden utförs. Syftet med denna studie är att beskriva patientens upplevelser av omvårdnaden på akutmottagningen. Den metod som använts är en litteraturöversikt av tolv artiklar med kvalitativ eller kvantitativ metod. Studien resulterade i tre huvudkategorier som patienterna upplevde som omvårdnad. Huvudkategorierna var: Kommunikation mellan vårdgivare och vårdtagare, sjuksköterskans professionalism och vårdmiljön. Resultatet visar även att patienter har olika behov av omvårdnad, beroende på hur sjuka eller skadade de är. Det är dock viktigt att utgå från varje patients livsvärld för att kunna erbjuda en personligt anpassad omvårdnad vilket skapar en trygghet för patienten. Studien visar även att det i framtida studier finns ett behov av att klargöra hur patienters upplevelser av omvårdnaden på akutmottagningen relateras till hur skadade och sjuka patienterna är.</p> / <p>Patients arrive at emergency departments with large variations of diseases, injuries, age and psychological states. The work at the emergency department is often more focused on the medical aspects of nursing care. It is the patient´s experiences of the care that act as an estimation for how well the care is performed. The aim of this study is to investigate the patient’s experiences of care at the emergency department. The method used is a literature review of twelve articles which have a qualitative or quantitative approach. The study resulted in three major categories that patients experienced as caring. The categories were: communication between caregiver and caretaker, the nurse´s professionalism and the care environment. The results of this literature review also showed that patients have different needs of care depending on how sick or hurt they are. It is however important to build on each patient's life world to offer a personalized care which creates a sense of security for the patient. The study also shows that future studies needs to clarify how patients' experiences of care in emergency departments are related to the injured and sick patients are.</p>

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