Overcrowding in emergency department: an international issue

Usefulness of Protocolized Point-of-Care Ultrasonography for Patients with Acute Renal Colic Who Visited Emergency Department: A Randomized Controlled Study

Background and Objectives: Ultrasonography is useful in evaluating patients with renal colic and it has high sensitivity and specificity for diagnosing ureter stones by revealing hydronephrosis. We evaluated the efficacy of point-of-care ultrasonography protocol in managing patients with acute renal colic who visited the emergency department (ED). Materials and Methods: Between March 2019 and July 2019, patients who visited the ED because of renal colic were randomly assigned by date of visit either to the conventional group (CG), who underwent routine diagnostic work-up without ultrasonography, or to the ultrasonography group (UG), who underwent bedside ultrasonography as an initial diagnostic testing. When hydronephrosis was detected in the UG group, a confirmatory non-contrast abdomen computed tomography scan was promptly performed. The ED length of stay, complications, and missed or delayed high-risk diagnosis were evaluated. Results: In total, 128 of 147 analyzed patients were confirmed to have ureter stones. The ED length of stay was significantly lower in the UG group than in the CG group (mean 172 min; 95% confidence interval (CI): 151–194 min vs. mean 234 min; 95% CI: 216–252 min). The medical cost was also remarkably lower in the UG group than in the CG group (259 USD vs. 319 USD; p < 0.001). The incidence of complications within 30 days after visiting ED and missed or delayed high-risk diagnosis were not significantly different between the two groups. Conclusions: We found that protocolized point-of-care ultrasonography in patients with acute renal colic who visited the ED can more effectively reduce the length of stay and medical cost without 30-day complication than usual clinical practice.

Nurses' perceptions and experiences of caring for patients who die in the emergency department setting

INTRODUCTION

The number of people dying in emergency departments (EDs) is increasing. However, EDs are not well designed or resourced for safe and effective End-Of-Life (EOL) care encounters, and there is little evidence regarding clinicians' perceptions and experiences of providing such care when the death is sudden and unexpected.

AIM

This study explored nurses' perceptions and experiences of caring for patients who die suddenly and unexpectedly in the ED.

METHODS

Open-end responses were collected as part of a larger descriptive survey design. The qualitative data were analysed thematically.

RESULTS

211 ED nurse completed the online survey. Within the qualitative data, five themes were identified during analysis: 1) key elements of EOL care, 2) systemic and environmental barriers, 3) educational deficits, 4) role ambiguity, and 5) emotional impact. Participants identified communication, a standardised approach, and better educational preparedness as the most important elements of EOL care when the death was sudden and unexpected.

CONCLUSIONS

ED nurses want to provide high quality care to dying patients and their families. However, their efforts are hampered by systemic and environmental barriers outside their control. There is a need for a culture shift to overcome the barriers that currently obstruct ED nurses from providing meaningful and effective EOL care in the ED.

Triage emergency nurse decision-making: Incidental findings from a focus group study

INTRODUCTION

Emergency Department (ED) triage decision-making is a complex process. Triage scales are used to determine patient acuity level, however, they do not provide information on how nurses make triage decisions. This focus group study was part of a larger project to develop a psychometrically sound instrument to measure triage decision-making by nurses; the Triage Decision-Making Instrument. We report important incidental findings that emerged during the study that the participants identified as factors impeding triage decision-making.

METHODS

Three focus groups were conducted with 11 triage Registered Nurses. They commented on the instrument items and identified factors that influence triage decision-making. Transcripts were analyzed using thematic analysis.

RESULTS

Three powerful inter-related themes emerged central to encumbering triage decision-making: competing systems (pre-hospital versus the ED), fluctuating patient volume resulting in 'intra-Canadian Triage and Acuity Scale' triaging, and personal capacity including experience and 'triage fatigue'.

DISCUSSION

The findings demonstrate how interrelated system factors impede nurses triage decision-making. Triage nurses require support in their role and initiatives are needed to reduce the pressure they feel in relation to resolving system issues. Larger system issues and the capacity of the individual decision-makers must be accounted for within the context of increasing effectiveness and safety of ED triage.

Do health care professionals' perceptions help to measure the degree of overcrowding in the emergency department? A pilot study in an Italian University hospital

BACKGROUND

Overcrowding in emergency departments (EDs) is internationally recognized as one of the greatest challenges to healthcare provision. Numerous studies have highlighted the ill-effects of overcrowding, including increased length of stay, mortality and cost per admission. This study measures overcrowding in EDs through health care professionals' perceptions of it, comparing the results with the NEDOCS score, an objectively validated measurement tool and describing meaningful tools and strategies used to manage ED overcrowding.

METHODS

This single-centre prospective, observational, pilot study was conducted from February 19th to March 7th, 2018 at the ED in the University Hospital of Ferrara, Italy to measure the agreement of the NEDOCS, comparing objective scores with healthcare professionals' perception of overcrowding, using the kappa statistic assessing linear weights according to Cohen's method. The tools and strategies used to manage ED overcrowding are described.

RESULTS

Seventy-two healthcare professionals (66.1% of 109 eligible subjects) were included in the analyses. The study obtained a total of 262 surveys from 23 ED physicians (31.9%), 31 nurses (43.1%) and 18 nursing assistants (25.0%) and a total of 262 NEDOCS scores. The agreement between the NEDOCS and the subjective scales was poor (k = 0.381, 95% CI 0.313-0.450).

CONCLUSIONS

The subjective health care professionals' perceptions did not provide an adequate real-time measure of the current demands and capacity of the ED. A more objective measure is needed to make quality decisions about health care professional needs and the ability to manage patients to ensure the provision of proper care.

Effectiveness of the hemoglobin index for screening of subarachnoid hemorrhage in out-of-hospital cardiopulmonary arrest patients: a retrospective observational study

Aim

The hemoglobin index (HbI) represents the amount of hemoglobin, which reflects regional tissue blood volume. The HbI is calculated in real time by a regional oxygen saturation (rSO₂) monitor. For the hypothesis of our HbI project, we theorized that HbI could be a new method for the screening of subarachnoid hemorrhage (SAH) in overcrowded emergency departments. As a first step, this study aimed to clarify the effectiveness of HbI in screening SAH in out‐of‐hospital cardiopulmonary arrest (OHCA) patients using the rSO₂ data of our previous studies.

Methods

In this single‐center, retrospective, observational study, we examined HbI in patients with OHCA transferred to the Trauma and Acute Critical Care Center at Osaka University Hospital (Osaka, Japan) during the period between April 2013 and December 2015. A sensor attached to the patient's forehead monitored HbI continuously.

Results

Among 63 patients (40 men and 23 women; mean age, 76 [interquartile range (IQR), 66–85] years) with OHCA, five were diagnosed as having SAH (SAH group) and 58 were not (non‐SAH group). The HbI values were significantly higher in the SAH group than in the non‐SAH group (1.35 [IQR: 0.80–2.69] versus 0.41 [IQR: 0.32–0.61]), P = 0.0042). In the SAH group, with an HbI cut‐off value of 1.18, the specificity and sensitivity were 96% and 80%, respectively, and the area under the receiver operating characteristic curve of HbI was 0.89.

Conclusions

The HbI might be useful for the screening of SAH in patients with OHCA. The application of HbI in the emergency department could be expected in the future.

Patients' time perception in the waiting room of an ambulatory emergency unit: a cross-sectional study

Background

Patient satisfaction has become an increasingly important element in a service-oriented healthcare market. Although satisfaction is influenced by many factors, the waiting time to be seen by medical staff has been shown to be one of the key criteria. However, waiting is not an objective experience and several factors can influence its perception.

Methods

We conducted a questionnaire-based, cross-sectional study among patients attending the emergency unit of a Swiss university hospital in order to explore the key factors influencing wait perception.

Results

A total of 509 patients participated in the study. Appropriate assessment of emergency level by caregivers, the feeling of being forgotten, respect of privacy, and lack of information on the exact waiting time were identified as significant variables for wait perception.

Conclusions

Our study confirmed the existence of a ‘golden hour’ when the patient is willing to wait until the medical encounter. In case the wait cannot be limited, an appropriate assessment of the emergency level by caregivers and avoiding the patients of feeling being forgotten are very important factors to avoid a negative perception of the waiting time before seeing a doctor.

Trial registration

(ID REQ-2016-00555).

Are service and patient indicators different in the presence or absence of nurse practitioners? The EDPRAC cohort study of Australian emergency departments

OBJECTIVES

To evaluate the impact of nurse practitioner (NP) service in Australian public hospital emergency departments (EDs) on service and patient safety and quality indicators.

DESIGN AND SETTING

Cohort study comprising ED presentations (July 2013-June 2014) for a random sample of hospitals, stratified by state/territory and metropolitan versus non-metropolitan location; and a retrospective medical record audit of ED re-presentations.

METHODS

Service indicator data (patient waiting times for Australasian Triage Scale categories 2, 3, 4 and 5; number of patients who did not-wait; length of ED stay for non-admitted patients) were compared between EDs with and without NPs using logistic regression and Cox proportional hazards regression, adjusting for hospital and patient characteristics and correlation of outcomes within hospitals. Safety and quality indicator data (rates of ED unplanned re-presentations) for a random subset of re-presentations were compared using Poisson regression.

RESULTS

Of 66 EDs, 55 (83%) provided service indicator data on 2 463 543 ED patient episodes while 58 (88%) provided safety and quality indicator data on 2853 ED re-presentations. EDs with NPs had significantly (p<0.001) higher rates of waiting times compared with EDs without NPs. Patients presenting to EDs with NPs spent 13 min (8%) longer in ED compared with EDs without NPs (median, (first quartile-third quartile): 156 (93-233) and 143 (84-217) for EDs with and without NPs, respectively). EDs with NPs had 1.8% more patients who did not wait, but similar re-presentations rates as EDs with NPs.

CONCLUSIONS

EDs with NPs had statistically significantly lower performance for service indicators. However, these findings should be treated with caution. NPs are relatively new in the ED workforce and low NP numbers, staffing patterns and still-evolving roles may limit their impact on service indicators. Further research is needed to explain the dichotomy between the benefits of NPs demonstrated in individual clinical outcomes research and these macro system-wide observations.

Deciding whether to consult the GP or an emergency department: A qualitative study of patient reasoning in Switzerland

Background: Non-urgent care is an important factor responsible for rising healthcare costs and general practitioners (GPs) are known to be more cost-effective than emergency departments (EDs).

Objectives: To understand the reasons why patients confronted with a medical problem perceived as urgent choose to consult either a GP or an ED.

Methods: We conducted a qualitative study in Switzerland, using data collected between 2014 and 2015 through semi-structured interviews of adults with non-vital medical problems. Half were recruited after an ambulatory consultation in an ED, and half were patients who consulted their GP. The audio-recorded interviews were transcribed, coded, and analysed according to the constant comparative method.

Results: The main reason given by patients who consulted their GP first was the quality of the relationship. The more meaningful the relationship, the more likely patients were to seek advice from their GP. One marker of a privileged relationship was GPs supplying their mobile phone number to the patient. The perceived nature of the complaint, for example, symptoms considered as life-threatening or severe pain, together with the expected waiting time in an ED were additional factors influencing the patients’ choice.

Conclusion: Our study showed that when patients are confronted with what they perceive as a medical emergency, the quality of the relationship with the GP, in particular the continuity of care provided, seem to be the major reasons why they consult their GP rather than an ED.

Profiling the hospital-dependent patient in a large academic hospital: Observational study

BACKGROUND

In older patients with acute illness, a condition of "hospital-dependence" may arise: patients get adapted to the hospital care and, once discharged, may experience health status decline, requiring repeated readmissions despite appropriate treatments.

AIMS

The objective of this case-series study was to describe the characteristics of 118 patients (72 F) aged ≥75 (mean 83.7 ± 4.9) who were urgently admitted to our institution at least 4 times in 2015.

METHODS

For each patient and admission, data on multimorbidity (Cumulative Illness Rating Scale Comorbidity Score and Severity Index), frailty (Rockwood Clinical Frailty Scale), functional dependence, functional status, polypharmacy, length of stay and interval between admissions were extrapolated from clinical records. Mortality during the years 2015 and 2016 was assessed on the institutional database.

RESULTS

At the first admission, patients had a high burden of polypharmacy (median number of drugs 8.5, IQR 6-11) and multimorbidity (Comorbidity Score 15.8 ± 4.1, Severity Index 2.9 ± 1.1). However, most (55.5%) were fit or pre-frail according to Clinical Frailty Scale (score 1-4). At multivariate models, Severity Index was significantly correlated with the length of stay (β ± SE 2.23 ± 0.89, p = .01) and readmission interval (β ± SE -22.49 ± 9.27, p = .02). Significantly increasing trends of multimorbidity and disability occurred across admissions. By the end of 2016, 66% of patients had died. Frailty (RR 2.005, 95%CI 1.054-3.814, p = .007) and cancer were the only predictors of mortality.

CONCLUSIONS

Hospital-dependent patients had severe multimorbidity, but exhibited an unexpectedly low prevalence of frailty/disability at baseline, though increasing across admissions. Trends of frailty and multimorbidity are paramount for profiling the hospital-dependence risk.

Supplementation with Lactobacillus reuteri ATCC PTA 4659 in patients affected by acute uncomplicated diverticulitis: a randomized double-blind placebo controlled trial

INTRODUCTION

Acute uncomplicated diverticulitis (AUD) is an inflammation of the colon diverticulum. We tested the efficacy of Lactobacillus reuteri 4659 (L. reuteri) in treating AUD. Primary outcome was reduced abdominal pain and inflammatory markers (C-RP). Secondary outcome was reduced hours of hospitalization.

PATIENTS AND METHODS

A double-blind, placebo RCT was conducted with 88 (34M/54F mean age 61.9 ± 13.9) patients with a diagnosis of AUD. Group A (44 patients, 26F): ciprofloxacin 400 mg/bid and metronidazole 500 mg/tid for 1 week, plus L. reuteri/bid for 10 days. Group B (44 patients, 28F): same antibiotic therapy for 1 week, plus placebo/bid for 10 days. All patients completed a daily visual analog scale (VAS) for abdominal pain.

RESULTS

Between days 1 and 3, the group A pain decreased by 4.5 points; group B decreased by 2.36 points (p < 0.0001). Between days 1 and 5, the group A decreased by 6.6 points; group B by 4.4 points (p < 0.0001). Between days 1 and 7, the group A decreased by 7.6 points; group B decreased by 5.6 points (p < 0.0001). Between days 1 and 10, the group A decreased by 8.1 points; group B decreased by 6.7 points (p < 0.0001). For C-RP value, the mean decrease between admission and after 72 h was 45.3 mg/L for group A and 27.49 mg/L for group B (p < 0.0001).

CONCLUSIONS

Our RCT showed that supplementation of the standard AUD therapy with L. reuteri strain 4659 significantly reduced abdominal pain and inflammatory markers compared with the placebo group. It also resulted in a shorter period of hospitalization, and thus has economic benefits.

TRIAL REGISTRATION

TRIALGOV: NCT03656328.

Over-triage occurs when considering the patient's pain in Korean Triage and Acuity Scale (KTAS)

Background

The Korean Triage and Acuity Scale (KTAS) was developed based on the Canadian Emergency Department Triage and Acuity Scale. In patients with pain, to determine the KTAS level, the pain scale is considered; however, since the degree of pain is subjective, this may affect the accuracy of KTAS. The purpose of this study was to evaluate the accuracy of KTAS in predicting patient's severity with the degree of pain used as a modifier.

Method

A retrospective observational cohort study was conducted in an urban tertiary hospital emergency department (ED). We investigated patients over 16 years old from January to June 2016. The patients were divided into the pain and non-pain groups according to whether the degree of pain was used as a modifier or not. We compared the predictive power of KTAS on the urgency of patients between the two groups. Acute area registration in the ED, emergency procedure, emergency operation, hospitalization, intensive care unit admission, and 7-day mortality were used as markers to determine urgent patients.

Results

Overall, 24,253 patients were included in the study, with 9,175 (37.8%) in the pain group. The proportions of patients with KTAS 1–3 were 61.4% in the pain and 75.6% in the non-pain groups. Among patients with KTAS 2–3, the proportion of urgent patients was higher in the non-pain group than the pain group (p<0.001). The odds ratios for urgent patients at each KTAS level revealed a more evident discriminatory power of KTAS for urgent patients in the non-pain group. The predictability of KTAS for urgent patients was higher in the non-pain group than the pain group (area under the curve; 0.736 vs. 0.765, p-value <0.001).

Conclusions

Considering the degree of pain with KTAS led to overestimation of patient severity and had a negative impact on the predictability of KTAS for urgent patients.

Risk Factors for Prolonged Length of Stay of Older Patients in an Academic Emergency Department: A Retrospective Cohort Study

Emergency departments (EDs) are challenged with a growing population of older patients. These patients are at risk for a prolonged length of stay (LOS) at the ED and face more complications and poorer clinical outcomes. We aimed to identify risk factors for a prolonged LOS of older patients at the ED. For this retrospective clinical database study, we analyzed medical records of 2000 patients ≥70 years old presenting at the ED of a large level I trauma center in the Netherlands. LOS above the 75^th percentile of LOS at our ED, 293 minutes, was considered prolonged. After bivariate analysis, we identified associations between LOS and patient, organizational, and clinical factors. Associations with a p < 0.05 were inserted in multivariable logistic regression models. We analyzed 1048 men (52%) and 952 women (48%) with a mean age of 78 ± 6.2 years. Risk factors for prolonged LOS of older patients at the ED were follows: higher number (more than one) of consultations (OR [odds ratio] 2.4, CI [confidence interval] 2.0-2.91), or diagnostic interventions (OR 1.5, CI 1.4-1.7); presenting complaints of a neurological (OR 2.2, CI 1.0-4.5) or internal medicine focus (OR 2.6, CI 1.4-4.6); patients with an altered consciousness (OR 3.3, CI 1.6-6.6); treatment by physicians of the departments of surgery (OR 3.4, CI 2.2-5.2), internal medicine (OR 2.6, CI 1.9-3.7), or pulmonology (OR 2.2, CI 1.4-3.6); and urgency category of ≥ U1. Awareness of factors associated with prolonged LOS of older patients presenting at the ED is essential. Physicians should recognize and take these factors into account, in order to improve clinical outcomes of the (strongly increasing) population of older patients at the ED.

Evaluation of triage quality in the emergency department: a scoping review protocol

The objective of this scoping review is to explore the existing literature on the evaluation of the quality of triage for patients of all ages and medical conditions in emergency departments (EDs).The question for this review is: How is triage in the ED evaluated? More specifically, we are interested in answering the following sub-questions.

Effectiveness of interventions to reduce occupational stress among emergency department staff: a systematic review protocol

REVIEW QUESTION

The aim of the review is to synthesize the best available evidence on interventions targeting occupational stress and burnout among emergency department (ED) staff. The specific review questions are.

Comparison of emergency department time performance between a Canadian and an Australian academic tertiary hospital

OBJECTIVE

To compare performance and factors predicting failure to reach Ontario and Australian government time targets between a Canadian (Sunnybrook Hospital) and an Australian (Austin Health) academic tertiary-level hospitals in 2012, and to assess for change of factors and performance in 2016 between the same hospitals.

METHODS

This was a retrospective, observational study of patient administrative data in two calendar years. The main outcome measure was reaching Ontario and Australian ED time targets for admissions, high and low urgency discharges. Secondary outcomes were factors predicting failure to reach these targets.

RESULTS

Between 2012 and 2016, Sunnybrook and Austin experienced increased patient volume of 10.2% and 19.2%, respectively. Bed capacity decreased at Sunnybrook (-10.8%) but increased at the Austin (+30.3%). For both years, Austin failed to achieve the Australian time target, but succeeded for all Ontario targets except for low urgency discharges. Sunnybrook failed all targets irrespective of year. The top factors for failing Ontario ED length-of-stay targets for both hospitals in 2012 and 2016 were bed request greater than 6 h, access block greater than 1 h, use of cross-sectional imaging, consultation and waiting for the emergency physician greater than 2 h.

CONCLUSION

Austin outperformed Sunnybrook for Ontario and Australian government time targets. Both hospitals failed the Australian targets. Factors predicting failure to achieve targets were different between hospitals, but were mainly clinical resources. Sunnybrook focussed on increasing human resources. Austin focussed on increasing human resources, observation unit and hospital beds. Intrinsic hospital characteristics and infrastructure influenced target success.

Development of a coping model for work-related fear among staff working in emergency department in Finland - study for nursing and medical staff

The emergency department is a workplace where the staff regularly encounter new challenges and factors that can cause fear. The aim of this study was to describe coping with work-related fear among emergency department staff. The study explains the current coping methods of emergency department staff and the requirement for support as well as the availability of support. A coping model for work-related fear was also developed and will be presented. The study was conducted using a survey developed specifically for this study, which included the Brief COPE Inventory. The study was conducted in 16 hospitals (N = 544) among the doctors, nurses, practical nurses, and orderlies of the emergency departments. The results were analysed using statistical methods such as frequencies, cross-tabulation, principal component analysis and binary logistic regression analysis. All values of p < 0.05 were considered statistically significant. The results showed that nearly all of the emergency department personnel had experienced work-related fear. Most of the respondents to the survey would have wanted more support, professional help, preventive action and more resources for the emergency department. The emergency department staff had used several coping methods to cope with fear. The most commonly used coping methods were problem-focused coping and social support. Based on the results of the study, it is possible to increase the availability of coping methods and further develop the existing coping methods.

Comparison of fit factors among healthcare providers working in the Emergency Department Center before and after training with three types of N95 and higher filter respirators

INTRODUCTION

N95 or higher filtering respirators have been recommended in healthcare settings, although there is still a risk of infection due to the improper selection and wearing of respirators. We aimed to assess the effects of training with N95 or higher filter respirators on the protection performance of respirators among healthcare providers in the emergency medical center (EMC).

METHODS

This randomized crossover study evaluated 23 healthcare providers. Quantitative fit tests (QNFTs) were performed before and after training using three types of N95 or higher filter respirators (cup-type, fold-type, valve-type). Training was performed by lecture, real-time feedback, and fit check. The primary outcome was the fit factor, and the secondary outcomes were overall fit factor, adequate protection rate, and respiratory preference.

RESULTS

Fit factors, overall fit factor, and adequate protection rate were higher after training than before training for the 3 types of respirators (all P < .05). For normal breathing, fit factors before and after training were 121 (10-185) vs 192 (161-200) for cup-type, 200 (39-200) vs 200 (200-200) for fold-type, and 85 (18-157) vs 173 (117-200) for valve-type. For normal breathing, the adequate protection rates before and after training were 62 (0-100) vs 100 (90-100) for cup-type, 100 (0-100) vs 100 (100-100) for fold-type, and 19 (0-100) vs 100 (44-100) for valve-type (all P < .05). The most preferred respirator type was the valve-type (10 persons, 45.5%).

CONCLUSIONS

Training on wearing an N95 or higher respirator improved the protection performance of respirators among healthcare providers working in the EMC. The selection of proper respirators and training would be beneficial to the safety of healthcare providers.

Mortality Associated With Emergency Department Boarding Exposure: Are There Differences Between Patients Admitted to ICU and Non-ICU Settings?

BACKGROUND

Emergency Department (ED) boarding threatens patient safety. It is unclear whether boarding differentially affects patients admitted to intensive care units (ICUs) versus non-ICU settings.

RESEARCH DESIGN AND SUBJECTS

We performed a 2-hospital, 18-month, cross-sectional, observational, descriptive study of adult patients admitted from the ED. We used Kaplan-Meier estimation and Cox Proportional Hazards regression to describe differences in boarding time among patients who died during hospitalization versus those who survived, controlling for covariates that could affect mortality risk or boarding exposure, and separately evaluating patients admitted to ICUs versus non-ICU settings.

MEASURES

We extracted age, race, sex, time variables, admission unit, hospital disposition, and Elixhauser comorbidity measures and calculated boarding time for each admitted patient.

RESULTS

Among 39,781 admissions from the EDs (21.3% to ICUs), non-ICU patients who died in-hospital had a 1.2-fold risk (95% confidence interval, 1.03-1.36; P=0.016) of having experienced longer boarding times than survivors, accounting for covariates. We did not observe a difference among patients admitted to ICUs.

CONCLUSIONS

Among non-ICU patients, those who died during hospitalization were more likely to have had incrementally longer boarding exposure than those who survived. This difference was not observed for ICU patients. Boarding risk mitigation strategies focused on ICU patients may have accounted for this difference, but we caution against interpreting that boarding can be safe. Segmentation by patients admitted to ICU versus non-ICU settings in boarding research may be valuable in ensuring that the safety of both groups is considered in hospital flow and boarding care improvements.

How spontaneous pneumothorax is managed in emergency departments: a French multicentre descriptive study

Background

Management of spontaneous pneumothorax (SP) is still subject to debate. Although encouraging results of recent studies about outpatient management with chest drains fitted with a one-way valve, no data exist concerning application of this strategy in real life conditions. We assessed how SP are managed in Emergency departments (EDs), in particular the role of outpatient management, the types of interventions and the specialty of the physicians who perform these interventions.

Methods

From June 2009 to May 2013, all cases of spontaneous primary (PSP) and spontaneous secondary pneumothorax (SSP) from EDs of 14 hospitals in France were retrospectively included. First line treatment (observation, aspiration, thoracic drainage or surgery), type of management (admitted, discharged to home directly from the ED, outpatient management) and the specialty of the physicians were collected from the medical files of the ED.

Results

Among 1868 SP included, an outpatient management strategy was chosen in 179 PSP (10%) and 38 SSP (2%), mostly when no intervention was performed. Only 25 PSP (1%) were treated by aspiration and discharged to home after ED admission. Observation was the chosen strategy for 985 patients (53%). In 883 patients with an intervention (47%), it was performed by emergency physicians in 71% of cases and thoracic drainage was the most frequent choice (670 patients, 76%).

Conclusions

Our study showed the low level of implementation of outpatient management for PS in France. Despite encouraging results of studies concerning outpatient management, chest tube drainage and hospitalization remain preponderant in the treatment of SP.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0213-2) contains supplementary material, which is available to authorized users.

The impact of Australian healthcare reforms on emergency department time-based process outcomes: An interrupted time series study

Background

In 2011, the Australian government introduced national healthcare reforms aimed at increasing the timeliness and quality of hospital care. The healthcare reforms included, but were not limited to, emergency department (ED) time-based targets, financial incentives, and public performance reporting of hospital data. We sought to evaluate the impact of the national healthcare reforms on ED time-based process outcomes.

Methods

A quasi-experimental study of ED presentations from 2006 to 2016 in the state of Victoria, Australia. Uncontrolled, interrupted time-series analyses were used to evaluate, by hospital peer groups, the effect of national healthcare reforms on: patient wait times for treatment; treatment within recommended time; and patient departure within four hours of arrival in ED.

Results

There were small improvements in ED time-based process outcomes following the introduction of the national healthcare reforms. These occurred in most hospital peer groups immediately and over the longer term, across the various triage categories. The largest improvements occurred in small hospitals and smallest improvements in medium sized hospitals. ED time-based targets, now abolished by the Australian government, were not achieved in any hospital peer groups.

Conclusions

Our findings suggest that national healthcare reforms had the potential to prompt fundamental changes in ED processes leading to significant improvements in ED performances across most hospital peer groups but were generally unable to reach the ED targets imposed nationally. ED performances also varied by hospital peer groups. Attention to ED time-based process outcomes within hospital peer groups may provide insights into hospital practices that could improve the quality and efficiency of ED care.

Inpatient disposition in overcrowded hospitals: is it safe and effective to use reverse triage and readmission screening tools for appropriate discharge? An observational prospective study of an Italian II level hospital

BACKGROUND

Reverse triage (RT) identifies patients eligible for discharge and have been proposed to cope with daily surge. Nevertheless, early discharge could increase the rate of readmission. Our aim is to test the effectiveness and safety of RT alone and with readmission screening tools (Identification Senior At Risk [ISAR], HOSPITAL, and Groeningen Frailty Index [GFI] scores) to predict appropriate discharge.

MATERIAL AND METHODS

We prospectively assessed every 4 days (t0 ) inpatients of medical divisions (High Dependency Unit (HDU), Internal Medicine (IM), and Geriatrics (Ger)) of an Italian Hospital. RT score was calculated for each patient and an RT ≤3 identified those eligible for safe discharge. ISAR, HOSPITAL, and GFI were then applied. We assessed reinstituting of interventions and transferring to an increased level of care unit at 4 days as an ethical proxy of consequential medical events following hypothetical discharge. Date of effective discharge, death, and readmission were measured at 4, 7, 15, and 30 days after the first evaluation.

RESULTS

Twenty-five (9.6%) out of 260 patients in our sample had an RT ≤3. Twenty-four (96%) of them compared with 205 (87%) of the RT >3 group (P = NS) were discharged. Patients with RT ≤3 were discharged significantly earlier (3.5 vs 8 days after t0 [P = 0.0002]). In the RT ≤3 group, all but one patient were alive and healthy at 7, 15, and 30 days. The HOSPITAL score seemed to have the best concordance with RT (84%), in comparison with the ISAR (52%) and the GFI (48%) scores. RT showed a low sensitivity (22%) and high specificity (95%), which was even higher when using RT associated with readmission screening tools.

CONCLUSIONS

Reverse triage proved to be a safe and conservative tool, with high specificity alone and with readmission screening tools. RT correctly identifies patients that will be discharged earlier.

Patients' knowledge about medication prescription in the emergency service

OBJECTIVE

To identify which orientations were received by the patient about the medication prescription and which professional performed it; to evaluate the patients' knowledge about prescription drugs and to correlate it to socioeconomic variables, comorbidities, and the frequency with which the patient seeks emergency service; and to evaluate the knowledge about the medication prescribed after the health care.

METHOD

This was a cross-sectional study on 304 patients that received emergency service's discharge along with medication prescription. Applied instruments: sociodemographic characterization and evaluation of the knowledge about the prescribed medication. We used a descriptive and inferential analysis.

RESULTS

Most subjects had no doubts about how or for how long to take the medication; and presented questions about adverse reactions and what to do in case of forgetting to take the medication doses. There was a significant association between age; educational level; comorbidity; the frequency of emergency service's use; and knowledge about medications.

CONCLUSION

a total of 48% of the patients declared to need information about adverse effects and what to do if they forget to take the medication.

Long length of stay at the emergency department is mostly caused by organisational factors outside the influence of the emergency department: A root cause analysis

Background

Emergency department (ED) crowding is common and associated with increased costs and negative patient outcomes. The aim of this study was to conduct an in-depth analysis to identify the root causes of an ED length of stay (ED-LOS) of more than six hours.

Methods

An observational retrospective record review study was conducted to analyse the causes for ED-LOS of more than six hours during a one-week period in an academic hospital in the Netherlands. Basic administrative data were collected for all visiting patients. A root cause analysis was conducted using the PRISMA-method for patients with an ED-LOS > 6 hours, excluding children and critical care room presentations.

Results

568 patients visited the ED during the selected week (January 2017). Eighty-four patients (15%) had an ED-LOS > 6 hours and a PRISMA-analysis was performed in 74 (88%) of these patients. 269 root causes were identified, 216 (76%) of which were organisational and 53 (22%) patient or disease related. 207 (94%) of the organisational factors were outside the influence of the ED. Descriptive statistics showed a mean number of 2,5 consultations, 59% hospital admissions or transfers and a mean age of 57 years in the ED-LOS > 6 hours group. For the total group, there was a mean number of 1,9 consultations, 29% hospital admissions or transfers and a mean age of 43 years.

Conclusions

This study showed that the root causes for an increased ED-LOS were mostly organisational and beyond the control of the ED. These results confirm that interventions addressing the complete acute care chain are needed in order to reduce ED-LOS and crowding in ED’s.

Emergency department throughput: an intervention

Shortening emergency department (ED) boarding time and managing hospital bed capacity by expediting the inpatient discharge process have been challenging for hospitals nationwide. The objective of this study is was to explore the effect of an innovative prospective intervention on hospital workflow, specifically on early inpatient discharges and the ED boarding time. The intervention consisted of a structured nursing "admission discharge transfer" (ADT) protocol receiving new admissions from the ED and helping out floor nursing with early discharges. ADT intervention was implemented in a 38-bed hospitalist run inpatient unit at an academic hospital. The study population consisted of 4486 patients (including inpatient and observation admissions) who were hospitalized to the medicine unit from March 2013-March 2014. Of these hospitalizations, 2259 patients received the ADT intervention. Patients' demographics, discharge and ED boarding data were collected for from March 4, 2013 to March 31, 2014 for both intervention and control groups (28 weeks each). Chi-square and unpaired t tests were utilized to compare population characteristics. Poisson regression analysis was conducted to estimate the association between intervention and hospital length of stay adjusted for differences in patient demographics. Mean age of the study population was 58.6 years, 23% were African Americans and 55% were women. A significant reduction in ED boarding time (p < 0.001) and improvement in early (before 2 PM) hospital discharges (p = 0.01) were noticed among patients in the intervention groups. There was a slight but significant reduction in hospital length of stay for observation patients in the intervention group; however, no such difference was noted for inpatient admissions. Our study showed that dedicating nursing resources towards ED-boarded patients and early inpatient discharges can significantly improve hospital workflow and reduce hospital length of stay.

Supervised workplace learning in postgraduate training: a realist synthesis

Context

This paper presents a realist synthesis of the literature that began with the objective of developing a theory of workplace learning specific to postgraduate medical education (PME). As the review progressed, we focused on informal learning between trainee and senior doctor or supervisor, asking what mechanisms occur between trainee and senior doctor that lead to the outcomes of PME, and what contexts shape the operation of these mechanisms and the outcomes they produce?

Methods

We followed the procedures outlined in the RAMESES Publication Standards for Realist Synthesis. We searched the English‐language literature published between 1995 and 2017 for empirical papers related to informal workplace learning between supervisor and trainee, excluding formal interventions such as workplace‐based assessment. We made a pragmatic decision to exclude general practice training to keep the review within manageable limits.

Results

We reviewed 5197 papers and selected 90. Synthesis revealed three workplace learning processes occurring between supervisors and trainees, each underpinned by a pair of mechanisms: supervised participation in practice (entrustment and support seeking); mutual observation of practice (monitoring and modelling), and dialogue during practice (meaning making and feedback). These mechanisms result in outcomes of PME, including safe participation in practice, learning skills, attitudes and behaviours and professional identity development. Contexts shaping the outcomes of these mechanisms were identified at individual, interpersonal, local and systems levels.

Conclusions

Our realist theory of workplace learning between supervisors and trainees is informed by theory and empirical research. It highlights the two‐way nature of supervision, the importance of trainees’ agency in their own learning and the deleterious effect of fragmented working patterns on supervisor–trainee learning mechanisms. Further empirical research is required to test and refine this theory. In the meantime, it provides a useful framework for the design of supportive learning environments and for the preparation of supervisors and trainees for their roles in workplace learning.

The authors describe a realist theory of learning between supervisor and postgraduate trainee in the workplace, emphasising the role of individual, interpersonal, local and systems contexts in shaping key mechanisms and their outcomes.

Factors associated with prolonged length of stay in the psychiatric emergency service

OBJECTIVE

Dedicated regional psychiatric emergency services (PES) were proposed as a better care model for psychiatric emergencies and a possible solution to boarding of psychiatric patients in the emergency department. However, there are limited data on factors associated with prolonged length of stay (LOS) in the PES. The objective of this study was finding factors associated with prolonged LOS in the PES and moving towards a solution to this problem.

METHODS

The study sample comprised 200 PES visits randomly chosen from January 2011 to December 2015 in a psychiatric hospital in Taiwan. Relevant data were collected comprehensively through the health information system and by reviewing medical records. The primary outcome was LOS longer than 24 hours while LOS longer than 48 hours was used as the secondary outcome.

RESULTS

Mean LOS was 17.6±23.2 hours, with 53 (26.5%) visits lasting more than 24 hours and 15 (7.5%) visits lasting more than 48 hours. After adjusting for related confounders, LOS longer than 24 hours was associated with use of restraints in the PES (adjusted odds ratio (aOR) = 3.13, 95% CI = 1.59-6.15) and history of illicit substance use (aOR = 2.46, 95% CI = 1.11-5.44). LOS longer than 48 hours was associated with use of restraints in the PES (aOR = 4.11, 95% CI = 1.2-14.14), history of illicit substance use (aOR = 6.16, 95% CI = 1.37-27.62) and first time visit to the hospital (aOR = 8.54, 95% CI = 2.03-35.96). Neither outcome was associated with transfer to an inpatient unit.

CONCLUSION

Prolonged LOS was common in the study sample. Discharged patients had an equally high rate of prolonged LOS as admitted patients. Therefore measures should be taken to facilitate timely discharge. Use of restraints and history of illicit substance use were common among patients with prolonged LOS.

Insight Into Health Care Services: A Characterization of Emergency Room Visits and Economic Hazards in the United States

OBJECTIVE

This study explores the impact of economic hazard areas on hospital-based emergency departments to determine whether economically hazardous environments, characterized by the change of population, income per capita, and unemployment rate, experience a higher number of emergency room visits than areas of lower rated economic hazard risk in the United States.

METHOD

A cross-sectional design was used of a nationally constructed data set of hospital-based emergency departments of over 6,000 hospitals in the United States. We identified our quality outcome measure as the emergency room visits rate within a hospital service area. We created the variable by dividing the number of emergency room visits by the population of the hospital services area in which the emergency room was located.

RESULTS

Results indicate that there is a difference in the incident rate ratio of emergency room visits between environments considered to be experiencing greater amounts of hazard, compared to lower amounts of hazard.

CONCLUSION

Hospital administrators and health policy-makers need to work in conjunction to focus efforts on public safety as a key objective in the delivery of emergency medical care. One crucial effort that hospital administrators need to focus on is improving emergency room capacity and efficiency as part of the disaster preparedness plan (Disaster Med Public Health Prep. 2019;13:470-475).

NHAMCS Validation of Emergency Severity Index as an Indicator of Emergency Department Resource Utilization

Introduction

Triage systems play a vital role in emergency department (ED) operations and can determine how well a given ED serves its local population. We sought to describe ED utilization patterns for different triage levels using the National Hospital Ambulatory Medical Care Survey (NHAMCS) database.

Methods

We conducted a multi-year secondary analysis of the NHAMCS database from 2009-2011. National visit estimates were made using standard methods in Analytics Software and Solutions (SAS, Cary, NC). We compared patients in the mid-urgency range in regard to ED lengths of stay, hospital admission rates, and numbers of tests and procedures in comparison to lower or higher acuity levels.

Results

We analyzed 100,962 emergency visits (representing 402,211,907 emergency visits nationwide). In 2011, patients classified as triage levels 1–3 had a higher number of diagnoses (5.5, 5.6 and 4.2, respectively) when compared to those classified as levels 4 and 5 (1.61 and 1.25). This group also underwent a higher number of procedures (1.0, 0.8 and 0.7, versus 0.4 and 0.4), had a higher ED length of stay (220, 280 and 237, vs. 157 and 135), and admission rates (32.2%, 32.3% and 15.5%, vs. 3.1% and 3.6%).

Conclusion

Patients classified as mid-level (3) triage urgency require more resources and have higher indicators of acuity as those in triage levels 4 and 5. These patients’ indicators are more similar to those classified as triage levels 1 and 2.

Effectiveness of collaboration between emergency department and intensive care unit teams on mortality rates of patients presenting with critical illness: a quantitative systematic review protocol

REVIEW OBJECTIVE

The objective of this review is to identify the effectiveness of collaboration between emergency department (ED) and intensive care unit teams on mortality rates of critically ill adult patients in the ED.

Quantifying emergency department crowding: comparison between two scores

INTRODUCTION

Emergency department (ED) crowding is a major international concern with a negative impact on both patient care and providers. Currently, there is no consensus regarding measure of crowding. Therefore, emergency physicians have to choose between numerous scoring systems, from simple to more complex. The aim of the present study was to compare the complex National Emergency Department Overcrowding Scale (NEDOCS) with the simple ED Occupancy rate (OR) determination. We further evaluated the correlation between these scores and a qualitative assessment of crowding.

METHOD

This study was conducted in two academic and one regional hospital in Liege Province, in Belgium; each accounting for an ED census of over 40,000 patient visits per year. Crowding measures were sampled four times a day, over a two-week period, in January 2016.

RESULTS

ED staff considered overcrowding as a major concern in the three ED. Median OR ranged from 68 to 100, while NEDOCS ranged from 64.5 to 76.3. A significant correlation was found in each ED between the OR and the NEDOCS (Pearson r = 0.973, 0.974 and 0.972), as well as between the OR, the NEDOCS and the subjective evaluation by the ED staff (p = 0.001).

CONCLUSION

Crowding evaluation in ED requires validated scores. Our study in three different hospitals demonstrates that simple OR appeared as accurate as more sophisticated NEDOCS. Furthermore, this measure is perfectly correlated with the feeling of ED staff.

Emergency department overcrowding: Quality improvement in a Taiwan Medical Center

BACKGROUND/PURPOSE

Overcrowding of hospital emergency departments (ED) is a worldwide health problem. The Taiwan Joint Commission on Hospital Accreditation has stressed the importance of finding solutions to overcrowding, including, reducing the number of patients with >48 h stay in the ED. Moreover, the Ministry of Health and Welfare aims at transferring non-critical patients to district or regional hospitals. We report the results of our Quality Improvement Project (QIP) on ED overcrowding, especially focusing on reducing length of stay (LOS) in ED.

METHODS

For QIP, the following 3 action plans were initiated: 1) Changing the choice architecture of patients' willingness to transfer from opt-in to opt-out; 2) increasing the turnover rate of beds and daily monitoring of the number of free beds for boarding ED patients; 3) reevaluation of patients with a LOS of >32 h after the morning shift.

RESULTS

Transfer rates increased minimally after implementation of this project, but the sample size was too small to achieve statistical significance. No significant increase was observed in the number of free medical beds, but discharge rates after 12 pm decreased significantly (p < 0.001). The proportion of over 48 h LOSs decreased from 4.9% to 3.7% before and after QIP implementation, respectively (p < 0.001).

CONCLUSION

Patients with LOS of >32 h were reevaluated first. After QIP, the proportion of LOSs of >48 h dropped significantly. Changing the choice architecture may require further systemic effort and a longer observation duration. Higher-level administrators will need to formulate a more comprehensive bed management plan to speed up the turnover rate of free inpatient beds.

[Standing Orders and Quality of Care at Triage in Emergency Services: Integrative Review]

INTRODUCTION

Overcrowding of emergency services is a widespread problem in western countries. This situation results in negative patient outcomes and influences the quality of care. Standing orders are a possible way to improve the quality and performance of the health system. The aim of this article is to identify, based on a review of the literature, the effects of standing orders initiated by triage nurses in emergency services on the quality of care.

METHODS

The quality of care dimensions of the Institute of Medicine (2001) were used as a frame of reference. The integrative review was performed on a selection of articles from Cochrane, CINALH, EMBASE, Medline, PubMed and Google Scholar. A total of 23 articles were selected and analysed.

RESULTS

The integrative review documented the effects of standing orders initiated by triage nurses on the six dimensions of quality of care: effectiveness, patient-centeredness, efficiency, timeliness, safety and equity. Standing orders are able to improve the efficiency of care by reducing, among other things, the time to treatment and diagnostic tests. They also reduce the length of stay of patients in emergency services.

CONCLUSION

Standing orders initiated by triage nurses in emergency services can have positive effects on the quality of care provided to the patient. Further research with more robust study designs is needed.

Distance to the Pediatric Emergency Department and Nonurgent Visits in Friuli Venezia Giulia, Italy

OBJECTIVES

Our objective was to assess how the distance from home to the closest pediatric emergency department (ED) affects nonurgent emergency room visits among the child population of the Northeastern Italian region of Friuli Venezia Giulia.

METHODS

The study was based on the administrative databases of the Regional Health Information System of Friuli Venezia Giulia. For the year 2014, we abstracted the records of all white-triage-tag visits of children younger than 16 years from the databases of the 3 regional pediatric EDs located in the 3 main cities. Those records were individually linked to the regional population's georeferenced address database through an anonymous univocal identifier. For each child younger than 16 years living within 20 km from an ED, we calculated the linear distance between the ED and home address. Distances were grouped into 7 circular distance bands: less than 2, 2 to 4, 4 to 6, 6 to 8, 8 to 10, 10 to 15, and 15 to 20 km. Within each band, we calculated the rate of ED visits during the year.

RESULTS

In 2014, there were 12,055 white-triage-tag visits accounting for 24.7% of all visits in the regional pediatric EDs. Although the overall rate of ED visits was different among the EDs, it decreased significantly with increasing distance to the ED, with a 6-fold difference between the innermost and the outermost bands.

CONCLUSIONS

In Friuli Venezia Giulia, short distance is a prompter for inappropriate pediatric ED attendance. Further research is needed in this region to understand the parental standpoint to implement strategies promoting uniform behaviors within the regional boundaries.

Risks predicting prolonged hospital discharge boarding in a regional acute care hospital

Background

Prolonged hospital discharge boarding can impact patient flow resulting in upstream Emergency Department crowding. We aim to determine the risks predicting prolonged hospital discharge boarding and their direct and indirect effects on patient flow.

Methods

Retrospective review of a single hospital discharge database was conducted. Variables including type of disposition, disposition boarding time, case management consultation, discharge medications prescriptions, severity of illness, and patient homeless status were analyzed in a multivariate logistic regression model. Hospital charges, potential savings of hospital bed hours, and whether detailed discharge instructions provided adequate explanations to patients were also analyzed.

Results

A total of 11,527 admissions was entered into final analysis. The median discharge boarding time was approximately 2 h. Adjusted Odds Ratio (AOR) of patients transferring to other hospitals was 7.45 (95% CI 5.35–10.37), to court or law enforcement custody was 2.51 (95% CI 1.84–3.42), and to a skilled nursing facility was 2.48 (95% CI 2.10–2.93). AOR was 0.57 (95% CI 0.47–0.71) if the disposition order was placed during normal office hours (0800–1700). AOR of early case management consultation was 1.52 (95% CI 1.37–1.68) versus 1.73 (95% CI 1.03–2.89) for late consultation. Eighty-eight percent of patients experiencing discharge boarding times within 2 h of disposition expressed positive responses when questioned about the quality of explanations of discharge instructions and follow-up plans based on satisfaction surveys. Similar results (86% positive response) were noted among patients whose discharge boarding times were prolonged (> 2 h, p = 0.44). An average charge of $6/bed/h was noted in all hospital discharges. Maximizing early discharge boarding (≤ 2 h) would have resulted in 16,376 hospital bed hours saved thereby averting $98,256.00 in unnecessary dwell time charges in this study population alone.

Conclusion

Type of disposition, case management timely consultation, and disposition to discharge dwell time affect boarding and patient flow in a tertiary acute care hospital. Efficiency of the discharge process did not affect patient satisfaction relative to the perceived quality of discharge instruction and follow-up plan explanations. Prolonged disposition to discharge intervals result in unnecessary hospital bed occupancy thereby negatively impacting hospital finances while delivering no direct benefit to patients.

Emergency department utilisation by older people in metropolitan Melbourne, 2008–12: findings from the Reducing Older Patient’s Avoidable Presentations for Emergency Care Treatment (REDIRECT) study

Objective Older patients are over-represented in emergency departments (ED), with many presenting for conditions that could potentially be managed in general practice. The aims of the present study were to examine the characteristics of ED presentations by older patients and to identify patient factors contributing to potentially avoidable general practitioner (PAGP)-type presentations. Methods A retrospective analysis was performed of routinely collected data comprising ED presentations by patients aged ≥70 years at public hospitals across metropolitan Melbourne from January 2008 to December 2012. Presentations were classified according to the National Healthcare Agreement definition for PAGP-type presentations. Presentations were characterised according to patient demographic and clinical factors and were compared across PAGP-type and non-PAGP-type groups. Results There were 744 519 presentations to the ED by older people, of which 103 471 (13.9%) were classified as PAGP-type presentations. The volume of such presentations declined over the study period from 20 893 (14.9%) in 2008 to 20 346 (12.8%) in 2012. External injuries were the most common diagnoses (13 761; 13.3%) associated with PAGP-type presentations. Sixty-one per cent of PAGP-type presentations did not involve either an investigation or a procedure. Patients were referred back to a medical officer (including a general practitioner (GP)) in 58.7% of cases. Conclusion Older people made a significant number of PAGP-type presentations to the ED during the period 2008–12. A low rate of referral back to the primary care setting implies a potential lost opportunity to redirect older patients from ED services back to their GPs for ongoing care. What is known about the topic? Older patients are increasingly attending EDs, with a proportion attending for problems that could potentially be managed in the general practice setting (termed PAGP-type presentations). What does this paper add? This study found that PAGP-type presentations, although declining, remain an important component of ED demand. Patients presented for a wide array of conditions and during periods that may indicate difficulty accessing a GP. What are the implications for practitioners? Strategies to redirect PAGP-type presentations to the GP setting are required at both the primary and acute care levels. These include increasing out-of-hours GP services, better triaging and appointment management in GP clinics and improved communication between ED clinicians and patients’ GPs. Although some strategies have been implemented, further examination is required to assess their ongoing effectiveness.

Association of socioeconomic status with outcomes in older adult community-dwelling patients after visiting the emergency department: a retrospective cohort study

OBJECTIVES

Older adults frequently visit the emergency department (ED). Socioeconomic status (SES) has an important impact on health and ED utilisation; however, the association between SES and ED utilisation in elderly remains unclear. The aim of this study was to investigate the association between SES in older adult patients visiting the ED on outcomes.

DESIGN

A retrospective study.

PARTICIPANTS

Older adults (≥65 years) visiting the ED, in the Netherlands. SES was stratified into tertiles based on average household income at zip code level: low (<€1800/month), intermediate (€1800-€2300/month) and high (>€2300/month).

PRIMARY OUTCOMES

Hospitalisation, inhospital mortality and 30-day ED return visits. Effect of SES on outcomes for all groups were assessed by logistic regression and adjusted for confounders.

RESULTS

In total, 4828 older adults visited the ED during the study period. Low SES was associated with a higher risk of hospitalisation among community-dwelling patients compared with high SES (adjusted OR 1.3, 95% CI 1.1 to 1.7). This association was not present for intermediate SES (adjusted OR 1.1, 95% CI 0.95 to 1.4). Inhospital mortality was comparable between the low and high SES group, even after adjustment for age, comorbidity and triage level (low OR 1.4, 95% CI 0.8 to 2.6, intermediate OR 1.3, 95% CI 0.8 to 2.2). Thirty-day ED revisits among community-dwelling patients were also equal between the SES groups (low: adjusted OR 1.0, 95% CI 0.7 to 1.4, and intermediate: adjusted OR 0.8, 95% CI 0.6 to 1.1).

CONCLUSION

In older adult ED patients, low SES was associated with a higher risk of hospitalisation than high SES. However, SES had no impact on inhospital mortality and 30-day ED revisits after adjustment for confounders.

Risk Factors and Outcomes of Emergency Room Visits in Intestinal Behçet's Disease

BACKGROUND/AIMS

Intestinal Behçet's disease (BD) is a chronic recurring intestinal vasculitic disorder that can lead to emergency room (ER) visits. We aimed to investigate the independent risk factors associated with intestinal BD-related ER visits.

METHODS

We retrospectively reviewed 606 patients with intestinal BD registered at the Inflammatory Bowel Disease Clinic of Severance Hospital, Seoul, Korea.

RESULTS

One hundred eighty-five patients (30.5%) visited the ER at least once (total visits, 510). In multivariate analysis, lower socioeconomic status (hazard ratio [HR] 1.884), higher comorbidity index (HR 1.548), corticosteroid use (HR 1.459), higher C-reactive protein (CRP; HR 1.375), and higher disease activity index for intestinal BD (DAIBD) score (HR 1.013) were independent risk factors. However, older age (HR 0.982), disease duration (HR 0.850), opioid use (HR 0.528), and higher hemoglobin level (HR 0.944) were significantly associated with decreased ER visits.

CONCLUSIONS

The ER attendance rate of patients with intestinal BD was 30.5%. Lower socioeconomic status, higher comorbidity index, corticosteroid use, higher CRP, and higher DAIBD score were positively associated with ER visits. Older age, disease duration, opioid use, and higher hemoglobin level were significantly associated with decreased ER visits.

Comparative quality measures of emergency care: an outcome cockpit proposal to survey clinical processes in real life

Background

Benchmarking of real-life quality of care may improve evaluation and comparability of emergency department (ED) care. We investigated process management variables for important medical diagnoses in a large, well-defined cohort of ED patients and studied predictors for low quality of care.

Methods

We prospectively included consecutive medical patients with main diagnoses of community-acquired pneumonia, urinary tract infection (UTI), myocardial infarction (MI), acute heart failure, deep vein thrombosis, and COPD exacerbation and followed them for 30 days. We studied predictors for alteration in ED care (treatment times, satisfaction with care, readmission rates, and mortality) by using multivariate regression analyses.

Results

Overall, 2986 patients (median age 72 years, 57% males) were included. The median time to start treatment was 72 minutes (95% CI: 23 to 150), with a median length of ED stay (ED LOS) of 256 minutes (95% CI: 166 to 351). We found delayed treatment times and longer ED LOS to be independently associated with main medical admission diagnosis and time of day on admission (shortest times for MI and longest times for UTI). Time to first physician contact (−0.01 hours, 95% CI: −0.03 to −0.02) and ED LOS (−0.01 hours, 95% CI: −0.02 to −0.04) were main predictors for patient satisfaction.

Conclusion

Within this large cohort of consecutive patients seeking ED care, we found time of day on admission to be an important predictor for ED timeliness, which again predicted satisfaction with hospital care. Older patients were waiting longer for specific treatment, whereas polymorbidity predicted an increased ED LOS.

Emergency Severity Index: accuracy in risk classification

OBJECTIVE

To verify agreement between estimative of predicted resources using the adapted Emergency Severity Index and the real amount of resources used by patients. To analyze the variables number of years since graduation, years of work experience and years of experience in emergency services especially with accurate anticipation of resources need.

METHODS

This retrospective analytical study with a quantitative approach included 538 medical records of patients assisted by 11 triage nurses. Data collected were related to assistances carried out from December 2012 to February 2013.

RESULTS

There was no significant association between the adequacy of the number of resources used, based on Emergency Severity Index score, number of years since graduation, year of work experience or years of experience in emergency services. Kappa agreement coefficient (0.34) showed that agreement was low between predicted and real used number of resources.

CONCLUSION

Nurses' accuracy index to predict resources for patients care from emergency room using the adapted Emergency Severity Index was lower than results reported in the studies in the literature that used the original scale. There was low agreement of diagnostic exams predicted by nurses and those really performed. There was no association among correct prediction of resources needed, number of years since graduation, years of experience in emergency services and years of work experience in the unit where the study was done.

Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis

OBJECTIVES

Rising demand for emergency and urgent care services is well documented, as are the consequences, for example, emergency department (ED) crowding, increased costs, pressure on services, and waiting times. Multiple factors have been suggested to explain why demand is increasing, including an aging population, rising number of people with multiple chronic conditions, and behavioral changes relating to how people choose to access health services. The aim of this systematic mapping review was to bring together published research from urgent and emergency care settings to identify drivers that underpin patient decisions to access urgent and emergency care.

METHODS

Systematic searches were conducted across Medline (via Ovid SP), EMBASE (via Ovid), The Cochrane Library (via Wiley Online Library), Web of Science (via the Web of Knowledge), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; via EBSCOhost). Peer-reviewed studies written in English that reported reasons for accessing or choosing emergency or urgent care services and were published between 1995 and 2016 were included. Data were extracted and reasons for choosing emergency and urgent care were identified and mapped. Thematic analysis was used to identify themes and findings were reported qualitatively using framework-based narrative synthesis.

RESULTS

Thirty-eight studies were identified that met the inclusion criteria. Most studies were set in the United Kingdom (39.4%) or the United States (34.2%) and reported results relating to ED (68.4%). Thirty-nine percent of studies utilized qualitative or mixed research designs. Our thematic analysis identified six broad themes that summarized reasons why patients chose to access ED or urgent care. These were access to and confidence in primary care; perceived urgency, anxiety, and the value of reassurance from emergency-based services; views of family, friends, or healthcare professionals; convenience (location, not having to make appointment, and opening hours); individual patient factors (e.g., cost); and perceived need for emergency medical services or hospital care, treatment, or investigations.

CONCLUSIONS

We identified six distinct reasons explaining why patients choose to access emergency and urgent care services: limited access to or confidence in primary care; patient perceived urgency; convenience; views of family, friends, or other health professionals; and a belief that their condition required the resources and facilities offered by a particular healthcare provider. There is a need to examine demand from a whole system perspective to gain better understanding of demand for different parts of the emergency and urgent care system and the characteristics of patients within each sector.

Effectiveness of collaboration between emergency department and intensive care unit teams on mortality rates of patients presenting with critical illness: a systematic review

BACKGROUND

The increasing volume of adult patients with critical illness entering emergency departments (EDs) burdens the resources of EDs worldwide. This subpopulation faces a high risk of mortality because they require specialized care which many EDs are not yet poised to deliver. An element crucial to delivering care and decreasing the mortality of critically ill patients in the ED is expert collaborative practice across disciplines. Several ED and intensive care unit (ICU) collaborative models exist including: emergency department intensive care units (EDICU) and medical emergency teams (MET).

OBJECTIVES

To evaluate the effectiveness of collaboration between the ED and ICUs on the mortality rates of critically ill adult ED patients.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adult ED patients, 18 years and over, with non-surgical critical illness meeting the criteria for ICU admission.

TYPES OF INTERVENTION(S)

Collaboration between the ED and ICU in the management of critically ill patients in the ED.

TYPES OF STUDIES

Observational and descriptive studies.

TYPE OF OUTCOME

All-cause mortality, including 30-day mortality and in-hospital mortality rates at any time period.

SEARCH STRATEGY

The comprehensive literature search included published and unpublished studies in English from the beginning of each database through November 30, 2016. Databases searched included: PubMed, CINAHL, Embase and Cochrane Central Register of Controlled Trials (CENTRAL). A search for gray literature and electronic hand searching of relevant journals was also performed.

METHODOLOGICAL QUALITY

Studies were assessed for methodological quality by four independent reviewers using standardized appraisal tools from the Joanna Briggs Institute (JBI).

DATA EXTRACTION

Data related to the methods, participants, interventions and findings were extracted using a standardized data extraction tool from JBI.

DATA SYNTHESIS

Statistical pooling into a meta-analysis was not possible due to the clinical and methodological heterogeneity in the interventions and outcome measures of the included studies. Results are presented in a narrative form.

RESULTS

Three collaborative models (EDICU, Direct Provider-Provider Collaboration and MET) were identified across five studies. Findings from these studies showed conflicting results. The reviewers were unable to synthesize the evidence to state conclusively the effectiveness of collaborative models on mortality rates of critically ill patients.

CONCLUSIONS

There is limited and conflicting evidence related to the effectiveness of EDICU collaborative models on the mortality rates of critically ill patients preventing the development of practice recommendations. This review underscores the need for more research into the benefits of collaborative models between the ED and ICU.

Hierarchical Genetic Algorithm and Fuzzy Radial Basis Function Networks for Factors Influencing Hospital Length of Stay Outliers

Objectives

Controlling hospital high length of stay outliers can provide significant benefits to hospital management resources and lead to cost reduction. The strongest predictive factors influencing high length of stay outliers should be identified to build a high-performance prediction model for hospital outliers.

Methods

We highlight the application of the hierarchical genetic algorithm to provide the main predictive factors and to define the optimal structure of the prediction model fuzzy radial basis function neural network. To establish the prediction model, we used a data set of 26,897 admissions from five different intensive care units with discharges between 2001 and 2012. We selected and analyzed the high length of stay outliers using the trimming method geometric mean plus two standard deviations. A total of 28 predictive factors were extracted from the collected data set and investigated.

Results

High length of stay outliers comprised 5.07% of the collected data set. The results indicate that the prediction model can provide effective forecasting. We found 10 common predictive factors within the studied intensive care units. The obtained main predictive factors include patient demographic characteristics, hospital characteristics, medical events, and comorbidities.

Conclusions

The main initial predictive factors available at the time of admission are useful in evaluating high length of stay outliers. The proposed approach can provide a practical tool for healthcare providers, and its application can be extended to other hospital predictions, such as readmissions and cost.

Impact of Middle East respiratory syndrome outbreak on the use of emergency medical resources in febrile patients

OBJECTIVE

Outbreaks of transmissible respiratory infection are suspected to have significant effects on the health of pediatric and geriatric patients. The objective was to assess the impact of the Middle East respiratory syndrome (MERS) outbreak on the use of emergency resources.

METHODS

An ecologic analysis of emergency department (ED) records between September and December 2015, was performed. Data was obtained from the National Emergency Department Information System database for Korea. All demographic and diagnostic data from patients presenting with febrile symptoms as a main complaint were collected. The data were compared to the equivalent period in the three years preceding the MERS outbreak in Korea.

RESULTS

Following the MERS outbreak, there was an increase in overall ED visits by febrile patients and the proportion of visits by febrile patients, relative to total ED attendances. This effect was more prominent in the children under five years. The duration of the chief complaint before ED arrival and the length of ED stay were significantly increased among younger pediatric patients. Decreased body temperature on arrival was observed in younger pediatric patients.

CONCLUSION

MERS outbreak appears to have had a significant effects on ED use by febrile patients. The use of emergency care services by pediatric patients makes them more vulnerable to an outbreak of a transmissable disease. An effective strategy to control emergency center visits by non-urgent febrile patients and provide proper medical services is urgently needed.