The last decade of symptom-oriented research in emergency medicine: triage, work-up, and disposition

Abstract

As a result of the ever-increasing use of imaging and clinical chemistry, symptom-oriented research has lost ground in many areas of clinical medicine. In emergency medicine, the importance of symptom-oriented research is obvious, as the three major tasks (triage, work-up and disposition) are still under-investigated. Scientific progress is closely linked to the analysis of readily available information, such as the patients' symptoms.A decade ago, there were more questions than answers. Therefore, we describe the state of the evidence and the importance of symptoms for decisions at triage, during work-up and for disposition. Recent advances in each field focusing on symptoms as predictors of outcome and/or diagnosis are shown. Finally, future directions of research regarding novel triage tools, efficient work-up and evidence-based disposition are discussed. Symptom-oriented research has been a driver for medical progress for centuries, and re-focusing on patient-centred clinical research will strengthen this field in the future in order to support smarter medicine.

Nontraumatic Headache in Adult Emergency Patients: Prevalence, Etiologies, and Radiological Findings

“…Therefore, there was no filtering of information by physicians. Although this initial filtering has been successfully applied for centuries [16], its general use may hamper symptom-oriented research, because a potentially important part of the information cannot be analyzed. As headache is typically a symptom among others [14], it has a higher probability to go unrecorded than, e.g., leg pain, the latter often reported as an isolated symptom.…”

“…Second, it is a secondary analysis of prospectively collected data. However, we have collected the data according to our long-term venture, symptom-oriented research [12,16]-the advantage being the assessment of an all-comer cohort with a minimal inclusion bias. Third, although all symptoms of all patients were prospectively and systematically documented by a study team around the clock, headache was not interrogated in depth, e.g., we did not predefine factors, such as vision disturbance or descriptions of thunderclap, and we left it up to patients to mention such symptoms in order to minimize suggestive interviewing or overreporting.…”

“…As the majority of ED patients report more than one symptom [13], and headache patients report a median of four symptoms (often in combination with nonspecific complaints [14,15]), it is highly likely that previous studies have underreported headache, potentially due to inclusion bias and the physician filter. Constructs such as "chief complaint" or "main symptom" heavily rely on several steps of selection and reduction of information [16]-physicians tending to focus on frequent and specific presenting symptoms [17]. This approach may have advantages regarding rapid and highly standardized work-up in clinical settings, but also disadvantages, both in clinical and in research settings.…”

Age, comorbidity, frailty status: effects on disposition and resource allocation during the COVID-19 pandemic

“…Early determination of frailty status, preferably during ED triage, could therefore be useful to identify older adults who may benefit from a comprehensive geriatric assessment [25]. In addition, it could assist disposition decisions [26] and possibly resource allocation, particularly at times of high patient influx, such as during the current COVID-19 pandemic. Disposition in this context means the decision for either discharge, admission or transfer after ED triage and work-up.…”

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

“…1 Chief complaints are often attributed at triage, allowing for a focused work-up, but introducing a possible anchoring bias to the patients' work-up at an early stage, 2-5 because working hypothesis and subsequent examinations are based on such complaints. 6 Other issues are the missing standardisation and the infrequent systematic recording of chief complaints. 7 However, screening and reduction of patient information by physicians has been developed over millennia, initiated by Hippocrates 8 and is still under-investigated.…”