Walk-ins in ED Vs GP out of hour service

BMC Health Serv Res. 2011 May 9;11:94.

Walk-ins seeking treatment at an emergency department or general practitioner out-of-hours service: a cross-sectional comparison.

Chmiel C, Huber CA, Rosemann T, Zoller M, Eichler K, Sidler P, Senn O.

Source

Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland. Corinne.Chmiel@usz.ch

Abstract

BACKGROUND:

Emergency Departments (ED) in Switzerland are faced with increasing numbers of patients seeking non-urgent treatment. The high rate of walks-ins with conditions that may be treated in primary care has led to suggestions that those patients would best cared for in a community setting rather than in a hospital. Efficient reorganisation of emergency care tailored to patients needs requires information on the patient populations using the various emergency services currently available. The aim of this study is to evaluate the differences between the characteristics of walk-in patients seeking treatment at an ED and those of patients who use traditional out-of-hours GP (General Practitioner) services provided by a GP-Cooperative (GP-C).

METHODS:

In 2007 and 2009 data was collected covering all consecutive patient-doctor encounters at the ED of a hospital and all those occurring as a result of contacting a GP-C over two evaluation periods of one month each. Comparison was made between a GP-C and the ED of the Waid City Hospital in Zurich. Patient characteristics, time and source of referral, diagnostic interventions and mode of discharge were evaluated. Medical problems were classified according to the International Classification of Primary Care (ICPC-2). Patient characteristics were compared using non-parametric tests and multiple logistic regression analysis was applied to investigate independent determinants for contacting a GP-C or an ED.

RESULTS:

Overall a total of 2974 patient encounters were recorded. 1901 encounters were walk-ins and underwent further analysis (ED 1133, GP-C 768). Patients consulting the GP-C were significantly older (58.9 vs. 43.8 years), more often female (63.5 vs. 46.9%) and presented with non-injury related medical problems (93 vs. 55.6%) in comparison with patients at the ED. Independent determining factors for ED consultation were injury, male gender and younger age. Walk-in distribution in both settings was equal over a period of 24 hours and most common during daytime hours (65%).Outpatient care was predominant in both settings but significantly more so at the GP-C (79.9 vs. 85.7%).

CONCLUSIONS:

We observed substantial differences between the two emergency settings in a non gate-keeping health care system. Knowledge of the distribution of diagnoses, their therapy, of diagnostic measures and of the factors which determine the patients' choice of the ED or the GP-C is essential for the efficient allocation of resources and the reduction of costs.

 

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Figure 2

Distribution of ICPC chapters presenting at the ED or GP-C. The GP-C dealt mainly with problems related to respiratory (Chapter R) and general complaints (Chapter A) (26.8% and 15.5%), as well as with musculoskeletal problems and gastrointestinal infections (Chapter L and D) (15.0 and 14.3%). Musculoskeletal- (Chapter L) and skin related problems (chapter S) were most common in walk-ins at the ED with a prevalence of 32.7%, and 28.4%, respectively.

Walk-ins seeking treatment at an emergency department or general practitioner out-of-hours service: a cross-sectional comparison

BMC Health Serv Res. BMC Health Serv Res;11:94-94.

Figure 4

Seasonal distribution of Infections at the GP-C. Infection related problems presented in the GP-C showed seasonal variation with regard to the affected organ system. In winter, infections of the respiratory system were more common (70.9%), in summer gastrointestinal infections (34.5%) predominated

Walk-ins seeking treatment at an emergency department or general practitioner out-of-hours service: a cross-sectional comparison

BMC Health Serv Res. BMC Health Serv Res;11:94-94.

Figure 1

Study flow. Study flow of different phases of data collection at the ED as well as GP-C from August 17 2007 until September 26 2009. In total 2206 ED and 768 GP-C encounters were registered. 1073 of the ED encounters were non walk-ins. All the patients consulting the GP-C were walk-ins. Out of the 1133 walk-ins at the ED a random sample of 257 (22.7%) encounters were coded according to ICPC. All of the 768 (100%) encounters in the GP-C were coded.

Walk-ins seeking treatment at an emergency department or general practitioner out-of-hours service: a cross-sectional comparison

BMC Health Serv Res. BMC Health Serv Res;11:94-94.

Figure 3

Distribution of ICPC components presenting at the ED or GP-C. Injuries related to the musculoskeletal system and the skin (Chapter L and S) were the most common diagnoses in ED walk-in patients (45.5%). At the GP-C Infections (34.3%) and other diagnoses (38.9%) predominated.

Walk-ins seeking treatment at an emergency department or general practitioner out-of-hours service: a cross-sectional comparison

BMC Health Serv Res. BMC Health Serv Res;11:94-94.

Figure 5

Musculoskeletal problems, distribution at the ED or GP-C. Musculoskeletal problems (chapter L) were frequent at the ED as well as the GP-C. At the ED the diagnose was mainly due to the component injury (69.0%), at the GP-C mainly due to component other diagnoses (69.0%), mostly comprised of lower back pain.

Walk-ins seeking treatment at an emergency department or general practitioner out-of-hours service: a cross-sectional comparison

BMC Health Serv Res. BMC Health Serv Res;11:94-94.

Approach to ALTE

 A mother brings in a 2 week old neonate with a history choking that said
 morning, turning blue and becoming limp. Same occurred while feeding. No
 other history was elicited.  When examined, neonate had temp of 98 degrees
 Fahrenheit, pulse rate of140 bpm, no other vitals recorded. When examined,
 the child was active, alert and the cardiovascular and abdominal
 examinations were reportedly normal. However, a few crepitations were
 elicited in the left lung base.   How will  you approach this case?

(This article is based on a case posed by Dr.Celeste Maycock,a real advocate of academic excellence) 

 As per definition this neonate fit in ALTE ( Acute Life Threatening Event). ALTE is subjective to care provider but it is important enough to be careful in managing this type of case as well as it is paramount to document care fully. Let us understand component of ATLE:

Frightenning to parents or care provider

blue (cynosis)

limping (loss of tone)

choking (unable to breath)

So this is a case of ATLE

Pt. came : need Red card inside : to be directed to ER: immediate vitals including RBG and SpO2

While looking at neonate place to medium  flow oxygen,Monitor Airway, breathing, circulation (ABCs) with respiratory compromise, establish an airway & provide supportive therapy (e.g., oxygen, mechanical ventilation) Monitor Vital signs

• Establish vascular access for sampling blood ):
• If sepsis is suspected or another specific cause is not identified, start on broad spectrum antibiotics (e.g., ampicillin and gentamycin) after obtaining a CBC, urinalysis, blood & urine cultures (if possible). Left untreated, sepsis may lead to pulmonary disease & left ventricular dysfunction.
• Administering meds (if needed.  kept on talking with mother and get all information from the mother  ante natal,perinatal including baby's last 2 week (for this case):

Now go for differential  one by one for  each component of ALTE

CYNOTIC:

Pregnancy HX ___>  Associated causes of cyanosis

• Gestational diabetes mellitus (GDM) -->TTN (ransient tachypnea of the newborn) (, RDS, hypoglycemia, TGA
• Oligohydramnios-->Pulmonary hypoplasia
• Pregnancy induced hypertension -->IUGR, polycythemia, hypoglycemia
• Lithium intake (1st trimester)--->Ebstein’s anomaly
• Advanced maternal age->Trisomy 21 associated with many congenital heart defects (cyanotic and acyanotic)

Labour Hx----> Associated causes of cyanosis

• PROM, fever, GBS +ve -->Sepsis
• Sedatives/anesthetics--->Respiratory depression, apnea
• C-section -->TTN, PPHN (persistent pulmonary hypertension of the newborn)
• Preterm infant-->RDS
• Meconium-->MAS (pneumonia)

   YOUR DIFFERENTIAL STARTS  HERE......MOTHER's HX FIRST

 

Do thorough Physical examination:  I always consider  dealing with neonate is almost a vetrenary practice: Neonate  doesnot say any thing.

 Look at the neonate differentiate cynosis is whether peripheral or central

 Look at the vitals,

     1/signs of respiratory distress : tachypnea, retractions, nasal flaring & grunting usually indicate a respiratory problem

     2/Congenital heart disease : absent or effortless tachypnea.

     3/Sepsis often has the following findings: peripheral cyanosis, HR, Increase  RR, Decrease BP, Increase/Decrease temp (DDX:  left-sided obstructive lesions:  hypoplastic left heart syndrome, critical aortic stenosis & severe coarctation of the aorta).

  4/Rule out choanal atresia.  If in doubt, attempt to insert a catheter through the nares

Listen for murmurs: a systolic murmur audible in most forms of cyanotic CHD (exception:  d-TGA with intact ventricular septum & no pulmonary stenosis).

Assess the abdomen: scaphoid abdomen in diaphgragmatic hernia

Consider neurological disorders: observe for apnea and periodic breathing, which may be related to immaturity of the nervous system.  Seizures can cause cyanosis if the infant fails to breathe during the episodes.

Tracheal atresia with tracheooesophageal connection can give cynosis with feeding effort.

Here it becomes imperative to think about the various mechanism of cyanosis. Then, organize your thoughts by anatomical systems.

Ventilation/perfusion mismatch : delivery

• Airway disease: transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), pneumonia, aspiration (meconium, blood, amniotic fluid), atelectasis, diaphragmatic hernia, pulmonary hypoplasia, pulmonary hemorrhage, CCAM
• Extrinsic compression of the lungs: pneumothorax, pleural effusion, hemothorax,
• Intracardiac: The 5 T’s: Tetralogy of Fallot, Tricuspid atresia, Transposition of the great arteries, Total anomalous pulmonary venous return, Truncus arteriosus; and pulmonary atresia, Ebsteins anomaly (abnormal tricuspid valve), hypoplastic left heart (shunts)
• Great vessel level: persistent pulmonary, hypertension of the newborn
• Intrapulmonary level: pulmonary arteriovenous malformation

Alveolar Hypoventilation

• CNS depression: asphyxia, maternal sedation, intraventricular hemorrhage, seizure, meningitis, encephalitis
• Airway obstruction: choanal atresia, laryngomalacia, Pierre Robin syndrome
• Neuromuscular disease: phrenic nerve inury, neonatal myasthenia gravis

Diffusion Impairment

• Pulmonary edema: left-sided obstructive cardiac disease (aortic stenosis), cardiomyopathy
• Pulmonary fibrosis

Decrease Hemoglobin O2 affinity

• Methemoglobinemia (congenital, drugs)

Decrease Peripheral circulation (peripheral cyanosis)

• Sepsis, shock of any cause, polycythemia, hypothermia, hypoglycemia, low cardiac output (hypocalcemia, cardiomyopathies, etc)

Investigation:

CBC

             Increase or decrease  WBC : sepsis

• Hematocrit > 65% : polycythemia

Serum glucose:

• to detect hypoglycemia

Arterial Blood Gases (ABGs):

• Arterial PO2: to confirm central cyanosis : SaO2 not as good an indicator due to  Increase fetal Hb affinity for O2 (left-shift)
• Increase PaCO2: may indicate pulmonary or CNS disorders, heart failure
• Decrease pH: sepsis, circulatory shock, severe hypoxemia
• Methemoglobinemia: Decrease SaO2, normal PaO2, chocolate-brown blood

Hyperoxia test:

• Administer 100 % oxygen for > 10 min
• PaO2 > 100 mmHg: pulmonary disease likely
• PaO2 < 70 mmHg, rise by < 30 mmHg or SaO2 unchanged:  cardiac cause (R-L shunt) likely
• Total anomalous pulmonary venous return may respond
• Pulmonary disease with a massive intrapulmonary shunt may not respond

Pre-ductal & Post-ductal PaO2 or SaO2 measurements (pre- and post- ductus arteriosus):

• Preductal artery (right radial) PaO2 10 – 15 mmHg > post ductal artery  (umbilical artery line) PaO2 : R – L ductal shunt (e.g., pulmonary diseases, commonly PPHN)
• SaO2 can also be measured (right hand & right or left leg) : significant if > 10-15 % difference.

CXR

          To identify pulmonary causes of cyanosis:  pneumothorax, pulmonary  hypoplasia, diaphragmatic hernia, pulmonary edema, pleural effusion, etc.

• Useful in evaluating congenital heart disease:  e.g., cardiomegaly & vascular congestion: heart failure
  • TGA : egg-on-a-string (anterior/posterior relationship of great vessels)
  • TOF : boot-shaped heart (RVH)
  • TAPVR :  snowman, figure 8 (anomalous drainage chamber in superior mediastinum)

Echocardiography

• Indicated if abnormal cardiac examination suggestive of congenital heart defect, failed hyperoxia test (cardiac disease suspected) or has unclear diagnosis

• An infant who fails the hyperoxia test & does not have PPHN or a CXR showing pulmonary disease likely has a congenital heart defect that’s ductus-dependent.

Limping neonate:

now we have to look into hypotonia of the neonate. At least 35 to 40 differnt conditions can give limp (hypotonia) of muscle but we need to focus which also cause  limping.

Seizure, hypoglycaemia, sepsis  etc.

 

Hypotonia in Neonate and Infants:

Hypotonia is reduced resistance to passive movement of joints. The deficit causing hypotonia originate in the brain, spinal cord, peripheral nerves, neuromuscular junction, and muscle. There are also non-neuromuscular entities that may be associated with hypotonia including:

1.     Prematurity

2.     Hypothyroidism

3.     Rickets

4.     Malnutrition

5.     Kernicterus

6.     Storage diseases

7.     Down Syndrome

8.     Sepsis

9.     Congestive Heart failure

10.  Hypoglycemia

The differential diagnosis of hypotonia is organized anatomically in to central and peripheral causes. Peripheral hypotonia is further divided into disorders of anterior horn cells, peripheral nerves, neuromuscular junction, and muscle. In general, a good history, physical examination, and neurologic exam will lead to the diagnosis.

Characteristicshypotonia (60-80% of cases)

History:

·      Seizures

·      Delay in attaining normal milestones

PE:

·      Don’t track visually

·      Fail to imitate facial gestures

·      Lethargic and less alter

·      Hyperactive DTRs, clones, persistence of primitive reflexes

·      Poor head control

Characteristics of Peripheral Hypotonia (15-30% of cases)

History:

·      Normal sleep-wake patterns

·      Feeding difficulties

PE:

·      Responds appropriately to surroundings

·      Profound generalized weakness

·      Absent reflexes

Central Hypotonia

Hypoxic encephalopathy (19% of cases)

Intracranial hemorrhage

Perinatal trauma

Infections – meningitis or encephalitis

Structural abnormalities

Chromosomal and Genetic abnormalities (31%)

·      Tiresome 21 (Downs Syndrome)

o   Characteristic features: hypotonia, mental retardation, and congenital heart defects

o   Dysmorphic features present in neonates: flat facial profile and nasal bridge, short neck with excess uncial folds, single transverse palmer crease, upslanting palpebral fissures

·      Fragile X

o   Genetic defect: expansion of trinucleotide repeat (CGG) on X chromosome

o   Hypotonia is mild and kids are usually diagnosed after failure to meet developmental milestones

o   Characteristic features: mental retardation, autistic features, macrocephaly, large ears, increased testicular size in puberty

·      Prader-Willi syndrome:

o   Characteristic features: hypotonia, hypogonadism, mental retardation, short stature, and obesity

o   Genetic defect: deletion of paternal copy of long arm of chromosome 15q11-13 or maternal uniparental dismay

Now we have differential for both" blue" and "limp" baby  , common are hypoglycaemia, sepsis, seizure, structural abnormalities...  so we need some more data from the docket....proper vitals including  Spo2 & RBG further CBC and routine blood work will help, clinically detailed resp and cvs examination data are important, reflexes should be noted,-----IMPLY PROPER Examination
and documentation.

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