Emergency and urgent care systems in Australia, Denmark, England, France, Germany and the Netherlands - Analyzing organization, payment and reforms

Characteristics and outcomes of emergency department patients across health care systems: an international multicenter cohort study

BACKGROUND

A wide variation of emergency medical system configurations across countries has limited the value of comparison of quality and performance measures in the past. Furthermore, lack of quantitative data on EDs prevents definition of the problems and possibilities for data driven improvement of quality of care. Therefore, the objective is to describe and compare Emergency Department (ED) populations and characteristics, and their outcomes in the Netherlands, Denmark and Australia, using a recently developed template for uniform reporting of standardized measuring and describing of care provided in the ED (structure, staffing and governance, population, process times and outcomes).

METHODS

This international multicenter cohort included all consecutive ED visits from National Quality Registries or Databases from participating sites from three countries. Patient and ED characteristics (using the template for uniform reporting) and relevant clinical outcomes were described and compared per country.

RESULTS

We included 212,515 ED visits in the Netherlands, 408,673 in Denmark and 556,652 in Australia. Patient characteristics differed markedly, with Australian ED patients being younger, less often triaged as "immediate", and less often triaged with the high-risk chief complaints "feeling unwell" compared to Danish and Dutch patients. ED characteristics mainly differed with respect to the mean annual census per ED (Netherlands 26,738 (SD 2630), Denmark 36,675 (SD 12974), Australia 50,712 (4884)), median (IQR) lengths of stay of patients discharged home (Netherlands 2.1 (1.4-3.1); Denmark 2.8 (1.7-5.0); Australia 3.3 (2.0-5.0) hrs) and proportion of hospitalizations (ranging from 30.6 to 39.8%). In-hospital mortality was 4.0% in Australia, higher compared to the Netherlands and Denmark (both 1.6%). Not all indicators of the framework were available in all registries.

CONCLUSIONS

Patient and ED characteristics and outcomes varied largely across countries. Meaningful interpretation of outcome differences across countries could be improved if quality registries would more consistently register the measures of the recently developed template for uniform reporting.

Health care utilization of patients with acute abdominal pain before and after emergency department visits

BACKGROUND

Acute abdominal pain (AAP) is a major driver for capacity-use in emergency departments (EDs) worldwide. Yet, the health care utilization of patients with AAP before and after the ED remains unclear. The primary objective of this study was to describe adult patients presenting to the ED with AAP and their outpatient care (OC) use before and after the ED. Secondary objectives included description of hospitalization rates, in-hospital mortality, ED re-visits, and exploration of potential risk factors for hospitalization and ED re-visits.

METHODS

For the analysis, we combined routine hospital data from patients who visited 15 EDs in Germany in 2016 with their statutory health insurance OC claims data from 2014 to 2017. Adult patients were included based on a chief complaint or an ED diagnosis indicating unspecific AAP or the Manchester Triage System indicator "Abdominal pain in adults". Baseline characteristics, ED diagnosis, frequency and reason of hospitalization, frequency and type of prior-OC (prOC) use up to 3 days before and of post-OC use up to 30 days after the ED visit.

MAIN RESULTS

We identified 28,085 adults aged ≥ 20 years with AAP. 39.8% were hospitalized, 33.9% sought prOC before the ED visit (48.6% of them were hospitalized) and 62.7% sought post-OC up to 30 days after the ED visit. Hospitalization was significantly more likely for elderly patients (aged 65 and above vs. younger; adjusted OR 3.05 [95% CI 2.87; 3.25]), prOC users (1.71 [1.61; 1.90]) and men (1.44 [1.37; 1.52]). In-hospital mortality rate was 3.1% overall. Re-visiting the ED within 30 days was more likely for elderly patients (1.32 [1.13; 1.55) and less likely for those with prOC use (0.37 [0.31; 0.44]).

CONCLUSIONS

prOC use was associated with more frequent hospitalizations but fewer ED re-visits. ED visits by prOC patients without subsequent hospitalization may indicate difficulties of OC resources to meet the complex diagnostic requirements and expectations of this patient population. Fewer ED re-visits in prOC users indicate effective care in this subgroup.

Healthcare utilisation by diabetic patients in Denmark: the role of primary care in reducing emergency visits

Improving the management of diabetic patients is receiving increasing attention in the health policy agenda due to increasing prevalence in the population and raising pressure on healthcare resources. This paper examines the determinants of healthcare services utilisation in patients with type-2 diabetes, investigating the potential substitution effect of general practice visits on the utilisation of emergency department visits. By using rich longitudinal data from Denmark and a bivariate econometric model, our analysis highlights primary care services that are more effective in preventing emergency department visits and socioeconomic groups of patients with a weak substitution response. Our results suggest that empowering primary care services, such as preventive assessment visits, may contribute to reducing emergency department visits significantly. Moreover, special attention should be devoted to vulnerable groups, such as patients from low socioeconomic background and older patients, who may find more difficult achieving a large substitution response.

Inappropriate Emergency Department Visits: Insights on Incidence, Associated, and Predictive Factors From 5,429 Visits

INTRODUCTION

Inappropriate visits (IVs) and overcrowded emergency departments (EDs) can result in many complications for patients and medical staff. This study aimed to assess the incidence, associated factors, and predictive factors of IVs to ED.

METHODS

This retrospective cohort single-center study was conducted in the ED of King Abdulaziz Medical City, Jeddah, Saudi Arabia. All ED visits in February 2023 were included. They were considered appropriate if the patient required investigation tests, underwent a procedure, was admitted to an inpatient ward, was admitted to the short-stay unit, was referred for follow-up at a specialist outpatient clinic after discharge from the ED, or was referred to the ED of another hospital. Failure to have at least one of these factors led to the visit being considered inappropriate.

RESULTS

A total of 5,429 visits were included. The incidence rate of IVs was 1128 (20.7%). Of the visits, 1,028 (18.9%) were attended by patients aged <10 years, and 2,825 (52.0%) by female patients. The most reported complaints were pulmonological in 1,029 visits (18.9%). Patients with appropriate visits (AVs) had significantly higher median BMI scores than those with IVs (25.9 (20 - 3) vs. 23.7 (16.36 - 29), P = <0.0001). Visits with pulmonological (447 (39.6%) vs. 582 (13.5%)) and otorhinolaryngologic (54 (4.7%) vs. 94 (2.1%)) complaints were significantly more likely to be inappropriate (P = <0.0001). In multiple logistic regression, being a male (OR: 1.3, CI: 1.1 - 1.5, P = <0.0001), being non-Saudi (OR: 2.7, CI: 2.0 - 3.6, P = <0.0001), and visiting on the weekend (OR: 1.1, CI: 1.0 - 1.3, P = 0.0366) were significantly predictive of the visits being inappropriate.

CONCLUSIONS

Our findings revealed a high incidence of IVs in the ED, with several factors predictive of IVs. Highlighting these factors can help minimize the incidence of IVs and, therefore, improve the quality of healthcare delivered to patients in need and their clinical outcomes.

Mapping the processes and information flows of a prehospital emergency care system in Rwanda: a process mapping exercise

OBJECTIVE

A vital component of a prehospital emergency care system is getting an injured patient to the right hospital at the right time. Process and information flow mapping are recognised methods to show where efficiencies can be made. We aimed to understand the process and information flows used by the prehospital emergency service in transporting community emergencies in Rwanda in order to identify areas for improvement.

DESIGN

Two facilitated process/information mapping workshops were conducted. Process maps were produced in real time during discussions and shared with participants for their agreement. They were further validated by field observations.

SETTING

The study took place in two prehospital care settings serving predominantly rural and predominantly urban patients.

PARTICIPANTS

24 healthcare professionals from various cadres. Field observations were done on 49 emergencies across both sites.

RESULTS

Two maps were produced, and four main process stages were described: (1) call triage by the dispatch/call centre team, (2) scene triage by the ambulance team, (3) patient monitoring by the ambulance team on the way to the health facility and (4) handover process at the health facility. The first key finding was that the rural site had multiple points of entry into the system for emergency patients, whereas the urban system had one point of entry (the national emergency number); processes were otherwise similar between sites. The second was that although large amounts of information were collected to inform decision-making about which health facility to transfer patients to, participants found it challenging to articulate the intellectual process by which they used this to make decisions; guidelines were not used for decision-making.

DISCUSSION

We have identified several areas of the prehospital care processes where there can be efficiencies. To make efficiencies in the decision-making process and produce a standard approach for all patients will require protocolising care pathways.

Telemedical stroke care significantly improves patient outcome in rural areas: Long-term analysis of the German NEVAS network

BACKGROUND

Comprehensive stroke centers (CSC) offer state-of-the-art stroke care in metropolitan centers. However, in rural areas, sufficient stroke expertise is much scarcer. Recently, telemedical stroke networks have offered instant consultation by stroke experts, enabling immediate administration of intravenous thrombolysis (IVT) on-site and decision on thrombectomy. While these immediate decisions are made during the consult, the impact of the network structures on stroke care in spoke hospitals is still not well described.

AIMS

This study was performed to determine if on-site performance in rural hospitals and patient outcome improve over time through participation and regular medical staff training within a telemedical stroke network.

METHODS

In this retrospective study, we analyzed data from stroke patients treated in four regional hospitals within the telemedical Neurovascular Network of Southwest Bavaria (NEVAS) between 2014 and 2019. We only included those patients that were treated in the regional hospitals until discharge at home or to neurorehabilitation. Functional outcome (modified Rankin scale) at discharge, mortality rate and periprocedural intracranial hemorrhage served as primary outcome parameters. Door-to-imaging and door-to-needle times were secondary outcome parameters.

RESULTS

In 2014-2019, 5,379 patients were treated for acute stroke with 477 receiving IVT. Most baseline characteristics were comparable over time. For all stroke patients, door-to-imaging times increased over the years, but significantly improved for potential IVT candidates and those finally treated with IVT. The percentage of patients with door-to-needle time <30 min increased from 10% to 25%. Clinical outcome at discharge improved for all stroke patients treated in the regional hospitals. Particularly for patients treated with IVT, good clinical outcome (modified Rankin scale 0-2) at discharge increased from 2014 to 2019 by 19% and mortality rates dropped from 13% to 5%.

CONCLUSIONS

24-h/7-day telemedical support and regular on-site medical staff training within a structured telemedicine stroke network such as NEVAS significantly improve on-site stroke care in rural areas, leading to a considerable benefit in clinical outcome.

DATA ACCESS STATEMENT

The data that support the findings of this study are available upon reasonable request and in compliance with the local and international ethical guidelines.

Tobacco Smoking or Nicotine Phenotype and Severity of Clinical Presentation at the Emergency Department (SMOPHED): Protocol for a Noninterventional Observational Study

BACKGROUND

In the last few years, several nicotine products have become available as alternatives to smoking tobacco. While laboratory and limited clinical studies suggest that these devices are less toxic compared to classic tobacco cigarettes, very little is known about their epidemiological impact. Visiting the emergency department (ED) often represents the first or even the only contact of patients with the health care system. Therefore, a study conducted at the ED to assess the impact of these products on health can be reliable and reflect a real-life setting.

OBJECTIVE

The aim of this noninterventional observational study (SMOPHED study) is to analyze the association between the severity of clinical presentation observed during ED visits among patients using various nicotine products and the subsequent outcomes, specifically hospitalization and mortality.

METHODS

Outcomes (hospitalization and mortality in the ED) will be examined in relation to various patterns of nicotine products use. We plan to enroll approximately 2000 participants during triage at the ED. These individuals will be characterized based on their patterns of tobacco and nicotine consumption, identified through a specific questionnaire. This categorization will allow for a detailed analysis of how different usage patterns of nicotine products correlate with the clinical diagnosis made during the ED visits and the consequent outcomes.

RESULTS

Enrollment into the study started in March 2024. We enrolled a total of 901 participants in 1 month (approximately 300 potential participants did not provide the informed consent to participate). The data will be analyzed by a statistician as soon as the database is completed. Full data will be published by December 2024.

CONCLUSIONS

There is substantial debate about the harm reduction potential of alternative nicotine products in terms of their smoking-cessation and risk-reduction potential. This study represents an opportunity to document epidemiological data on the link between the use of different types of nicotine products and disease diagnosis and severity during an ED visit, and thus evaluate the harm reduction potential claims for these products.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54041.

Acute patients discharged without an established diagnosis: risk of mortality and readmission of nonspecific diagnoses compared to disease-specific diagnoses

BACKGROUND

Nonspecific discharge diagnoses after acute hospital courses represent patients discharged without an established cause of their complaints. These patients should have a low risk of adverse outcomes as serious conditions should have been ruled out. We aimed to investigate the mortality and readmissions following nonspecific discharge diagnoses compared to disease-specific diagnoses and assessed different nonspecific subgroups.

METHODS

Register-based cohort study including hospital courses beginning in emergency departments across 3 regions of Denmark during March 2019-February 2020. We identified nonspecific diagnoses from the R- and Z03-chapter in the ICD-10 classification and excluded injuries, among others-remaining diagnoses were considered disease-specific. Outcomes were 30-day mortality and readmission, the groups were compared by Cox regression hazard ratios (HR), unadjusted and adjusted for socioeconomics, comorbidity, administrative information and laboratory results. We stratified into short (3-<12 h) or lengthier (12-168 h) hospital courses.

RESULTS

We included 192,185 hospital courses where nonspecific discharge diagnoses accounted for 50.7% of short and 25.9% of lengthier discharges. The cumulative risk of mortality for nonspecific vs. disease-specific discharge diagnoses was 0.6% (0.6-0.7%) vs. 0.8% (0.7-0.9%) after short and 1.6% (1.5-1.7%) vs. 2.6% (2.5-2.7%) after lengthier courses with adjusted HRs of 0.97 (0.83-1.13) and 0.94 (0.85-1.05), respectively. The cumulative risk of readmission for nonspecific vs. disease-specific discharge diagnoses was 7.3% (7.1-7.5%) vs. 8.4% (8.2-8.6%) after short and 11.1% (10.8-11.5%) vs. 13.7% (13.4-13.9%) after lengthier courses with adjusted HRs of 0.94 (0.90-0.98) and 0.95 (0.91-0.99), respectively. We identified 50 clinical subgroups of nonspecific diagnoses, of which Abdominal pain (n = 12,462; 17.1%) and Chest pain (n = 9,599; 13.1%) were the most frequent. The subgroups described differences in characteristics with mean age 41.9 to 80.8 years and mean length of stay 7.1 to 59.5 h, and outcomes with < 0.2-8.1% risk of 30-day mortality and 3.5-22.6% risk of 30-day readmission.

CONCLUSIONS

In unadjusted analyses, nonspecific diagnoses had a lower risk of mortality and readmission than disease-specific diagnoses but had a similar risk after adjustments. We identified 509 clinical subgroups of nonspecific diagnoses with vastly different characteristics and prognosis.

From symptom onset to ED departure: understanding the acute care chain for patients with undifferentiated complaints: a prospective observational study

BACKGROUND

For most acute conditions, the phase prior to emergency department (ED) arrival is largely unexplored. However, this prehospital phase has proven an important part of the acute care chain (ACC) for specific time-sensitive conditions, such as stroke and myocardial infarction. For patients with undifferentiated complaints, exploration of the prehospital phase of the ACC may also offer a window of opportunity for improvement of care. This study aims to explore the ACC of ED patients with undifferentiated complaints, with specific emphasis on time in ACC and patient experience.

METHODS

This Dutch prospective observational study, included all adult (≥ 18 years) ED patients with undifferentiated complaints over a 4-week period. We investigated the patients' journey through the ACC, focusing on time in ACC and patient experience. Additionally, a multivariable linear regression analysis was employed to identify factors independently associated with time in ACC.

RESULTS

Among the 286 ED patients with undifferentiated complaints, the median symptom duration prior to ED visit was 6 days (IQR 2-10), during which 58.6% of patients had contact with a healthcare provider before referral. General Practitioners (GPs) referred 80.4% of the patients, with the predominant patient journey (51.7%) involving GP referral followed by self-transportation to the ED. The median time in ACC was 5.5 (IQR 4.0-8.4) hours of which 40% was spent before the ED visit. GP referral and referral to pulmonology were associated with a longer time in ACC, while referral during evenings was associated with a shorter time in ACC. Patients scored both quality and duration of the provided care an 8/10.

CONCLUSION

Dutch ED patients with undifferentiated complaints consulted a healthcare provider in over half of the cases before their ED visit. The median time in ACC is 5.5 h of which 40% is spent in the prehospital phase. Those referred by a GP and to pulmonology had a longer, and those in the evening a shorter time in ACC. The acute care journey starts hours before patients arrive at the ED and 6 days of complaints precede this journey. This timeframe could serve as a window of opportunity to optimise care.

Variations in the intended utilization of emergency care in case of gastrointestinal diseases

Frequent utilization of emergency care and overcrowded emergency departments (EDs) are highly relevant topics due to their harmful consequences for patients and staff. The present study examines variations of intended health care use in urgent and non-urgent cases among the general population. In a cross-sectional telephone survey, a sample of N = 1,204 adults residing in Hamburg, Germany, was randomly drawn. At the beginning of the survey, one of 24 different vignettes (case stories) describing symptoms of inflammatory gastrointestinal diseases were presented to the participants. The vignettes varied in sex (male/female), age (15, 49, 72 years), daytime (Tuesday morning, Tuesday evening), and urgency (low, high). Participants were asked in an open-ended question about their primal intended utilization if they or their children would be affected by such symptoms. Overall, about 14 % chose emergency facilities (ED, ambulance, emergency practice) despite presentation of non-urgent conditions (n = 602). Intended emergency care use varied considerably even if the degree of urgency was comparable. Adolescence, male sex, and symptoms occurring in the evening were associated with increased ED and ambulance use. Inappropriate utilization of ED and ambulance (analyses regarding utilization due to non-urgent problems) was more often observed among male respondents and those with a migration background (1st generation). Information campaigns focused on emergency care use and reorganisation of emergency care wards are possible interventions.

Disease incidence and not case fatality drives the rural disadvantage in myocardial-infarction-related mortality in Germany

OBJECTIVE

Demographic and infrastructural developments might compromise medical care provision in rural regions, particularly for acute health conditions. Studying the case of myocardial infarction (MI), we investigated how MI-related mortality at ages 65+ varies between rural and urban regions in Germany and to what extent differences are driven by varying case fatality and disease incidence.

METHODS

The study relies on data containing all hospitalizations, cause-specific deaths and population counts for the total German population between years 2012-2018 and ages 65+. MI-related mortality, MI incidence and case fatality are compared between urban and rural regions in a population-wide analysis. The impacts of changing incidence and case fatality on rural-urban MI-related mortality differences are assessed using a counterfactual approach.

RESULTS

Rural regions in Germany show systematically higher MI-related death rates and MI incidence at ages 65+ compared to urban regions. Higher mortality is primarily the result of higher MI incidence in rural regions, while case fatality is largely similar. The rural excess in MI-related death rates would be nullified and 1 out of 6 MI-related deaths in rural regions could be prevented if rural regions in Germany would have at least the median MI incidence of urban regions.

CONCLUSIONS

MI incidence and not case fatality drives the rural disadvantage in MI-related mortality in Germany. Higher MI incidence points towards potential regional variation in the effectiveness of disease prevention. The findings highlight that improving disease prevention at the patient level carries larger opportunities for reducing regional MI-related mortality inequalities in Germany.

Patients pathways before and after treatments in emergency departments: A retrospective analysis of secondary data in Germany

Increasing emergency department (ED) utilization induces considerable pressure on ED staff and organization in Germany. Reasons for certain ED attendances are seen partly in insufficient continuity of care outside of hospitals. To explore the health care patterns before and after an ED attendance in Germany, we used claims data from nine statutory health insurance funds, covering around 25 % of statutory health insurees (1). We descriptively analyzed ED attendances for adult patients in 2016 according to their sociodemographic characteristics and diagnoses (2). Based on the ED attendance as initial event, we investigated health care provider utilization 180 days before and after the respective ED treatment and are presented by means of Sankey diagrams. In total, 4,757,536 ED cases of 3,164,343 insured individuals were analyzed. Back pain was the most frequent diagnosis in outpatient ED cases (5.0 %), and 80.2 % of the patients visited primary care physicians or specialists 180 days before and 78.8 % 180 days after ED treatment. Among inpatient cases, heart failure (4.6 %) was the leading diagnosis and 74.6 % used primary care physicians or specialists 180 days before and 65.1 % 180 days after ED treatment. The ED re-attendance slightly increased for back pain (4.9 % to 7.9 %) and decreased for heart failure (13.4 % to 12.6 %).

Trends in Atrial Fibrillation Management-Results from a National Multi-Center Urgent Care Network Registry

BACKGROUND

Atrial fibrillation (AF) is a common diagnosis in patients presenting to urgent care centers (UCCs), yet there is scant research regarding treatment in these centers. While some of these patients are managed within UCCs, some are referred for further care in an emergency department (ED).

OBJECTIVES

We aimed to identify the rate of patients referred to an ED and define predictors for this outcome. We analyzed the rates of AF diagnosis and hospital referral over the years. Finally, we described trends in patient anticoagulation (AC) medication use.

METHODS

This retrospective study included 5873 visits of patients over age 18 visiting the TEREM UCC network with a diagnosis of AF over 11 years. Multivariate analysis was used to identify predictors for ED referral.

RESULTS

In a multivariate model, predictors of referral to an ED included vascular disease (OR 1.88 (95% CI 1.43-2.45), p < 0.001), evening or night shifts (OR 1.31 (95% CI 1.11-1.55), p < 0.001; OR 1.68 (95% CI 1.32-2.15), p < 0.001; respectively), previously diagnosed AF (OR 0.31 (95% CI 0.26-0.37), p < 0.001), prior treatment with AC (OR 0.56 (95% CI 0.46-0.67), p < 0.001), beta blockers (OR 0.63 (95% CI 0.52-0.76), p < 0.001), and antiarrhythmic medication (OR 0.58 (95% CI 0.48-0.69), p < 0.001). Visits diagnosed with AF increased over the years (p = 0.030), while referrals to an ED decreased over the years (p = 0.050). The rate of novel oral anticoagulant prescriptions increased over the years.

CONCLUSIONS

The rate of referral to an ED from a UCC over the years is declining but remains high. Referrals may be predicted using simple clinical variables. This knowledge may help to reduce the burden of hospitalizations.

Comparing emergency department visits 10-year apart at a tertiary care center in Lebanon

Presentations to the emergency department (ED) are growing worldwide. With the increasing risk factors of non-communicable disease (NCD) and communicable diseases (CD) in low- and middle-income countries, it is crucial to understand how ED presentations are changing with time to meet patients' needs and allocate acute care resources. The aim of this study is to compare the changes in patient and diseases characteristics over 2 time periods 10 year apart at the largest tertiary care center in Lebanon. This was a retrospective descriptive study of patients presenting to the ED at a large tertiary care center in 2009/2010 and 2018/2019. The discharge diagnoses were coded into Clinical Classification Software codes. We used descriptive statistics, odds ratios (OR), and non-parametric test to compare the different diagnoses. The total number of ED visits increased by 33% from 2009/2010 to 2018/2019. The highest increase rate was among patients older than 65 years (2.6%), whereas the percentage of pediatric patients decreased from 30.8% to 25.3%. ED presentations shifted from NCD to CD. A shift in the discharge diagnoses was also noted within age groups, specifically a shift in cardiovascular diseases to a younger age. Our study suggests that the role of the ED is changing and moving towards treating the aging population and CD. There is a need to invest and mitigate CD, better allocate resources to accommodate the aging population, focus on awareness campaigns targeting early detection of cardiovascular diseases and modifying its risk factors.

Do patients referred to emergency departments after being assessed in primary care differ from other ED patients? Retrospective analysis of a random sample from two German metropolitan EDs

BACKGROUND

To assess differences between patients referred to emergency departments by a primary care physician (PCP) and those presenting directly and the impact of referral on the likelihood of admission.

DESIGN OF STUDY

Retrospective cohort study.

SETTING

EDs of two nonacademic general hospitals in a German metropolitan region.

PARTICIPANTS

Random sample of 1500 patients out of 80,845 presentations during the year 2019.

RESULTS

Age was 55.8 ± 22.9 years, and 51.4% was female. A total of 34.7% presented by emergency medical services (EMS), and 47.7% were walk-ins. One-hundred seventy-four (11.9%) patients were referred by PCPs. Referrals were older (62.4 ± 20.1 vs 55.0 ± 23.1 years, p < .001) and had a higher Charlson Comorbidity Index (CCI) (3 (1-5) vs 2 (0-4); p < .001). Referrals received more ultrasound examinations independently from their admission status (27.6% vs 15.7%; p < .001) and more CT and laboratory investigations. There were no differences in sex, Manchester Triage System (MTS) category, or pain-scale values. Referrals presented by EMS less often (9.2% vs 38.5%; p < .001). Admission rates were 62.6% in referrals and 37.1% in non-referrals (p < .001). Referral (OR 3.976 95% CI: 2.595-6.091), parenteral medication in ED (OR 2.674 (1.976-3.619)), higher MTS category (1.725 (1.421-2.093)), transport by EMS (1.623 (1.212-2.172)), abnormal vital parameters (1.367 (0.953-1.960)), higher CCI (1.268 (1.196-1.344)), and trauma (1.268 (1.196-1.344)) were positively associated with admission in multivariable analysis, whereas ultrasound in ED (0.450 (0.308-0.658)) and being a nursing home resident (0.444 (0.270-0.728)) were negatively associated.

CONCLUSION

Referred patients were more often admitted. They received more laboratory investigations, ultrasound examinations, and computed tomographies. Difficult decisions regarding the necessity of admission requiring typical resources of EDs may be a reason for PCP referrals.

Identification of low-acuity attendances in routine clinical information documented in German Emergency Departments

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.

Mortality before and after reconfiguration of the Danish hospital-based emergency healthcare system: a nationwide interrupted time series analysis

OBJECTIVES

The study aimed to investigate how the 'natural experiment' of reconfiguring the emergency healthcare system in Denmark affected in-hospital and 30-day mortality on a national level. The reconfiguration included the centralisation of hospitals and the establishment of emergency departments with specialists present around the clock.

DESIGN

Hospital-based cohort study.

SETTING

All public hospitals in Denmark.

PARTICIPANTS

Patients with an unplanned contact from 1 January 2007 until 31 December 2016.

INTERVENTIONS

Stepped-wedge reconfiguration of the Danish emergency healthcare system.

MAIN OUTCOME MEASURES

We determined the adjusted ORs for in-hospital mortality and HRs for 30-day mortality using logistic and Cox regression analysis adjusted for sex, age, Charlson Comorbidity Index, income, education, mandatory referral and the changes in the out of hours system in the Capital Region. The main outcomes were stratified by the time of arrival. We performed subgroup analyses on selected diagnoses: myocardial infarction, stroke, pneumonia, aortic aneurysm, bowel perforation, hip fracture and major trauma.

RESULTS

We included 11 367 655 unplanned hospital contacts. The adjusted OR for overall in-hospital mortality after reconfiguration of the emergency healthcare system was 0.998 (95% CI 0.968 to 1.010; p=0.285), and the adjusted OR for 30-day mortality was 1.004 (95% CI 1.000 to 1.008; p=0.045)). Subgroup analyses showed some possible benefits of the reconfiguration such as a reduction in-hospital and 30-day mortality for myocardial infarction, stroke, aortic aneurysm and major trauma.

CONCLUSIONS

The Danish emergency care reconfiguration programme was not associated with an improvement in overall in-hospital mortality trends and was associated with a slight slowing of prior improvements in 30-day mortality trends.

Telerehabilitation Delivery in Canada and the Netherlands: Results of a Survey Study

BACKGROUND

Following the onset of the COVID-19 pandemic, telerehabilitation (TR) has been expanding to address the challenges and risks of in-person delivery. It is likely that a level of TR delivery will continue after the pandemic because of its advantages, such as reducing geographical barriers to service. Many pandemic-related TR initiatives were put in place quickly. Therefore, we have little understanding of current TR delivery, barriers and facilitators, and how therapists anticipate integrating TR into current practice. Knowing this information will allow the incorporation of competencies specifically related to the use and provision of TR into professional profiles and entry-to-practice education, thereby promoting high-quality TR care.

OBJECTIVE

This study aimed to obtain a descriptive overview of current TR practice among rehabilitation therapists in Canada and the Netherlands and identify perceived barriers to and facilitators of practice.

METHODS

A web-based cross-sectional survey was conducted with occupational, physical, and respiratory therapists and dietitians in Canada (in French and English) and the Netherlands (in Dutch and English) between November 2021 and March 2022. Recruitment was conducted through advertisements on social media platforms and email invitations facilitated by regulatory and professional bodies. The survey included demographic and practice setting information; whether respondents delivered TR, and if so, components of delivery; confidence and satisfaction ratings with delivery; and barriers to and facilitators of use. TR satisfaction and uptake were measured using the Telehealth Usability Questionnaire and modified Technology Acceptance Model. Data were first summarized descriptively, and then, comparisons were conducted between professions.

RESULTS

Overall, 723 survey responses were received, mostly from Canada (n=666, 92.1%) and occupational therapists (n=434, 60%). Only 28.1% (203/723) reported receiving specific training in TR, with 1.2% (9/723) indicating that it was part of their professional education. Approximately 19.5% (139/712) reported not using TR at all, whereas most participants (366/712, 51.4%) had been using this approach for 1 to 2 years. Services delivered were primarily teleconsultation and teletreatment with individuals. Respondents offering TR were moderately satisfied with their service delivery and found it to be effective; 90.1% (498/553) indicated that they were likely to continue offering TR after the pandemic. Technology access, confidence, and setup were rated the highest as facilitators, whereas technology issues and the clinical need for physical contact were the most common barriers.

CONCLUSIONS

Professional practice and experience with TR were similar in both countries, suggesting the potential for common strategic approaches. The high prevalence of current practice and strong indicators of TR uptake suggest that therapists are likely to continue TR delivery after the pandemic; however, most therapists (461/712, 64.7%) felt ill prepared for practice, and the need to target TR competencies during professional and postprofessional education is critical. Future studies should explore best practice for preparatory and continuing education.

Association between acute care collaborations and health care utilization as compared to stand-alone facilities in the Netherlands: a quasi-experimental study

Health systems invest in coordination and collaboration between emergency departments (ED) and after-hours primary care providers (AHPCs) to alleviate pressure on the acute care chain. There are substantial gaps in the existing evidence, limited in sample size, follow-up care, and costs. We assess whether acute care collaborations (ACCs) are associated with decreased ED utilization, hospital admission rates, and lower costs per patient journey, compared with stand-alone facilities. The design is a quasi-experimental study using claims data. The study included 610 845 patients in the Netherlands (2017). Patient visits in ACCs were compared to stand-alone EDs and AHPCs. The number of comorbidities was similar in both groups. Multiple logistic and gamma regressions were used to determine whether patient visits to ACCs were negatively associated with ED utilization, hospital admission rates, and costs. Logistic regression analysis did not find an association between patients visiting ACCs and ED utilization compared to patients visiting stand-alone facilities [odds ratio (OR), 1.01; 95% confidence interval (CI), 1.00-1.03]. However, patients in ACCs were associated with an increase in hospital admissions (OR, 1.07; 95% CI, 1.04-1.09). ACCs were associated with higher total costs incurred during the patient journey (OR, 1.02; 95% CI, 1.01-1.03). Collaboration between EDs and AHPCs was not associated with ED utilization, but was associated with increased hospital admission rates, and higher costs. These collaborations do not seem to improve health systems' financial sustainability.

Readmission trends before and after a national reconfiguration of emergency departments in Denmark

OBJECTIVE

In order to achieve better and more efficient emergency health care, the Danish public hospital system has been reconfigured, with hospital emergency care being centralised into extensive and specialised emergency departments. This article examines how this reconfiguration has affected patient readmission rates.

METHODS

We included all unplanned hospital admissions (aged ≥18 years) at public, non-psychiatric hospitals in four geographical regions in Denmark between 1 January 2007 and 24 December 2017. Using an interrupted time-series design, we examined trend changes in the readmission rates. In addition to analysing the overall effect, analyses stratified according to admission time of day and weekdays/weekends were conducted. The analyses were adjusted for patient characteristics and other system changes.

RESULTS

The seven-day readmission rate increased from 2.6% in 2007 to 3.8% in 2017, and the 30-day rate increased from 8.1% to 11.5%. However, the rates were less than what they would have been had the reconfiguration not been introduced. The reconfiguration reduced the seven-day readmission rate by 1.4% annually (hazard ratio [CI 95%] 0.986 [0.981-0.991]) and the 30-day rate by 1% annually (hazard ratio [CI 95%] 0.99 [0.987-0.993]).

CONCLUSIONS

Reconfiguration reduced the rate of increase in readmissions, but nevertheless readmissions still increased across the study period. It seems hospitals and policymakers will need to identify further ways to reduce patient loads.

Performance of scoring systems in selecting short stay medical admissions suitable for assessment in same day emergency care: an analysis of diagnostic accuracy in a UK hospital setting

OBJECTIVES

To assess the performance of the Amb score and Glasgow Admission Prediction Score (GAPS) in identifying acute medical admissions suitable for same day emergency care (SDEC) in a large urban secondary centre.

DESIGN

Retrospective assessment of routinely collected data from electronic healthcare records.

SETTING

Single large urban tertiary care centre.

PARTICIPANTS

All unplanned admissions to general medicine on Monday-Friday, episodes starting 08:00-16:59 hours and lasting up to 48 hours, between 1 April 2019 and 9 March 2020.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive value of the Amb score and GAPS in identifying patients discharged within 12 hours of arrival.

RESULTS

7365 episodes were assessed. 94.6% of episodes had an Amb score suggesting suitability for SDEC. The positive predictive value of the Amb score in identifying those discharged within 12 hours was 54.5% (95% CI 53.3% to 55.8%). The area under the receiver operating characteristic curve (AUROC) for the Amb score was 0.612 (95% CI 0.599 to 0.625).42.4% of episodes had a GAPS suggesting suitability for SDEC. The positive predictive value of the GAPS in identifying those discharged within 12 hours was 50.5% (95% CI 48.4% to 52.7%). The AUROC for the GAPS was 0.606 (95% CI 0.590 to 0.622).41.4% of the population had both an Amb and GAPS score suggestive of suitability for SDEC and 5.7% of the population had both and Amb and GAPS score suggestive of a lack of suitability for SDEC.

CONCLUSIONS

The Amb score and GAPS had poor discriminatory ability to identify acute medical admissions suitable for discharge within 12 hours, limiting their utility in selecting patients for assessment within SDEC services within this diverse patient population.

Predicting Patient Length of Stay in Australian Emergency Departments Using Data Mining

Length of Stay (LOS) is an important performance metric in Australian Emergency Departments (EDs). Recent evidence suggests that an LOS in excess of 4 h may be associated with increased mortality, but despite this, the average LOS continues to remain greater than 4 h in many EDs. Previous studies have found that Data Mining (DM) can be used to help hospitals to manage this metric and there is continued research into identifying factors that cause delays in ED LOS. Despite this, there is still a lack of specific research into how DM could use these factors to manage ED LOS. This study adds to the emerging literature and offers evidence that it is possible to predict delays in ED LOS to offer Clinical Decision Support (CDS) by using DM. Sixteen potentially relevant factors that impact ED LOS were identified through a literature survey and subsequently used as predictors to create six Data Mining Models (DMMs). An extract based on the Victorian Emergency Minimum Dataset (VEMD) was used to obtain relevant patient details and the DMMs were implemented using the Weka Software. The DMMs implemented in this study were successful in identifying the factors that were most likely to cause ED LOS > 4 h and also identify their correlation. These DMMs can be used by hospitals, not only to identify risk factors in their EDs that could lead to ED LOS > 4 h, but also to monitor these factors over time.

Length of stay as quality indicator in emergency departments: analysis of determinants in the German Emergency Department Data Registry (AKTIN registry)

Several indicators reflect the quality of care within emergency departments (ED). The length of stay (LOS) of emergency patients represents one of the most important performance measures. Determinants of LOS have not yet been evaluated in large cohorts in Germany. This study analyzed the fixed and influenceable determinants of LOS by evaluating data from the German Emergency Department Data Registry (AKTIN registry). We performed a retrospective evaluation of all adult (age ≥ 18 years) ED patients enrolled in the AKTIN registry for the year 2019. Primary outcome was LOS for the whole cohort; secondary outcomes included LOS stratified by (1) patient-related, (2) organizational-related and (3) structure-related factors. Overall, 304,606 patients from 12 EDs were included. Average LOS for all patients was 3 h 28 min (95% CI 3 h 27 min-3 h 29 min). Regardless of other variables, patients admitted to hospital stayed 64 min longer than non-admitted patients. LOS increased with patients' age, was shorter for walk-in patients compared to medical referral, and longer for non-trauma presenting complaints. Relevant differences were also found for acuity level, day of the week, and emergency care levels. We identified different factors influencing the duration of LOS in the ED. Total LOS was dependent on patient-related factors (age), disease-related factors (presentation complaint and triage level), and organizational factors (weekday and admitted/non-admitted status). These findings are important for the development of management strategies to optimize patient flow through the ED and thus to prevent overcrowding.

Finding good alternatives to hospitalisation: a data register study in five municipal acute wards in Norway

BACKGROUND

In Norway, municipal acute wards (MAWs) have been implemented in primary healthcare since 2012. The MAWs were intended to offer decentralised acute medical care 24/7 for patients who otherwise would be admitted to hospital. The aim of this study was to assess whether the MAW represents the alternative to hospitalisation as intended, through 1) describing the characteristics of patients intended as candidates for MAWs by primary care physicians, 2) exploring the need for extended diagnostics prior to admission in MAWs, and 3) exploring factors associated with patients being transferred from the MAWs to hospital.

METHODS

The study was based on register data from five MAWs in Norway in the period 2014-2020.

RESULTS

In total, 16 786 admissions were included. The median age of the patients was 78 years, 60% were women, and the median length of stay was three days. Receiving oral medication (OR 1.23, 95% CI 1.09-1.40), and the MAW being located nearby the hospital (OR 2.29, 95% CI 1.92-2.72) were factors associated with patients admitted to MAW after extended diagnostics. Patients needing advanced treatment, such as oxygen therapy (OR 2.13, 95% CI 1.81-2.51), intravenous medication (OR 1.60, 95% CI 1.45-1.81), intravenous fluid therapy (OR 1.32, 95% CI 1.19-1.47) and MAWs with long travel distance from the MAW to the hospital (OR 1.46, 95% CI 1.22-1.74) had an increased odds for being transferred to hospital.

CONCLUSIONS

Our findings indicate that MAWs do not represent the alternative to hospitalisation as intended. The results show that patients receiving extended diagnostics before admission to MAW got basic treatment, while patients in need of advanced medical treatment were transferred to hospital from a MAW. This indicates that there is still a potential to develop MAWs in order to fulfil the intended health service level.

Identification through the Manchester Triage System of the older population at risk of delirium: A case-control study

OBJECTIVE

To identify the flow charts and discriminators of the Manchester Triage System that are most likely to identify the onset of delirium in older people.

BACKGROUND

Delirium is an underdiagnosed geriatric syndrome, and up to 80% of all cases of delirium go undetected in emergency departments. Patient triage seeks to manage clinical risk with a view to safely and appropriately managing patient flows.

DESIGN

A case-control study was performed according to the STROBE checklist.

SETTING

The emergency department of a secondary hospital.

PARTICIPANTS

Older adults aged ≥65 years and admitted from 1 January to 31 December 2020.

METHODS

Older patients were identified from the emergency department research database. Cases were defined as patients diagnosed with delirium (n = 128), excluding cases of delirium due to alcohol or substance abuse. Controls were randomised from the remaining patients (n = 128).

RESULTS

A total of 29.35% of the subjects admitted to the emergency department were older adults with an incidence of delirium of 0.7%. The flow charts with the highest probability of delirium were 'unwell adult' [OR = 3.04 (95%CI:1.82-5.1)] and 'behaving strangely' [OR = 16.06 (95%CI:3.72-69.29)], and the discriminators were 'rapid onset' [OR = 3.3 (95%CI:1.85-5.88)] and 'new neurological deficit less than 24 h old' [OR = 4.76 (95%%CI:1.01-22.5). The area under the curve for 'unwell adult' in the presence of dementia, previous stroke and fall in the previous 30 days was 0.73 (95%CI: 0.67-0.79), and that for 'behaving strangely' in the presence of diabetes was 0.75 (95%CI: 0.69-0.81).

CONCLUSIONS

Knowing which flow charts, discriminators and risk factors are most likely to predict delirium allows the identification of the older population at risk for triage screening in emergency departments.

RELEVANCE TO CLINICAL PRACTICE

Risk factors such as diabetes, dementia, previous stroke and recent fall among 'unwell adult' or 'behaving strangely' triaged older persons should be assessed for the probable presence of delirium.

Incidence of Sudden Cardiac Death in the European Union

BACKGROUND

Although sudden cardiac death (SCD) is recognized as a high-priority public health topic, reliable estimates of the incidence of SCD or, more broadly, out-of-hospital cardiac arrest (OHCA), in the population are scarce, especially in the European Union.

OBJECTIVES

The study objective was to determine the incidence of SCD and OHCA in the European Union.

METHODS

The study examined 4 large (ie, >2 million inhabitants) European population-based prospective registries collecting emergency medical services (EMS)-attended (ie, with attempted resuscitation) OHCA and SCD (OHCA without obvious extracardiac causes) for >5 consecutive years from January 2012 to December 2017 in the Paris region (France), the North Holland region (the Netherlands), the Stockholm region (Sweden), and in all of Denmark.

RESULTS

The average annual incidence of SCD in the 4 registries ranged from 36.8 per 100,000 (95% CI: 23.5-50.1 per 100,000) to 39.7 per 100,000 (95% CI: 32.6-46.8 per 100,000). When extrapolating to each European country and accounting for age and sex, this yields to 249,538 SCD cases per year (95% CI: 155,377-343,719 SCD cases per year). The average annual incidence of OHCA in the 4 registries ranged from 47.8 per 100,000 (95% CI: 21.2-74.4 per 100,000) to 57.9 per 100,000 (95% CI: 19.6-96.3 per 100,000), corresponding to 343,496 OHCA cases per year (95% CI: 216,472-464,922 OHCA cases per year) in the European Union. Incidence rates of SCD and OHCA increased with age and were systematically higher in men compared with women.

CONCLUSIONS

By combining data from 4 large, population-based registries with at least 5 years of data collection, this study provided an estimate of the incidence of SCD and OHCA in the European Union.

Effect of time intervals in critical care provided by helicopter emergency medical services on 30-day survival after trauma

BACKGROUND

Trauma is the leading cause of death especially in children and young adults. Prehospital care following trauma emphasizes swift transport to a hospital following initial care. Previous studies have shown conflicting results regarding the effect of time on the survival following major trauma. In our study we investigated the effect of prehospital time-intervals on 30-day mortality on trauma patients that received prehospital critical care.

METHODS

We performed a retrospective study on all trauma patients encountered by helicopter emergency medical services in Finland from 2012 to 2018. Patients discharge diagnoses were classed into (1) trauma without traumatic brain injury, (2) isolated traumatic brain injury and (3) trauma with traumatic brain injury. Emergency medical services response time, helicopter emergency medical services response time, on-scene time and transport time were used as time-intervals and age, Glasgow coma scale, hypotension, need for prehospital airway intervention and ICD-10 based Injury Severity Score were used as variables in logistic regression analysis.

RESULTS

Mortality data was available for 4,803 trauma cases. The combined 30-day mortality was 12.1% (582/4,803). Patients with trauma without a traumatic brain injury had the lowest mortality, at 4.3% (111/2,605), whereas isolated traumatic brain injury had the highest, at 22.9% (435/1,903). Patients with both trauma and a traumatic brain injury had a mortality of 12.2% (36/295). Following adjustments, no association was observed between time intervals and 30-day mortality.

DISCUSSION

Our study revealed no significant association between different timespans and mortality following severe trauma in general. Trends in odds ratios can be interpreted to favor more expedited care, however, no statistical significance was observed. As trauma forms a heterogenous patient group, specific subgroups might require different approaches regarding the prehospital timeframes.

STUDY TYPE

prognostic/therapeutic/diagnostic test.

Implementing a new emergency department: a qualitative study of health professionals' change responses and perceptions

Background

The aim of the study is two-fold. It explores how managers and key employees at the Emergency Department (ED) and specialist departments in a university hospital in the Capital Region of Denmark respond to the planned change to a new ED, and how they perceive the change involved in the implementation of the new ED. The study investigates what happens when health professionals are confronted with implementation of policy that changes their organization and everyday work lives. Few studies provide in-depth investigations of health professionals’ reactions to the implementation of new EDs, and particularly how they influence the implementation of a nationwide organizational change framed within a political strategy.

Methods

The study used semi-structured individual interviews with 51 health professionals involved in implementation activities related to an organizational change of establishing a new ED with new patient pathways for acutely ill patients. The data was deductively analyzed using Leon Coetsee’s theoretical framework of change responses, but the analysis also allowed for a more inductive reading of the material.

Results

Fourteen types of responses to establishing a new ED were identified and mapped onto six of the seven overall change responses in Coetsee’s framework. The participants perceived the change as particularly three changes. Firstly, they wished to create the best possible acute patient pathway in relation to their specialty. Whether the planned new ED would redeem this was disputed. Secondly, participants perceived the change as relocation to a new building, which both posed potentials and worries. Thirdly, both hopeful and frustrated statements were given about the newly established medical specialty of emergency medicine (EM), which was connected to the success of the new ED.

Conclusions

The study showcases how implementation processes within health care are not straightforward and that it is not only the content of the implementation that determines the success of the implementation and its outcomes but also how these are perceived by managers and employees responsible for the process and their context. In this way, managers must recognize that it cannot be pre-determined how implementation will proceed, which necessitates fluid implementation plans and demands implementation managements skills.

Intended healthcare utilisation in cases of severe COVID-19 and inflammatory gastrointestinal disease: results of a population survey with vignettes

OBJECTIVES

To examine variations in intended healthcare utilisation in severe cases of COVID-19 and inflammatory gastrointestinal disease (IGD).

DESIGN

Representative cross-sectional telephone survey.

SETTING AND PARTICIPANTS

1207 randomly drawn adults of the city of Hamburg, Germany, between November 2020 and January 2021.

OUTCOME MEASURES

Different vignettes with severe symptoms were presented varying in sex, age (child, middle-aged person, older person), daytime (Tuesday morning or Tuesday evening) and disease (COVID-19 or IGD), while the degree of urgency was equivalent for all cases. The respondents were asked for the intended healthcare utilisation resulting in three different alternatives: general practitioner (GP)/paediatrician, medical on-call service ('116117') and emergency care (accident and emergency department, emergency practice, rescue service). In multivariate analyses, associations of characteristics of the vignettes and participants (sex, age, education, migration background) with intended healthcare utilisation were tested. In a further step, analyses were conducted separately for IGD and COVID-19.

RESULTS

Regarding the vignettes' characteristics, intended utilisation of GP/paediatrician is associated with female sex, higher age, daytime (morning) and COVID-19 symptoms, the medical on-call service with male sex, daytime (evening) and COVID-19 symptoms and the emergency medicine with younger age, daytime (evening) and IGD. Women chose more often the GP/paediatrician, men preferred emergency medicine. Only in case of IGD, higher educated persons more often chose the medical on-call service while people with a migration background decided less often for medical on-call service and emergency medicine.

CONCLUSIONS

Despite comparable urgency, the findings suggest variations of intended healthcare utilisation depending on various characteristics of the vignettes and respondents. Depending on the type of disease inequalities vary. Overall, information about healthcare alternatives in severe cases has to be improved and clear pathways to facilitate healthcare utilisation has to be further developed.

Evaluation of an Ambulatory Emergency Care Centre at a tertiary hospital in Perth, Western Australia

BACKGROUND

Emergency Departments around the world are under increasing pressure due to rising demand. In the United Kingdom ambulatory emergency care has been demonstrated to deliver safe and effective care for emergency patients and has now become an accepted treatment modality.

METHODS

This paper outlines a quality improvement project undertaken to evaluate an ambulatory emergency care centre implemented at a tertiary hospital in Perth, Western Australia, from February to August 2021.

RESULTS

The findings demonstrated a 4% improvement in the Western Australian Emergency Access Target for a four week period, a 6.3% reduction in the number of patients admitted with a length of stay less than 24 h and that patient's attending the Ambulatory Emergency Care Centre were managed as safely as if they were seen in the Emergency Department.

Experiences of nursing care for patients who self-harm and suggestions for future practices: The perspectives of emergency care nurses

Self-harm is a major challenge in healthcare systems. Emergency department nurses provide care to numerous patients with self-harm injuries. Accordingly, nurse-patient interactions are vital to improve the physical and psychological outcomes of this complex patient group. Previous studies have proposed the establishment of improved teaching programs to increase the competence of emergency department nurses within mental health care; however, few studies have comprehensively investigated the experiences and suggestions for future nursing practices. Therefore, we gathered in-depth knowledge of Danish emergency department nurses' experiences caring for patients who self-harm and obtained their suggestions on future nursing practices. Ten semi-structured interviews were conducted to capture the nurses' individual perspectives. The scientific theory is based on phenomenology and hermeneutics. Interpretative phenomenological analysis was used, and three themes were identified: (i) importance of having the competences to establish a relationship in the acute phase; (ii) acute care from a biomedical perspective; and (iii) highlighting ideas for improved future practices. The emergency department nurses were aware of the importance of mental health care but found their competence and motivation situated in medical care. The nurses felt that they lacked skills to undertake in-depth mental care for patients who self-harm and that the healthcare system failed to help this group of patients. Based on these findings, rather than aiming at improving nursing skills, we suggest a close collaboration between the emergency and psychiatric departments to improve the quality of care for patients who self-harm. We also recommend organizational changes within the emergency department, such as the introduction of a so-called 'social track'.

Factors associated with choice of health service delivery for after-hours, urgent, non-life-threatening conditions: a patient survey

The objective of this study was to determine factors associated with patient or carer choice of presentation to an emergency department, an urgent care clinic and an after-hours general practice on Sundays in south-east Queensland. The design of the study was a cross-sectional survey of patients or carers. The study setting was an emergency department, an urgent care clinic and an after-hours general practice. Patients or carers of patients were invited to take part in the study while they were waiting to consult the doctor. Patients were more likely to present to community clinics (i.e. urgent care clinic and an after-hours general practice) if they usually came to the facility (P < 0.001), were concerned about cost (P < 0.001), were influenced by the perceived severity of the sickness (P < 0.001), were unable to get an appointment elsewhere (P < 0.001), thought that there would be less waiting time (P < 0.001) and thought there was better doctor explanation (P = 0.007). This research was limited to 337 surveys. Larger studies could further explore insights gained from this study. The results suggest that public health campaigns could focus on promoting community clinic care for urgent non-life-threatening conditions. These campaigns should include information on waiting times, need for referral, conditions safely managed, range of services provided and quality of service. Designing community facilities for hospital avoidance of patients with non-life-threatening urgent conditions could involve public health campaigns, facility upgrades, and subsidies for transport and attendance.

Non-emergent care visits in a turkish tertiary care emergency department after 2008 health policy changes: review and analysis

Background

The Turkish government liberalized national healthcare policies in 2008 enabling Turkish citizens to seek general care in hospital emergency departments (ED). The number of ED visits has exceeded the total population every year for the last ten years. To explain this phenomenon and to identify trends and risk factors for non-emergent visits, we retrospectively reviewed the ED records of a tertiary hospital and the Turkish Ministry of Health bulletin.

Methods

This retrospective record-based study was conducted at a tertiary hospital in Samsun province of Turkey. A total of 87,528 records of adult patients who visited the ED between January 1 and December 31, 2017, were included in this study. We evaluated the pattern of ED use for non-emergent patients by age, gender, nationality, time of visit, means of arrival, ICD (International Classification of Diseases) diagnostic codes, triage codes, number of repeated and out-of-hours visits. We used the Turkish Ministry of Health statistics bulletins to compare the number of ED visits across the country by year.

Results

The non-emergent visit rate in ED was found 9.9%. The rate of non-emergent ED visits was significantly higher in the 18-44 age group, in the female gender, and in those who arrived at the ED without an ambulance. The number of non-emergent visits was very similar between weekends and weekdays but was significantly higher in working hours on weekdays than out-of-hours (p<0.001). The most frequent diagnostic code was “Pain, unspecified” (R52) and the rate of repeat visits was 14.8% of non-emergent ED visits. According to binary logistic analysis, non-emergency visits were associated with 18-44 age group (OR = 2.75), female gender (OR = 1.11) and non-ambulance transportation (OR = 9.86).

Conclusions

Our results showed that the 18-44 age group and female gender seek care in the ED for non-emergent problems more than the other parts of the population. The numbers of ED visits in the last decade continued to increase regardless of population growth. The health policy changes may have facilitated access to rapid physical and laboratory examination but also an exacerbation of the free-rider problem in ED services.

The challenge of involving old patients with polypharmacy in their medication during hospitalization in a medical emergency department: An ethnographic study

Background

More than 70% of patients admitted to emergency departments (EDs) in Denmark are older patients with multimorbidity and polypharmacy vulnerable to adverse events and poor outcomes. Research suggests that patient involvement and shared decision-making (SDM) could optimize the treatment of older patients with polypharmacy. The patients become more aware of potential outcomes and, therefore, often tend to choose less medication. However, implementing SDM in clinical practice is challenging if it does not fit into existing workflows and healthcare systems.

Aim

The aim was to explore the determinants of patient involvement in decisions made in the ED about the patient’s medication.

Methods

The design was a qualitative ethnographic study. We observed forty-eight multidisciplinary healthcare professionals in two medical EDs focusing on medication processes and patient involvement in medication. Based on field notes, we developed a semi-structured interview guide. We conducted 20 semi-structured interviews with healthcare professionals to elaborate on the findings. Data were analyzed with thematic analyses.

Findings

We found five themes (determinants) which affected patient involvement in decisions about medicine in the ED: 1) blurred roles among multidisciplinary healthcare professionals, 2) older patients with polypharmacy increase complexity, 3) time pressure, 4) faulty IT- systems, and 5) the medicine list as a missed enabler of patient involvement.

Conclusion

There are several barriers to patient involvement in decisions about medicine in the ED and some facilitators. A tailored medication conversation guide based on the SDM methodology combined with the patient’s printed medicine list and well-functioning IT- systems can function as a boundary object, ensuring the treatment is optimized and aligned with the patient’s preferences and goals.

Epidemiology and risk factors of sudden cardiac arrest

PURPOSE OF REVIEW

Sudden cardiac arrest (SCA) remains a major health burden around the globe, most often occurring in the community (out-of-hospital cardiac arrest [OHCA]). SCA accounts for 15-20% of all natural deaths in adults in the USA and Western Europe, and up to 50% of all cardiovascular deaths. To reduce this burden, more knowledge is needed about its key facets such as its incidence in various geographies, its risk factors, and the populations that may be at risk.

RECENT FINDINGS

SCA results from a complex interaction of inherited and acquired causes, specific to each individual. Resolving this complexity, and designing personalized prevention and treatment, requires an integrated approach in which big datasets that contain all relevant factors are collected, and a multimodal analysis. Such datasets derive from multiple data sources, including all players in the chain-of-care for OHCA. This recognition has led to recently started large-scale collaborative efforts in Europe.

SUMMARY

Our insights into the causes of SCA are steadily increasing thanks to the creation of big datasets dedicated to SCA research. These insights may be used to earlier recognize of individuals at risk, the design of personalized methods for prevention, and more effective resuscitation strategies for OHCA.

Using explainable machine learning to identify patients at risk of reattendance at discharge from emergency departments

Short-term reattendances to emergency departments are a key quality of care indicator. Identifying patients at increased risk of early reattendance could help reduce the number of missed critical illnesses and could reduce avoidable utilization of emergency departments by enabling targeted post-discharge intervention. In this manuscript, we present a retrospective, single-centre study where we created and evaluated an extreme gradient boosting decision tree model trained to identify patients at risk of reattendance within 72 h of discharge from an emergency department (University Hospitals Southampton Foundation Trust, UK). Our model was trained using 35,447 attendances by 28,945 patients and evaluated on a hold-out test set featuring 8847 attendances by 7237 patients. The set of attendances from a given patient appeared exclusively in either the training or the test set. Our model was trained using both visit level variables (e.g., vital signs, arrival mode, and chief complaint) and a set of variables available in a patients electronic patient record, such as age and any recorded medical conditions. On the hold-out test set, our highest performing model obtained an AUROC of 0.747 (95% CI 0.722–0.773) and an average precision of 0.233 (95% CI 0.194–0.277). These results demonstrate that machine-learning models can be used to classify patients, with moderate performance, into low and high-risk groups for reattendance. We explained our models predictions using SHAP values, a concept developed from coalitional game theory, capable of explaining predictions at an attendance level. We demonstrated how clustering techniques (the UMAP algorithm) can be used to investigate the different sub-groups of explanations present in our patient cohort.

Access, Use, and Patient-Reported Experiences of Emergency Care During the COVID-19 Pandemic: Population-Based Survey

Background

An increase in the number of people presenting to emergency departments (EDs) is contributing to ED overcrowding. In the early stages of the COVID-19 pandemic, there was a significant reduction in the number of ED presentations in Australia, creating an opportunity to learn from patients’ experiences of alternative management options.

Objective

The aim of this study is to report on the use and experience of health services by Australian adults experiencing a health issue during the COVID-19 pandemic for which they would have presented at an ED prior to the pandemic.

Methods

An online survey was conducted in May 2020. Reported health issues were categorized using an existing classification system. Data collected included demographics, care pathways, levels of concern at times of health issue and survey completion, and patient-reported experiences with care.

Results

A total of 1289 eligible respondents completed the survey. Almost 25% (309/1289) of respondents avoided an ED presentation, of which 58% (179/309) used an alternative form of health care and 42% (130/309) self-managed. Respondents making face-to-face or telehealth appointments with their general practitioner (GP) reported high levels of ED avoidance (135/286, 47%) and mostly positive experiences of care provided by GPs. A high proportion of those who self-managed reported high levels of concern at the time of completing the survey (42/130, 32%).

Conclusions

Telehealth consultations with GPs may be a more promotable alternative to the ED beyond the COVID-19 pandemic, providing easier access to a doctor with access to patients’ medical histories than an appointment for a face-to-face consultation. GP telehealth consultations may also address barriers to accessing health care for those with potentially the greatest need. The reported use and positive experiences with GP telehealth appointments should inform further research on their appropriateness as an alternative to the ED.

Self-reported health and life satisfaction in older emergency department patients: sociodemographic, disease-related and care-specific associated factors

BACKGROUND

Self-reported health (SRH) and life satisfaction (LS) are patient-reported outcomes (PROs) that independently predict mortality and morbidity in older adults. Emergency department (ED) visits due to serious health problems or accidents might pose critical life events for patients. This study aimed (a) to characterize older patients' SRH and LS during the distinct event of an ED stay, and (b) to analyze concomitant associations of PROs with ED patients' sociodemographic, disease-specific and care-related variables.

METHODS

Study personnel recruited mostly older ED patients from three disease groups during a two-year period (2017-2019) in eight EDs in central Berlin, Germany, in the context of the health services research network EMANet. Cross-sectional data from the baseline patient survey and associated secondary data from hospital information systems were analyzed. Multilevel linear regression models with random intercept were applied to assess concomitant associations with SRH (scale: 0 (worst) to 100 (best)) and LS (scale: 0 (not at all satisfied) to 10 (completely satisfied)) as outcomes, including sensitivity analyses.

RESULTS

The final sample comprised N = 1435 participants. Mean age was 65.18 (SD: 16.72) and 50.9% were male. Mean ratings of SRH were 50.10 (SD: 23.62) while mean LS scores amounted to 7.15 (SD: 2.50). Better SRH and higher LS were found in patients with cardiac symptoms (SRH: β = 4.35, p = .036; LS: β = 0.53, p = .006). Worse SRH and lower LS were associated with being in need of nursing care (SRH: β = - 7.52, p < .001; LS: β = - 0.59, p = .003) and being unemployed (SRH: β = - 8.54, p = .002; LS: β = - 1.27, p < .001). Sex, age, number of close social contacts, and hospital stays in the previous 6 months were additionally related to the outcomes. Sensitivity analyses largely supported results of the main sample.

CONCLUSIONS

SRH and LS were associated with different sociodemographic and disease-related variables in older ED patients. Nursing care dependency and unemployment emerged as significant factors relating to both outcomes. Being able to identify especially vulnerable patients in the ED setting might facilitate patient-centered care and prevent negative health outcomes. However, further longitudinal research needs to analyze trajectories in both outcomes and suitable intervention possibilities in the ED setting.

TRIAL REGISTRATION

EMANet sub-studies were registered separately: German Clinical Trials Register (EMAAge: DRKS00014273, registration date: May 16, 2018; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014273; EMACROSS: DRKS00011930, registration date: April 25, 2017; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011930); ClinicalTrials.gov (EMASPOT: NCT03188861, registration date: June 16, 2017; https://clinicaltrials.gov/ct2/show/NCT03188861?term=NCT03188861&draw=2&rank=1).

What if something happens tonight? A qualitative study of primary care physicians' perspectives on an alternative to hospital admittance

BACKGROUND

Due to demographic changes, hospital emergency departments in many countries are overcrowded. Internationally, several primary healthcare models have been introduced as alternatives to hospitalisation. In Norway, municipal acute wards (MAWs) have been implemented as primary care wards that provide observation and medical treatment for 24 h. The intention is to replace hospitalisation for patients who require acute admission but not specialist healthcare services. The aim of this study was to explore primary care physicians' (PCPs') perspectives on admission to a MAW as an alternative to hospitalisation.

METHODS

The study had a qualitative design, including interviews with 21 PCPs in a county in southeastern Norway. Data were analysed with a thematic approach.

RESULTS

The PCPs described uncertainty when referring patients to the MAW because of the fewer diagnostic opportunities there than in the hospital. Admission of patients to the MAW was assumed to be unsafe for both PCPs, MAW nurses and physicians. The PCPs assumed that medical competence was lower at the MAW than in the hospital, which led to scepticism about whether their tentative diagnoses would be reconsidered if needed and whether a deterioration of the patients' condition would be detected. When referring patients to a MAW, the PCPs experienced disagreements with MAW personnel about the suitability of the patient. The PCPs emphasised the importance of patients' and relatives' participation in decisions about the level of treatment. Nevertheless, such participation was not always possible, especially when patients' wishes conflicted with what PCPs considered professionally sound.

CONCLUSIONS

The PCPs reported concerns regarding the use of MAWs as an alternative to hospitalisation. These concerns were related to fewer diagnostic opportunities, lower medical expertise throughout the day, uncertainty about the selection of patients and challenges with user participation. Consequently, these concerns had an impact on how the PCPs utilised MAW services.

INDEED-Utilization and Cross-Sectoral Patterns of Care for Patients Admitted to Emergency Departments in Germany: Rationale and Study Design

Introduction: The crowding of emergency departments (ED) has been a growing problem for years, putting the care of critically ill patients increasingly at risk. The INDEED project's overall aim is to get a better understanding of ED utilization and to evaluate corresponding primary health care use patterns before and after an ED visit while driving forward processes and methods of cross-sectoral data merging. We aim to identify adequate utilization of EDs and potentially avoidable patient contacts as well as subgroups and clusters of patients with similar care profiles.

Methods: INDEED is a joint endeavor bringing together research institutions and hospitals with EDs in Germany. It is headed by the Charité–Universitätsmedizin Berlin, collaborating with Otto von Guericke University Magdeburg, Technische Universität Berlin, the Central Research Institute of Ambulatory/Outpatient Health Care in Germany (Zi), and the AOK Research Institute as part of the Federal Association of AOK, as well as experts in the technological, legal, and regulatory aspects of medical research (TMF). The Institute for Information Technology (OFFIS) was involved as the trusted third party of the project. INDEED is a retrospective study of approximately 400,000 adult patients with statutory health insurance who visited the ED of one of 16 participating hospitals in 2016. The routine hospital data contain information about treatment in the ED and, if applicable, about the subsequent hospital stay. After merging the patients' hospital data from 2016 with their outpatient billing data from 2 years before to 1 year after the ED visit (years 2014–2017), a harmonized dataset will be generated for data analyses. Due to the complex data protection challenges involved, first results will be available in 2021.

Discussion: INDEED will provide knowledge on extracting and harmonizing large scale data from varying routine ED and hospital information systems in Germany. Merging these data with the corresponding outpatient care data of patients offers the opportunity to characterize the patient's treatment in outpatient care before and after ED use. With this knowledge, appropriate interventions may be developed to ensure adequate patient care and to avoid adverse events such as ED crowding.

Do access, quality and cost of general practice affect emergency department use?

Limited access, poor experience, and high out-of-pocket (OOP) costs of primary care services may lead to avoidable emergency department (ED) presentations. But, the evidence has been limited with most of the studies using surveys conducted in EDs. Using detailed health survey data of Australian women linked to multiple administrative datasets, we extend the literature by estimating the effects of access, costs, and experience of general practice (GP) services on the probability of ED attendance while accounting for a large set of health and socioeconomic covariates. Our findings suggest that improvements in access to primary care services can significantly reduce the demand for low acuity ED presentations. We also show that the impact of increased accessibility of GP services is expected to be the highest for socioeconomic vulnerable populations and patients whose access is the poorest. This evidence can be useful for the design of targeted policies aimed at improving access to doctors in particular areas that are socioeconomically disadvantaged and where medical skill shortages are significant. However, policies aimed at reduction in primary care OOP costs or improvement in the perception of GP quality are less likely to be effective in reducing the number of non-urgent ED presentations.

Emergency department use following incentives to provide after-hours primary care: a retrospective cohort study

BACKGROUND:

Access to primary care outside of regular working hours is limited in many countries. This study investigates the relation between the after-hours premium, an incentive for primary care physicians to provide services after hours, and less-urgent visits to the emergency department in Ontario, Canada.

METHODS:

We analyzed a retrospective cohort of a random sample of Ontario residents from April 2002 to March 2006, and a subcohort of patients followed from April 2005 to March 2016. We linked patient and primary care physician data with emergency department visit data. We used fixed-effects regression models to analyze the association between the introduction of the after-hours premium, as well as subsequent increases in the value of the premium, and the number of monthly emergency department visits.

RESULTS:

The sample consisted of 586 534 patients between 2002 and 2006, and 201 594 patients from 2005 to 2016. After controlling for patient and physician characteristics, seasonality and time-invariant patient confounding factors, introduction of the after-hours premium was associated with a reduction of 1.26 less-urgent visits to the emergency department per 1000 patients per month (95% confidence interval −1.48 to −1.04). Most of this reduction was observed in after-hours visits. Sensitivity analysis showed that the monthly reduction in less-urgent visits to the emergency department was in the range of −1.24 to −1.16 per 1000 patients. Subsequent increases in the after-hours premium were associated with a small reduction in less-urgent visits to the emergency department.

INTERPRETATION:

Ontario’s experience suggests that incentivizing physicians to improve access to after-hours primary care reduces some less-urgent visits to the emergency department. Other jurisdictions may consider incentives to limit less-urgent visits to the emergency department.

Exploring Perceptions of Parents on the Use of Emergency Department On-site Primary Care Services for the Treatment of Children With Non-urgent Conditions

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.

An integrated approach for designing in-time and economically sustainable emergency care networks: A case study in the public sector

Emergency Care Networks (ECNs) were created as a response to the increased demand for emergency services and the ever-increasing waiting times experienced by patients in emergency rooms. In this sense, ECNs are called to provide a rapid diagnosis and early intervention so that poor patient outcomes, patient dissatisfaction, and cost overruns can be avoided. Nevertheless, ECNs, as nodal systems, are often inefficient due to the lack of coordination between emergency departments (EDs) and the presence of non-value added activities within each ED. This situation is even more complex in the public healthcare sector of low-income countries where emergency care is provided under constraint resources and limited innovation. Notwithstanding the tremendous efforts made by healthcare clusters and government agencies to tackle this problem, most of ECNs do not yet provide nimble and efficient care to patients. Additionally, little progress has been evidenced regarding the creation of methodological approaches that assist policymakers in solving this problem. In an attempt to address these shortcomings, this paper presents a three-phase methodology based on Discrete-event simulation, payment collateral models, and lean six sigma to support the design of in-time and economically sustainable ECNs. The proposed approach is validated in a public ECN consisting of 2 hospitals and 8 POCs (Point of Care). The results of this study evidenced that the average waiting time in an ECN can be substantially diminished by optimizing the cooperation flows between EDs.

Communication training and the prescribing pattern of antibiotic prescription in primary health care

BACKGROUND

The treatment of upper respiratory tract infections (URTIs) accounts for the majority of antibiotic prescriptions in primary care, although an antibiotic therapy is rarely indicated. Non-clinical factors, such as time pressure and the perceived patient expectations are considered to be reasons for prescribing antibiotics in cases where they are not indicated. The improper use of antibiotics, however, can promote resistance and cause serious side effects. The aim of the study was to clarify whether the antibiotic prescription rate for infections of the upper respiratory tract can be lowered by means of a short (2 x 2.25h) communication training based on the MAAS-Global-D for primary care physicians.

METHODS

In total, 1554 primary care physicians were invited to participate in the study. The control group was formed from observational data. To estimate intervention effects we applied a combination of difference-in-difference (DiD) and statistical matching based on entropy balancing. We estimated a corresponding multi-level logistic regression model for the antibiotic prescribing decision of German primary care physicians for URTIs.

RESULTS

Univariate estimates detected an 11-percentage-point reduction of prescriptions for the intervention group after the training. For the control group, a reduction of 4.7% was detected. The difference between both groups in the difference between the periods was -6.5% and statistically significant. The estimated effects were nearly identical to the effects estimated for the multi-level logistic regression model with applied matching. Furthermore, for the treatment of young women, the impact of the training on the reduction of antibiotic prescription was significantly stronger.

CONCLUSIONS

Our results suggest that communication skills, implemented through a short communication training with the MAAS-Global-D-training, lead to a more prudent prescribing behavior of antibiotics for URTIs. Thereby, the MAAS-Global-D-training could not only avoid unnecessary side effects but could also help reducing the emergence of drug resistant bacteria. As a consequence of our study we suggest that communication training based on the MAAS-Global-D should be applied in the postgraduate training scheme of primary care physicians.