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Slagman A, Fischer-Rosinský A, Legg D, Schmieder K, Möckel M. Identification of low-acuity attendances in routine clinical information documented in German Emergency Departments. BMC Emerg Med 2023; 23:64. [PMID: 37280527 DOI: 10.1186/s12873-023-00838-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/31/2023] [Indexed: 06/08/2023] Open
Abstract
INTRODUCTION It has not yet been possible to ascertain the exact proportion, characterization or impact of low-acuity emergency department (ED) attendances on the German Health Care System since valid and robust definitions to be applied in German ED routine data are missing. METHODS Internationally used methods and parameters to identify low-acuity ED attendances were identified, analyzed and then applied to routine ED data from two EDs of the tertiary care hospitals Charité-Universitätsmedizin Berlin, Campus Mitte (CCM) and Campus Virchow (CVK). RESULTS Based on the three routinely available parameters `disposition´, `transport to the ED´ and `triage´ 33.2% (n = 30 676) out of 92 477 presentations to the two EDs of Charité-Universitätsmedizin Berlin (CVK, CCM) in 2016 could be classified as low-acuity presentations. CONCLUSION This study provides a reliable and replicable means of retrospective identification and quantification of low-acuity attendances in German ED routine data. This enables both intra-national and international comparisons of figures across future studies and health care monitoring.
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Affiliation(s)
- Anna Slagman
- Emergency and Acute Medicine (CVK, CCM), Health Services Research in Emergency and Acute Medicine, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Antje Fischer-Rosinský
- Emergency and Acute Medicine (CVK, CCM), Health Services Research in Emergency and Acute Medicine, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - David Legg
- Emergency and Acute Medicine (CVK, CCM), Health Services Research in Emergency and Acute Medicine, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kristin Schmieder
- Emergency and Acute Medicine (CVK, CCM), Health Services Research in Emergency and Acute Medicine, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Martin Möckel
- Emergency and Acute Medicine (CVK, CCM), Health Services Research in Emergency and Acute Medicine, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Botes M, Cooke R, Bruce J. Experiences of primary health care practitioners dealing with emergencies - 'We are on our own'. Afr J Prim Health Care Fam Med 2023; 15:e1-e9. [PMID: 36744459 PMCID: PMC9900295 DOI: 10.4102/phcfm.v15i1.3553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 10/20/2022] [Accepted: 10/30/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Primary health care (PHC) focuses on health promotion and disease prevention; however, acute episodes and emergencies still occur at this level of care. The World Health Organization (WHO) proposes strengthening emergency care at a PHC level as a way of lessening the burden of disease on the overall health system. It is not known how health care practitioners at the PHC level experience management of emergencies. AIM To explore and describe the experiences of PHC practitioners dealing with emergencies at PHC facilities in Gauteng, South Africa. SETTING The study was conducted in the District Health Services of Gauteng province in South Africa, including clinics, community health care centres and district hospitals. METHODS Using a qualitative approach, semi-structured interviews were conducted with a purposively selected sample of professional nurses and doctors from various levels of the district health care system. Data were transcribed and analysed using qualitative thematic analysis. RESULTS Various themes were identified related to the individual confidence and competence of the PHC practitioner, the team approach, the process of role and task allocation and the need for training. CONCLUSION The study provided a voice for the needs of health care practitioners dealing with emergencies at the PHC level. The designing of a targeted and contextually appropriate approach to emergency care training of health care practitioners in the PHC setting that improves team dynamics and team performance, is recommended.Contribution: The insights of PHC practitioners dealing with emergencies contribute contextual relevance to any strategic improvement of care at this level.
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Affiliation(s)
- Meghan Botes
- Department of Nursing Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Richard Cooke
- Department of Family Medicine and Primary Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Judith Bruce
- Department of Nursing Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Eysenbach G, Kleib M, Norris C, O'Rourke HM, Montgomery C, Douma M. The Use and Structure of Emergency Nurses' Triage Narrative Data: Scoping Review. JMIR Nurs 2023; 6:e41331. [PMID: 36637881 PMCID: PMC9883744 DOI: 10.2196/41331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Emergency departments use triage to ensure that patients with the highest level of acuity receive care quickly and safely. Triage is typically a nursing process that is documented as structured and unstructured (free text) data. Free-text triage narratives have been studied for specific conditions but never reviewed in a comprehensive manner. OBJECTIVE The objective of this paper was to identify and map the academic literature that examines triage narratives. The paper described the types of research conducted, identified gaps in the research, and determined where additional review may be warranted. METHODS We conducted a scoping review of unstructured triage narratives. We mapped the literature, described the use of triage narrative data, examined the information available on the form and structure of narratives, highlighted similarities among publications, and identified opportunities for future research. RESULTS We screened 18,074 studies published between 1990 and 2022 in CINAHL, MEDLINE, Embase, Cochrane, and ProQuest Central. We identified 0.53% (96/18,074) of studies that directly examined the use of triage nurses' narratives. More than 12 million visits were made to 2438 emergency departments included in the review. In total, 82% (79/96) of these studies were conducted in the United States (43/96, 45%), Australia (31/96, 32%), or Canada (5/96, 5%). Triage narratives were used for research and case identification, as input variables for predictive modeling, and for quality improvement. Overall, 31% (30/96) of the studies offered a description of the triage narrative, including a list of the keywords used (27/96, 28%) or more fulsome descriptions (such as word counts, character counts, abbreviation, etc; 7/96, 7%). We found limited use of reporting guidelines (8/96, 8%). CONCLUSIONS The breadth of the identified studies suggests that there is widespread routine collection and research use of triage narrative data. Despite the use of triage narratives as a source of data in studies, the narratives and nurses who generate them are poorly described in the literature, and data reporting is inconsistent. Additional research is needed to describe the structure of triage narratives, determine the best use of triage narratives, and improve the consistent use of triage-specific data reporting guidelines. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1136/bmjopen-2021-055132.
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Affiliation(s)
| | - Manal Kleib
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Colleen Norris
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | | | | | - Matthew Douma
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
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Sutarsa IN, Kasim R, Steward B, Bain-Donohue S, Slimings C, Hall Dykgraaf S, Barnard A. Do General Practitioners in a Visiting Medical Officer Arrangement Improve the Perceived Quality of Care of Rural and Remote Patients? A Qualitative Study in Australia. Healthcare (Basel) 2022; 10:healthcare10061045. [PMID: 35742096 PMCID: PMC9223112 DOI: 10.3390/healthcare10061045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 11/16/2022] Open
Abstract
Background: In rural and remote Australia, general practitioners (GPs) provide care across the continuum from primary to secondary care, often in Visiting Medical Officer (VMO) arrangements with a local hospital. However, little is known about the role of GP-VMOs in improving the perceived quality of care and health outcomes for rural and remote communities. Methods: We collected qualitative data from three GP-VMOs (all aged >55 years) and 10 patients (all aged over 65 years) in three local health districts of New South Wales, Australia. Thirteen in-depth interviews were conducted between October 2020 and February 2021. We employed thematic analysis to identify key roles of GP-VMOs in improving the perceived quality of care and health outcomes of rural and remote patients. Results: Our study advances the current understanding regarding the role of GP-VMOs in improving the perceived quality of services and health outcomes of rural and remote patients. Key roles of GP-VMOs in improving the perceived quality of care include promoting the continuity of care and integrated health services, cultivating trust from local communities, and enhancing the satisfaction of patients. Conclusions: GP-VMOs work across primary and secondary care creating better linkages and promoting the continuity of care for rural and remote communities. Employing GP-VMOs in rural hospitals enables the knowledge and sensitivity gained from their ongoing interactions with patients in primary care to be effectively utilised in the delivery of hospital care.
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Affiliation(s)
- I Nyoman Sutarsa
- Rural Clinical School, Medical School, College of Health and Medicine, The Australian National University, Acton, ACT 2601, Australia; (R.K.); (B.S.); (S.B.-D.); (C.S.); (S.H.D.); (A.B.)
- Department of Population Health and Preventive Medicine, Faculty of Medicine, Udayana University, Denpasar 80232, Bali, Indonesia
- Correspondence:
| | - Rosny Kasim
- Rural Clinical School, Medical School, College of Health and Medicine, The Australian National University, Acton, ACT 2601, Australia; (R.K.); (B.S.); (S.B.-D.); (C.S.); (S.H.D.); (A.B.)
| | - Ben Steward
- Rural Clinical School, Medical School, College of Health and Medicine, The Australian National University, Acton, ACT 2601, Australia; (R.K.); (B.S.); (S.B.-D.); (C.S.); (S.H.D.); (A.B.)
| | - Suzanne Bain-Donohue
- Rural Clinical School, Medical School, College of Health and Medicine, The Australian National University, Acton, ACT 2601, Australia; (R.K.); (B.S.); (S.B.-D.); (C.S.); (S.H.D.); (A.B.)
| | - Claudia Slimings
- Rural Clinical School, Medical School, College of Health and Medicine, The Australian National University, Acton, ACT 2601, Australia; (R.K.); (B.S.); (S.B.-D.); (C.S.); (S.H.D.); (A.B.)
| | - Sally Hall Dykgraaf
- Rural Clinical School, Medical School, College of Health and Medicine, The Australian National University, Acton, ACT 2601, Australia; (R.K.); (B.S.); (S.B.-D.); (C.S.); (S.H.D.); (A.B.)
| | - Amanda Barnard
- Rural Clinical School, Medical School, College of Health and Medicine, The Australian National University, Acton, ACT 2601, Australia; (R.K.); (B.S.); (S.B.-D.); (C.S.); (S.H.D.); (A.B.)
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Feral-Pierssens AL, Morris J, Marquis M, Daoust R, Cournoyer A, Lessard J, Berthelot S, Messier A. Safety assessment of a redirection program using an electronic application for low-acuity patients visiting an emergency department. BMC Emerg Med 2022; 22:71. [PMID: 35488215 PMCID: PMC9052637 DOI: 10.1186/s12873-022-00626-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Emergency departments (EDs) are operating at or above capacity, which has negative consequences on patients in terms of quality of care and morbi-mortality. Redirection strategies for low-acuity ED patients to primary care practices are usually based on subjective eligibility criteria that sometimes necessitate formal medical assessment. Literature investigating the effect of those interventions is equivocal. The aim of the present study was to assess the safety of a redirection process using an electronic clinical support system used by the triage nurse without physician assessment. Methods A single cohort observational study was performed in the ED of a level 1 academic trauma center. All low-acuity patients redirected to nearby clinics through a clinical decision support system (February–August 2017) were included. This system uses different sets of medical prerequisites to identify patients eligible to redirection. Data on safety and patient experience were collected through phone questionnaires on day 2 and 10 after ED visit. The primary endpoint was the rate of redirected patients returning to any ED for an unexpected visit within 48 h. Secondary endpoints were the incidence of 7-day return visit and satisfaction rates. Results A total of 980 redirected low-acuity patients were included over the period: 18 patients (2.8%) returned unexpectedly to an ED within 48 h and 31 patients (4.8%) within 7 days. No hospital admission or death were reported within 7 days following the first ED visit. Among redirected patients, 81% were satisfied with care provided by the clinic staff. Conclusion The implementation of a specific electronic-guided decision support redirection protocol appeared to provide safe deferral to nearby clinics for redirected low-acuity patients. EDs are pivotal elements of the healthcare system pathway and redirection process could represent an interesting tool to improve the care to low-acuity patients.
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Affiliation(s)
- Anne-Laure Feral-Pierssens
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada. .,CR-CSIS, Sherbrooke University, Longueuil, Québec, Canada. .,Health Educations and Promotion Laboratory (LEPS EA3412), University Sorbonne Paris Nord, Bobigny, France. .,SAMU 93 - Emergency Department, Avicenne Hospital, Assistance Publique Hôpitaux de Paris, Bobigny, France.
| | - Judy Morris
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Martin Marquis
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada
| | - Raoul Daoust
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Alexis Cournoyer
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada.,Hôpital Maisonneuve-Rosemont, CIUSSS-EIM, Montréal, Québec, Canada.,Corporation d'Urgences-santé, Montréal, Québec, Canada
| | - Justine Lessard
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Simon Berthelot
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada.,Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Alexandre Messier
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
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Jeyaraman MM, Alder RN, Copstein L, Al-Yousif N, Suss R, Zarychanski R, Doupe MB, Berthelot S, Mireault J, Tardif P, Askin N, Buchel T, Rabbani R, Beaudry T, Hartwell M, Shimmin C, Edwards J, Halas G, Sevcik W, Tricco AC, Chochinov A, Rowe BH, Abou-Setta AM. Impact of employing primary healthcare professionals in emergency department triage on patient flow outcomes: a systematic review and meta-analysis. BMJ Open 2022; 12:e052850. [PMID: 35443941 PMCID: PMC9058787 DOI: 10.1136/bmjopen-2021-052850] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 02/26/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To identify, critically appraise and summarise evidence on the impact of employing primary healthcare professionals (PHCPs: family physicians/general practitioners (GPs), nurse practitioners (NP) and nurses with increased authority) in the emergency department (ED) triage, on patient flow outcomes. METHODS We searched Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) (inception to January 2020). Our primary outcome was the time to provider initial assessment (PIA). Secondary outcomes included time to triage, proportion of patients leaving without being seen (LWBS), length of stay (ED LOS), proportion of patients leaving against medical advice (LAMA), number of repeat ED visits and patient satisfaction. Two independent reviewers selected studies, extracted data and assessed study quality using the National Institute for Health and Care Excellence quality assessment tool. RESULTS From 23 973 records, 40 comparative studies including 10 randomised controlled trials (RCTs) and 13 pre-post studies were included. PHCP interventions were led by NP (n=14), GP (n=3) or nurses with increased authority (n=23) at triage. In all studies, PHCP-led intervention effectiveness was compared with the traditional nurse-led triage model. Median duration of the interventions was 6 months. Study quality was generally low (confounding bias); 7 RCTs were classified as moderate quality. Most studies reported that PHCP-led triage interventions decreased the PIA (13/14), ED LOS (29/30), proportion of patients LWBS (8/10), time to triage (3/3) and repeat ED visits (5/6), and increased the patient satisfaction (8/10). The proportion of patients LAMA did not differ between groups (3/3). Evidence from RCTs (n=8) as well as other study designs showed a significant decrease in ED LOS favouring the PHCP-led interventions. CONCLUSIONS Overall, PHCP-led triage interventions improved ED patient flow metrics. There was a significant decrease in ED LOS irrespective of the study design, favouring the PHCP-led interventions. Evidence from well-designed high-quality RCTs is required prior to widespread implementation. PROSPERO REGISTRATION NUMBER CRD42020148053.
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Affiliation(s)
- Maya M Jeyaraman
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rachel N Alder
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Leslie Copstein
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nameer Al-Yousif
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Roger Suss
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ryan Zarychanski
- Department of Medical Oncology and Hematology, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Malcolm B Doupe
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Simon Berthelot
- Centre de recherche du CHU de Québec-Université Laval, Axe Santé des populations et Pratiques optimales en santé, Laval, Quebec, Canada
| | - Jean Mireault
- HEC Pôle santé, Université de Montréal, Montreal, Quebec, Canada
| | - Patrick Tardif
- Department of Emergency Medicine, Cité de la santé de Laval, Laval, Quebec, Canada
| | - Nicole Askin
- WRHA Virtual Library, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tamara Buchel
- Manitoba College of Family Physicians, Winnipeg, Manitoba, Canada
| | - Rasheda Rabbani
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Thomas Beaudry
- Patient and Public Engagement Collaborative Partnership, George & Fay Yee Center for Healthcare Innovation, Winnipeg, Manitoba, Canada
| | - Melissa Hartwell
- Primary and Integrated Health care Innovation Network, Edmonton, Alberta, Canada
| | - Carolyn Shimmin
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jeanette Edwards
- Community Health Quality and Learning, Shared Health Manitoba, Winnipeg, Manitoba, Canada
| | - Gayle Halas
- Manitoba Primary and Integrated Health care Innovation Network, Winnipeg, Manitoba, Canada
| | - William Sevcik
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, St. Michael's Hospital Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Alecs Chochinov
- Department of Emergency Medicine, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmed M Abou-Setta
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
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Picard CT, Kleib M, O'Rourke HM, Norris CM, Douma MJ. Emergency nurses' triage narrative data, their uses and structure: a scoping review protocol. BMJ Open 2022; 12:e055132. [PMID: 35418428 PMCID: PMC9014040 DOI: 10.1136/bmjopen-2021-055132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The first clinical interaction most patients have in the emergency department occurs during triage. An unstructured narrative is generated during triage and is the first source of in-hospital documentation. These narratives capture the patient's reported reason for the visit and the initial assessment and offer significantly more nuanced descriptions of the patient's complaints than fixed field data. Previous research demonstrated these data are useful for predicting important clinical outcomes. Previous reviews examined these narratives in combination or isolation with other free-text sources, but used restricted searches and are becoming outdated. Furthermore, there are no reviews focused solely on nurses' (the primary collectors of these data) narratives. METHODS AND ANALYSIS Using the Arksey and O'Malley scoping review framework and PRISMA-ScR reporting guidelines, we will perform structured searches of CINAHL, Ovid MEDLINE, ProQuest Central, Ovid Embase and Cochrane Library (via Wiley). Additionally, we will forward citation searches of all included studies. No geographical or study design exclusion criteria will be used. Studies examining disaster triage, published before 1990, and non-English language literature will be excluded. Data will be managed using online management tools; extracted data will be independently confirmed by a separate reviewer using prepiloted extraction forms. Cohen's kappa will be used to examine inter-rater agreement on pilot and final screening. Quantitative data will be expressed using measures of range and central tendency, counts, proportions and percentages, as appropriate. Qualitative data will be narrative summaries of the authors' primary findings. PATIENT AND PUBLIC INVOLVEMENT No patients involved. ETHICS AND DISSEMINATION No ethics approval is required. Findings will be submitted to peer-reviewed conferences and journals. Results will be disseminated using individual and institutional social media platforms.
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Affiliation(s)
- Christopher Thomas Picard
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
- Royal Alexandra Hospital, Emergency, Alberta Health Services, Edmonton, Alberta, Canada
| | - Manal Kleib
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Hannah M O'Rourke
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Colleen M Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew J Douma
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
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Scantlebury A, Brant H, Anderson H, Leggett H, Salisbury C, Cowlishaw S, Voss S, Benger JR, Adamson J. Potential impacts of general practitioners working in or alongside emergency departments in England: initial qualitative findings from a national mixed-methods evaluation. BMJ Open 2021; 11:e045453. [PMID: 34031113 PMCID: PMC8149439 DOI: 10.1136/bmjopen-2020-045453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore the potential impacts of introducing General Practitioners into Emergency Departments (GPED) from the perspectives of service leaders, health professionals and patients. These 'expectations of impact' can be used to generate hypotheses that will inform future implementations and evaluations of GPED. DESIGN Qualitative study consisting of 228 semistructured interviews. SETTING 10 acute National Health Service (NHS) hospitals and the wider healthcare system in England. Interviews were undertaken face to face or via telephone. Data were analysed thematically. PARTICIPANTS 124 health professionals and 94 patients and carers. 10 service leaders representing a range of national organisations and government departments across England (eg, NHS England and Department of Health) were also interviewed. RESULTS A range of GPED models are being implemented across the NHS due to different interpretations of national policy and variation in local context. This has resulted in stakeholders and organisations interpreting the aims of GPED differently and anticipating a range of potential impacts. Participants expected GPED to affect the following areas: ED performance indicators; patient outcome and experience; service access; staffing and workforce experience; and resources. Across these 'domains of influence', arguments for positive, negative and no effect of GPED were proposed. CONCLUSIONS Evaluating whether GPED has been successful will be challenging. However, despite uncertainty surrounding the direction of effect, there was agreement across all stakeholder groups on the areas that GPED would influence. As a result, we propose eight domains of influence that will inform our subsequent mixed-methods evaluation of GPED. TRIAL REGISTRATION NUMBER ISRCTN51780222.
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Affiliation(s)
- Arabella Scantlebury
- York Trials Unit, Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Heather Brant
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - Helen Anderson
- York Trials Unit, Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Heather Leggett
- York Trials Unit, Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Chris Salisbury
- School of Social and community medicine, University of Bristol, Bristol, UK
| | - Sean Cowlishaw
- Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sarah Voss
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - Jonathan Richard Benger
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
- Academic Department of Emergency Care, NHS Bristol North Somerset and South Gloucestershire Clinical Commissioning Group, Bristol, UK
| | - Joy Adamson
- York Trials Unit, Department of Health Sciences, University of York, York, North Yorkshire, UK
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Abstract
Introduction In response to emergency department over-crowding primary care practitioners (PCPs) have been incorporated into care pathways to provide integrated care. We consider why a pilot project of PCP-led streaming in a German emergency department failed, the challenges encountered transplanting models between differing systems and cultures, and if the concept constitutes integrated care. Theory and Methods The original design was a mixed methods data gather around PCP-streaming of non-urgent self-referrers in an emergency department. Results The demand for the PCP-streaming was low, which was at odds with pre-study estimates. The study was stopped prematurely without adequate data; this is an opinion-based article. Discussion A fundamental of emergency care is a central emergency department. An emergency department can be the fulcrum from which urgent inter-disciplinary hospital care is initiated and coordinated. Objective triage is fundamental to this and regional healthcare planning. With such fundamentals in place, PCP integration has the potential to facilitate and provide integrated care. Relevant elements of the Rainbow Model of Integrated Care frame the discussion. Conclusion The key element deficient in each barrier to our project, yet present in successful studies, was normative integration.
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Management of non-urgent paediatric emergency department attendances by GPs: a retrospective observational study. Br J Gen Pract 2020; 71:e22-e30. [PMID: 33257462 PMCID: PMC7716877 DOI: 10.3399/bjgp20x713885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/20/2020] [Indexed: 11/21/2022] Open
Abstract
Background Non-urgent emergency department (ED) attendances are common among children. Primary care management may not only be more clinically appropriate, but may also improve patient experience and be more cost-effective. Aim To determine the impact on admissions, waiting times, antibiotic prescribing, and treatment costs of integrating a GP into a paediatric ED. Design and setting Retrospective cohort study explored non-urgent ED presentations in a paediatric ED in north-west England. Method From 1 October 2015 to 30 September 2017, a GP was situated in the ED from 2.00 pm until 10.00 pm, 7 days a week. All children triaged as ‘green’ using the Manchester Triage System (non-urgent) were considered to be ‘GP appropriate’. In cases of GP non-availability, children considered non-urgent were managed by ED staff. Clinical and operational outcomes, as well as the healthcare costs of children managed by GPs and ED staff across the same timeframe over a 2-year period were compared. Results Of 115 000 children attending the ED over the study period, a complete set of data were available for 13 099 categorised as ‘GP appropriate’; of these, 8404 (64.2%) were managed by GPs and 4695 (35.8%) by ED staff. Median duration of ED stay was 39 min (interquartile range [IQR] 16–108 min) in the GP group and 165 min (IQR 104–222 min) in the ED group (P<0.001). Children in the GP group were less likely to be admitted as inpatients (odds ratio [OR] 0.16; 95% confidence interval [CI] = 0.13 to 0.20) and less likely to wait >4 hours before being admitted or discharged (OR 0.11; 95% CI = 0.08 to 0.13), but were more likely to receive antibiotics (OR 1.42; 95% CI = 1.27 to 1.58). Treatment costs were 18.4% lower in the group managed by the GP (P<0.0001). Conclusion Given the rising demand for children’s emergency services, GP in ED care models may improve the management of non-urgent ED presentations. However, further research that incorporates causative study designs is required.
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Sam M, Cook DL, Rowland AG, Butler J. Exploring Perceptions of Parents on the Use of Emergency Department On-site Primary Care Services for the Treatment of Children With Non-urgent Conditions. Compr Child Adolesc Nurs 2020:1-18. [PMID: 33026268 DOI: 10.1080/24694193.2020.1820116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
This study was conducted to understand the reasons parents of children with minor conditions attend the Children's Emergency Department (ED), and their views about onsite pediatric same day care (SDC) service as an alternative treatment center. The study was a cross-sectional survey of parents attending an inner-city, district general hospital children's ED, with children aged under 16 years old who were allocated to low triage categories. A convenience sample of 58 parents of 58 children were recruited. All the 58 responses were analyzed. Incomplete questionnaires were not excluded. 47% of attendances were because of minor injury. Most presentations were within 24 hours of the injury or illness. 72% of parents were employed. 91% were registered with a General Practitioner (GP). 29% contacted a GP before the ED visit. The majority of participants who contacted a GP were referred to the ED; others were advised to wait to see if the child's condition improved and to attend the ED if there were any concerns or the child deteriorated in any way. About 50% of those that did not contact GP said the GP surgery was closed and 8% felt the GP could not help. 90% of parents perceived their child's condition as urgent requiring immediate treatment. About 33% of parents said they would be happy for their children to be treated at an onsite SDC center. The study showed limited access to GP services in the community and dissatisfaction with community services and perceived urgency of treatment prompted parents of children with minor conditions to attend the ED. This could mean significant ED attendance by children with minor conditions. The majority of the parents in the study would welcome an onsite pediatric SDC if appropriate to meet their children's care needs. Establishing an onsite SDC may help relieve the ED pressures to attend to more clinically urgent and emergency cases.
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Affiliation(s)
- Mfon Sam
- Research and Innovation Department, Trafford General Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Dianne L Cook
- Emergency Department, North Manchester General Hospital, The Pennine Acute Hospitals NHS Trust, Manchester, UK
- School of Health and Society, University of Salford, Salford, UK
| | - Andrew G Rowland
- Emergency Department, North Manchester General Hospital, The Pennine Acute Hospitals NHS Trust, Manchester, UK
- School of Health and Society, University of Salford, Salford, UK
- Research and Innovation Department, The Northern Care Alliance NHS Group, Salford, UK
| | - James Butler
- Emergency Department, The Royal Oldham Hospital, The Northern Care Alliance NHS Group, Oldham, UK
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Leite H. The impact of non-urgent patients in emergency departments' operations. INTERNATIONAL JOURNAL OF QUALITY & RELIABILITY MANAGEMENT 2020. [DOI: 10.1108/ijqrm-01-2020-0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeGlobally, the presence of non-urgent patients in emergency departments (EDs) is considered one of the main reasons for creating excessive waiting times and overcrowding in units. This paper aims to understand the impact of non-urgent patients in EDs' operations.Design/methodology/approachThis study is based on qualitative case studies conducted within two Brazilian EDs, and uses interviews and observations to access the data.FindingsFrom a thematic analysis, three key themes emerged: characteristics of non-urgent demands in EDs, negative aspects of non-urgent patients in EDs, and the impact of the healthcare system model on EDs. These themes bring to light the impact that non-urgent patients have in EDs' operations, and provide theoretical and practical implications.Research limitations/implicationsThe limitation of this work is bound by the understanding of the non-urgent demands in EDs. Therefore, a benchmarking approach (investigating state-of-the-art practices to avoid such impact) was not applied but was suggested for future research instead.Practical implicationsThe research provides significant contributions to practitioners and policymakers, aiding future discussions to improve healthcare coverage and performance.Social implicationsThe research provides significant contributions for managers and policymakers, aiding future discussions to improve healthcare. For instance, the use of well-known techniques (e.g. lean, six sigma) are discussed and suggested to enhance healthcare capacity and performance. Furthermore, the policymakers are called upon to evaluate the healthcare access and provide regulations that involve innovative approaches to widen healthcare access.Originality/valueBased upon empirical data, this research extends the discussions related to non-urgent patient in EDs and is not limited merely to descriptive analysis, but by providing practical propositions and discussions related to the impact of these patients' presence in EDs' operations. Finally, the research provides a range of suggestions for future research related to the EDs' operational performance.
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Ayorinde AA, Williams I, Mannion R, Song F, Skrybant M, Lilford RJ, Chen YF. Publication and related bias in quantitative health services and delivery research: a multimethod study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.
Objectives
To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.
Methods
The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).
Results
We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.
Conclusions
This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.
Study registration
This study is registered as PROSPERO CRD42016052333 and CRD42016052366.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Abimbola A Ayorinde
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Iestyn Williams
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
| | - Russell Mannion
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
| | - Fujian Song
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Magdalena Skrybant
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Richard J Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Bittencourt RJ, Stevanato ADM, Bragança CTNM, Gottems LBD, O'Dwyer G. Interventions in overcrowding of emergency departments: an overview of systematic reviews. Rev Saude Publica 2020; 54:66. [PMID: 32638885 PMCID: PMC7319499 DOI: 10.11606/s1518-8787.2020054002342] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/15/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To present an overview of systematic reviews on throughput interventions to solve the overcrowding of emergency departments. METHODS Electronic searches for reviews published between 2007 and 2018 were made on PubMed, Cochrane Library, EMBASE, Health Systems Evidence, CINAHL, SciELO, LILACS, Google Scholar and the CAPES periodicals portal. Data of the included studies was extracted into a pre-formatted sheet and their methodological quality was assessed using AMSTAR 2 tool. Eventually, 15 systematic reviews were included for the narrative synthesis. RESULTS The interventions were grouped into four categories: (1) strengthening of the triage service; (2) strengthening of the ED’s team; (3) creation of new care zones; (4) change in ED’s work processes. All studies observed positive effect on patient’s length of stay, expect for one, which had positive effect on other indicators. According to AMSTAR 2 criteria, eight revisions were considered of high or moderate methodological quality and seven, low or critically low quality. There was a clear improvement in the quality of the studies, with an improvement in focus and methodology after two decades of systematic studies on the subject. CONCLUSIONS Despite some limitations, the evidence presented on this overview can be considered the cutting edge of current scientific knowledge on the topic.
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Affiliation(s)
- Roberto José Bittencourt
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Angelo de Medeiros Stevanato
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Carolina Thomé N M Bragança
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Leila Bernarda Donato Gottems
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Gisele O'Dwyer
- Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
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Cooper A, Carson-Stevens A, Hughes T, Edwards A. Is streaming patients in emergency departments to primary care services effective and safe? BMJ 2020; 368:m462. [PMID: 32098900 DOI: 10.1136/bmj.m462] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Alison Cooper
- Division of Population Medicine, School of Medicine, Cardiff University, UK
| | | | | | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, UK
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Touzet S, Occelli P, Denis A, Cornut PL, Fassier JB, Le Pogam MA, Duclos A, Burillon C. Impact of a comprehensive prevention programme aimed at reducing incivility and verbal violence against healthcare workers in a French ophthalmic emergency department: an interrupted time-series study. BMJ Open 2019; 9:e031054. [PMID: 31492791 PMCID: PMC6731840 DOI: 10.1136/bmjopen-2019-031054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE AND SETTING Primary prevention, comprising patient-oriented and environmental interventions, is considered to be one of the best ways to reduce violence in the emergency department (ED). We assessed the impact of a comprehensive prevention programme aimed at preventing incivility and verbal violence against healthcare professionals working in the ophthalmology ED (OED) of a university hospital. INTERVENTION The programme was designed to address long waiting times and lack of information. It combined a computerised triage algorithm linked to a waiting room patient call system, signage to assist patients to navigate in the OED, educational messages broadcast in the waiting room, presence of a mediator and video surveillance. PARTICIPANTS All patients admitted to the OED and those accompanying them. DESIGN Single-centre prospective interrupted time-series study conducted over 18 months. PRIMARY OUTCOME Violent acts self-reported by healthcare workers committed by patients or those accompanying them against healthcare workers. SECONDARY OUTCOMES Waiting time and length of stay. RESULTS There were a total of 22 107 admissions, including 272 (1.4%) with at least one act of violence reported by the healthcare workers. Almost all acts of violence were incivility or verbal harassment. The rate of violence significantly decreased from the pre-intervention to the intervention period (24.8, 95% CI 20.0 to 29.5, to 9.5, 95% CI 8.0 to 10.9, acts per 1000 admissions, p<0.001). An immediate 53% decrease in the violence rate (incidence rate ratio=0.47, 95% CI 0.27 to 0.82, p=0.0121) was observed in the first month of the intervention period, after implementation of the triage algorithm. CONCLUSION A comprehensive prevention programme targeting patients and environment can reduce self-reported incivility and verbal violence against healthcare workers in an OED. TRIAL REGISTRATION NUMBER NCT02015884.
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Affiliation(s)
- Sandrine Touzet
- Pôle de Santé Publique, Hospices Civils de Lyon, Lyon, France
- Laboratoire Health Services and Performance Research (HESPER) EA 7425, Université de Lyon, Lyon, France
| | - Pauline Occelli
- Pôle de Santé Publique, Hospices Civils de Lyon, Lyon, France
- Laboratoire Health Services and Performance Research (HESPER) EA 7425, Université de Lyon, Lyon, France
| | - Angelique Denis
- Pôle de Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Pierre-Loïc Cornut
- Hôpital Edouard Herriot, Service d'ophtalmologie, Hospices Civils de Lyon, Lyon, France
| | - Jean-Baptiste Fassier
- Pôle de Santé Publique, Hospices Civils de Lyon, Lyon, France
- UMRESTTE, Université de Lyon, Lyon, France
| | - Marie-Annick Le Pogam
- Institute of Social and Preventive Medicine (IUMSP), University Hospital of Lausanne, Lausanne, Switzerland
| | - Antoine Duclos
- Pôle de Santé Publique, Hospices Civils de Lyon, Lyon, France
- Laboratoire Health Services and Performance Research (HESPER) EA 7425, Université de Lyon, Lyon, France
| | - Carole Burillon
- Hôpital Edouard Herriot, Service d'ophtalmologie, Hospices Civils de Lyon, Lyon, France
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Amir Behghadami M, Janati A, Sadeghi-Bazargani H, Gholizadeh M, Rahmani F, Arab-Zozani M. Developing and validating an instrument to assess non-hospital health centers' preparedness to provide initial emergency care: a study protocol. BMJ Open 2019; 9:e026651. [PMID: 31352412 PMCID: PMC6661924 DOI: 10.1136/bmjopen-2018-026651] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 06/23/2019] [Accepted: 06/28/2019] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Basic emergency management in urban and rural areas is a critical challenge. This paper presents the protocol for developing, validating and piloting an instrument to assess the preparedness of non-hospital health centres which deliver initial emergency care. METHODS AND ANALYSIS This study will be designed based on a sequential exploratory mixed method in two phases, in each of which there are three steps. In the first step of phase I, an extensive systematic review will be conducted. In the second step, through focus group discussions (FGDs), the experts' views on the definition of domains and items of the instrument will be compiled. In addition, semistructured interviews with the target group will be performed. Then, qualitative framework analysis will be performed. In the last step of phase I, the results of both steps will be triangulated by a panel of experts to define the domains and items to be included in the instrument. Phase II will include content validity, feasibility and reliability of the instrument. Content validity of the instrument will be assessed using modified Kappa coefficient based on clarity and relevance criteria. Feasibility of the instrument will be assessed through its implementation in 10 non-hospital health centres in Tabriz, which will be selected randomly. Reliability will be assessed in a pilot on 30 non-hospital health centres through using stratified random sampling method. Reliability of the instrument will be assessed through measuring internal consistency, test-retest reliability and inter-rater agreement. The main statistical methods for assessing reliability will include Cronbach's alpha, intraclass correlation coefficient and Kendall's tau-b. All the statistical analyses will be performed using Stata V.14. ETHICS AND DISSEMINATION This study is approved by Tabriz University of Medical Sciences Research Ethics Committee (IR.TBZMED.REC.1397.145). The results of the study will be presented at national scientific conferences and published in peer-reviewed journals.
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Affiliation(s)
- Mehrdad Amir Behghadami
- Iranian Center of Excellence in Health Management, Department of Health Service Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
- Student Research Committee (SRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Janati
- Iranian Center of Excellence in Health Management, Department of Health Service Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Masoumeh Gholizadeh
- Iranian Center of Excellence in Health Management, Department of Health Service Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farzad Rahmani
- Emergency Medicine Department, Sina Medical Research and Training Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Arab-Zozani
- Iranian Center of Excellence in Health Management, Department of Health Service Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
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Cooper A, Davies F, Edwards M, Anderson P, Carson-Stevens A, Cooke MW, Donaldson L, Dale J, Evans BA, Hibbert PD, Hughes TC, Porter A, Rainer T, Siriwardena A, Snooks H, Edwards A. The impact of general practitioners working in or alongside emergency departments: a rapid realist review. BMJ Open 2019; 9:e024501. [PMID: 30975667 PMCID: PMC6500276 DOI: 10.1136/bmjopen-2018-024501] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 12/14/2018] [Accepted: 01/24/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%-43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are 'free to care for the sickest patients'. However, the research evidence to support this initiative is weak. DESIGN Rapid realist literature review. SETTING Emergency departments. INCLUSION CRITERIA Articles describing general practitioners working in or alongside emergency departments. AIM To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system. RESULTS Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes. CONCLUSIONS Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research. PROSPERO REGISTRATION NUMBER CRD42017069741.
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Affiliation(s)
- Alison Cooper
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Freya Davies
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Centre for Health Economics, Swansea University, Swansea, UK
| | | | | | - Liam Donaldson
- London School of Hygiene and Tropical Medicine, London, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Peter D Hibbert
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Thomas C Hughes
- Emergency Department, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Alison Porter
- College of Medicine, Swansea University, Swansea, UK
| | - Tim Rainer
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | - Helen Snooks
- College of Medicine, Swansea University, Swansea, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
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Seeger I, Kreienmeyer L, Hoffmann F, Freitag MH. Cross-sectional study in an out-of-hours primary care centre in northwestern Germany - patient characteristics and the urgency of their treatment. BMC FAMILY PRACTICE 2019; 20:41. [PMID: 30836946 PMCID: PMC6399868 DOI: 10.1186/s12875-019-0929-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 02/26/2019] [Indexed: 11/20/2022]
Abstract
Background Due to the increasing number of non-urgent visits to emergency departments, it is becoming increasingly important to also investigate emergency care in out-of-hours (OOH) primary care. The aim of this study was to provide an insight into the care structures of an OOH primary care centre, to evaluate the reasons for encounter (RFE) and to assess the urgency of the treatment from the physicians´ point of view. Methods In the summer of 2017, we conducted a cross-sectional study over four weeks in the OOH primary care centre of Oldenburg, a city in Lower Saxony with about 160,000 inhabitants. We collected socio-demographic data, RFE and the duration of the complaints. The International Classification for Primary Care 2nd Edition (ICPC-2) was used to categorize symptoms. The attending physicians supplemented information on further treatment (including hospitalization) and the urgency of consultation in the OOH primary care centre. Results A total of 892 of the 1098 OOH patients which were visiting the OOH primary care centre took part in the study (participation: 81.2%). More than half of the patients were between 18 and 39 years old. A quarter of all RFE named by study participants were in the ICPC-2 category “skin”. More than 60% of patients had the symptoms for more than two days before visiting the OOH primary care centre. In 34.5% of all cases no medication was prescribed and one in six patients received further diagnostic tests such as urinalysis and blood tests (15.8%). From the physicians’ point of view, 26.3% of all study participants could have been treated by the family doctor during the regular consultation hours. Conclusion The study shows that in the OOH primary care centre about a quarter of all patients could have waited until regular consultation hours. Mostly young patients used the easily accessible and free care in the OOH primary care centre. Further studies are necessary to better understand the individual reasons of patients to use the OOH primary care centre.
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Affiliation(s)
- Insa Seeger
- Department for Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, D-26111, Oldenburg, Germany.
| | - Laura Kreienmeyer
- Department for Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, D-26111, Oldenburg, Germany
| | - Falk Hoffmann
- Department for Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, D-26111, Oldenburg, Germany
| | - Michael H Freitag
- Department for Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, D-26111, Oldenburg, Germany
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Jessup RL, O'Connor DA, Putrik P, Rischin K, Nezon J, Cyril S, Shepperd S, Buchbinder R. Alternative service models for delivery of healthcare services in high-income countries: a scoping review of systematic reviews. BMJ Open 2019; 9:e024385. [PMID: 30700481 PMCID: PMC6352783 DOI: 10.1136/bmjopen-2018-024385] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Costs associated with the delivery of healthcare services are growing at an unsustainable rate. There is a need for health systems and healthcare providers to consider the economic impacts of the service models they deliver and to determine if alternative models may lead to improved efficiencies without compromising quality of care. The aim of this protocol is to describe a scoping review of the extent, range and nature of available synthesised research on alternative delivery arrangements for health systems relevant to high-income countries published in the last 5 years. DESIGN We will perform a scoping review of systematic reviews of trials and economic studies of alternative delivery arrangements for health systems relevant to high-income countries published on 'Pretty Darn Quick' (PDQ)-Evidence between 1 January 2012 and 20 September 2017. All English language systematic reviews will be included. The Cochrane Effective Practice and Organisation of Care taxonomy of health system interventions will be used to categorise delivery arrangements according to: how and when care is delivered, where care is provided and changes to the healthcare environment, who provides care and how the healthcare workforce is managed, co-ordination of care and management of care processes and information and communication technology systems. This work is part of a 5-year Partnership Centre for Health System Sustainability aiming to investigate and create interventions to improve health-system-performance sustainability. ETHICS AND DISSEMINATION No primary data will be collected, so ethical approval is not required. The study findings will be published and presented at relevant conferences.
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Affiliation(s)
- Rebecca L Jessup
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Allied Health, Northern Health, Melbourne, Victoria, Australia
| | - Denise A O'Connor
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Polina Putrik
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kobi Rischin
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Janet Nezon
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sheila Cyril
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Uthman OA, Walker C, Lahiri S, Jenkinson D, Adekanmbi V, Robertson W, Clarke A. General practitioners providing non-urgent care in emergency department: a natural experiment. BMJ Open 2018; 8:e019736. [PMID: 29748341 PMCID: PMC5950695 DOI: 10.1136/bmjopen-2017-019736] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To examine whether care provided by general practitioners (GPs) to non-urgent patients in the emergency department differs significantly from care provided by usual accident and emergency (A&E) staff in terms of process outcomes and A&E clinical quality indicators. DESIGN Propensity score matched cohort study. SETTING GPs in A&E colocated within the University Hospitals Coventry and Warwickshire NHS Trust between May 2015 and March 2016. PARTICIPANTS Non-urgent attendances visits to the A&E department. MAIN OUTCOMES Process outcomes (any investigation, any blood investigation, any radiological investigation, any intervention, admission and referrals) and A&E clinical indicators (spent 4 hours plus, left without being seen and 7-day reattendance). RESULTS A total of 5426 patients seen by GPs in A&E were matched with 10 852 patients seen by emergency physicians (ratio 1:2). Compared with standard care in A&E, GPs in A&E significantly: admitted fewer patients (risk ratio (RR) 0.28, 95% CI 0.25 to 0.31), referred fewer patients to other specialists (RR 0.31, 95% CI 0.24 to 0.40), ordered fewer radiological investigations (RR 0.38, 95% CI 0.34 to 0.42), ordered fewer blood tests (0.57, 95% CI 0.52 to 0.61) and ordered fewer investigations (0.93, 95% CI 0.90 to 0.96). However, they intervened more, offered more primary care follow-up (RR 1.78, 95% CI 1.67 to 1.89) and referred more patients to outpatient and other A&E clinics (RR 2.29, 95% CI 2.10 to 2.49). Patients seen by GPs in A&E were on average less likely to spend 4 hours plus in A&E (RR 0.37, 95% CI 0.30 to 0.45) compared with standard care in A&E. There was no difference in reattendance after 7 days (RR 0.96, 95% CI 0.84 to 1.09). CONCLUSION GPs in A&E tended to manage self-reporting minor cases with fewer resources than standard care in A&E, without increasing reattendance rates.
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Affiliation(s)
- Olalekan A Uthman
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Clare Walker
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Sudakshina Lahiri
- Institute of Digital Healthcare, WMG, The University of Warwick, Coventry, UK
| | - David Jenkinson
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Victor Adekanmbi
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Wendy Robertson
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Aileen Clarke
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
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Gonçalves‐Bradley D, Khangura JK, Flodgren G, Perera R, Rowe BH, Shepperd S. Primary care professionals providing non-urgent care in hospital emergency departments. Cochrane Database Syst Rev 2018; 2:CD002097. [PMID: 29438575 PMCID: PMC6491134 DOI: 10.1002/14651858.cd002097.pub4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND In many countries emergency departments (EDs) are facing an increase in demand for services, long waits, and severe crowding. One response to mitigate overcrowding has been to provide primary care services alongside or within hospital EDs for patients with non-urgent problems. However, it is unknown how this impacts the quality of patient care and the utilisation of hospital resources, or if it is cost-effective. This is the first update of the original Cochrane Review published in 2012. OBJECTIVES To assess the effects of locating primary care professionals in hospital EDs to provide care for patients with non-urgent health problems, compared with care provided by regularly scheduled emergency physicians (EPs). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library; 2017, Issue 4), MEDLINE, Embase, CINAHL, PsycINFO, and King's Fund, from inception until 10 May 2017. We searched ClinicalTrials.gov and the WHO ICTRP for registered clinical trials, and screened reference lists of included papers and relevant systematic reviews. SELECTION CRITERIA Randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs attending to patients with non-urgent conditions, as compared to the care provided by regularly scheduled EPs. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified four trials (one randomised trial and three non-randomised trials), one of which is newly identified in this update, involving a total of 11,463 patients, 16 general practitioners (GPs), 9 emergency nurse practitioners (NPs), and 69 EPs. These studies evaluated the effects of introducing GPs or emergency NPs to provide care to patients with non-urgent problems in the ED, as compared to EPs for outcomes such as resource use. The studies were conducted in Ireland, the UK, and Australia, and had an overall high or unclear risk of bias. The outcomes investigated were similar across studies, and there was considerable variation in the triage system used, the level of expertise and experience of the medical practitioners, and type of hospital (urban teaching, suburban community hospital). Main sources of funding were national or regional health authorities and a medical research funding body.There was high heterogeneity across studies, which precluded pooling data. It is uncertain whether the intervention reduces time from arrival to clinical assessment and treatment or total length of ED stay (1 study; 260 participants), admissions to hospital, diagnostic tests, treatments given, or consultations or referrals to hospital-based specialist (3 studies; 11,203 participants), as well as costs (2 studies; 9325 participants), as we assessed the evidence as being of very low-certainty for all outcomes.No data were reported on adverse events (such as ED returns and mortality). AUTHORS' CONCLUSIONS We assessed the evidence from the four included studies as of very low-certainty overall, as the results are inconsistent and safety has not been examined. The evidence is insufficient to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs and NPs versus EPs in the ED to mitigate problems of overcrowding, wait times, and patient flow.
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Affiliation(s)
| | - Jaspreet K Khangura
- University of AlbertaDepartment of Emergency Medicine790 University Terrace Building8303 ‐ 112 StreetEdmontonAlbertaCanadaT6G 2T4
| | - Gerd Flodgren
- Norwegian Institute of Public HealthDivision of Health ServicesMarcus Thranes gate 6OsloNorway0403
| | - Rafael Perera
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
| | - Brian H Rowe
- University of AlbertaDepartment of Emergency Medicine790 University Terrace Building8303 ‐ 112 StreetEdmontonAlbertaCanadaT6G 2T4
| | - Sasha Shepperd
- University of OxfordNuffield Department of Population HealthOxfordUK
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Smith L, Narang Y, Ibarz Pavon AB, Edwardson K, Bowers S, Jones K, Lane S, Ryan M, Taylor-Robinson D, Carrol E. To GP or not to GP: a natural experiment in children triaged to see a GP in a tertiary paediatric emergency department (ED). BMJ Qual Saf 2017; 27:521-528. [PMID: 28971883 PMCID: PMC6047147 DOI: 10.1136/bmjqs-2017-006605] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 08/30/2017] [Accepted: 09/07/2017] [Indexed: 12/02/2022]
Abstract
Objective To evaluate the impact of integrating a general practitioner (GP) into a tertiary paediatric emergency department (ED) on admissions, waiting times and antibiotic prescriptions. Design Retrospective cohort study. Setting Alder Hey Children’s NHS Foundation Trust, a tertiary paediatric hospital in Liverpool, UK. Participants From October 2014, a GP was colocated within the ED, from 14:00 to 22:00 hours, 7 days a week. Children triaged green on the Manchester Triage System without any comorbidities were classed as ‘GP appropriate’. The natural experiment compared patients triaged as ‘GP appropriate’ and able to be seen by a GP between 14:00 and 22:00 hours (GP group) to patients triaged as ‘GP appropriate’ seen outside of the hours when a GP was available (ED group). Intention-to-treat (ITT) analysis was used to assess the main outcomes. Results 5223 patients were designated as ‘GP appropriate’—18.2% of the total attendances to the ED over the study period. There were 2821 (54%) in the GP group and 2402 (46%) in the ED group. The median duration of stay in the ED was 94 min (IQR 63–141) for the GP group compared with 113 min (IQR 70–167) for the ED group (p<0.0005). Using the ITT analysis equivalent, we demonstrated that the GP group were less likely to: be admitted to hospital (2.2% vs 6.5%, OR 0.32, 95% CI 0.24 to 0.44), wait longer than 4 hours (2.3% vs 5.1%, OR 0.45, 95% CI 0.33 to 0.61) or leave before being seen (3.1% vs 5.7%, OR 0.53, 95% CI 0.41 to 0.70), but more likely to receive antibiotics (26.1% vs 20.5%, OR 1.37, 95% CI 1.10 to 1.56). Sensitivity analyses yielded similar results. Conclusions Introducing a GP to a paediatric ED service can significantly reduce waiting times and admissions, but may lead to more antibiotic prescribing. This study demonstrates a novel, potentially more efficient ED care pathway in the current context of rising demand for children’s emergency services.
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Affiliation(s)
- Laurie Smith
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Yajur Narang
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | | | - Karl Edwardson
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Simon Bowers
- Liverpool Clinical Commissioning Group, Liverpool, UK
| | | | - Steve Lane
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Mary Ryan
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Enitan Carrol
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
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Goh GL, Huang P, Kong MCP, Chew SP, Ganapathy S. Unplanned reattendances at the paediatric emergency department within 72 hours: a one-year experience in KKH. Singapore Med J 2017; 57:307-13. [PMID: 27353384 DOI: 10.11622/smedj.2016105] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Unscheduled reattendances at the paediatric emergency department may contribute to overcrowding, which may increase financial burdens. The objectives of this study were to determine the rate of reattendances and characterise factors influencing these reattendances and hospital admission during the return visits. METHODS Medical records of all patients who attended the emergency department at KK Women's and Children's Hospital, Singapore, from 1 June 2013 to 31 May 2014 were retrospectively reviewed. We collected data on patient demographics, attendance data and clinical characteristics. Planned reattendances, recalled cases, reattendances for unrelated complaints and patients who left without being seen were excluded. A multivariate analysis was conducted to determine the odds ratio of variables associated with hospital admission for reattendances. RESULTS Of 162,566 children, 6,968 (4.3%) returned within 72 hours, and 2,925 (42.0% of reattendance group) were admitted on their return visits. Children more likely to reattend were under three years of age, Chinese, triaged as Priority 2 at the first visit, and were initially diagnosed with respiratory or gastrointestinal conditions. However, children more likely to be admitted on their return visits were over 12 years of age, Malay, had a higher triage acuity or were uptriaged, had the presence of a comorbidity, and were diagnosed with gastrointestinal conditions. CONCLUSION We identified certain subgroups in the population who were more likely to be admitted if they reattended. These findings would help in implementing further research and directing strategies to reduce potentially avoidable reattendances and admissions.
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Affiliation(s)
- Guan Lin Goh
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.,Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | - Peiqi Huang
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.,Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | | | - So-Phia Chew
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
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Alsaad SSM, Abu-Grain SHS, El-Kheir DYM. Preparedness of Dammam primary health care centers to deal with emergency cases. J Family Community Med 2017; 24:181-188. [PMID: 28932163 PMCID: PMC5596631 DOI: 10.4103/jfcm.jfcm_5_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES: The objective of the study was to assess the availability of human and nonhuman resources for emergency medical services (EMSs) at the primary health care (PHC) level. MATERIALS AND METHODS: A cross-sectional study with mixed research methods (quantitative and qualitative) was carried out in governmental PHC centers in Dammam, Eastern Province of Saudi Arabia, between September 2014 and January 2015. Using systematic random sampling technique, 13 out of 26 PHC centers were included in the study. The study consisted of two main parts: The first involved the completion of an observational checklist to assess the availability and adequacy of human and nonhuman resources (workforce, emergency infrastructure, equipment, drugs and supporting facilities). The second part involved face-to-face interviews with key informants of nurses from the emergency room (ER) in the sampled centers. RESULTS: Analysis of the checklist showed that the total number of physicians “actually” present ranged from 2 to 8 per center and nurses actually present were 4–11 whereas the officially assigned number was 3–12 physicians and 8–17 nurses per center. Only 2 out of 13 (15.4%) centers had a place reserved for EMS in each male and female section. Only 4 (30.8%) PHC centers had a male ER located on the ground floor, near the entrance, and with a separate ramp. None of the centers had the emergency drugs such as metergotamine, calcium chloride, and naloxone. Regarding ER equipment, none of the studied centers had cervical collars, mouth gags, or a tracheostomy sets. Only one (7.6%) center had a functioning fully equipped ambulance. Five (38.46%) centers were equipped with electrocardiogram and X-ray machines. In the interviews, the informants confirmed the deficiencies identified in the checklist. CONCLUSION: Resources for EMS at Dammam PHC centers were deficient in infrastructure and supporting facilities.
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Affiliation(s)
- Sanaa S M Alsaad
- Qatif Primary Health Care Centers, Ministry of Health, Dammam, Saudi Arabia
| | | | - Dalia Y M El-Kheir
- Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Schmiedhofer M, Möckel M, Slagman A, Frick J, Ruhla S, Searle J. Patient motives behind low-acuity visits to the emergency department in Germany: a qualitative study comparing urban and rural sites. BMJ Open 2016; 6:e013323. [PMID: 27852722 PMCID: PMC5129074 DOI: 10.1136/bmjopen-2016-013323] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The increasing number of low-acuity visits to emergency departments (ED) is an important issue in Germany, despite the fact that all costs of inpatient and outpatient treatment are covered by mandatory health insurance. We aimed to explore the motives of patients categorised with low-acuity conditions for visiting an ED. METHODS We conducted a qualitative study in two urban and one rural ED. We recruited a purposive sample of adults, who were assigned to the lowest two categories in the Manchester triage system. One-to-one interviews took place in the ED during patients' waiting time for treatment. Interview transcripts were analysed using the qualitative data management software MAXQDA. A qualitative content analysis approach was taken to identify motives and to compare the rural with the urban sites. RESULTS A total of 86 patients were asked to participate; of these, n=15 declined participation and n=7 were excluded because they were admitted as inpatients, leaving a final sample of 40 female and 24 male patients. We identified three pathways leading to an ED visit: (1) without primary care contact, (2) after unsuccessful attempts to see a resident specialist or general practitioner (GP) and (3) recommendation to visit the ED by an outpatient provider. The two essential motives were (1) convenience and (2) health anxiety, triggered by time constraints and focused usage of multidisciplinary medical care in a highly equipped setting. All participants from the rural region were connected to a GP, whom they saw more or less regularly, while more interviewees from the urban site did not have a permanent GP. Still, motives to visit the ED were in general the same. CONCLUSIONS We conclude that the ED plays a pivotal role in ambulatory acute care which needs to be recognised for adequate resource allocation. TRIAL REGISTRATION NUMBER DRK S00006053.
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Affiliation(s)
- Martina Schmiedhofer
- Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Charité Mitte (CCM), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Möckel
- Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Charité Mitte (CCM), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Slagman
- Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Charité Mitte (CCM), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Frick
- Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Charité Mitte (CCM), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan Ruhla
- Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Charité Mitte (CCM), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Searle
- Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Charité Mitte (CCM), Charité-Universitätsmedizin Berlin, Berlin, Germany
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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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Jarvis PRE. Improving emergency department patient flow. Clin Exp Emerg Med 2016; 3:63-68. [PMID: 27752619 PMCID: PMC5051606 DOI: 10.15441/ceem.16.127] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/02/2016] [Accepted: 03/02/2016] [Indexed: 11/23/2022] Open
Abstract
Emergency departments (ED) face significant challenges in delivering high quality and timely patient care on an ever-present background of increasing patient numbers and limited hospital resources. A mismatch between patient demand and the ED's capacity to deliver care often leads to poor patient flow and departmental crowding. These are associated with reduction in the quality of the care delivered and poor patient outcomes. A literature review was performed to identify evidence-based strategies to reduce the amount of time patients spend in the ED in order to improve patient flow and reduce crowding in the ED. The use of doctor triage, rapid assessment, streaming and the co-location of a primary care clinician in the ED have all been shown to improve patient flow. In addition, when used effectively point of care testing has been shown to reduce patient time in the ED. Patient flow and departmental crowding can be improved by implementing new patterns of working and introducing new technologies such as point of care testing in the ED.
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Dinh MM, Berendsen Russell S, Bein KJ, Chalkley DR, Muscatello D, Paoloni R, Ivers R. Statewide retrospective study of low acuity emergency presentations in New South Wales, Australia: who, what, where and why? BMJ Open 2016; 6:e010964. [PMID: 27165649 PMCID: PMC4874101 DOI: 10.1136/bmjopen-2015-010964] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE The present study aims to use a statewide population-based registry to assess the prevalence of low acuity emergency department (ED) presentations, describe the trend in presentation rates and to determine whether they were associated with various presentation characteristics such as the type of hospital as well as clinical and demographic variables. DESIGN AND SETTING This was a retrospective analysis of a population-based registry of ED presentations in New South Wales (NSW). Generalised estimating equations with log links were used to determine factors associated with low acuity presentations to account for repeat presentations and the possibility of clustering of outcomes. PARTICIPANTS Patients were included in this analysis if they presented to an ED between January 2010 and December 2014. The outcomes of interest were low acuity presentation, defined as those who self-presented (were not transported by ambulance), were assigned a triage category of 4 or 5 (semiurgent or non-urgent) and discharged back to usual residence from ED. RESULTS There were 10.7 million ED presentations analysed. Of these, 45% were classified as a low acuity presentation. There was no discernible increase in the rate of low acuity presentations across NSW between 2010 and 2014. The strongest predictors of low acuity ED presentation were age <40 years of age (OR 1.77); injury or musculoskeletal administrative and non-urgent procedures (OR 2.96); ear, nose and throat, eye or oral (OR 5.53); skin or allergy-type presenting problems (OR 2.84). CONCLUSIONS Low acuity ED presentations comprise almost half of all ED presentations. Alternative emergency models of care may help meet the needs of these patients.
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Affiliation(s)
- Michael M Dinh
- Royal Prince Alfred Hospital, New South Wales, Australia
- The University of Sydney, Discipline of Emergency Medicine, New South Wales, Australia
| | - Saartje Berendsen Russell
- Royal Prince Alfred Hospital, New South Wales, Australia
- The University of Sydney, School of Nursing, New South Wales, Australia
| | - Kendall J Bein
- Royal Prince Alfred Hospital, New South Wales, Australia
| | | | - David Muscatello
- University of New South Wales, School of Public Health and Community Medicine, New South Wales, Australia
| | - Richard Paoloni
- The University of Sydney, Discipline of Emergency Medicine, New South Wales, Australia
| | - Rebecca Ivers
- Injury Division, The George Institute for Global Health, The University of Sydney, New South Wales, Australia
- Flinders University, School of Nursing and Midwifery, South Australia, Australia
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Turner J, Coster J, Chambers D, Cantrell A, Phung VH, Knowles E, Bradbury D, Goyder E. What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03430] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.ObjectiveThe purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.Data sourcesMEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.MethodsWe have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.ResultsThe review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.LimitationsAlthough there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.ConclusionsThe evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.FundingThe National Institute for Health Research Health Services and Delivery Research Programme.
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Affiliation(s)
- Janette Turner
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Joanne Coster
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Viet-Hai Phung
- College of Social Science, University of Lincoln, Lincoln, UK
| | - Emma Knowles
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Bradbury
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Zou Y, Zhang X, Hao Y, Shi L, Hu R. General practitioners versus other physicians in the quality of primary care: a cross-sectional study in Guangdong Province, China. BMC FAMILY PRACTICE 2015; 16:134. [PMID: 26452648 PMCID: PMC4600296 DOI: 10.1186/s12875-015-0349-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 09/24/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The primary care in China can be provided by general practitioners (GPs) and other physicians (non-GPs). However, China's general practice system has never been really established. Chinese patients tend to consider the quality of primary care provided by GPs much lower than that of non-GPs. Besides, many GPs presently prefer leaving their own positions and seeking better development in big hospitals, which has made the already weak GP system weaker. Yet, few studies have specially compared the quality of primary care provided by Chinese GPs and other physicians and no studies have explored the independent predictors of Chinese GPs' intentions to stay on their current job. In this study, we aimed to compare the quality of primary care offered by GPs with non-GPs and to explore the independent predictors of GPs' future work intentions. METHODS This cross-sectional study applied multi-stage random cluster sampling methodology. The data were collected from November 2013 to September 2014 in Guangdong Province. In total, 401 effective questionnaires were selected from the physicians. Quality of primary care was assessed using the Primary Care Assessment Tool (PCAT) Provider Part, representing six primary care domains: ongoing care, coordination (i.e., referrals and information systems), comprehensiveness (i.e., service available and service provided), family-centeredness, community orientation and cultural competence. RESULTS Of 401 participating physicians, 163 (40.6 %) were GPs. The total PCAT score was 26.32 ± 2.24 which was the sum score of the six domains and represent the quality of primary care. GPs achieved significantly different total scores and scores on three individual scales: comprehensiveness: service available, comprehensiveness: service provided and community orientation. Multiple linear regressions revealed GPs had a higher total score and scores for comprehensiveness: service provided and community orientation after adjusting for sociodemographic characteristics. In addition, GPs were more likely to intend to stay in their current job in the coming year, and this was associated with their educational level. CONCLUSIONS Our findings showed that GPs reported higher quality of primary care than other physicians, and were more inclined to stay in their current job. With more comprehensive care and community orientation provided by GPs, residents could reach basic medical cares and needn't to crowd into larger hospitals.
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Affiliation(s)
- Yaming Zou
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, 74 Zhongshan Road 2, Guangzhou, 510080, P.R China.
| | - Xiao Zhang
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, 74 Zhongshan Road 2, Guangzhou, 510080, P.R China.
| | - Yuantao Hao
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, 74 Zhongshan Road 2, Guangzhou, 510080, P.R China.
| | - Leiyu Shi
- Department of Health Policy & Management, Bloomberg School of Public Health, Primary Care Policy Center, Johns Hopkins University, Baltimore, USA.
| | - Ruwei Hu
- Department of Health Management, School of Public Health, Sun Yat-sen University, 74 Zhongshan Road 2, Guangzhou, 510080, P.R China.
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Caporale N, Morselli-Labate AM, Nardi E, Cogliandro R, Cavazza M, Stanghellini V. Acute abdominal pain in the emergency department of a university hospital in Italy. United European Gastroenterol J 2015; 4:297-304. [PMID: 27087960 DOI: 10.1177/2050640615606012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/22/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Acute abdominal pain (AAP) is one of the most common causes of referral to an emergency department (ED), but information about its impact is limited. OBJECTIVES The objectives of this article are to define the prevalence of AAP among ED visits in a large university hospital and analyze its main clinical features. METHODS All patients admitted at the Sant'Orsola, Malpighi University Hospital of Bologna ED on 12 a priori selected sample days in 2013 were included. General data were recorded for each patient. A total of 192 clinical variables were recorded for each patient with abdominal pain. RESULTS During the observation period the ED assisted 2623 patients with a daily admission rate of 219 ± 20 (mean ± SD). Of these, 239 patients complained of AAP as their chief complaint at entry (prevalence = 9.1%). AAP prevalence was significantly higher in females than in males (10.4% vs. 7.8%; OR = 1.37; p = 0.021) as well as in foreign over Italian patients (13.2% vs. 8.5%; OR = 1.64; p = 0.007). The most frequent ED operative diagnoses were non-specific abdominal pain (n = 86, 36.0%) and gastrointestinal (GI) tract-related pain (n = 79, 33.1%; n = 19 upper GI, n = 60 lower GI). CONCLUSIONS AAP is a common cause of referral at EDs. Despite technological advances, non-specific abdominal pain is still the main operative diagnosis.
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Affiliation(s)
- Nicolò Caporale
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | | | - Elena Nardi
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Rosanna Cogliandro
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Mario Cavazza
- Emergency department of Sant'Orsola, Malpighi University Hospital, Bologna, Italy
| | - Vincenzo Stanghellini
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Cowling TE, Soljak MA, Bell D, Majeed A. Emergency hospital admissions via accident and emergency departments in England: time trend, conceptual framework and policy implications. J R Soc Med 2014; 107:432-8. [PMID: 25377736 PMCID: PMC4224646 DOI: 10.1177/0141076814542669] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Michael A Soljak
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Derek Bell
- Department of Medicine, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
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Bosch X, Escoda O, Nicolás D, Coloma E, Fernández S, Coca A, López-Soto A. Primary care referrals of patients with potentially serious diseases to the emergency department or a quick diagnosis unit: a cross-sectional retrospective study. BMC FAMILY PRACTICE 2014; 15:75. [PMID: 24775097 PMCID: PMC4021313 DOI: 10.1186/1471-2296-15-75] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 04/22/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND In Spain, primary healthcare (PHC) referrals for diagnostic procedures are subject to long waiting-times, and physicians and patients often use the emergency department (ED) as a shortcut. We aimed to determine whether patients evaluated at a hospital outpatient quick diagnosis unit (QDU) who were referred to ED from 12 PHC centers could have been directly referred to QDU, thus avoiding ED visits. As a secondary objective, we determined the proportion of QDU patients who might have been evaluated in a less rapid, non-QDU setting. METHODS We carried out a cross-sectional retrospective cohort study of patients with potentially serious conditions attended by the QDU from December 2007 to December 2012. We established 2 groups of patients: 1) patients referred from PHC to QDU (PHC-QDU group) and 2) patients referred from PHC to ED, then to QDU (PHC-ED-QDU group). Two observers assessed the appropriateness/inappropriateness of each referral using a scoring system. The interobserver agreement was assessed by calculating the kappa index. Multivariate logistic regression analysis was performed to identify the factors associated with the dependent variable 'ED referral'. RESULTS We evaluated 1186 PHC-QDU and 1004 PHC-ED-QDU patients and estimated that 93.1% of PHC-ED-QDU patients might have been directly referred to QDU. In contrast, 96% of PHC-QDU patients were found to be appropriately referred to QDU first. The agreement for PHC-QDU referrals (PHC-QDU group) was rated as excellent (ϰ=0.81), while it was rated as good for PHC-ED referrals (PHC-ED-QDU group) (ϰ=0.75). The mean waiting-time for the first QDU visit was longer in PHC-QDU (4.8 days) than in PHC-ED-QDU (2.6 days) patients (P=.001). On multivariate analysis, anemia (OR 2.87, 95% CI 1.49-4.55, P<.001), rectorrhagia (OR 2.18, 95% CI 1.10-3.77, P=.01) and febrile syndrome (OR 2.53, 95% CI 1.33-4.12, P=.002) were independent factors associated with ED referral. Nearly one-fifth of all QDU patients were found who might have been evaluated in a less rapid, non-QDU setting. CONCLUSIONS Most PHC-ED-QDU patients might have been directly referred to QDU from PHC, avoiding the inconvenience of the ED visit. A stricter definition of QDU evaluation criteria may be needed to improve and hasten PHC referrals.
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Affiliation(s)
- Xavier Bosch
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain.
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Thompson MIW, Lasserson D, McCann L, Thompson M, Heneghan C. Suitability of emergency department attenders to be assessed in primary care: survey of general practitioner agreement in a random sample of triage records analysed in a service evaluation project. BMJ Open 2013; 3:e003612. [PMID: 24319279 PMCID: PMC3855530 DOI: 10.1136/bmjopen-2013-003612] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To assess the proportion of emergency department (ED) attendances that would be suitable for primary care and the inter-rater reliability of general practitioner (GP) assessment of primary care suitability. DESIGN OF STUDY Survey of GPs' agreement of suitability for primary care on a random anonymised sample of all ED patients attending over a 1-month period. SETTING ED of a UK Hospital serving a population of 600 000. METHOD Four GPs independently used data extracted from clinical notes to rate the appropriateness for management in primary care as well as need for investigations, specialist review or admission. Agreement was assessed using Cohen's κ. RESULTS The mean percentage of patients that GPs considered suitable for primary care management was 43% (range 38-47%). The κ for agreement was 0.54 (95% CI 0.44 to 0.64) and 0.47(95% CI 0.38 to 0.59). In patients deemed not suitable for primary care, GPs were more likely to determine the need for specialist review (relative risks (RR)=3.5, 95% CI 3.0 to 4.2, p<0.001) and admission (RR=3.9, 95% CI 3.2 to 4.7, p<0.001). In patients assessed as suitable for primary care, GPs would initiate investigations in 51% of cases. Consensus over primary care appropriateness was higher for paediatric than for adult attenders. CONCLUSIONS A significant number of patients attending ED could be managed by GPs, including those requiring investigations at triage. A stronger agreement among GPs over place of care may be seen for paediatric than for adult attenders. More effective signposting of patients presenting with acute or urgent problems and supporting a greater role for primary care in relieving the severe workflow pressures in ED in the UK are potential solutions.
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Affiliation(s)
- Mary I W Thompson
- Department of Epidemiology and Public Health, University of Exeter Medical School, Exeter, UK
| | - Daniel Lasserson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lloyd McCann
- Medical Services, MercyAscot Hospitals, Auckland, New Zealand
| | - Matthew Thompson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Carl Heneghan
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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