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Background and Importance: Differences between men and women visiting the emergency department (ED) with nonsurgical complaints have mostly been investigated in small, diagnosis-based subpopulations., Objective: This study investigated sex-differences in an unselected cohort of nonsurgical ED patients., Design: Secondary data of all patients attending two EDs of the Charité, Universitätsmedizin Berlin collected in the framework of their medical evaluation was reviewed., Settings and Participants: Within a 1-year-period all 34 333 adult internal patients presenting to one of the two EDs were included and analysed., Outcomes Measure and Analyses: Sex-stratified descriptive analysis of the in-hospital course and outcome of the ED patients was performed as primary endpoint. Admission data, ED processes and diagnoses were analyzed as secondary endpoints., Main Results: A total of 51.2% of all patients were women. Women were slightly younger (median 56 years vs. men 58 years; P < 0.001) and presented more frequently with abdominal pain and headache. Men rather showed chest pain and dyspnea. Accordingly, women had more gastroenterological diseases; men were more often diagnosed with cardiological and pneumological diseases. Women were less frequently admitted for inpatient treatment [35.3 vs. men 43.7%; difference 8.4 percentage points (95% confidence interval (CI), 7.3-9.4)] and intensive care treatment [5.8 vs. men 9.0%; difference 3.2 percentage points (95% CI, 2.7-3.8)]. Inpatient-mortality did not show significant sex differences [4.6 women vs. 4.8% men; difference 0.2 percentage points (95% CI, -0.6 to 0.8)]., Conclusions: There are significant differences in characteristics, symptoms, diagnoses and clinical course between men and women. Further investigations could identify causes and measures like sex-specific algorithms for ED-work processes., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: For several years, Emergency Departments (ED) in Germany have observed increasing patient numbers, resulting in ED crowding. This leads to the question of whether patients with nonurgent conditions could also receive adequate treatment in primary care. Our objective was to develop a quantitative questionnaire to investigate in a larger patient group the reasons for this and to describe the implications for a patient survey in the ED., Methods: The development of the questionnaire was based on a literature search and the results of the qualitative EPICS-2 study. Two pretest surveys were conducted in three EDs at the Charité - Universitätsmedizin Berlin. We included patients aged ≥ 18 years with outpatient treatment and the categories blue (nonurgent), green (standard), or yellow (urgent) according to the Manchester Triage System (MTS)., Results: In total, 189 patients were recruited in two surveys (pretest 1: n = 89, pretest 2 n = 100). The final questionnaire includes 24 items, which were evaluated and adapted during both pretests. The items evaluate basic clinical characteristics, reasons for choosing the ED, prior contacts in primary care, utilization of primary care after-hours services as well as sociodemographic characteristics. Data from the hospital information system were used to link the survey data with clinical characteristics., Conclusions: The questionnaire is based on reasons for ED utilization. We recommend the written, self-applied questionnaire for patient surveys with plausibility checks conducted by staff. It is necessary to consider the heterogenic study surroundings in the ED, which requires a lot of flexibility during data collection.

Purpose: The aim of this study is to evaluate the impact of age on the diagnostic performance of high-sensitivity troponin T (hsTnT) under routine conditions., Materials and Methods: Data of 4118 consecutive emergency department (ED) patients who underwent a routine TnT measurement between 11 October 2012 and 30 November 2013 were analysed. Diagnostic accuracy of hsTnT was compared in four age categories (<50, 50-64, 65-74, ≥75 years of age) for different cut-off values. Primary endpoint was a main hospital diagnosis of NSTEMI., Results: The median age of the study population (n = 4118) was 61 years (IQR: 45-75 years). NSTEMI was diagnosed in 3.3% (n = 136) of all patients. There were significant differences in hsTnT concentrations between age-groups (p < 0.001) in all patients, but not in NSTEMI patients (p = 0.297). 72.2% of all patients ≥75 years of age (583/808) without NSTEMI had hsTnT concentrations above the 99th percentile of a healthy reference population. Specificity at 14 ng/L was 93.6% (95% CI: 92.12-94.87) in patients below 50 years of age and 27.9% (95% CI: 24.78-31.08) in patients 75 years of age and older., Conclusions: Patients' age needs to be considered at least one influencing factor on hsTnT concentrations at admission and should be included in the clinical interpretation of hsTnT concentrations for further clinical workup beneath other influencing factors like comorbidities and symptom onset time. The implementation of age-specific cut-off values could be considered for single troponin testing at admission but is associated with an increased risk of underdiagnosis of NSTEMI.

Background: The increasing utilization of Emergency Departments (ED) by outpatients with acute but non-urgent conditions contributes to ED crowding. This study aims to explore the motives of patients categorized as non-urgent for visiting the ED. Methods: A qualitative study based on semi-structured interviews was conducted at 2 ED's at Charité Berlin. A total of 40 patients categorized as non-urgent were interviewed. Data were analyzed using Qualitative Content Analysis. Results: In addition to unavailable appointments or having to wait a long time for an appointment with general practitioners and specialists, patients stated better time-flexibility, the University Hospital's quality of care and the availability of multidisciplinary care as reasons to seek medical care in the ED. Because of the 24/7 availability of EDs, some patients seem to make little effort to seek an appointment with a GP or a specialist outside the hospital. Conclusion: Our interview data indicate an independent function of EDs in outpatient care. It must be assumed that even a full coverage of service guarantee by the association of statuary health insurance physicians would not reduce ED utilization to cases of medical urgency only. To ensure sustainable medical quality for urgent as well as non-urgent medical care seekers, EDs need appropriate resources to cover the demand., Competing Interests: Interessenkonflikt:: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background  The increasing number of low-acuity visits to Emergency Departments (ED) is an important issue in Germany and contributes to ED crowding. A sustainable solution needs deeper knowledge of patients' underlying rationales. Methods  To explore patients' motives we conducted 31 semi-structured face-to-face interviews with low-acuity ED patients in a rural region in Saxony-Anhalt. Subsequently we interviewed 12 General Practitioners (GP)s about their perspectives on patients visiting ED with low-acuity conditions and referring patients to ED. A qualitative content analysis approach was used for data analysis. Results  All patients were connected to a GP. One third had visited ED because of 24/7 availability when consultation hours and working times overlapped. Another third had addressed EDs full range of laboratory and imaging technology with a subjective need for fast diagnosis. One group reported that they had been referred to the ED by their GP. The interviewed GPs classified patients' ED usage for time-constraints as impatience and growing demand, while they expressed greater understanding for patients striving to ED for anxiety reasons. Most GPs sometimes referred patients to ED for diagnostic reasons. Conclusion  The findings demonstrate that ED usage with non-urgent conditions takes place for different reasons. Therefore, ED plays a pivotal role not only in emergency care, but also in ambulant care. The growing demand for ambulant care indicates a need for changed health care structures., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: A point of care test (POCT) for troponin T (TnT) in the Emergency Department (ED) was compared to a high-sensitivity TnT (hsTnT) central laboratory test (CLT) to determine the influence of test system and different cut-off values on the diagnostic performance in patients with suspected acute coronary syndrome (ACS) under routine conditions., Methods: All patients with routine TnT testing in the ED were enrolled. Only internal medicine patients without STEMI and with both troponin values were analyzed. TnT was measured with a contemporary sensitive POCT assay in the ED and with a hs-assay in the central laboratory. The diagnostic performance was analyzed at two different cut-off points (99th percentile and conventional rule-in cut-offs). Primary endpoint was the diagnosis of NSTEMI., Results: Of all patients (n=3423), 3.6% had a diagnosis of NSTEMI (n=124). For the hsTnT assay, 28.4% of all values were at or below the lower limit of detection (LOD) as compared to 75.7% of the POC-TnT-values. The area under the receiver operating curves did not differ significantly between the assays (hsTnT: 0.912(95%-CI: 0.884-0.940); POC-TnT: 0.896(95%-CI: 0.859-0.933)). The diagnostic performance was very similar for both assays: the positive predictive value was below 50% for troponin values below 100ng/L and hardly increased for values between 100 and 600ng/L for hs and conventional assays., Conclusions: In our cohort of emergency patients, the diagnostic performance of conventional POC-testing was comparable to hsTnT. A 99th percentile cut-off may be useful for rule-out of NSTEMI, but seems limited for routine rule-in strategies., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives: The increasing number of low-acuity visits to emergency departments (ED) is an important issue in Germany, despite the fact that all costs of inpatient and outpatient treatment are covered by mandatory health insurance. We aimed to explore the motives of patients categorised with low-acuity conditions for visiting an ED., Methods: We conducted a qualitative study in two urban and one rural ED. We recruited a purposive sample of adults, who were assigned to the lowest two categories in the Manchester triage system. One-to-one interviews took place in the ED during patients' waiting time for treatment. Interview transcripts were analysed using the qualitative data management software MAXQDA. A qualitative content analysis approach was taken to identify motives and to compare the rural with the urban sites., Results: A total of 86 patients were asked to participate; of these, n=15 declined participation and n=7 were excluded because they were admitted as inpatients, leaving a final sample of 40 female and 24 male patients. We identified three pathways leading to an ED visit: (1) without primary care contact, (2) after unsuccessful attempts to see a resident specialist or general practitioner (GP) and (3) recommendation to visit the ED by an outpatient provider. The two essential motives were (1) convenience and (2) health anxiety, triggered by time constraints and focused usage of multidisciplinary medical care in a highly equipped setting. All participants from the rural region were connected to a GP, whom they saw more or less regularly, while more interviewees from the urban site did not have a permanent GP. Still, motives to visit the ED were in general the same., Conclusions: We conclude that the ED plays a pivotal role in ambulatory acute care which needs to be recognised for adequate resource allocation., Trial Registration Number: DRK S00006053., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Laboratory parameters in emergency medicine can be divided into 3 categories. Urgent obligatory parameters are necessary for immediate therapeutic decisions and must be available within 60 minutes. For these, testing in the emergency department (ED) as point-of-care-testing (POCT) should be considered. The second category are obligatory parameters which require diagnostic / therapeutic consequences in the emergency department, but are not necessary for immediate life-saving actions. Due to international consensus of a 4-hour length of stay target for ED, results should be available within this time. The third category are parameters which do not lead to immediate diagnostic or therapeutic consequences, but are important for process management and patient flow in the ED. They should therefore be available as emergency tests. POC-testing should be used for a limited number of very urgent parameters and should be organized as a satellite laboratory in cooperation with the central laboratory., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Over the past few years, the number of patients attending emergency services has increased steadily. As a result, emergency departments (EDs) worldwide face frequent crowding, with the risk of reduced treatment quality and impaired patient outcome, patient and staff dissatisfaction and inefficient use of ED resources. A qualitative process analysis and process modelling was used as a method to detect critical process steps in the ED with respect to time and efficiency., Methods: The analysis was carried out by independent external process experts. Over a period of 1 week, the complete treatment process of 25 patients was recorded. The monitoring of overall activities, decision points, causalities and interfaces was based on the treatment of 100 additional patients and on interviews with nurses and physicians. The project was closed with the identification of the three most critical process steps and modelling of the standard emergency care process in an event-process chain (EPC)., Results: The most time-crucial steps detected by the analysis were the process of developing a tentative diagnosis, including consultation and advice seeking by inexperienced physicians, the interface to imaging diagnostics and the search of hospital beds for inpatients. The results were visualized by standardized modelling of an event-process chain (EPC)., Conclusion: The process analysis helped to identify inefficient process steps in the ED. Modelling with EPC is a useful tool to visualize and to understand the complexity of the emergency medical care and to identify key performance indicators for effective quality management.

Objectives: To evaluate the relationship between chief complaints and their underlying diseases and outcome in medical emergency departments (EDs)., Methods: All 34 333 patients who attended two of the EDs of the Charité Berlin over a 1-year period were included in the analysis. Data were retrieved from the hospital information system. For study purposes, the chief complaint (chest pain, dyspnoea, abdominal pain, headache or 'none of these symptoms') was prospectively documented in an electronic file by the ED-physician. Documentation was mandatory., Results: The majority of patients (66%) presented with 'none of these symptoms', 11.5% with chest pain, 11.1% with abdominal pain and 7.4% with dyspnoea. In total, 39.4% of all patients were admitted to the hospital. The leading diagnosis was acute coronary syndrome (50.7%) for chest pain in-patients and chronic obstructive pulmonary disease (16.5%) and heart failure (16.1%) for in-patients with dyspnoea. The causes of abdominal pain in in-patients were of diverse gastrointestinal origin (47.2%). In-hospital mortality of in-patients was 4.7%. Patients with chest pain had significantly lower in-hospital mortality (0.9%) than patients with dyspnoea (9.4%) and abdominal pain (5.1%)., Conclusion: The majority of emergency patients lack diagnosis-specific symptoms. Chief complaints help preselect patients but must not be mistaken as disease specific. Mortality largely differs depending on the chief complaint. In chest pain patients, standardized processes may be one factor that explains the low mortality in this group.