Disagreements between emergency patients and physicians regarding chief complaint – Patient factors and prognostic implications

Rueegg, Marco; Nickel, Christian H.; Bingisser, Roland

doi:10.1111/ijcp.14070

Cited by 9 publications

(4 citation statements)

References 43 publications

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“…While it is understandable that patients with a high number of symptoms at triage may take more time, it is a rather new finding that the chief complaints are often replaced by treating physicians. In both cases, patients have a higher use of resources and rate of admission [20,22]. As our study was a hypothesis-generating venture, the case complexity could only be speculated to contribute to these findings.…”

Section: Discussionmentioning

confidence: 76%

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Throughput delays: causes, predictors, and outcomes – observational cohort in a Swiss emergency department

Arnold,

Busch,

Terhalle

et al. 2023

Swiss Med Wkly

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BACKGROUND: Optimal throughput times in emergency departments can be adjudicated by emergency physicians. Emergency physicians can also define causes of delays during work-up, such as waiting for imaging, clinical chemistry, consultations, or exit blocks. For adequate streaming, the identification of predictors of delays is important, as the attribution of resources depends on acuity, resources, and expected throughput times. OBJECTIVE: This observational study aimed to identify the causes, predictors, and outcomes of emergency physician-adjudicated throughput delays. METHODS: Two prospective emergency department cohorts from January to February 2017 and from March to May 2019 around the clock in a tertiary care centre in Switzerland were investigated. All consenting patients were included. Delay was defined as the subjective adjudication of the responsible emergency physician regarding delay during emergency department work-up. Emergency physicians were interviewed for the occurrence and cause of delays. Baseline demographics, predictor values, and outcomes were recorded. The primary outcome – delay – was presented using descriptive statistics. Univariable and multivariable logistic regression analyses were performed to assess the associations between possible predictors and delays and hospitalization, intensive care, and death with delay. RESULTS: In 3656 (37.3%) of 9818 patients, delays were adjudicated. The patients with delays were older (59 years, interquartile range [IQR]: 39–76 years vs 49 years, IQR: 33–68 years) and more likely had impaired mobility, nonspecific complaints (weakness or fatigue), and frailty than the patients without delays. The main causes of delays were resident work-up (20.4%), consultations (20.2%), and imaging (19.4%). The predictors of delays were an Emergency Severity Index of 2 or 3 at triage (odds ratio [OR]: 3.00; confidence interval [CI]: 2.21–4.16; OR: 3.25; CI: 2.40–4.48), nonspecific complaints (OR: 1.70; CI: 1.41–2.04), and consultation and imaging (OR: 2.89; CI: 2.62–3.19). The patients with delays had an increased risk for admission (OR: 1.56; CI: 1.41–1.73) but not for mortality than those without delays. CONCLUSION: At triage, simple predictors such as age, immobility, nonspecific complaints, and frailty may help to identify patients at risk of delay, with the main reasons being resident work-up, imaging, and consultations. This hypothesis-generating observation will allow the design of studies aimed at the identification and elimination of possible throughput obstacles.

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Section: Discussionmentioning

confidence: 76%

“…Original article chief complaint as the main symptom and reason for visiting the ED, and chief complaint replacement as replacement of the patient-defined chief complaint by the resident (unaware of the recorded chief complaint at presentation) after history-taking [22].…”

Section: Definitions and Processesmentioning

confidence: 99%

Throughput delays: causes, predictors, and outcomes – observational cohort in a Swiss emergency department

Arnold,

Busch,

Terhalle

et al. 2023

Swiss Med Wkly

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“…While dizziness as the main presenting complaint has been shown to be among the more frequent in several studies [ 27 , 28 ], the relatively high incidence of dizziness as a secondary or accompanying complaint is a rather new finding [ 9 ]. In spite of inherent uncertainties, both patients and caregivers may have regarding “primary” or “accompanying” complaint [ 29 ], this classification is decisive for the subsequent work-up. Secondary dizziness seems to be neglected frequently, due to the “physician filter” [ 5 , 30 ], or deemed less meaningful (carrying less diagnostic information) due to the importance and predominance of the primary complaint (such as trauma or chest pain).…”

Section: Discussionmentioning

confidence: 99%

Emergency Presentations for Dizziness—Radiological Findings, Final Diagnoses, and Mortality

Busch

Arnold

Karakoumis

et al. 2023

International Journal of Clinical Practice

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Background. Dizziness is a frequent presentation in patients presenting to emergency departments (EDs), often triggering extensive work-up, including neuroimaging. Therefore, gathering knowledge on final diagnoses and outcomes is important. We aimed to describe the incidence of dizziness as primary or secondary complaint, to list final diagnoses, and to determine the use and yield of neuroimaging and outcomes in these patients. Methods. Secondary analysis of two observational cohort studies, including all patients presenting to the ED of the University Hospital of Basel from 30th January 2017–19th February 2017 and from 18th March 2019–20th May 2019. Baseline demographics, Emergency Severity Index (ESI), hospitalization, admission to Intensive Care Units (ICUs), and mortality were extracted from the electronic health record database. At presentation, patients underwent a structured interview about their symptoms, defining their primary and secondary complaints. Neuroimaging results were obtained from the picture archiving and communication system (PACS). Patients were categorized into three non-overlapping groups: dizziness as primary complaint, dizziness as secondary complaint, and absence of dizziness. Results. Of 10076 presentations, 232 (2.3%) indicated dizziness as their primary and 984 (9.8%) as their secondary complaint. In dizziness as primary complaint, the three (out of 73 main conditions defined) main diagnoses were nonspecific dizziness (47, 20.3%), dysfunction of the peripheral vestibular system (37, 15.9%), as well as somatization, depression, and anxiety (20, 8.6%). 104 of 232 patients (44.8%) underwent neuroimaging, with relevant findings in 5 (4.8%). In dizziness as primary complaint 30-day mortality was 0%. Conclusion. Work-up for dizziness in emergency presentations has to consider a broad differential diagnosis, but due to the low yield, it should include neuroimaging only in few and selected cases, particularly with additional neurological abnormalities. Presentation with primary dizziness carries a generally favorable prognosis lacking short-term mortality. .

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“…The discordance between the patients’ information (considered to be subjective) and objective measurements by caregivers may indeed be a signal similar to a “red flag”. If symptoms do not correspond to the associated signs, physicians tend to ignore a part of the information, but this “physician filter” is associated with both higher rates of hospitalization and higher use of resources [ 14 , 15 ]. Therefore, the third aim was to assess discordance between fever as a symptom and altered body temperature as a sign: first, to gauge its prevalence, and second, to use discordance to stratify patient groups regarding outcomes.…”

Section: Introductionmentioning

confidence: 99%

Prevalence and Prognosis of Fever Symptoms, Hypo-, and Hyperthermia in Unselected Emergency Patients

Malinovska

Nickel

et al. 2021

JCM

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Assessments of history and body temperature are cornerstones of the diagnostic workup in all patients presenting to emergency departments (ED). Yet, the objective measurement of temperature and the subjective perception of fever can differ. This is a secondary exploratory analysis of a consecutive all-comer study, performed at an adult ED in Switzerland. Trained medical students interviewed all patients if fever was present. Altered temperature (>38.0 °C/<36.0 °C) measured at triage using an ear thermometer was used as the reference standard for diagnostic performance. In case of a disagreement between fever symptoms and altered temperature, discordance was noted. Outcome measures for case severity (acute morbidity, hospitalization, intensive care, and in-hospital mortality) were extracted from the electronic health records. Odds ratios (OR) for discordance between signs and symptoms and outcomes were calculated. Among 2183 patients, 325 patients reported fever symptoms. The sensitivity of fever symptoms as a test for altered temperature was 36.3%. Specificity was 91.5%. The negative predictive value was 84.1%, positive likelihood ratio was 4.2 and negative likelihood ratio was 0.7. The adjusted OR for discordance between fever symptoms and altered temperature was 1.71 (95% CI: 1.2–2.44) for acute morbidity, 1.56 (95% CI: 1.13–2.15) for hospitalization, and 1.12 (95% CI: 0.64–1.59) for intensive care. Unadjusted OR for mortality was 1.5 (95% CI: 0.69–3.25). Fever symptoms and altered temperature broadly overlap, but presentations can be stratified according to concordance between signs and symptoms. In case of discordance, the odds for acute morbidity and hospitalization are increased. Discordance may therefore be further investigated as a red flag for a serious outcome.

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Disagreements between emergency patients and physicians regarding chief complaint – Patient factors and prognostic implications

Cited by 9 publications

References 43 publications

Throughput delays: causes, predictors, and outcomes – observational cohort in a Swiss emergency department

Throughput delays: causes, predictors, and outcomes – observational cohort in a Swiss emergency department

Emergency Presentations for Dizziness—Radiological Findings, Final Diagnoses, and Mortality

Prevalence and Prognosis of Fever Symptoms, Hypo-, and Hyperthermia in Unselected Emergency Patients

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