<p>Comparing Expert and Non-Expert Assessment of Patients Presenting with Neurological Symptoms to the Emergency Department: A Retrospective Observational Study</p>

Abstract

Objective: Referrals to neurology in emergency departments (ED) are continuously increasing, currently representing 15% of all admissions. Existing triage systems were developed for general medical populations and have not been validated for patients with neurological symptoms. Methods: To characterize neurological emergencies, we first retrospectively analyzed symptoms, service times and resources of the cohort of neurological referrals to a German interdisciplinary ED (IED) during 2017 according to urgency determined by final IED diagnosis. In a second step, we performed a retrospective assignment of consecutive patients presenting in April 2017 according to internal guidelines as either acute (requiring diagnostic/therapeutic procedures within 24 hrs) or non-acute neurological conditions as well as a retrospective classification according to the Emergency Severity Index (ESI). Both assessments were compared with the urgency according to the final ER diagnosis. Results: In a 12-month period, 36.4% of 5340 patients were rated as having an urgent neurological condition; this correlated with age, door-to-doctor time, imaging resource use and admission (p < 0.001, respectively). In a subset of 275 patients, 59% were retrospectively triaged as acute according to neurological expertise and 48% according to ESI categories 1 and 2. Neurological triage identified urgency with a significantly higher sensitivity (94.8, p < 0.01) but showed a significantly lower specificity (55.1, p < 0.05) when compared to ESI (80.5 and 65.2, respectively). Conclusion: The ESI may not take specific aspects of neurological emergency (eg, timesensitivity) sufficiently into account. Refinements of existing systems or supplementation with dedicated neurological triage tools based on neurological expertise and experience may improve the triage of patients with neurological symptoms.

Experience of a Neuro-Emergency Expert in the Emergency Department during One Year of the COVID-19 Pandemic

“…In terms of disposition, 55% of enrolled patients were admitted to the hospital, 41.8% were determined for outpatient follow-up, and 1.1% were transferred to another hospital. The admission rate was similar to that reported by Hoyer et al and Linden et al (50.0–57.7%) [ 1 , 3 , 10 ].…”

“…The diagnoses made most frequently by neuro-emergency experts in the ED were acute ischemic stroke, benign paroxysmal positional vertigo, vestibular neuritis, seizures, cerebral hemorrhage, and metabolic encephalopathy. The order of diagnosis frequency in other studies was AIS, seizure, and headache [ 1 , 5 , 10 , 13 , 14 ]; our results had similar AIS frequency but fewer cases of headache. Most cases of primary headache with no abnormal findings on brain CT scans were discharged by the ED physicians after controlling their symptoms and referred for outpatient treatment.…”

“…The mean LOS in our ED (207 min) was longer than the LOS reported by Linden et al (156 min) but shorter than the LOS reported by Hoyer et al (250 min) and Hansen et al (408 min) [ 1 , 3 , 12 ]. The most frequently observed LOS in our study was 120–240 min (553 patients, 47.9%), and 218 patients (18.9%) stayed in the ED for >360 min.…”

“…Neurological symptoms in emergency department (ED) settings vary on a spectrum of presentation and diagnosis. Approximately 9–15% of patients admitted to the ED have neurological symptoms, accounting for a significant proportion of the patients visiting the ED [ 1 , 2 , 3 ]. However, neurology is still considered a complex and unknown area for most doctors [ 4 ].…”

Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting

“…The positive impact of early stroke identification and ED pre-notification in general (30) may generate a false sense of security with ED personnel overrelying on EMS staff 's diagnostic impression and decisionmaking (31). Similarly, widely-used triage tools have been shown to under-appreciate the idiosyncrasies of neurological emergencies (32,33). Atypical stroke symptoms may not only obscure subtler neurological abnormality, but they may also make the clinical assessment, especially by non-neurologists, difficult.…”