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Elders have a higher rate of return visits to the emergency department (ED) than other patients. It is critical to understand the risk factors for return visits to the ED by elders. The aim of this study was to determine the factors associated with return visits to the ED by elders. This study retrospectively reviewed the hospital charts of elders who returned to the ED within 72 h after discharge from ED. The risk factors identified in the Triage Risk Screening Tool were applied in this study. Of the elders discharged from the ED, 8.64% made a return visit to the ED within 72 h. The highest revisit rate occurred within 24 h after discharge. Factors associated with return ED visits within 24 h by elders were difficulty walking and having discharge care needs. The factor associated with ED return visits within 24–48 h was polypharmacy. Difficulty walking, having discharge care needs, and hospitalization within the past 120 days were associated with return visits made within 48–72 h following discharge. Identifying the reasons for return visits to the ED and providing a continuous review of geriatric assessment and discharge planning could reduce unnecessary revisits. [ABSTRACT FROM AUTHOR]

Purpose: To understand how emergency nurses develop resilience in the context of workplace violence. Design: This study employed grounded theory methodology. Thirty nurses from three hospital emergency departments in Taiwan were interviewed between August and December 2018. Methods: Semistructured interviews were used to collect data. Interviews were audio‐recorded and transcribed verbatim. Findings: The process through which emergency nurses who had experienced workplace violence developed resilience took place in three stages: the release of emotions after the assault; the interpretation of conflicting thoughts and actions; and the establishment of strategies to cope with workplace violence in the future. The core theme was the motivating role of professional commitment to emergency patient care. Conclusions: The results of this study can inform the development of support systems to enhance the resilience of nurses experiencing workplace violence by alerting healthcare administrators and governing institutions to their needs. Clinical Relevance: Emergency nurses viewed professional growth and professional commitment as an invisible motivator in the development of resilience following an encounter with workplace violence. [ABSTRACT FROM AUTHOR]

Background: Leukocytosis is a common laboratory finding in emergency departments worldwide. Various infectious diseases are common causes of leukocytosis in hospitalized adult patients. Most emergency physicians have a high awareness of sepsis or severe infection, which requires empirical antibiotics. However, there are many other etiologies for leukocytosis. The outcome of prescribing broad-spectrum antibiotics in the emergency department for leukocytosis patients is not well-understood. Objectives: Our objectives were to determine whether prescribing antibiotics in the emergency department affect outcome for hospitalized adult patients with leukocytosis. Methods: A retrospective cohort study of hospitalized adult emergency department patients with leukocytosis was conducted in a tertiary hospital in Taiwan between June 2016 and June 2017. Patients with leukocytosis (white blood cell count >11,000 cells per μL) who were admitted via the emergency department at the Kaohsiung Veterans General Hospital, from June 2016 to June 2017 were enrolled. Patients aged ⩽18 years, pregnant women, those who received prophylactic antibiotics prior to operation, and those with a final diagnosis of hematologic malignancy were excluded from this study. The primary outcome measure was hospital stay, and the secondary outcome measure was mortality. All collected data were statistically analyzed. Results: A total of 8054 hospitalized adult patients with leukocytosis were included (the exclusion criteria included patients aged ⩽18 years, pregnant women, those who received prophylactic antibiotics prior to surgery, and those with a final diagnosis of hematologic malignancy); all patients were admitted via the emergency department. In all, 4486 patients received initial antibiotic treatment in the emergency department, whereas 3568 patients did not receive antibiotics in the emergency department and ward/intensive care unit within 3 days. There was no statistically significant difference in hospital days (p = 0.239) or mortality (p = 0.345) between those who received and did not receive antibiotics in the emergency department. Conclusion: Hospitalized adult patients with leukocytosis did not necessarily require antibiotics in the emergency department except when they had a differential diagnosis that requires antibiotic treatment. [ABSTRACT FROM AUTHOR]

Aims and objectives To understand the experiences and concerns of patients in the emergency department during inpatient boarding. Background Boarding in the emergency department is an increasingly common phenomenon worldwide. Emergency department staff, patients and their families become more stressed as the duration of boarding in the emergency department increases. Yet, there is limited knowledge of the experiences and concerns of boarded patients. Design The qualitative approach of phenomenography was used in the study. Methods The phenomenographic study was conducted in one emergency department that treats approximately 15,000 patients each month. Twenty emergency department boarding patients were recruited between July-September 2014. Semi-structured interviews were used for data collection. The seven steps of qualitative data analysis for a phenomenographic study - familiarisation, articulation, condensation, grouping, comparison, labelling and contrasting - were employed to develop an understanding of participants' experiences and concerns during their inpatient boarding in the emergency department. Results The perceptions that emerged from the data were collected into four categories of description of the phenomenon of emergency department boarding patients: a helpless choice; loyalty to specific hospitals and doctors; an inevitable challenge of life; and distrust of the healthcare system. The outcome space for the emergency department boarding patients was waiting and hoping for a cure. Conclusion The experiences and concerns of emergency department boarding patients include physical, psychological, spiritual and health system dimensions. It is necessary to develop an integrated model of care for these patients. Relevance to clinical practice Understanding the experiences and concerns of patients who are placed on boarding status in the ED will help emergency healthcare professionals to improve the quality of emergency care. There is a need to develop a care model and associated intervention measures for emergency department patients during the boarding process. The results of this study will help health regulatory authorities to develop an appropriate emergency department boarding system so that patients receive better emergency care. [ABSTRACT FROM AUTHOR]

Published research on discharge planning is written from the perspective of hospital wards and community services. Limited research focuses on discharge planning in the emergency department (ED). The objective of this study was to identify ED nurses’ perceptions of factors influencing the implementation of discharge planning. This qualitative study collected data from 25 ED nurses through in-depth interviews and a drawing task in which participants were asked to depict on paper the implementation of discharge planning in their practice. Factors influencing discharge planning were grouped into three categories: discharge planning as a neglected issue in the ED, heavy workload, and the negative attitudes of ED patients and their families. The study highlighted a need for effective discharge planning to be counted as an essential clinical competency for ED nurses and factored into their everyday workload. Nurses perceived that organizational culture, and parents’ and relatives’ attitudes were barriers to implementing discharge teaching in the ED. [ABSTRACT FROM AUTHOR]

Aims and objectives. The purpose of this research was to explore the medical decision-making processes of patients in emergency departments. Background. Studies indicate that patients should be given enough time to acquire relevant information and receive adequate support when they need to make medical decisions. It is difficult to satisfy these requirements in emergency situations. Limited research has addressed the topic of decision-making among emergency patients. Design. This qualitative study used a broadly defined grounded theory approach to explore decision-making in an emergency department in Taiwan. Methods. Thirty emergency patients were recruited between June and December 2011 for semi-structured interviews that were audio-taped and transcribed verbatim. Results. The study identified three stages in medical decision-making by emergency patients: predecision (interpreting the problem); decision (a balancing act) and postdecision (reclaiming the self). Transference was identified as the core category and pattern of behaviour through which patients resolved their main concerns. This transference around decision-making represents a type of bricolage. Conclusions. The findings fill a gap in knowledge about the decision-making process among emergency patients. Relevance to clinical practice. The results inform emergency professionals seeking to support patients faced with complex medical decision-making and suggest an emphasis on informed patient decision-making, advocacy, patient-centred care and in-service education of health staff. [ABSTRACT FROM AUTHOR]

Background: Dengue is a major health problem in tropical areas, including Taiwan. Dengue virus infection affects various types of cells and results in elevation of serum inflammatory molecules. Because these molecules may be associated with dengue virus infection, the aim of this study was to identify novel molecules in febrile patients with dengue infection. In addition, we determined whether these molecules were correlated with the count of leukocytes and platelets.Methods: Febrile adults (Age >18 years old) who presented to the emergency department and were confirmed dengue virus infection were enrolled in this study. Serum from dengue patients and healthy controls was collected and serum level of sepsis-associated inflammatory molecules was measured by Luminex assay.Results: Elevated level of macrophage migration inhibitory factor, soluble vascular cell adhesion molecule-1, sFasL, resistin and interferon-γ were detected in patients' serum. Higher levels of neutrophil gelatinase-associated lipocalin (NGAL) and resistin were detected in dengue patients with normal leukocyte count and all dengue patients, respectively. Furthermore, the serum level of NGAL, but not resistin, was correlated with cell count in dengue patients.Conclusion: Our results revealed that resistin and NGAL are novel dengue-associated molecules. These results may help elucidate the regulatory mechanisms of anti-dengue immune responses. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to develop and evaluate a machine learning (ML) model to predict invasive bacterial infections (IBIs) in young febrile infants visiting the emergency department (ED). Methods: This retrospective study was conducted in the EDs of three medical centers across Taiwan from 2011 to 2018. We included patients age in 0–60 days who were visiting the ED with clinical symptoms of fever. We developed three different ML algorithms, including logistic regression (LR), supportive vector machine (SVM), and extreme gradient boosting (XGboost), comparing their performance at predicting IBIs to a previous validated score system (IBI score). Results: During the study period, 4211 patients were included, where 126 (3.1%) had IBI. A total of eight, five, and seven features were used in the LR, SVM, and XGboost through the feature selection process, respectively. The ML models can achieve a better AUROC value when predicting IBIs in young infants compared with the IBI score (LR: 0.85 vs. SVM: 0.84 vs. XGBoost: 0.85 vs. IBI score: 0.70, p-value < 0.001). Using a cost sensitive learning algorithm, all ML models showed better specificity in predicting IBIs at a 90% sensitivity level compared to an IBI score > 2 (LR: 0.59 vs. SVM: 0.60 vs. XGBoost: 0.57 vs. IBI score >2: 0.43, p-value < 0.001). Conclusions: All ML models developed in this study outperformed the traditional scoring system in stratifying low-risk febrile infants after the standardized sensitivity level. [ABSTRACT FROM AUTHOR]

Background: Intensive care unit (ICU) admission following a short-term emergency department (ED) revisit has been considered a particularly undesirable outcome among return-visit patients, although their in-hospital prognosis has not been discussed. We aimed to compare clinical outcomes between adult patients admitted to the ICU after unscheduled ED revisits and those admitted during index ED visits. Method: This retrospective study was conducted at two tertiary medical centers in Taiwan from 1 January 2016 to 31 December 2017. All adult non-trauma patients admitted to the ICU directly via the ED during the study period were included and divided into two comparison groups: patients admitted to the ICU during index ED visits and those admitted to the ICU during return ED visits. The outcomes of interest included in-hospital mortality, mechanical ventilation (MV) support, profound shock, hospital length of stay (HLOS), and total medical cost. Results: Altogether, 12,075 patients with a mean (standard deviation) age of 64.6 (15.7) years were included. Among these, 5.3% were admitted to the ICU following a return ED visit within 14 days and 3.1% were admitted following a return ED visit within 7 days. After adjusting for confounding factors for multivariate regression analysis, ICU admission following an ED revisit within 14 days was not associated with an increased mortality rate (adjusted odds ratio (aOR): 1.08, 95% confidence interval (CI): 0.89 to 1.32), MV support (aOR: 1.06, 95% CI: 0.89 to 1.26), profound shock (aOR: 0.99, 95% CI: 0.84 to 1.18), prolonged HLOS (difference: 0.04 days, 95% CI: −1.02 to 1.09), and increased total medical cost (difference: USD 361, 95% CI: −303 to 1025). Similar results were observed after the regression analysis in patients that had a 7-day return visit. Conclusion: ICU admission following a return ED visit was not associated with major in-hospital outcomes including mortality, MV support, shock, increased HLOS, or medical cost. Although ICU admissions following ED revisits are considered serious adverse events, they may not indicate poor prognosis in ED practice. [ABSTRACT FROM AUTHOR]

Objective: To investigate factors associated with recognition and delayed isolation of pulmonary tuberculosis (PTB). Background: Precise identification of PTB in the emergency department (ED) remains challenging. Methods: Retrospectively reviewed PTB suspects admitted via the ED were divided into three groups based on the acid-fast bacilli culture report and whether they were isolated initially in the ED or general ward. Factors related to recognition and delayed isolation were statistically compared. Results: Only 24.94% (100/401) of PTB suspects were truly active PTB and 33.77% (51/151) of active PTB were unrecognized in the ED. Weight loss (p = 0.022), absence of dyspnea (p = 0.021), and left upper lobe field (p = 0.024) lesions on chest radiographs were related to truly active PTB. Malignancy (p = 0.015), chronic kidney disease (p = 0.047), absence of a history of PTB (p = 0.013), and lack of right upper lung (p ≤ 0.001) and left upper lung (p = 0.020) lesions were associated with PTB being missed in the ED. Conclusions: Weight loss, absence of dyspnea, and left upper lobe field lesions on chest radiographs were related to truly active PTB. Malignancy, chronic kidney disease, absence of a history of PTB, and absence of right and/or left upper lung lesions on chest radiography were associated with isolation delay. [ABSTRACT FROM AUTHOR]

Blood culture is frequently used to detect bacteremia in febrile children. However, a high rate of negative or false-positive blood culture results is common at the pediatric emergency department (PED). The aim of this study was to use machine learning to build a model that could predict bacteremia in febrile children. We conducted a retrospective case-control study of febrile children who presented to the PED from 2008 to 2015. We adopted machine learning methods and cost-sensitive learning to establish a predictive model of bacteremia. We enrolled 16,967 febrile children with blood culture tests during the eight-year study period. Only 146 febrile children had true bacteremia, and more than 99% of febrile children had a contaminant or negative blood culture result. The maximum area under the curve of logistic regression and support vector machines to predict bacteremia were 0.768 and 0.832, respectively. Using the predictive model, we can categorize febrile children by risk value into five classes. Class 5 had the highest probability of having bacteremia, while class 1 had no risk. Obtaining blood cultures in febrile children at the PED rarely identifies a causative pathogen. Prediction models can help physicians determine whether patients have bacteremia and may reduce unnecessary expenses. [ABSTRACT FROM AUTHOR]

Background: Hyperlactatemia is known to be associated with adverse outcome in critical illness. In this study, we attempted to identify if hyperlactatemia on emergency department (ED) arrival is a reliable predictor for in-hospital mortality in necrotizing fasciitis (NF) patients. Method: A prospective cohort study of hospitalized patients with NF was conducted in two tertiary teaching hospitals in Taiwan between March 2010 and March 2018. Blood samples were collected in the ED upon arrival, and the lactate levels were determined. Sequential organ failure assessment (SOFA) scores were calculated during the first 24 h after admission. All collected data were statistically analyzed. Result: Of the 707 NF patients, 40 (5.66%) died in the hospital. The median (interquartile range) blood lactate level in all NF patients was 3.6 mmol/l (2.2–4.8). The blood lactate level upon ED arrival was significantly associated with mortality (odds ratio [OR] = 1.35; 95% confidence interval [CI], 1.30–1.46; P < 0.001), even after adjustment for age and SOFA score (OR = 1.27; P < 0.001). Multivariate regression analysis showed that a high blood lactate level (OR = 1.17; 95% CI, 1.07–1.29; P = 0.001) and a high SOFA score (OR = 1.15; 95% CI, 1.11–1.20; P < 0.001) were independent risk factors for in-hospital mortality in NF. Blood lactate achieved an area under-the-receiver-operating-characteristic curve (AUC) of 0.79 (P < 0.001) for predicting mortality that was similar to that of SOFA score (AUC = 0.82; P < 0.001). Blood lactate displayed a sensitivity of 62% and a specificity of 86% in predicting mortality at the optimal cutoff value of 5.80 mmol/l. Conclusion: In necrotizing fasciitis patients, hyperlactatemia on ED arrival is independently associated with in-hospital mortality. NF patients with hyperlactatemia on ED arrival should be closely monitored for signs of deterioration and consider early and aggressive intervention to prevent mortality. [ABSTRACT FROM AUTHOR]