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Nahidi S, Forero R, McCarthy S, Man N, Gibson N, Mohsin M, Mountain D, Fatovich D, Fitzgerald G, Toloo G(S. Qualitative analysis of perceptions and experiences of emergency department staff in relation to implementation and outcomes of the Four‐Hour Rule/National Emergency Access Target in Australia. Emerg Med Australas 2018; 31:378-386. [DOI: 10.1111/1742-6723.13166] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/25/2018] [Accepted: 07/27/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Shizar Nahidi
- Simpson Centre for Health Services ResearchSouth Western Sydney Clinical School, The University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Sydney New South Wales Australia
| | - Roberto Forero
- Simpson Centre for Health Services ResearchSouth Western Sydney Clinical School, The University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Sydney New South Wales Australia
| | - Sally McCarthy
- Prince of Wales Clinical SchoolThe University of New South Wales Sydney New South Wales Australia
- Emergency Care InstituteAgency for Clinical Innovation Sydney New South Wales Australia
| | - Nicola Man
- Simpson Centre for Health Services ResearchSouth Western Sydney Clinical School, The University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Sydney New South Wales Australia
| | - Nick Gibson
- School of Nursing and MidwiferyEdith Cowan University Perth Western Australia Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching UnitSouth Western Sydney Local Health District Sydney New South Wales Australia
- School of PsychiatryFaculty of Medicine, The University of New South Wales Sydney New South Wales Australia
| | - David Mountain
- Emergency DepartmentSir Charles Gairdner Hospital Perth Western Australia Australia
- Division of Emergency Medicine, Faculty of Health and Medical SciencesThe University of Western Australia Perth Western Australia Australia
| | - Daniel Fatovich
- Division of Emergency Medicine, Faculty of Health and Medical SciencesThe University of Western Australia Perth Western Australia Australia
- Centre for Clinical Research in Emergency MedicineHarry Perkins Institute of Medical Research Perth Western Australia Australia
- Emergency DepartmentRoyal Perth Hospital Perth Western Australia Australia
| | - Gerard Fitzgerald
- School of Public Health and Social WorkQueensland University of Technology Brisbane Queensland Australia
| | - Ghasem (Sam) Toloo
- School of Public Health and Social WorkQueensland University of Technology Brisbane Queensland Australia
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Nahidi S, Forero R, Man N, Mohsin M, Fitzgerald G, Toloo G(S, McCarthy S, Gibson N, Fatovich D, Mountain D. Impact of the Four‐Hour Rule/National Emergency Access Target policy implementation on emergency department staff: A qualitative perspective of emergency department management changes. Emerg Med Australas 2018; 31:362-371. [DOI: 10.1111/1742-6723.13164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/04/2018] [Accepted: 07/25/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Shizar Nahidi
- Simpson Centre for Health Services Research, South Western Sydney Clinical SchoolThe University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Sydney New South Wales Australia
| | - Roberto Forero
- Simpson Centre for Health Services Research, South Western Sydney Clinical SchoolThe University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Sydney New South Wales Australia
| | - Nicola Man
- Simpson Centre for Health Services Research, South Western Sydney Clinical SchoolThe University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Sydney New South Wales Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching UnitSouth Western Sydney Local Health District Sydney New South Wales Australia
- School of PsychiatryFaculty of Medicine, The University of New South Wales Sydney New South Wales Australia
| | - Gerard Fitzgerald
- School of Public Health and Social WorkQueensland University of Technology Brisbane Queensland Australia
| | - Ghasem (Sam) Toloo
- School of Public Health and Social WorkQueensland University of Technology Brisbane Queensland Australia
| | - Sally McCarthy
- Prince of Wales Clinical SchoolThe University of New South Wales Sydney New South Wales Australia
- Emergency Care InstituteAgency for Clinical Innovation Sydney New South Wales Australia
| | - Nick Gibson
- School of Nursing and MidwiferyEdith Cowan University Perth Western Australia Australia
| | - Daniel Fatovich
- Centre for Clinical Research in Emergency MedicineHarry Perkins Institute of Medical Research Perth Western Australia Australia
- Emergency DepartmentRoyal Perth Hospital Perth Western Australia Australia
- Division of Emergency MedicineFaculty of Health and Medical Sciences, The University of Western Australia Perth Western Australia Australia
| | - David Mountain
- Division of Emergency MedicineFaculty of Health and Medical Sciences, The University of Western Australia Perth Western Australia Australia
- Emergency DepartmentSir Charles Gairdner Hospital Perth Western Australia Australia
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Eriksson J, Gellerstedt L, Hillerås P, Craftman ÅG. Registered nurses' perceptions of safe care in overcrowded emergency departments. J Clin Nurs 2018; 27:e1061-e1067. [PMID: 29076280 DOI: 10.1111/jocn.14143] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To explore registered nurses' perceptions of safe practice in care for patients with an extended length of stay in the emergency department. BACKGROUND Extended length of stay and overcrowding in emergency departments are described internationally as one of the most comprehensive challenges of modern emergency care. An emergency department is not designed, equipped or staffed to provide care for prolonged periods of time. This context, combined with a high workload, poses a risk to patient safety, with additional medical errors and an increased number of adverse events. From this perspective, it is important to extend our knowledge and to describe registered nurses' experiences of safe practice. DESIGN A qualitative, inductive and descriptive study. METHODS Qualitative interview study carried out in five emergency departments. Data were analysed using a qualitative content analysis with a latent approach. RESULTS Patient safety meets obstacles in the clinical environment involving experiencing deficiencies regarding patient safety in the clinical setting and the impact of working procedures and routines. Moreover, nurses are challenged in their professional responsibilities involving balancing essential nursing care and actual workload; it is common to experience emotional reactions based on feelings of loss of control. CONCLUSIONS From the nurses' perspective, a prolonged stay in the emergency department may lead to negative consequences for both patient safety and care as well as registered nurses' psychosocial experiences. An extended length of stay significantly reduces the level of nursing and caring that registered nurses can perform in the emergency department. RELEVANCE TO CLINICAL PRACTICE This study indicates that emergency departments should review their procedures to avoid both deviations from normal practice and moral stress among registered nurses. This can contribute to an increased understanding and insight about the challenge of patient safety in an emergency department setting.
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Affiliation(s)
- Julia Eriksson
- Sophiahemmet University, Stockholm, Sweden.,Infektionskliniken, Karolinska University Hospital, Solna, Sweden
| | - Linda Gellerstedt
- Sophiahemmet University, Stockholm, Sweden.,Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Hillerås
- Sophiahemmet University, Stockholm, Sweden.,Swedish Red Cross University College.,Department of NEUROTEC, Karolinska Institutet, Stockholm
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Which indicators to include in a crowding scale in an emergency department? A national French Delphi study. Eur J Emerg Med 2018; 25:257-263. [DOI: 10.1097/mej.0000000000000454] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Forero R, Man N, Ngo H, Mountain D, Mohsin M, Fatovich D, Toloo GS, Celenza A, FitzGerald G, McCarthy S, Richardson D, Xu F, Gibson N, Nahidi S, Hillman K. Impact of the four-hour National Emergency Access Target on 30 day mortality, access block and chronic emergency department overcrowding in Australian emergency departments. Emerg Med Australas 2018; 31:58-66. [DOI: 10.1111/1742-6723.13151] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Roberto Forero
- Simpson Centre for Health Services Research; The University of New South Wales; Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research; Sydney New South Wales Australia
| | - Nicola Man
- Simpson Centre for Health Services Research; The University of New South Wales; Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research; Sydney New South Wales Australia
| | - Hanh Ngo
- Division of Emergency Medicine; Faculty of Health and Medical Sciences, The University of Western Australia; Perth Western Australia Australia
| | - David Mountain
- Division of Emergency Medicine; Faculty of Health and Medical Sciences, The University of Western Australia; Perth Western Australia Australia
- Emergency Department; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit; South Western Sydney Local Health District; Sydney New South Wales Australia
- School of Psychiatry; Faculty of Medicine, The University of New South Wales; Sydney New South Wales Australia
| | - Daniel Fatovich
- Division of Emergency Medicine; Faculty of Health and Medical Sciences, The University of Western Australia; Perth Western Australia Australia
- Emergency Department; Royal Perth Hospital; Perth Western Australia Australia
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
| | - Ghasem Sam Toloo
- School of Public Health and Social Work; Queensland University of Technology; Brisbane Queensland Australia
| | - Antonio Celenza
- Division of Emergency Medicine; Faculty of Health and Medical Sciences, The University of Western Australia; Perth Western Australia Australia
- Emergency Department; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Gerry FitzGerald
- School of Public Health and Social Work; Queensland University of Technology; Brisbane Queensland Australia
| | - Sally McCarthy
- Emergency Care Institute; Agency for Clinical Innovation; Sydney New South Wales Australia
- Emergency Department; Prince of Wales Hospital; Sydney New South Wales Australia
| | - Drew Richardson
- Medical School, Australian National University, Canberra; Australian Capital Territory Australia
- Emergency Department; Canberra Hospital, Canberra; Australian Capital Territory Australia
| | - Fenglian Xu
- Simpson Centre for Health Services Research; The University of New South Wales; Sydney New South Wales Australia
| | - Nick Gibson
- School of Nursing and Midwifery; Edith Cowan University; Perth Western Australia Australia
| | - Shizar Nahidi
- Simpson Centre for Health Services Research; The University of New South Wales; Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research; Sydney New South Wales Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research; The University of New South Wales; Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research; Sydney New South Wales Australia
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Forero R, Man N, McCarthy S, Richardson D, Mohsin M, Toloo GS, FitzGerald G, Ngo H, Mountain D, Fatovich D, Celenza A, Gibson N, Xu F, Nahidi S, Hillman K. Impact of the National Emergency Access Target policy on emergency departments' performance: A time-trend analysis for New South Wales, Australian Capital Territory and Queensland. Emerg Med Australas 2018; 31:253-261. [PMID: 30043403 DOI: 10.1111/1742-6723.13142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/30/2018] [Accepted: 06/13/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the impact of the Australian National Emergency Access Target (NEAT) policy introduced in 2012 on ED performance. METHODS A longitudinal cohort study of NEAT implementation using linked data, for 12 EDs across New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD) between 2008 and 2013. Segmented regression in a multi-level model was used to analyse ED performance over time before and after NEAT introduction. The main outcomes measures were ED length of stay ≤4 h, access block, number of ED presentations, short-stay admission (≤24 h), >24 h admissions, unplanned ED re-attendances within 7 days and 'left at own risk' (including 'did not wait for assessment'). RESULTS Two years after NEAT introduction, ED length of stay ≤4 h increased in NSW and QLD (odds ratio [OR] = 2.48 and 3.24; P < 0.001) and access block decreased (OR = 0.41 and 0.22; P < 0.001), but not in ACT (OR = 1.28; P > 0.05). ED presentations increased over time before and after NEAT introduction with a significant increase above the projected trend in NSW after NEAT (mean ratio = 1.07). Short-stay admissions increased in QLD (OR = 2.60), ACT (OR = 1.68) and NSW (OR = 1.35). Unplanned ED re-attendances did not change significantly. Those who left at their own risk decreased significantly in NSW and QLD (OR = 0.38 and 0.67). CONCLUSION ED presentations continued to increase over time in all jurisdictions. NSW and QLD, but not ACT, showed significant improvements in time-based measures. Significant increases in short-stay admissions suggest a strategic change in ED process associated with NEAT implementation. Rates of unplanned ED re-attendances and those leaving at their own risk showed no evidence for adverse effects from NEAT.
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Affiliation(s)
- Roberto Forero
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Nicola Man
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Sally McCarthy
- Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - Drew Richardson
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia.,Emergency Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit, South Western Sydney Local Health District, Sydney, New South Wales, Australia.,School of Psychiatry, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Ghasem Sam Toloo
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Gerry FitzGerald
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Hanh Ngo
- Division of Emergency Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - David Mountain
- Division of Emergency Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Daniel Fatovich
- Division of Emergency Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia.,Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Antonio Celenza
- Division of Emergency Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Nick Gibson
- School of Nursing and Midwifery, Edith Cowan University, Perth, Western Australia, Australia
| | - Fenglian Xu
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shizar Nahidi
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
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Elamir H. Improving patient flow through applying lean concepts to emergency department. Leadersh Health Serv (Bradf Engl) 2018; 31:293-309. [PMID: 30016921 DOI: 10.1108/lhs-02-2018-0014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose This paper aims to propose lean-based interventions that address the main causes of emergency department overcrowding. Emergency department overcrowding (EDOC) and increased length of stay (LOS) have been key global issues for more than 20 years, as they have serious repercussions. No measurements have been done to assess the situation nationally. Expanding emergency departments (EDs) and adding more beds have never succeeded in eliminating wastes and targeting the root causes of the problem. Design/methodology/approach This paper is a quantitative analytical applied research. The paper used direct observation for seven days to collect patient flow data on ED patients at a secondary care hospital in Kuwait. It calculated wait times and services to identify the major causes of EDOC and increased LOS. Findings Around one-third of the ED design capacity was used by 12 per cent of the patients who stayed >6 h each. The wasted waiting time represents 56.2 per cent of the aggregated LOS, which puts lean management (LM) on the top of the process reengineering approaches suitable for improving overcrowding by reducing waste. Guided by the LM concepts, the paper proposes solutions that fall into three themes. The selected solutions address the vital few causes of the EDOC and prolonged EDLOS. Originality/value This paper is the first study of its kind in Kuwait, and one of the most outstanding studies in the Gulf region, in terms of the number of the daily ED visits and the comprehensive multi-level proposed interventions.
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Affiliation(s)
- Hossam Elamir
- Department of Quality and Accreditation, Ministry of Health, Kuwait
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Lee DCA, Williams C, Lalor AF, Brown T, Haines TP. Hospital readmission risks in older adults following inpatient subacute care: A six-month follow-up study. Arch Gerontol Geriatr 2018; 77:142-149. [PMID: 29763856 DOI: 10.1016/j.archger.2018.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 05/01/2018] [Accepted: 05/07/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND High rates of unplanned hospital readmissions are a burden on healthcare systems and individuals. This study examined factors at, and after initial hospital discharge and their associations with unplanned hospital readmission for older adults up to six months post-discharge from subacute care. METHODS Older subacute care patients were surveyed prior to discharge, and assessed monthly post-discharge for six months. Data included the Geriatric Depression Scale, Phone-Fitt sub-scales, Friendship Scale, modified Lubben Social Network Scale, unplanned hospital readmission, self-reported physical capacity and falls in the last month were collected. Regression analyses were used to examine relationships between unplanned hospital readmission and variables that may predispose this outcome. RESULTS Participants (n = 311) completed the baseline assessment. N = 218 (70%) completed all at six-month post-discharge. Eighty-nine (29%) participants shared 143 readmissions. Those with cancer history (adjusted OR [95% CI]) (1.97 [1.15, 3.39]), neurological disease other than stroke (2.95 [1.32, 6.57]) and dependence on others to assist in bending tasks (1.94 [1.14, 3.29]) at initial discharge were associated with readmission within six months post-discharge. Those who fell in the last month (adjusted OR [robust 95% CI]) (2.28 [1.43, 3.64]), being less physical active (0.98 [0.96, 0.99]), and dependence on others in moving around residence (2.63 [1.37, 5.06]) after initial discharge were associated with a readmission in the next month within six months post-discharge. CONCLUSION Trials investigating the effectiveness of strategies to reduce falls, build physical capacity, increase physical activity level, and connection with health care services after discharge to prevent readmission are warranted.
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Affiliation(s)
- Den-Ching A Lee
- School of Primary and Allied Health Care, Faculty of Medicine, Nursing, and Health Sciences, Monash University (Peninsula Campus), Moorooduc Highway, Frankston, Victoria 3199, Australia.
| | - Cylie Williams
- Peninsula Health, 2 Hastings Road, Frankston, Victoria 3199, Australia; Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing, and Health Sciences, Monash University (Peninsula Campus), Moorooduc Highway, Frankston, Victoria 3199, Australia
| | - Aislinn F Lalor
- Department of Occupational Therapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing, and Health Sciences, Monash University (Peninsula Campus), Moorooduc Highway, Frankston, Victoria 3199, Australia
| | - Ted Brown
- Department of Occupational Therapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing, and Health Sciences, Monash University (Peninsula Campus), Moorooduc Highway, Frankston, Victoria 3199, Australia
| | - Terry P Haines
- School of Primary and Allied Health Care, Faculty of Medicine, Nursing, and Health Sciences, Monash University (Peninsula Campus), Moorooduc Highway, Frankston, Victoria 3199, Australia
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Causes of Emergency Department Overcrowding and Blockage of Access to Critical Services in Beijing: A 2-Year Study. J Emerg Med 2018; 54:665-673. [PMID: 29573904 PMCID: PMC7135171 DOI: 10.1016/j.jemermed.2018.02.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 02/01/2018] [Accepted: 02/06/2018] [Indexed: 11/22/2022]
Abstract
Background Emergency department (ED) overcrowding is a serious issue worldwide. Objectives This study was done to evaluate the degree of overcrowding in local “teaching hospitals” in Beijing, and to ascertain the apparent root causes for the pervasive degree of overcrowding in these EDs. Methods This is a multicenter cross-sectional study. The studied population included all ED patients from 18 metropolitan teaching hospital EDs in Beijing for calendar years 2013 and 2014. Patient characteristics, and the primary reasons that these patients sought care in these EDs, are described. Results The total numbers of annual emergency visits were 1,554,387 and 1,615,571 in 2013 and 2014, respectively. High acuity cases accounted for 4.6% and 5.5% of the total annual emergency visits in 2013 and 2014, respectively. The percentage of patients placed into “Observation” beds, which were created to accommodate patients deemed to have problems too complex to be treated in an inpatient bed, or to accommodate patients simply needing chronic care, was 11.9% and 13.1% in 2013 and 2014, respectively. The ED-boarded patients accounted for 2.71% and 2.6% of the total annual emergency visits in 2013 and 2014, respectively. The average waiting time to admit the ED-boarded patients was 37.1 h and 36.2 h in 2013 and 2014, respectively. Respiratory symptoms were the most common presenting complaints, and an upper respiratory infection was the most common ED diagnosis. Patients who had pneumonia or various manifestations of end-stage diseases, such as advanced dementia or multiple organ dysfunction, were the most common characteristics of patients who had stays in “Observation” units. Conclusions One principal reason for ED crowding in Beijing lies in the large numbers of patients who persist in the expectation of receiving ongoing care in the ED for minor illnesses. However, as is true in many nations, one of the other most important root causes of ED crowding is “access block,” the inability to promptly move patients deemed by emergency physicians to need inpatient care to an inpatient bed for that care. However, in our system, another challenge, not widely described as a contributor to crowding in other nations, is that doctors assigned to inpatient services have been empowered to refuse to admit patients perceived to have overly “complex” needs. Further, patients with multisystem illnesses or end-stage status, who need ongoing chronic care to manage activities of daily living, have begun to populate Beijing EDs in increasing numbers. This is an issue with various root causes.
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Ngo H, Forero R, Mountain D, Fatovich D, Man WN, Sprivulis P, Mohsin M, Toloo S, Celenza A, Fitzgerald G, McCarthy S, Hillman K. Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013. PLoS One 2018; 13:e0193902. [PMID: 29538401 PMCID: PMC5851625 DOI: 10.1371/journal.pone.0193902] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 02/22/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning. METHODS A state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique. FINDINGS There were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients. After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most 'crowded' ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing. CONCLUSIONS The FHR had a consistent effect on 'flow' measures: significantly reducing ED overcrowding and access block and enhancing ED efficiency. Time-based outcome measures mostly improved with the FHR. There is some evidence of increased ED attendance, but no evidence of increased ED re-attendance. Effects on patient disposition status were mixed. Overall, this reflects the value of investing resources into the ED/hospital system to improve efficiency and patient experience. Further research is required to illuminate the exact mechanisms of the effects of FHR on the ED and hospital functioning across Australia.
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Affiliation(s)
- Hanh Ngo
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
| | - Roberto Forero
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
| | - David Mountain
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Sir Charles Gairdner Hospital, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Daniel Fatovich
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- Royal Perth Hospital, Perth, WA, Australia
- Centre for Clinical Research in Emergency, University of Western Australia, Nedlands, Perth, WA, Australia
| | - Wing Nicola Man
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
| | - Peter Sprivulis
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit, SWSLHD, NSW Health, Liverpool, Sydney, NSW, Australia
- School of Psychiatry, Faculty of Medicine, UNSW, Kensington, Sydney, NSW, Australia
| | - Sam Toloo
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
| | - Antonio Celenza
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Gerard Fitzgerald
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
| | - Sally McCarthy
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- Emergency Care Institute, NSW Agency for Clinical Innovation, Chatswood, Sydney, NSW, Australia
- Prince of Wales Clinical School, UNSW, Randwick, Sydney, NSW Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
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Zhang X, Kim J, Patzer RE, Pitts SR, Patzer A, Schrager JD. Prediction of Emergency Department Hospital Admission Based on Natural Language Processing and Neural Networks. Methods Inf Med 2017; 56:377-389. [PMID: 28816338 DOI: 10.3414/me17-01-0024] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 07/26/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe and compare logistic regression and neural network modeling strategies to predict hospital admission or transfer following initial presentation to Emergency Department (ED) triage with and without the addition of natural language processing elements. METHODS Using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a cross-sectional probability sample of United States EDs from 2012 and 2013 survey years, we developed several predictive models with the outcome being admission to the hospital or transfer vs. discharge home. We included patient characteristics immediately available after the patient has presented to the ED and undergone a triage process. We used this information to construct logistic regression (LR) and multilayer neural network models (MLNN) which included natural language processing (NLP) and principal component analysis from the patient's reason for visit. Ten-fold cross validation was used to test the predictive capacity of each model and receiver operating curves (AUC) were then calculated for each model. RESULTS Of the 47,200 ED visits from 642 hospitals, 6,335 (13.42%) resulted in hospital admission (or transfer). A total of 48 principal components were extracted by NLP from the reason for visit fields, which explained 75% of the overall variance for hospitalization. In the model including only structured variables, the AUC was 0.824 (95% CI 0.818-0.830) for logistic regression and 0.823 (95% CI 0.817-0.829) for MLNN. Models including only free-text information generated AUC of 0.742 (95% CI 0.731- 0.753) for logistic regression and 0.753 (95% CI 0.742-0.764) for MLNN. When both structured variables and free text variables were included, the AUC reached 0.846 (95% CI 0.839-0.853) for logistic regression and 0.844 (95% CI 0.836-0.852) for MLNN. CONCLUSIONS The predictive accuracy of hospital admission or transfer for patients who presented to ED triage overall was good, and was improved with the inclusion of free text data from a patient's reason for visit regardless of modeling approach. Natural language processing and neural networks that incorporate patient-reported outcome free text may increase predictive accuracy for hospital admission.
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Affiliation(s)
- Xingyu Zhang
- Justin D. Schrager, MD, MPH, Emory University School of Medicine, Department of Emergency Medicine, 531 Asbury Circle, Annex Building N340, Atlanta, GA 30322, USA, E-mail:
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Van Der Linden MC, Khursheed M, Hooda K, Pines JM, Van Der Linden N. Two emergency departments, 6000km apart: Differences in patient flow and staff perceptions about crowding. Int Emerg Nurs 2017; 35:30-36. [PMID: 28659247 DOI: 10.1016/j.ienj.2017.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Emergency department (ED) crowding is a worldwide public health issue. In this study, patient flow and staff perceptions of crowding were assessed in Pakistan (Aga Khan University Hospital (AKUH)) and in the Netherlands (Haaglanden Medical Centre Westeinde (HMCW)). Bottlenecks affecting ED patient flow were identified. METHODS First, a one-year review of patient visits was performed. Second, staff perceptions about ED crowding were collected using face-to-face interviews. Non-participant observation and document review were used to interpret the findings. RESULTS At AKUH 58,839 (160visits/day) and at HMCW 50,802 visits (140visits/day) were registered. Length of stay (LOS) at AKUH was significantly longer than at HMCW (279min (IQR 357) vs. 100min (IQR 152)). There were major differences in patient acuities, admission and mortality rates, indicating a sicker population at AKUH. Respondents from both departments experienced hampered patient flow on a daily basis, and perceived similar causes for crowding: increased patients' complexity, long treatment times, and poor availability of inpatient beds. CONCLUSION Despite differences in environment, demographics, and ED patient flow, respondents perceived similar bottlenecks in patient flow. Interventions should be tailored to specific ED and hospital needs. For both EDs, improving the outflow of boarded patients is essential.
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Affiliation(s)
| | - Munawar Khursheed
- Emergency Department, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Jesse M Pines
- Office for Clinical Practice Innovation, Departments of Emergency Medicine and Health Policy & Management, George Washington University, Washington, DC, USA
| | - Naomi Van Der Linden
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
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Zeitz K, Watson D. Principles of capacity management, applied in the mental health context. AUST HEALTH REV 2017. [PMID: 28637582 DOI: 10.1071/ah17007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective The aim of the paper was to describe a suite of capacity management principles that have been applied in the mental health setting that resulted in a significant reduction in time spent in two emergency departments (ED) and improved throughput. Methods The project consisted of a multifocal change approach over three phases that included: (1) the implementation of a suite of fundamental capacity management activities led by the service and clinical director; (2) a targeted Winter Demand Plan supported by McKinsey and Co.; and (3) a sustainability of change phase. Descriptive statistics was used to analyse the performance data that was collected through-out the project. Results This capacity management project has resulted in sustained patient flow improvement. There was a reduction in the average length of stay (LOS) in the ED for consumers with mental health presentations to the ED. At the commencement of the project, in July 2014, the average LOS was 20.5h compared with 8.5h in December 2015 post the sustainability phase. In July 2014, the percentage of consumers staying longer than 24h was 26% (n=112); in November and December 2015, this had reduced to 6% and 7 5% respectively (less than one consumer per day). Conclusion Improving patient flow is multifactorial. Increased attendances in public EDs by people with mental health problems and the lengthening boarding in the ED affect the overall ED throughput. Key strategies to improve mental health consumer flow need to focus on engagement, leadership, embedding fundamentals, managing and target setting. What is known about the topic? Improving patient flow in the acute sector is an emerging topic in the health literature in response to increasing pressures of access block in EDs. What does this paper add? This paper describes the application of a suite of patient flow improvement principles that were applied in the mental health setting that significantly reduced the waiting time for consumers in two EDs. What are the implications for practitioners? No single improvement will reduce access block in the ED for mental health consumers. Reductions in waiting times require a concerted, multifocal approach across all components of the acute mental health journey.
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Affiliation(s)
- Kathryn Zeitz
- University of Adelaide, Adelaide, SA 5005, Australia
| | - Darryl Watson
- University of Adelaide, Adelaide, SA 5005, Australia
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Muscatello DJ, Bein KJ, Dinh MM. Influenza-associated delays in patient throughput and premature patient departure in emergency departments in New South Wales, Australia: A time series analysis. Emerg Med Australas 2017; 30:77-80. [PMID: 28544364 DOI: 10.1111/1742-6723.12808] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/28/2017] [Accepted: 04/13/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Influenza outbreaks cause overcrowding in EDs. We aimed to quantify the impact of influenza on the National Emergency Access Targets and premature patient departure in New South Wales, Australia. METHODS This was a retrospective observational study of 11 million presentations to 115 hospitals during 2010-2014, using routinely collected administrative records. A time series generalised additive regression model was used to assess the correlation between weekly influenza activity and the weekly proportion of patients leaving the ED in >4 h and the proportion that departed before commencing or completing treatment ('did not wait'), after controlling for background winter and holiday effects. RESULTS During 2011-2014, peak annual circulating influenza was associated with the peak weekly proportion of presentations that left in >4 h. The maximum estimated absolute weekly change in that proportion was 3.88 (95% confidence interval 3.02-4.74) percentage points in 2014. For presentations that did not wait, influenza circulation was associated with statistically significant increases in all years, with a maximum weekly value of 2.68 (95% confidence interval 2.31-3.06) percentage points in 2012. CONCLUSIONS Circulating influenza was associated with sustained increases and peaks in delayed patient throughput and premature patient departures. Influenza surveillance information may assist with development of health system and hospital workforce planning and bed management activities.
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Affiliation(s)
- David J Muscatello
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Kendall J Bein
- Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael M Dinh
- Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Discipline of Emergency Medicine, The University of Sydney, Sydney, New South Wales, Australia
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Factors associated with failure of emergency wait-time targets for high acuity discharges and intensive care unit admissions. CAN J EMERG MED 2017; 20:112-124. [DOI: 10.1017/cem.2017.16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjectiveOntario established emergency department length-of-stay (EDLOS) targets but has difficulty achieving them. We sought to determine predictors of target time failure for discharged high acuity patients and intensive care unit (ICU) admissions.MethodsThis was a retrospective, observational study of 2012 Sunnybrook Hospital emergency department data. The main outcome measure was failing to meet government EDLOS targets for high acuity discharges and ICU emergency admissions. The secondary outcome measures examined factors for low acuity discharges and all admissions, as well as a run chart for 2015 – 2016 ICU admissions. Multiple logistic regression models were created for admissions, ICU admissions, and low and high acuity discharges. Predictor variables were at the patient level from emergency department registries.ResultsFor discharged high acuity patients, factors predicting EDLOS target failure were having physician initial assessment duration (PIAD)>2 hours (OR 5.63 [5.22-6.06]), consultation request (OR 10.23 [9.38-11.14]), magnetic resonance imaging (MRI) (OR 19.33 [12.94-28.87]), computed tomography (CT) (OR 4.24 [3.92-4.59]), and ultrasound (US) (OR 3.47 [3.13-3.83]). For ICU admissions, factors predicting EDLOS target failure were bed request duration (BRD)>6 hours (OR 364.27 [43.20-3071.30]) and access block (AB)>1 hour (OR 217.27 [30.62-1541.63]). For discharged low acuity patients, factors predicting failure for the 4-hour target were PIAD>2 hours (OR 15.80 [13.35-18.71]), consultation (OR 20.98 [14.10-31.22]), MRI (OR 31.68 [6.03-166.54]), CT (OR 16.48 [10.07-26.98]), and troponin I (OR 13.37 [6.30-28.37]).ConclusionSunnybrook factors predicting failure of targets for high acuity discharges and ICU admissions were hospital-controlled. Hospitals should individualize their approach to shortening EDLOS by analysing its patient population and resource demands.
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Zhu T, Luo L, Zhang X, Shen W. Modeling the Length of Stay of Respiratory Patients in Emergency Department Using Coxian Phase-Type Distributions With Covariates. IEEE J Biomed Health Inform 2017; 22:955-965. [PMID: 28489556 DOI: 10.1109/jbhi.2017.2701779] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Variability and unpredictability are typical features of emergency departments (EDs) where patients randomly arrive with diverse conditions. Patient length of stay (LOS) represents the consumption level of hospital resources, and it is positively skewed and heterogeneous. Both accurate modeling of patient ED LOS and analysis of potential blocking causes are especially useful for patient scheduling and resource management. To tackle the uncertainty of ED LOS, this paper introduces two methods: statistical modeling and distribution fitting. The models are applied to 894 respiratory diseases patients data in the year 2014 from ED of a Chinese public tertiary hospital. Covariates recorded include patient region, gender, age, arrival time, arrival mode, triage category, and treatment area. A Coxian phase-type (PH) distribution model with covariates is proposed as an alternative method for modeling ED LOS. The expectation-maximization (EM) algorithm is used to implement parameter estimation. The results show that ED LOS data can be modeled well by the proposed models. Distributions of ED LOS differ significantly with respect to patients' gender, arrival mode, and treatment area. Using the fitted Coxian PH model will assist ED managers in identifying patients who are most likely to have an extreme ED LOS and in predicting the forthcoming workload for resources.
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Strudwick K, Bell A, Russell T, Martin-Khan M. Developing quality indicators for the care of patients with musculoskeletal injuries in the Emergency Department: study protocol. BMC Emerg Med 2017; 17:14. [PMID: 28476098 PMCID: PMC5420082 DOI: 10.1186/s12873-017-0124-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/18/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Musculoskeletal injuries are a common presentation to the Emergency Department (ED). The quality of care provided is important to the patients, clinicians, organisations and purchasers of care. In the context of the increasing burden of musculoskeletal disease, quality of care needs to occur despite financial impacts, variations in care, and pressure to reach time-based performance measures. This study aims to develop a suite of evidence-based quality indicators (QI) which will provide a measure of the quality of care for patients with musculoskeletal injuries in the ED. METHODS This study will utilise a multi-phase mixed methods protocol, commencing with a systematic review of the literature to identify and critically appraise existing QIs for musculoskeletal injuries in the ED. The study will then build on the gaps identified in the review to develop a suite of preliminary QIs, in accordance with established research methodology under the governance of an expert panel. The developed QI set will then be field-tested for feasibility and validity in selected EDs. After field-testing, the suite will be refined in consultation with the expert panel and finalised using a formal voting process. DISCUSSION The assessment of performance against QIs provides a quantitative measure for the quality of care provided to patients, to identify and target quality improvement activities. The QIs developed through this study will be evidence-based and balanced across the areas of structures, processes and outcomes. The rigorous methodology used to develop and test the QIs will result in QIs that are meaningful, valid, feasible to collect and efficiently measurable, amenable to improvement, and selected by experts in the emergency medicine field. The final QI suite will have applications across EDs that affords comparison, benchmarking and optimisation of emergency care for patients.
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Affiliation(s)
- Kirsten Strudwick
- Emergency and Physiotherapy Departments, QEII Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland Australia
- School of Health and Rehabilitation, The University of Queensland, Brisbane, Queensland Australia
| | - Anthony Bell
- Department of Emergency Medicine, The Royal Brisbane and Women’s Hospital, Metro North Hospital and Health Service, Brisbane, Queensland Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland Australia
| | - Trevor Russell
- School of Health and Rehabilitation, The University of Queensland, Brisbane, Queensland Australia
| | - Melinda Martin-Khan
- Centre for Research in Geriatric Medicine, School of Medicine, The University of Queensland, Brisbane, Queensland Australia
- Centre for Online Health, School of Medicine, The University of Queensland, Brisbane, Queensland Australia
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The impact of an Emergency Department ambulance offload nurse role: A retrospective comparative study. Int Emerg Nurs 2017; 32:39-44. [DOI: 10.1016/j.ienj.2016.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 12/11/2016] [Accepted: 12/21/2016] [Indexed: 11/22/2022]
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Shetty AL, Teh C, Vukasovic M, Joyce S, Vaghasiya MR, Forero R. Impact of emergency department discharge stream short stay unit performance and hospital bed occupancy rates on access and patient flowmeasures: A single site study. Emerg Med Australas 2017; 29:407-414. [DOI: 10.1111/1742-6723.12777] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/19/2017] [Accepted: 02/20/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Amith L Shetty
- Emergency Department; Westmead Hospital; Sydney New South Wales Australia
- Sydney Medical School - Westmead Campus, The University of Sydney; Sydney New South Wales Australia
| | - Caleb Teh
- The Sydney Children's Hospitals Network, The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Matthew Vukasovic
- Emergency Department; Westmead Hospital; Sydney New South Wales Australia
| | - Shannon Joyce
- Emergency Department; Westmead Hospital; Sydney New South Wales Australia
| | - Milan R Vaghasiya
- Emergency Department; Westmead Hospital; Sydney New South Wales Australia
| | - Roberto Forero
- Health Services Planning, Simpson Centre for Health Services Research, South Western Sydney Clinical School; The University of New South Wales; Sydney New South Wales Australia
- The Ingham Institute for Applied Research; Liverpool Hospital; Liverpool New South Wales Australia
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Gibson A, Randall D, Tran DT, Byrne M, Lawler A, Havard A, Robinson M, Jorm LR. Emergency Department Attendance after Telephone Triage: A Population-Based Data Linkage Study. Health Serv Res 2017; 53:1137-1162. [PMID: 28369871 DOI: 10.1111/1475-6773.12692] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To investigate compliance with telephone helpline advice to attend an emergency department (ED) and the acuity of patients who presented to ED following a call. DATA SOURCES/COLLECTION METHODS In New South Wales (NSW), Australia, 2009-2012, all (1.04 million) calls to a telephone triage service, ED presentations, hospital admissions and death registrations, linked using probabilistic data linkage. STUDY DESIGN Population-based, observational cohort study measuring ED presentations within 24 hours of a call in patients (1) with dispositions to attend ED (compliance) and (2) low-urgency dispositions (self-referral), triage categories on ED presentation. PRINCIPAL FINDINGS A total of 66.5 percent of patients were compliant with dispositions to attend an ED. A total of 6.2 percent of patients with low-urgency dispositions self-referred to the ED within 24 hours. After age adjustment, healthdirect compliant patients were significantly less likely (7.8 percent) to receive the least urgent ED triage category compared to the general NSW ED population (16.9 percent). CONCLUSIONS This large population-based data linkage study provides precise estimates of ED attendance following calls to a telephone triage service and details the predictors of ED attendance. Patients who attend an ED compliant with a healthdirect helpline disposition are significantly less likely than the general ED population to receive the lowest urgency triage category on arrival.
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Affiliation(s)
- Amy Gibson
- Centre for Big Data Research in Health, UNSW, Sydney, NSW, Australia
| | - Deborah Randall
- Centre for Big Data Research in Health, UNSW, Sydney, NSW, Australia
| | - Duong T Tran
- Centre for Big Data Research in Health, UNSW, Sydney, NSW, Australia
| | - Mary Byrne
- Healthdirect Australia, Sydney, NSW, Australia
| | - Anthony Lawler
- Department of Health and Human Services, University of Tasmania and Healthdirect Australia, Hobart, Tasmania, Australia
| | - Alys Havard
- Centre for Big Data Research in Health, UNSW, Sydney, NSW, Australia
| | - Maureen Robinson
- Healthdirect Australia, Clinical Governance, Sydney, NSW, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health, UNSW, Sydney, NSW, Australia
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Abstract
The number of patients treated in hospital emergency departments in Germany has risen in recent years to approximately 20 million. This escalation also applies to the increasing numbers of patients presenting with neurological symptoms and diseases, which occur in approximately 20 % of emergency patients. In addition to patients with stroke, inflammatory or degenerative central nervous system (CNS) and peripheral nervous system (PNS) disorders who need urgent treatment, more and more patients with nonspecific complaints or conditions attend emergency departments for elective treatment, not least because timely appointments with specialist neurologists in practices could not be obtained. Neurological expertise and presence in emergency departments at the level of specialist standard are therefore indispensable for providing a professional level of treatment, which also corresponds to current legal requirements. The implementation of a generalist emergency physician in Germany, as introduced in some European countries, would mean a retrograde step for neurological expertise in emergency admission management. The discipline of neurology must work together with other emergency disciplines to improve the financing of emergency departments and provide neurologists working there with a substantive curriculum of further and continuing education in emergency-related aspects of neurology. The discipline of neurology has a responsibility to emergency patients within its range of competencies and must, therefore, strengthen and improve its role in healthcare politics and concerning organizational and personnel aspects of neurological emergencies.
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Backay A, Bystrzycki A, Smit DV, Keogh M, O'Reilly G, Mitra B. Accuracy of rapid disposition by emergency clinicians. AUST HEALTH REV 2017. [DOI: 10.1071/ah15052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives Rapid disposition protocols are increasingly being considered for implementation in emergency departments (EDs). Among patients presenting to an adult tertiary referral hospital, this study aimed to compare prediction accuracy of a rapid disposition decision at the conclusion of history and examination, compared with disposition following standard assessment. Methods Prospective observational data were collected for 1 month between October and November 2012. Emergency clinicians (including physicians, registrars, hospital medical officers, interns and nurse practitioners) filled out a questionnaire within 5 min of obtaining a history and clinical examination for eligible patients. Predicted patient disposition (representing ‘rapid disposition’) was compared with final disposition (determined by ‘standard assessment’). Results There were 301 patient episodes included in the study. Predicted disposition was correct in 249 (82.7%, 95% confidence interval (CI) 78.0–86.8) cases. Accuracy of predicting discharge to home appeared highest among emergency physicians at 95.8% (95% CI 78.9–99.9). Overall accuracy at predicting admission was 79.7% (95% CI 67.2–89.0). The remaining 20.3% (95% CI 11.0–32.8) were not admitted following standard assessment. Conclusion Rapid disposition by ED clinicians can predict patient destination accurately but was associated with a potential increase in admission rates. Any model of care using rapid disposition decision making should involve establishment of inpatient systems for further assessment, and a culture of timely inpatient team transfer of patients to the most appropriate treating team for ongoing patient management. What is known about the topic? In response to the National Emergency Access Targets, there has been widespread adoption of rapid-disposition-themed care models across Australia. Although there is emerging data that clinicians can predict disposition accurately, this data is currently limited. What does this paper add? Results of this study support the previously limited evidence that ED practitioners can accurately predict disposition early in the patient journey through ED, and that accuracy is similar across clinician groups. In addition to overall prediction accuracy, admission, discharge and treating team predictions were separately measured. These additional outcomes lend insight into safety and performance aspects relating to a rapid disposition model of care. What are the implications for practitioners? This study offers practical insights that could aid safe and efficient implementation of a rapid disposition model of care.
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[Position paper for a reform of medical emergency care in German emergency departments]. Med Klin Intensivmed Notfmed 2016; 110:364-75. [PMID: 26024948 DOI: 10.1007/s00063-015-0050-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The hospital emergency departments play a central role for the in- and outpatient care of patients with medical emergencies in Germany. In this position paper we point out some general financial and organizational problems of German emergency departments and urge for a higher significance of emergency care in the German health system as an element of public services. The corresponding reform proposals include a change in hospital financing towards a more budget-based system for the emergency departments, an improved structural planning for regional and transregional emergency care, an intensified cooperation with the emergency services of the ambulatory care physicians, a better organizational representation of emergency care within the hospitals and an advancement of emergency medicine in postgraduate medical education.
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Oliveira GN, Vancini-Campanharo CR, Lopes MCBT, Barbosa DA, Okuno MFP, Batista REA. Correlation between classification in risk categories and clinical aspects and outcomes. Rev Lat Am Enfermagem 2016; 24:e2842. [PMID: 27982310 PMCID: PMC5171782 DOI: 10.1590/1518-8345.1284.2842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 09/23/2016] [Indexed: 12/04/2022] Open
Abstract
Objective to correlate classification in risk categories with the clinical profiles, outcomes and origins of patients. Method analytical cross-sectional study conducted with 697 medical forms of adult patients. The variables included: age, sex, origin, signs and symptoms, exams, personal antecedents, classification in risk categories, medical specialties, and outcome. The Chi-square and likelihood ratio tests were used to associate classifications in risk categories with origin, signs and symptoms, exams, personal antecedents, medical specialty, and outcome. Results most patients were women with an average age of 44.5 years. Pain and dyspnea were the symptoms most frequently reported while hypertension and diabetes mellitus were the most common comorbidities. Classifications in the green and yellow categories were the most frequent and hospital discharge the most common outcome. Patients classified in the red category presented the highest percentage of ambulance origin due to surgical reasons. Those classified in the orange and red categories also presented the highest percentage of hospitalization and death. Conclusion correlation between clinical aspects and outcomes indicate there is a relationship between the complexity of components in the categories with greater severity, evidenced by the highest percentage of hospitalization and death.
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Affiliation(s)
- Gabriella Novelli Oliveira
- Master's student, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil, Enfermeira, Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Dulce Aparecida Barbosa
- PhD, Associated Professor, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Ruth Ester Assayag Batista
- PhD, Adjunct Professor, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Are all after-hours diagnostic imaging appropriate? An Australian Emergency Department pilot study. Ann Med Surg (Lond) 2016; 12:75-78. [PMID: 27942379 PMCID: PMC5134081 DOI: 10.1016/j.amsu.2016.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/22/2016] [Accepted: 11/22/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This study was aimed at determining the extent to which after-hours diagnostic imaging is appropriate within the case hospital's Emergency Department. This was amid growing concerns of the inappropriateness of some medical investigations within the Australian health-care system. METHODS After-hours referral data and patient notes were used in reviewing the clinical case. Diagnostic imaging was deemed appropriate if reflective of clinical guidelines, and if not reflective, whether the investigation changed the patient's ongoing management. RESULTS Results indicated that 96.37% of after-hours diagnostic imaging adhered to clinical guidelines and was appropriately requested, with 95.85% changing the ongoing management of the patient. The most sought after diagnostic imaging procedures were Chest X-Ray (30.83%), and CT Brain (16.58%), with 99.16% and 98.44 appropriateness respectively. Chest pain (14.49%) and motor vehicle accidents (8.12%) were the leading reason for ordering after-hours imaging. CONCLUSION This study provided an Emergency Department example as it relates to after-hours diagnostic imaging appropriateness. This study found that most after-hours referrals were appropriate.
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‘Care in a chair’ – The impact of an overcrowded Emergency Department on the time to treatment and length of stay of self-presenting patients with abdominal pain. Int Emerg Nurs 2016; 29:9-14. [DOI: 10.1016/j.ienj.2016.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 08/01/2016] [Accepted: 08/14/2016] [Indexed: 11/20/2022]
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Emergency department crowding affects triage processes. Int Emerg Nurs 2016; 29:27-31. [DOI: 10.1016/j.ienj.2016.02.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 02/10/2016] [Accepted: 02/21/2016] [Indexed: 11/19/2022]
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Effects of emergency department crowding on the delivery of timely care in an inner-city hospital in the Netherlands. Eur J Emerg Med 2016; 23:337-43. [DOI: 10.1097/mej.0000000000000268] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Blom MC, Erwander K, Gustafsson L, Landin-Olsson M, Jonsson F, Ivarsson K. Primary triage nurses do not divert patients away from the emergency department at times of high in-hospital bed occupancy - a retrospective cohort study. BMC Emerg Med 2016; 16:39. [PMID: 27658706 PMCID: PMC5034663 DOI: 10.1186/s12873-016-0102-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 09/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency department (ED) overcrowding is frequently described in terms of input- throughput and output. In order to reduce ED input, a concept called primary triage has been introduced in several Swedish EDs. In short, primary triage means that a nurse separately evaluates patients who present in the Emergency Department (ED) and either refers them to primary care or discharges them home, if their complaints are perceived as being of low acuity. The aim of the present study is to elucidate whether high levels of in-hospital bed occupancy are associated with decreased permeability in primary triage. The appropriateness of discharges from primary triage is assessed by 72-h revisits to the ED. METHODS The study is a retrospective cohort study on administrative data from the ED at a 420-bed hospital in southern Sweden from 2011-2012. In addition to crude comparisons of proportions experiencing each outcome across strata of in-hospital bed occupancy, multivariate models are constructed in order to adjust for age, sex and other factors. RESULTS A total of 37,129 visits to primary triage were included in the study. 53.4 % of these were admitted to the ED. Among the cases referred to another level of care, 8.8 % made an unplanned revisit to the ED within 72 h. The permeability of primary triage was not decreased at higher levels of in-hospital bed occupancy. Rather, the permeability was slightly higher at occupancy of 100-105 % compared to <95 % (OR 1.09 95 % CI 1.02-1.16). No significant association between in-hospital bed occupancy and the probability of 72-h revisits was observed. CONCLUSIONS The absence of a decreased permeability of primary triage at times of high in-hospital bed occupancy is reassuring, as the opposite would have implied that patients might be denied entry not only to the hospital, but also to the ED, when in-hospital beds are scarce.
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Affiliation(s)
- Mathias C Blom
- IKVL/Avd för medicin, Universitetssjukhuset, Hs 32, EA-blocket, plan 2, 221 85 Lund, Sweden
| | - Karin Erwander
- IKVL/Avd för medicin, Universitetssjukhuset, Hs 32, EA-blocket, plan 2, 221 85 Lund, Sweden
| | - Lars Gustafsson
- Helsingborgs lasarett, IK-enheten, S Vallgatan 5, 251 87 Helsingborg, Sweden
| | - Mona Landin-Olsson
- IKVL/Avd för medicin, Universitetssjukhuset, Hs 32, EA-blocket, plan 2, 221 85 Lund, Sweden
| | - Fredrik Jonsson
- Pre- och intrahospital akutsjukvård, Helsingborgs lasarett, S Vallgatan 5, 251 87 Helsingborg, Sweden
| | - Kjell Ivarsson
- IKVL/Avd för medicin, Universitetssjukhuset, Hs 32, EA-blocket, plan 2, 221 85 Lund, Sweden
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80
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Efficiency in the emergency department - A complex relationship between throughput rates and staff perceptions. Int Emerg Nurs 2016; 29:15-20. [PMID: 27524106 DOI: 10.1016/j.ienj.2016.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/16/2016] [Accepted: 07/28/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION It is well known that emergency departments (EDs) suffer from crowding and throughput challenges, which make the ED a challenging workplace. However, the interplay between the throughput of patients and how staff experience work is seldom studied. The aim of this study was to investigate whether staff experience of work (efficiency, work-related efforts and rewards, and quantity and quality of work) differs between days with low and high patient throughput rates. METHOD Throughput times were collected from electronic medical records and staff (n=252 individuals, mainly nurses) ratings in daily questionnaires over a total of six weeks. Days were grouped into low and high throughput rate days for the orthopedic, surgical and internal medicine sections, respectively, and staff ratings were compared. RESULTS On days with low throughput rates, employees rated their efficiency, effort, reward and quantity of work significantly higher than on days with high throughput rates. There was no difference in perceived quality of work. CONCLUSIONS There is a complex relationship between ED throughput rates and staff perceptions of efficiency and efforts/rewards with work, suggesting that whereas low throughput may be troublesome from a patient and organizational perspective, working conditions may still be perceived as more favorable.
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81
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Mustafa F, Gilligan P, Obu D, O'Kelly P, O'Hea E, Lloyd C, Kelada S, Heffernan A, Houlihan P. 'Delayed discharges and boarders': a 2-year study of the relationship between patients experiencing delayed discharges from an acute hospital and boarding of admitted patients in a crowded ED. Emerg Med J 2016; 33:636-40. [PMID: 27352789 DOI: 10.1136/emermed-2015-205039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 06/06/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Many believe that hospital crowding manifesting in the ED with the boarding of admitted patients is a result of significant numbers of acute hospital beds being occupied by patients awaiting discharge to nursing homes, step-down facilities or home with or without additional support. This observational study was performed to establish the actual relationship between boarders in the ED and patients experiencing delayed discharge. METHODS Data relating to the number of patients in the ED and their points in their patient pathway were entered into a logbook on a daily basis by the most senior doctor on duty. 630 days of observations of patients boarded in the ED were compared with the number of inpatients with delayed discharges, obtained from the hospital information system, to see if large numbers of inpatients with delayed discharges are associated with crowding in the ED. RESULTS Two years of data showed an annual ED census of more than 47 000, with a daily mean ED admission rate of 29.85 patients and a daily mean ED boarding figure of 29 patients. A mean of 15.4% of the 823 hospital beds was occupied by patients with delayed discharges, and the hospital ran at, or near, full capacity (99%-105%) all the time. Results obtained highlighted a statistically significant relationship between delayed discharges in the hospital and ED crowding as a result of boarders (p value<0.001, with a regression coefficient of 0.16, 95% CI 0.12 to 0.20). The study also showed that the number of boarders was related to the number of ED admissions in the preceding 24 hours (p=0.036, with a regression coefficient of 0.14, 95% CI 0.05 to 0.28). CONCLUSIONS Delayed hospital discharges significantly contribute to crowding in the ED. Healthcare systems should target timely discharge of inpatients experiencing delayed discharge in an urgent and efficient manner to improve timely access to acute hospital beds for patients requiring emergency admission.
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Affiliation(s)
- Farah Mustafa
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
| | - Peadar Gilligan
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
| | - Deborah Obu
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
| | | | - Eimear O'Hea
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sherif Kelada
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
| | | | - Patricia Houlihan
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
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Mountain D, Ercleve T, Allely P, McQuillan B, Yamen E, Beilby J, Lim EM, Rogers J, Geelhoed E. REACTED - Reducing Acute Chest pain Time in the ED: A prospective pre-/post-interventional cohort study, stratifying risk using early cardiac multi-markers, probably increases discharges safely. Emerg Med Australas 2016; 28:383-90. [DOI: 10.1111/1742-6723.12590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 01/05/2016] [Accepted: 02/14/2016] [Indexed: 11/30/2022]
Affiliation(s)
- David Mountain
- School of Primary, Aboriginal and Rural Health Care (Emergency); University of Western Australia; Perth Western Australia Australia
- Department of Emergency Medicine; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Tor Ercleve
- School of Primary, Aboriginal and Rural Health Care (Emergency); University of Western Australia; Perth Western Australia Australia
- Department of Emergency Medicine; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Peter Allely
- School of Primary, Aboriginal and Rural Health Care (Emergency); University of Western Australia; Perth Western Australia Australia
- Department of Emergency Medicine; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Brendan McQuillan
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
- Department of Cardiovascular Medicine; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Eric Yamen
- Department of Cardiovascular Medicine; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - John Beilby
- School of Pathology and Laboratory Medicine; University of Western Australia; Perth Western Australia Australia
- Department of Biochemistry; Pathwest; Perth Western Australia Australia
| | - Ee-Mun Lim
- School of Pathology and Laboratory Medicine; University of Western Australia; Perth Western Australia Australia
- Department of Biochemistry; Pathwest; Perth Western Australia Australia
| | - Jeremy Rogers
- Faculty of Medicine, Dentistry and Health Sciences; University of Western Australia; Perth Western Australia Australia
| | - Elizabeth Geelhoed
- School of Population Health; University of Western Australia; Perth Western Australia Australia
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Tse R, Thompson N, Moscova M, Sindhusake D, Shetty A, Young N. Do delays in radiology lead to breaches in the 4-hour rule? Clin Radiol 2016; 71:523-31. [PMID: 26997429 DOI: 10.1016/j.crad.2016.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 01/27/2016] [Accepted: 02/08/2016] [Indexed: 10/22/2022]
Abstract
AIM To assess trends in medical imaging requests before and after the 4-hour rule commenced and to assess the imaging time component of emergency department (ED) length of stay (LOS). MATERIALS AND METHODS Retrospective analysis of ED patients and imaging requests 1 year prior to and 3 years after implementation of the 4-hour rule (April to December for 2011-2014) was performed at a single adult tertiary referral Level 1 trauma hospital with Level 6 ED. Logistic regression was used to evaluate trends in the number of ED patient presentations, patient triage categories, and imaging requests for these patients. The imaging component of the total ED LOS was compared for patients who met the 4-hour target and patients who did not. RESULTS Compared to 2011 (before the 4-hour rule), ED presentations increased 4.74% in 2012, 12.7% in 2013, 21.28% in 2014 (p<0.01). Total imaging requests increased 23.05% in 2012, 48.04% in 2013, 60.77% in 2014 (p<0.01). For patients breaching the 4-hour rule, the mean time before radiology request was 2.4-2.8 hours; mean time from imaging request to completion was 1.2-1.3 hours; mean time from imaging completion to discharge from ED was the longest component of ED LOS (4.9-5.9 hours). CONCLUSIONS There has been a significant increase in imaging requests, with a trend towards more CT and less radiography requests. Imaging requests for patients who breached the 4-hour target were made on average 2.4-2.8 hours after triage and average time after imaging in itself, exceeded 4 hours. Imaging is not likely a causative factor for patients breaching the 4-hour target.
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Affiliation(s)
- R Tse
- Department of Radiology, Westmead Hospital, Hawkesbury Rd, Westmead, NSW 2145, Australia
| | - N Thompson
- Department of Radiology, Westmead Hospital, Hawkesbury Rd, Westmead, NSW 2145, Australia
| | - M Moscova
- Graduate School of Medicine, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia; Faculty of Medicine, The University of Sydney, NSW 2006, Australia.
| | - D Sindhusake
- School of Medicine, Western Sydney University, Campbelltown, NSW, Australia
| | - A Shetty
- Faculty of Medicine, The University of Sydney, NSW 2006, Australia; Emergency Department, Westmead Hospital, Hawkesbury Rd, Westmead, NSW, Australia; NHMRC Centre of Excellence in Critical Infection, Westmead Millennium Institute, Westmead Hospital Emergency Department, Corner Hawkesbury and Darcy Roads, Westmead, NSW 2145, Australia
| | - N Young
- Department of Radiology, Westmead Hospital, Hawkesbury Rd, Westmead, NSW 2145, Australia; Faculty of Medicine, The University of Sydney, NSW 2006, Australia
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84
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A review of inpatient ward location and the relationship to Medical Emergency Team calls. Int Emerg Nurs 2016; 31:52-57. [PMID: 26970906 DOI: 10.1016/j.ienj.2016.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 02/17/2016] [Accepted: 02/21/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify the relationship between in-hospital location and patient outcomes as measured by Medical Emergency Team calls. STUDY DESIGN A narrative systematic review of the literature. DATA SOURCES A systematic search of the literature was conducted in October 2014 using the electronic databases: Embase, Cochrane, Medline, CINAHL, Science Direct and Google Scholar for the most recent literature from 1997 to 2014. INCLUSION CRITERIA Non-randomised study designs such as case control or cohort studies were eligible. Articles were selected independently by two researchers using a predetermined selection criterion. DATA SYNTHESIS The screening process removed manuscripts that did not meet the inclusion criteria resulting in an empty review with one manuscript meeting most of the criteria for inclusion. The protocol was revised to a narrative synthesis including a broader scope of studies. The search strategy was expanded and modified to include manuscripts of any study design that comprise both inlier and outlier patients. Two manuscripts were selected for the narrative synthesis. CONCLUSION Two recently published studies investigated the incidence of MET calls for outlier patients, and whilst MET calls were increased in outlier hospital patients, definitive conclusions associated with patient outcomes cannot be made at this time due to paucity of studies.
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85
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Warren MB, Campbell RL, Nestler DM, Pasupathy KS, Lohse CM, Koch KA, Schlechtinger E, Schmidt ST, Melin GJ. Prolonged length of stay in ED psychiatric patients: a multivariable predictive model. Am J Emerg Med 2016; 34:133-9. [DOI: 10.1016/j.ajem.2015.09.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 09/10/2015] [Accepted: 09/26/2015] [Indexed: 10/23/2022] Open
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Freund Y, Rousseau A, Guyot-Rousseau F, Claessens YE, Hugli O, Sanchez O, Simon T, Riou B. PERC rule to exclude the diagnosis of pulmonary embolism in emergency low-risk patients: study protocol for the PROPER randomized controlled study. Trials 2015; 16:537. [PMID: 26607669 PMCID: PMC4660778 DOI: 10.1186/s13063-015-1049-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/06/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The diagnosis of Pulmonary Embolism (PE) in the emergency department (ED) is crucial. As emergency physicians fear missing this potential life-threatening condition, PE tends to be over-investigated, exposing patients to unnecessary risks and uncertain benefit in terms of outcome. The Pulmonary Embolism Rule-out Criteria (PERC) is an eight-item block of clinical criteria that can identify patients who can safely be discharged from the ED without further investigation for PE. The endorsement of this rule could markedly reduce the number of irradiative imaging studies, ED length of stay, and rate of adverse events resulting from both diagnostic and therapeutic interventions. Several retrospective and prospective studies have shown the safety and benefits of the PERC rule for PE diagnosis in low-risk patients, but the validity of this rule is still controversial. We hypothesize that in European patients with a low gestalt clinical probability and who are PERC-negative, PE can be safely ruled out and the patient discharged without further testing. METHODS/DESIGN This is a controlled, cluster randomized trial, in 15 centers in France. Each center will be randomized for the sequence of intervention periods: a 6-month intervention period (PERC-based strategy) followed by a 6-month control period (usual care), or in reverse order, with 2 months of "wash-out" between the 2 periods. Adult patients presenting to the ED with a suspicion of PE and a low pre test probability estimated by clinical gestalt will be eligible. The primary outcome is the percentage of failure resulting from the diagnostic strategy, defined as diagnosed venous thromboembolic events at 3-month follow-up, among patients for whom PE has been initially ruled out. DISCUSSION The PERC rule has the potential to decrease the number of irradiative imaging studies in the ED, and is reported to be safe. However, no randomized study has ever validated the safety of PERC. Furthermore, some studies have challenged the safety of a PERC-based strategy to rule-out PE, especially in Europe where the prevalence of PE diagnosed in the ED is high. The PROPER study should provide high-quality evidence to settle this issue. If it confirms the safety of the PERC rule, physicians will be able to reduce the number of investigations, associated subsequent adverse events, costs, and ED length of stay for patients with a low clinical probability of PE. TRIAL REGISTRATION NCT02375919 .
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Affiliation(s)
- Yonathan Freund
- Paris Sorbonne Université, UPMC univ-Paris 6, UMRS INSERM 1166, IHU ICAN, Paris, France. .,Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
| | - Alexandra Rousseau
- Plateforme de recherche clinique de l'est parisien (URCEST-CRCEST), Hôpital St Antoine, APHP, Paris, France.
| | - France Guyot-Rousseau
- Plateforme de recherche clinique de l'est parisien (URCEST-CRCEST), Hôpital St Antoine, APHP, Paris, France.
| | | | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland.
| | - Olivier Sanchez
- Pneumology and Intensive Care Unit, Hôpital Européen Georges Pompidou, APHP, Université Paris Descartes, Sorbonne Paris Cite, Paris, France.
| | - Tabassome Simon
- Paris Sorbonne Université, UPMC univ-Paris 6, UMRS INSERM 1166, IHU ICAN, Paris, France. .,Plateforme de recherche clinique de l'est parisien (URCEST-CRCEST), Hôpital St Antoine, APHP, Paris, France.
| | - Bruno Riou
- Paris Sorbonne Université, UPMC univ-Paris 6, UMRS INSERM 1166, IHU ICAN, Paris, France. .,Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
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87
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Becker JB, Lopes MCBT, Pinto MF, Campanharo CRV, Barbosa DA, Batista REA. Triage at the Emergency Department: association between triage levels and patient outcome. Rev Esc Enferm USP 2015; 49:783-9. [DOI: 10.1590/s0080-623420150000500011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 07/09/2015] [Indexed: 11/22/2022] Open
Abstract
AbstractOBJECTIVEIdentify association between sociodemographic, clinical and triage categories with protocol outcomes developed at Hospital São Paulo (HSP).METHODSRetrospective cohort study conducted with patients older than 18 years submitted to the triage protocol in August 2012. Logistic regression was used to associate the risk categories to outcomes (p-value ≤0,05).RESULTSMen with older age and those treated in clinical specialties had higher rates of hospitalization and death. Patients in the high-priority group had hospitalization and mortality rates five and 10.6 times, respectively (p < 0.0001).CONCLUSIONThe high-priority group experienced higher hospitalization and mortality rates. The protocol was able to detect patients with more urgent conditions and to identify risk factors for hospitalization and death.
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88
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The impact of a flow strategy for patients who presented to an Australian emergency department with a mental health illness. Int Emerg Nurs 2015; 23:265-73. [DOI: 10.1016/j.ienj.2015.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 01/29/2015] [Accepted: 01/31/2015] [Indexed: 11/20/2022]
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Ben-Yakov M, Kapral MK, Fang J, Li S, Vermeulen MJ, Schull MJ. The Association Between Emergency Department Crowding and the Disposition of Patients With Transient Ischemic Attack or Minor Stroke. Acad Emerg Med 2015; 22:1145-54. [PMID: 26398233 DOI: 10.1111/acem.12766] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 02/13/2015] [Accepted: 05/25/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergency department (ED) crowding has been associated with adverse events, including short-term death and hospitalization among discharged patients. The mechanisms are poorly understood, but may include altered physician decision-making about ED discharge of higher-risk patients. One example is patients with transient ischemic attack (TIA) and minor stroke, who are at high risk of subsequent stroke. While hospitalization is frequently recommended, little consensus exists on which patients require admission. OBJECTIVES The authors sought to determine the association of ED crowding with the disposition of patients with minor stroke or TIA. METHODS This was a retrospective cohort study of prospectively collected data from the Registry of the Canadian Stroke Network at 12 EDs in Ontario, Canada, between 2003 and 2008, linked to administrative health databases. A hierarchical logistic regression model was used to determine the association between crowding at the time the patient was seen in the ED (defined as mean ED length of stay) and patient disposition (admission/discharge), after adjusting for patient and hospital-level variables. RESULTS The study cohort included 9,759 patients (4,607 with TIA and 5,152 with minor stroke); 49.5% were discharged from the ED. The mean (±SD) age of study patients was 70.78 (±13.40) years, with 52.9% being male, 37.3% arriving by emergency medical services, and 92.3% triaged as emergent or urgent. Greater severity of ED crowding was associated with a lower likelihood of discharge, regardless of ED size. CONCLUSIONS These results suggest that crowding may influence clinical decision-making in the disposition of patients with TIA or minor stroke and that, as crowding worsens, the likelihood of hospitalization increases.
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Affiliation(s)
- Maxim Ben-Yakov
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Department of Emergency Medicine Sick Kids Hospital; Toronto Ontario Canada
| | - Moira K. Kapral
- Division of General Internal Medicine; University Health Network; Institute for Clinical Evaluative Sciences; Institute for Health Policy, Management and Evaluation; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Canadian Stroke Network; Ottawa Ontario Canada
| | - Jiming Fang
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Research Institute; Institute for Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Shudong Li
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Research Institute; Institute for Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Marian J. Vermeulen
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Research Institute; Institute for Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Clinical Epidemiology Unit; Sunnybrook Health Sciences Centre; Toronto Ontario Canada
| | - Michael J. Schull
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Clinical Epidemiology Unit; Sunnybrook Health Sciences Centre; Toronto Ontario Canada
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Boden DG, Agarwal A, Hussain T, Martin SJ, Radford N, Riyat MS, So K, Su Y, Turvey A, Whale CI. Lowering levels of bed occupancy is associated with decreased inhospital mortality and improved performance on the 4-hour target in a UK District General Hospital. Emerg Med J 2015; 33:85-90. [PMID: 26380995 DOI: 10.1136/emermed-2014-204479] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 07/23/2015] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To evaluate whether there is an association between an intervention to reduce medical bed occupancy and performance on the 4-hour target and hospital mortality. METHODS This before-and-after study was undertaken in a large UK District General Hospital over a 32 month period. A range of interventions were undertaken to reduce medical bed occupancy within the Trust. Performance on the 4-hour target and hospital mortality (hospital standardised mortality ratio (HSMR), summary hospital-level mortality indicator (SHMI) and crude mortality) were compared before, and after, intervention. Daily data on medical bed occupancy and percentage of patients meeting the 4-hour target was collected from hospital records. Segmented regression analysis of interrupted time-series method was used to estimate the changes in levels and trends in average medical bed occupancy, monthly performance on the target and monthly mortality measures (HSMR, SHMI and crude mortality) that followed the intervention. RESULTS Mean medical bed occupancy decreased significantly from 93.7% to 90.2% (p=0.02). The trend change in target performance, when comparing preintervention and postintervention, revealed a significant improvement (p=0.019). The intervention was associated with a mean reduction in all markers of mortality (range 4.5-4.8%). SHMI (p=0.02) and crude mortality (p=0.018) showed significant trend changes after intervention. CONCLUSIONS Lowering medical bed occupancy is associated with reduced patient mortality and improved ability of the acute Trust to achieve the 95% 4-hour target. Whole system transformation is required to create lower average medical bed occupancy.
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Affiliation(s)
- D G Boden
- Emergency Department, Royal Derby Hospital, Derby, UK
| | - A Agarwal
- Division of Medicine, Royal Derby Hospital, Derby, UK
| | - T Hussain
- Division of Medicine, Royal Derby Hospital, Derby, UK
| | - S J Martin
- Division of Medicine, Royal Derby Hospital, Derby, UK
| | - N Radford
- Department of Operations, Royal Derby Hospital, Derby, UK
| | - M S Riyat
- Emergency Department, Royal Derby Hospital, Derby, UK
| | - K So
- Emergency Department, Royal Derby Hospital, Derby, UK
| | - Y Su
- Dr Su Statistics, Consulting firm, Kaunakakai, Hawaii, USA
| | - A Turvey
- Information Services, RDH, Derby, UK
| | - C I Whale
- Division of Medicine, Royal Derby Hospital, Derby, UK
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Innes K, Crawford K, Jones T, Blight R, Trenham C, Williams A, Griffiths D, Morphet J. Transdisciplinary care in the emergency department: A qualitative analysis. Int Emerg Nurs 2015; 25:27-31. [PMID: 26248807 DOI: 10.1016/j.ienj.2015.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 07/10/2015] [Accepted: 07/16/2015] [Indexed: 11/26/2022]
Abstract
In response to increasing demands some emergency departments have introduced transdisciplinary care coordination teams. Such teams comprise staff from multiple disciplines who are trained to perform roles outside their usual scope of practice. This study aimed to critically evaluate the patient, carer and ED staff perceptions of the transdisciplinary model of care in an emergency department in a Melbourne metropolitan hospital. The evaluation of the transdisciplinary team involved interviews with patients and carers who have received the transdisciplinary team services, and focus groups with emergency nursing and transdisciplinary team staff. Analysis of the data revealed that the transdisciplinary model provided an essential service, where staff members were capable of delivering care across all disciplines. The ability to perform comprehensive patient assessments ensured safe discharge, with follow-up services in place. The existence of this team was seen to free up time for the emergency nursing staff, enabling them to see other patients, and improving department efficiency while providing quality care and increasing staff satisfaction. This study identified several important factors which contributed to the success of the transdisciplinary team, which was well integrated into the larger emergency department team.
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Affiliation(s)
- Kelli Innes
- School of Nursing & Midwifery, Monash University, Peninsula Campus, McMahons Road, Frankston, Victoria 3199, Australia
| | - Kimberley Crawford
- School of Nursing & Midwifery, Monash University, Wellington Road, Clayton, Victoria 3800, Australia
| | - Tamsin Jones
- School of Nursing & Midwifery, Monash University, Peninsula Campus, McMahons Road, Frankston, Victoria 3199, Australia
| | - Renee Blight
- Peninsula Health, 2 Hastings Road, Frankston, Victoria 3199, Australia
| | - Catherine Trenham
- Peninsula Health, 2 Hastings Road, Frankston, Victoria 3199, Australia
| | - Allison Williams
- School of Nursing & Midwifery, Monash University, Wellington Road, Clayton, Victoria 3800, Australia
| | - D Griffiths
- School of Nursing & Midwifery, Monash University, Peninsula Campus, McMahons Road, Frankston, Victoria 3199, Australia
| | - Julia Morphet
- School of Nursing & Midwifery, Monash University, Peninsula Campus, McMahons Road, Frankston, Victoria 3199, Australia.
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92
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Wu D, Zhou X, Ye L, Gan J, Zhang M. Emergency department crowding and the performance of damage control resuscitation in major trauma patients with hemorrhagic shock. Acad Emerg Med 2015. [PMID: 26205164 DOI: 10.1111/acem.12726] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Uncontrolled hemorrhagic shock is the leading cause of potentially preventable death in major trauma patients. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, hemostatic resuscitation, and damage control surgery, has been highly recommended for trauma patients. This study investigated whether emergency department (ED) crowding was associated with poor performance of the DCR strategies in treating hemorrhagic shock trauma patients. METHODS This was a retrospective cohort study in an urban tertiary hospital conducted from January 2010 to December 2013. Major trauma patients who presented to the ED with hemorrhagic shock were included. ED crowding, measured by ED occupancy rate, was categorized into three groups (low, medium, and high). The performance of DCR and inpatient outcomes were analyzed using multivariate logistic analysis. RESULTS Of the 3,037 major trauma patients assessed, 852 met the inclusion criteria and were enrolled in the study. Patients in the high-crowding group had delayed initiation of transfusion (high vs. medium and low, 2.5 hours vs. 2.1 hours and 1.0 hours, respectively, p = 0.01), received less blood products in the ED (both comparisons p < 0.01), and experienced delays in procedures (4.5 hours vs. 3.3 hours and 2.4 hours, p < 0.01). However, the amount of crystalloid solution was similar among patients in all three groups (p = 0.17). In multivariate analysis, more patients from the high-crowding group developed traumatic coagulopathy in the intensive care unit (29.7% vs. 24.1% and 16.3%, p < 0.01), while no clear relationship was found between ED crowding and 30-day mortality or early lactate clearance rate (p > 0.05). CONCLUSIONS ED crowding was associated with poor performance of DCR for major trauma patients in the ED. New strategies should be implemented to ameliorate crowded conditions and potential adverse outcomes.
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Affiliation(s)
- Dingqian Wu
- Departments of Emergency Medicine; Second Affiliated Hospital; School of Medicine & Institute of Emergency Medicine; Zhejiang University; Hangzhou China
| | - Xiaoxia Zhou
- Hangzhou XiXi Hospital; affiliated hospital of Zhejiang Chinese Medical University; Hangzhou China
| | - Ligang Ye
- Departments of Emergency Medicine; Second Affiliated Hospital; School of Medicine & Institute of Emergency Medicine; Zhejiang University; Hangzhou China
| | - Jianxin Gan
- Hangzhou XiXi Hospital; affiliated hospital of Zhejiang Chinese Medical University; Hangzhou China
| | - Mao Zhang
- Departments of Emergency Medicine; Second Affiliated Hospital; School of Medicine & Institute of Emergency Medicine; Zhejiang University; Hangzhou China
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93
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Elder E, Johnston AN, Crilly J. Review article: systematic review of three key strategies designed to improve patient flow through the emergency department. Emerg Med Australas 2015. [PMID: 26206428 DOI: 10.1111/1742-6723.12446] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To explore the literature regarding three key strategies designed to promote patient throughput in the ED. CINAHL, Medline, PubMed, Scopus and Australian Government databases were searched for articles published between 1980 and 2014 using the key search terms ED flow/throughput, ED congestion, crowding, overcrowding, models of care, physician-assisted triage, medical assessment units, nurse practitioner, did not wait (DNW) and ED length of stay (LOS). Abstracts and articles not published in English and articles published before 1980 were excluded from the review. Quantitative and qualitative studies were considered for inclusion. The National Health Medical Research Council (NHMRC) Level of Evidence Hierarchy (2009) was applied to included studies. Twenty-one articles met criteria for review. The level of evidence assessed using the NHMRC guidelines of studies ranged from I to IV, with the majority falling into the Level II-2 (n = 6) and III-3 (n = 9) range. ED LOS was the outcome most often reported. Study quality was limited with few studies adjusting for confounding factors. Only one level I systematic review was included in this review. Advanced practice nursing roles, physician-assisted triage and medical assessment units are models of care that can positively impact ED throughput. They have been shown to decrease ED LOS and DNW rates. Confounding factors, such as site specific staffing requirements, patient acuity and rest-of-hospital processes, can also impact on patient throughput through the ED.
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Affiliation(s)
- Elizabeth Elder
- School of Nursing and Midwifery, Griffith Health, Gold Coast Campus, Griffith University, Brisbane, Queensland, Australia
| | - Amy Nb Johnston
- Department of Emergency Medicine and Griffith Health Institute, Gold Coast Hospital and Health Service and Griffith University, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Department of Emergency Medicine and Griffith Health Institute, Gold Coast Hospital and Health Service and Griffith University, Gold Coast, Queensland, Australia
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94
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Innes K, Jackson D, Plummer V, Elliott D. Care of patients in emergency department waiting rooms - an integrative review. J Adv Nurs 2015; 71:2702-14. [DOI: 10.1111/jan.12719] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Kelli Innes
- Faculty of Health; University of Technology Sydney; New South Wales Australia
- Faculty of Medicine, Nursing and Health Sciences; School of Nursing and Midwifery; Monash University; Frankston Victoria Australia
| | - Debra Jackson
- Faculty of Health; University of Technology Sydney; New South Wales Australia
| | - Virginia Plummer
- Faculty of Medicine, Nursing and Health Sciences; School of Nursing and Midwifery; Monash University; Frankston Victoria Australia
| | - Doug Elliott
- Faculty of Health; University of Technology Sydney; New South Wales Australia
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95
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Perera ML, Gnaneswaran N, Roberts MJ, Giles M, Liew D, Ritchie P, Chan STF. The ‘four-hour target’ and the impact on Australian metropolitan acute surgical services. ANZ J Surg 2015; 86:74-8. [DOI: 10.1111/ans.13186] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Marlon L. Perera
- Department of Surgery; Western Health; Melbourne Victoria Australia
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
| | | | - Matthew J. Roberts
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
| | - Marian Giles
- Department of Surgery; Western Health; Melbourne Victoria Australia
| | - Danny Liew
- Department of Statistics; Western Health; Melbourne Victoria Australia
| | - Peter Ritchie
- Emergency Department; Western Health; Melbourne Victoria Australia
| | - Steven T. F. Chan
- Department of Surgery; Western Health; Melbourne Victoria Australia
- Academic Surgery; The University of Melbourne; Melbourne Victoria Australia
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96
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Aboagye-Sarfo P, Mai Q, Sanfilippo FM, Preen DB, Stewart LM, Fatovich DM. Growth in Western Australian emergency department demand during 2007-2013 is due to people with urgent and complex care needs. Emerg Med Australas 2015; 27:202-9. [DOI: 10.1111/1742-6723.12396] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Patrick Aboagye-Sarfo
- Clinical Modelling; Health System Improvement Unit; Innovation and Health System Reform; Department of Health; Perth Western Australia Australia
| | - Qun Mai
- Clinical Modelling; Health System Improvement Unit; Innovation and Health System Reform; Department of Health; Perth Western Australia Australia
- Centre for Health Services Research, School of Population Health; The University of Western Australia; Perth Western Australia Australia
| | - Frank M Sanfilippo
- Clinical Epidemiology Unit; School of Population Health; The University of Western Australia; Perth Western Australia Australia
| | - David B Preen
- Centre for Health Services Research, School of Population Health; The University of Western Australia; Perth Western Australia Australia
| | - Louise M Stewart
- Centre for Population Health Research, Curtin University; Perth Western Australia Australia
| | - Daniel M Fatovich
- Emergency Medicine; Royal Perth Hospital; The University of Western Australia; Perth Western Australia Australia
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97
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Riessen R, Gries A, Seekamp A, Dodt C, Kumle B, Busch HJ. Positionspapier für eine Reform der medizinischen Notfallversorgung in deutschen Notaufnahmen. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0013-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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98
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Weiland TJ, Lane H, Jelinek GA, Marck CH, Weil J, Boughey M, Philip J. Managing the advanced cancer patient in the Australian emergency department environment: findings from a national survey of emergency department clinicians. Int J Emerg Med 2015; 8:14. [PMID: 25984244 PMCID: PMC4424226 DOI: 10.1186/s12245-015-0061-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 04/14/2015] [Indexed: 11/17/2022] Open
Abstract
Background Delivery of care to people with advanced cancer in the emergency department (ED) is complicated by competing service demands, workloads and physical design constraints. We explored emergency clinicians’ attitudes to the ED environment when caring for patients who present with advanced cancer, and how these attitudes are affected by access to palliative care services, palliative care education, staff type, ED experience and patient demographic, hospital type and region. Methods We electronically surveyed clinicians from the College of Emergency Nursing Australasia, Australian College of Emergency Nursing and Australasian College for Emergency Medicine working in an Australian ED. Results Respondents were 444 doctors and 237 nurses. They reported overcrowding, noise, lack of time and privacy as barriers to care. Most (93.3%) agreed/strongly agreed that the dying patient should be allocated private space in ED. 73.6% (451) felt unable to provide a desired level of care to advanced cancer patients in ED. Clinician attitudes were affected by staff type, experience, ED demographic and hospital type, but not education in palliative care. Conclusions ED environments place pressure on clinicians delivering care to people with advanced cancer. Integrating palliative care services in ED and redesigning EDs to better match its multifaceted functions should be considered.
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Affiliation(s)
- Tracey J Weiland
- Emergency Practice Innovation Centre, St Vincent's Hospital Melbourne, Victoria Parade, Fitzroy 3065 Australia ; Department of Medicine, The University of Melbourne, Parkville, 3052 Australia
| | - Heather Lane
- Centre for Palliative Care, The University of Melbourne (St Vincent's Hospital), Fitzroy, 3065 Australia ; St Vincent's Hospital Melbourne, Fitzroy, 3065 Australia
| | - George A Jelinek
- Emergency Practice Innovation Centre, St Vincent's Hospital Melbourne, Victoria Parade, Fitzroy 3065 Australia ; Department of Medicine, The University of Melbourne, Parkville, 3052 Australia
| | - Claudia H Marck
- Emergency Practice Innovation Centre, St Vincent's Hospital Melbourne, Victoria Parade, Fitzroy 3065 Australia ; Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Jennifer Weil
- St Vincent's Hospital Melbourne, Fitzroy, 3065 Australia
| | - Mark Boughey
- Centre for Palliative Care, The University of Melbourne (St Vincent's Hospital), Fitzroy, 3065 Australia ; St Vincent's Hospital Melbourne, Fitzroy, 3065 Australia
| | - Jennifer Philip
- Centre for Palliative Care, The University of Melbourne (St Vincent's Hospital), Fitzroy, 3065 Australia ; St Vincent's Hospital Melbourne, Fitzroy, 3065 Australia
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99
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Keizer Beache S, Guell C. Non-urgent accident and emergency department use as a socially shared custom: a qualitative study. Emerg Med J 2015; 33:47-51. [PMID: 25841166 PMCID: PMC4717374 DOI: 10.1136/emermed-2014-204039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 02/26/2015] [Indexed: 11/06/2022]
Abstract
Objective We explored attitudes of non-urgent accident and emergency department (AED) patients in the middle-income healthcare setting Saint Vincent and the Grenadines (SVG) in the Caribbean to understand how and why they decide to seek emergency care and resist using primary care facilities. Methods In 2013, we conducted 12 semistructured interviews with a purposive sample of non-urgent AED users from a variety of social backgrounds. Verbatim transcripts were analysed with a grounded theory approach. Results In this study, we found, first, that participants automatically chose to visit the AED and described this as a locally shared custom. Second, the healthcare system in SVG reinforced this habitual use of the AED, for example, by health professionals routinely referring non-urgent cases to the AED. Third, there was also some deliberate use; patients took convenience and the systemic encouragement into account to determine that the AED was the most appropriate choice for healthcare. Conclusions We conclude that the attitudes and habits of the Vincentian non-urgent patient are major determinants of their AED use and are intricately linked to local, socially shared practices of AED use. Findings show that health services research should reconsider rational choice behaviour models and further explore customs of health-seeking.
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Affiliation(s)
- Simone Keizer Beache
- Public Health Group, Faculty of Medical Sciences, University of the West Indies, Bridgetown, Barbados
| | - Cornelia Guell
- Public Health Group, Faculty of Medical Sciences, University of the West Indies, Bridgetown, Barbados MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
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100
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Kellett J, Deane B. When should a doctor see me when I get sick? A study of the time of day acutely ill medical patients present and the time they wait to see a doctor in Ireland. Eur J Intern Med 2014; 25:926-9. [PMID: 25468249 DOI: 10.1016/j.ejim.2014.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 10/17/2014] [Accepted: 11/05/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Reconfiguration of the Irish Health Service has diverted of large numbers of acutely ill medical patients to a reduced number of hospitals and may have caused in delays in treatment. Although prompt care improves outcomes for patients with acute myocardial infarction, stroke, infection and shock, there is surprisingly little evidence for its value in other conditions. METHODS The time of admission and time patients waited to be seen and clerked by a doctor was reviewed on all medical patients admitted to Nenagh Hospital prior to service reconfiguration (i.e. from 17 February 2000 to 6 March 2004). RESULTS Over the study period of 1442,days 9435 patients were admitted (i.e. 6.5 patients per day or 0.3 per hour) and waited 37.6 SD 53.1min after admission before they were seen by a doctor. The peak time of admission is in the late afternoon and early evening and there was a liner correlation between the delay before seeing a doctor and the time of admission. The 1095 patients who waited 80min or more to be seen and clerked by a doctor (median delay 120min) were more likely to die (odds ratio 1.36 95% CI 1.03-1.81, p <0.03). CONCLUSION Waiting to be seen by a doctor may increase the risk of death to some patients. For these patients it is probably safer to be seen quickly by any doctor, rather than travel many miles and wait several hours to see a better one.
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