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Smith AB, Davis KJ. Emergency short stay area improves access and flow in a rural hospital. Emerg Med Australas 2023; 35:771-776. [PMID: 37087104 DOI: 10.1111/1742-6723.14220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVES Shoalhaven District Memorial Hospital is a rural (MM3) 150-bed hospital in Nowra, New South Wales, whose ED has evolved to a FACEM-led model of care (MOC). It has never had an emergency short stay area (ESSA). The objective of the present study was to pilot an ESSA and determine whether this MOC would increase the operational performance of the ED. METHODS An ESSA was designed and delivered by emergency medicine medical, nursing and allied health practitioners. The study period was July-December 2021, with a seasonally matched retrospective cohort of records extracted for comparison (July-December 2020). Both took place within the context of the ongoing COVID-19 pandemic. The primary outcome measured was percentage of admitted patients meeting Emergency Treatment Performance (ETP). Secondary outcomes included discharge ETP, overall ED and inpatient length of stay (LOS), mortality and representation rates. RESULTS The admission ETP for patients after the implementation of the ESSA significantly increased, from 13.9% to 31.6% (χ2 = 288, P < 0.001). Discharge ETP significantly declined. There was no effect improvement on overall ETP. There was no change to mortality or representation rates. Average admission LOS decreased. CONCLUSIONS The introduction of the ESSA significantly improved the ETP of admitted patients. Ongoing refinement of the ESSA admission processes, as well as the lifting of certain COVID-19 restrictions, could show even greater improvements in this and other areas. Ongoing research in this field is necessary, as well as a more detailed cost-benefit analysis.
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Affiliation(s)
- Anne B Smith
- Emergency Department, Shoalhaven District Memorial Hospital, Illawarra Shoalhaven Local Health District, Nowra, New South Wales, Australia
| | - Kimberley J Davis
- Research Central, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
- Graduate Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
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Downes MA, Lovett CJ, Isbister GK. Paediatric poisoning presentations reported to a regional toxicology service in Australia. J Paediatr Child Health 2021; 57:1049-1053. [PMID: 33586836 DOI: 10.1111/jpc.15387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/06/2021] [Accepted: 01/10/2021] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study is to describe the epidemiology and health-care utilisation of paediatric emergency department (ED) presentations due to poisoning. METHODS A retrospective review of all ED presentations of paediatric poisoning cases (<18 years) reported to a tertiary toxicology service from 2015 to 2016 was conducted. Cases were classified into three age groups: pre-school (0-6 years), primary school (7-11 years) and adolescent (12-17 years). Outcomes included patient transfer, length of ED stay (LOS) and proportion admitted to a medical ward, mental health unit or intensive care unit (ICU). RESULTS From 764 consultations over a 2-year period, 87 were excluded as non-ED presentations. From these, there were 194 (29%; 47% female) pre-school aged, 34 (5%; 41% female) primary school aged and 449 (66%; 77% female) adolescent presentations. Deliberate self-poisoning was most common in 394 of 449 (88%) adolescents. Accidental exposures accounted for 159 (82%) of pre-school presentations and natural toxins occurred in all three age groups. Paracetamol, selective serotonin reuptake inhibitors, antipsychotics and ibuprofen were the most common toxins. Discharge from ED occurred in 147 of 194 (76%) pre-school, 24 of 34 (71%) primary school and 223 of 449 (50%) adolescent presentations. Of the 449 adolescents, 137 (31%) were admitted medically (median LOS 19.9 h), 19 were admitted to ICU (median LOS 71 h) and 70 (16%) admitted to mental health (median LOS 122 h). Five pre-school aged children were admitted to ICU. CONCLUSIONS Adolescent deliberate self-poisoning has a significant impact on hospital resources, with mental health problems requiring extended length of stay. There were fewer pre-school accidental poisoning consultations, which were mainly discharged from ED.
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Affiliation(s)
- Michael A Downes
- Department of Clinical Toxicology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia.,Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
| | - Caitlyn J Lovett
- Department of Clinical Toxicology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia.,Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Geoffrey K Isbister
- Department of Clinical Toxicology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia.,Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
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Parish S, Carter A, Liu YH, Humble I, Trott N, Jacups S, Little M. The impact of the introduction of a toxicology service on the intensive care unit. Clin Toxicol (Phila) 2019; 57:778-783. [PMID: 30729819 DOI: 10.1080/15563650.2019.1566553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To examine the impact of a clinical toxicology service on toxicology patients admitted to an intensive care department Methods: The authors performed a retrospective chart audit of all patients presenting to Cairns Emergency Department (ED) over a five-year period from 2011 to 2016 with a toxicology diagnosis requiring Intensive Care Unit (ICU) admission. They were divided into two groups: pre-toxicology (1 April 2011 to 30 September 2012), and post-toxicology service (1 October 2012 to 31 of March 2016) introduction. Patients were identified using ED and ICU databases. Patient charts were manually searched, and data entered on a preformatted data extraction tool. The data were statistically compared pre- versus post-toxicology service introduction using univariate (t-tests and Pearson's Chi Square) and multivariate modelling. Where appropriate, continuous variables were log transformed to enable parametric analyses. Results: There were 37 patients in the pre-toxicology and 102 in the post-toxicology group, with an increased median APACHE III J score in the post toxicology group (39 vs. 49). The introduction of a toxicology service was associated with statistically significant reductions in median ICU length of stay (LOS) (32.9 vs. 20.6 h), median duration of mechanical ventilation (29.1 vs. 20.6 h) and median time to psychiatry review (19.4 vs. 6.7 h). The reduction in ICU LOS remained statistically significant (p = 0.036) when adjusted by sex, age and duration of mechanical ventilation. There was neither increase in mortality, nor readmissions from EDSSU to ICU. Conclusions: This study has demonstrated that the introduction of a toxicology service was associated with a reduction in median ICU LOS, duration of mechanical ventilation and time to psychiatric review in patients with a toxicology diagnosis admitted to our ICU.
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Affiliation(s)
- Shaun Parish
- a Royal North Shore Hospital, formerly Cairns Hospital , Saint Leonards , Sydney , Australia
| | - Angus Carter
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia.,c DonateLife QLD.,d School of Medicine and Dentistry, James Cook University , Cairns , Australia
| | - Yu-Hsuan Liu
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia
| | - Ian Humble
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia
| | - Nicholas Trott
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia
| | - Susan Jacups
- e The Cairns Institute, James Cook University (JCU) , Cairns , Australia
| | - Mark Little
- f Department of Emergency Medicine, Cairns Hospital , Cairns , Australia.,g NSW Poisons Information Centre , Sydney , Australia
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Hondebrink L, Rietjens SJ, Donker DW, Hunault CC, van den Hengel-Koot I, Verputten PM, de Vries I, Kaasjager KAH, Dekker D, de Lange DW. A quarter of admitted poisoned patients have a mild poisoning and require no treatment: An observational study. Eur J Intern Med 2019; 66:41-47. [PMID: 31113710 DOI: 10.1016/j.ejim.2019.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/13/2019] [Accepted: 05/13/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Poisoned patients are frequently admitted following Emergency Department (ED) presentation, while the necessity of such admissions is hardly investigated. We determined the proportion and characteristics of poisoned patients who were admitted, but in retrospect had an uneventful admission. METHODS For this observational cohort study, all patients presented to the ED of a Dutch University Hospital with various poisonings during a 1.5-year period (January 2015-July 2016) were included. The uneventfulness of admissions, defined as patients with a low Poisoning Severity Score (PSS) who received no treatment, was determined in retrospect. RESULTS We included 417 patients who visited the ED for poisoning. 247 Patients were admitted: 30% to a general ward, 58% to a MCU, and 12% to the ICU. The poisoning severity scores of the admitted patients were none to mild in 38%, moderate to severe in 59%, and fatal in 2%. Upon admission, 60% of the patients received treatment. In retrospect, 77% of the admitted patients had a moderate, severe or fatal poisoning and/or required treatment. However, 23% of the admitted patients had a mild poisoning and required no treatment. This group involved younger patients (median age of 23 versus 42 years) and a higher proportion of patients reporting exposure to only one substance (65% versus 51%). CONCLUSIONS The majority of poisoned patients presented to the ED was admitted, while in retrospect, a quarter of these admissions were uneventful. Predictive parameters should be sought to identify patients who can be sent home safely.
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Affiliation(s)
- Laura Hondebrink
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - Saskia J Rietjens
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Claudine C Hunault
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Irma van den Hengel-Koot
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Pauline M Verputten
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Irma de Vries
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Karin A H Kaasjager
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Douwe Dekker
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Internal Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Dylan W de Lange
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
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Overdoses and Substance Toxicity in Patients Admitted to Intensive Care Units in a Midwestern U.S. City. J Trauma Nurs 2018. [PMID: 29521774 DOI: 10.1097/jtn.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Toxic exposures with serious outcomes have increased over the last decade. Limited data exists on the pattern and outcomes of overdose-exposure patients requiring intensive care unit (ICU) admission. The primary objective of this study was to characterize the causes, treatments, and outcomes of toxic exposures in a mid-sized Midwestern health system. The secondary objective was to report cumulative economic costs associated with these patients. Data were obtained from medical records of patients 18 years or older with a diagnosis code of overdose admitted to the ICU at 2 teaching hospitals between August 1, 2012, and July 31, 2014. There were 470 (10%) of the 4,495 total ICU admissions that met inclusion criteria during the study period. Average patient age was 39 (SD = 14.2) years, with 64% females. Intentional overdose exposure was the cause of 87% of admissions. The majority (70%) of exposures involved multiple pharmacological agents, including ethanol. Most patients did not require therapeutic maneuvers, nor used decontamination methods. Primary substance classes included analgesics, benzodiazepines, ethanol, selective serotonin reuptake inhibitor antidepressants, and methamphetamine. Two hundred sixty-five (56%) patients were ICU to direct home discharges, whereas 198 (42%) were transferred to a lower level of care. The mortality rate in the sample was 1%. Average hospital charges per admission were $20,375 and average ICU charges were $5,284, which summed to more than $2 million in total charges. Causes, treatments, and outcomes of toxic exposures admitted to the ICU in a mid-sized Midwestern city reveal a potential ICU burden. Financial health care costs associated with these toxic exposures were substantial. Greater public health efforts are needed to attempt to minimize preventable admissions and better understand antecedents.
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Legg RG, Little M. Inpatient toxicology services improve resource utilization for intoxicated patients: a systematic review. Br J Clin Pharmacol 2018; 85:11-19. [PMID: 30238503 DOI: 10.1111/bcp.13768] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/14/2018] [Accepted: 09/10/2018] [Indexed: 11/29/2022] Open
Abstract
AIMS Presentations of intoxicated patients to hospital are frequent and increasing. We aimed to review the existing evidence that the presence of inpatient clinical toxicology services reduces use of resources without impacting on the care of these patients. METHODS We conducted a literature search using the Cochrane Library, PubMed, and Embase for articles that measured length of stay (and other outcomes) for the target population, with toxicology services as an intervention. The articles were reviewed with respect to the ROBINS-I tool. RESULTS Seven relevant articles were identified. Six of these studies demonstrated reduced hospital length of stay for intoxicated patients in hospitals with inpatient toxicology services. None of the articles demonstrated a detriment in morbidity or mortality. There were also improvements in other resource-related outcomes. CONCLUSIONS The presence of inpatient toxicology services appears to improve resource utilization, in reduction of length of stay, as well as a number of other related outcomes. It does this without compromising on patient morbidity or mortality. Thus, it should be considered as a potential model of care for future toxicology services, especially with current trends of increasing demand for service efficiency.
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Affiliation(s)
- Robert G Legg
- Paediatric Medicine, Townsville Hospital, Queensland, Australia
| | - Mark Little
- Cairns Hospital, Queensland, Australia.,NSW Poisons Information Centre, NSW, Australia
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