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Ylä-Mattila J, Koivistoinen T, Siippainen H, Huhtala H, Mustajoki S. Factors associated with hospital revisitation within 7 days among patients discharged at triage: a case-control study. Eur J Emerg Med 2024:00063110-990000000-00135. [PMID: 38963674 DOI: 10.1097/mej.0000000000001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
BACKGROUND AND IMPORTANCE Existing data are limited for determining the medical conditions best suited for an emergency department (ED) redirection strategy in a heterogeneous, nonurgent patient population. OBJECTIVE The aim was to establish factors associated with hospital revisits within 7 days among patients discharged or redirected by a triage team. DESIGN, SETTINGS, AND PARTICIPANTS An observational single-center case-control study was conducted at the Tampere University Hospital ED for the full calendar year of 2019. The cases comprised unplanned hospital revisits within 7 days of being discharged or redirected by triage, while the controls were discharged or redirected but did not revisit. OUTCOME MEASURES AND ANALYSIS The primary outcome was an unplanned hospital revisit within 7 days. A subgroup analysis was conducted for revisits leading to hospitalization. Basic demographics, comorbidities before triage, and triage visit characteristics were considered as predictive factors for the revisit. A backward stepwise conditional logistic regression analysis was performed. MAIN RESULTS During the calendar year of 2019, there were a total of 92 406 ED visits. Of these, 7216 (7.8%) visits were discharged or redirected by triage, and 6.5% (n = 467) of all these patients revisited. Of the revisiting patients, 25% (n = 117) were hospitalized. In multivariable analysis, higher age was associated with both revisitation [odds ratio (OR): 1.01, 95% confidence interval (CI): 1.00-1.02] and hospitalization (OR: 1.02, 95% CI: 1.00-1.04). Furthermore, using other visits as a reference, abdominal pain was associated with revisitation and hospitalization (OR: 3.70, 95% CI: 2.24-6.11 and OR: 5.28, 95% CI: 2.08-13.4, respectively). CONCLUSION Higher age and abdominal pain were associated with hospital revisitation and hospitalization within 7 days among patients directly discharged or redirected by the triage team. Regardless of the triage system in use, there might be patient groups that should be evaluated more cautiously if a triage-based discharge or redirection strategy is to be considered.
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Affiliation(s)
- Jari Ylä-Mattila
- Emergency Department, Tampere University Hospital
- Faculty of Medicine and Health Technology, Tampere University, Tampere
| | | | | | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
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Koech L, Ströhl S, Lauerer M, Oslislo S, Bayeff-Filloff M, Thoß R, Nagel E, Carnarius S, Stillfried D. [Redirection of patients from the emergency department to ambulatory care: a feasibility study]. DAS GESUNDHEITSWESEN 2024; 86:339-345. [PMID: 38354744 PMCID: PMC11077551 DOI: 10.1055/a-2206-1738] [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] [Indexed: 02/16/2024]
Abstract
BACKGROUND § 120 para. 3b SGB V mandates the Federal Joint Committee to define guidelines for the initial assessment of self-referred walk-in patients as well as for the redirection of patients who can be treated by office-based physicians. A corresponding streaming and redirection process was tested in a feasibility study at the RoMed Clinic Rosenheim. MATERIALS AND METHODS For the duration of the study, triage nurses of the emergency department (ED) first assessed self-referred walk-in patients with the Manchester Triage System (MTS). Patients in categories green and blue who did not obviously need the ED's resources were additionally assessed by health professionals of the Association of Statutory Health Insurance Physicians of Bavaria using the software Structured Initial Medical Assessment in Germany (SmED). Patients with a recommendation for non-hospital medical treatment were streamed to the out-of-hours practice on campus or were redirected to a physician office after video consultation with an office-based physician. Patient pathways were documented and a qualitative survey using semistructured guided interviews of all stakeholder groups was carried out. RESULTS 1,091 self-referred walk-in patients were included. Direct streaming to the ED occurred in 525 cases,13 refused to participate. Based on SmED, 24 additional patients were referred to the ED, 514 patients were streamed to the out-of-hours practice, 23 received a video consultation and five left the ED. After video consultation, eight patients were redirected to a physician's office, 10 were discharged, and five referred to the ED of which one did not want an office-based physician. No returnees from practices to the ED were identified. Generally, the redirection process was evaluated positively in the interviews (n=18). In particular, potential for technical improvement was identified. CONCLUSION Overall, the results indicate the feasibility of the redirection process and high acceptance levels. Using SmED in addition to MTS appeared useful before redirection but not necessary for streaming on campus. Redirection to physician offices can help reduce strain on the ED when the out-of-hours practice is not operating. In addition to arranging acute care appointments, video consultations offer an additional potential to treat patients. In a follow-up study, a broader range of patients should be included and appropriateness of redirection decisions should be evaluated.
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Affiliation(s)
- Lea Koech
- Zentralinstitut für die kassenärztliche Versorgung in
der Bundesrepublik Deutschland, Berlin, Germany
| | - Sarah Ströhl
- Forschung, GWS – Gesundheit, Wissenschaft, Strategie GmbH,
Bayreuth, Germany
- Institut für Medizinmanagement und Gesundheitswissenschaften,
Universität Bayreuth, Bayreuth, Germany
| | - Michael Lauerer
- Forschung, GWS – Gesundheit, Wissenschaft, Strategie GmbH,
Bayreuth, Germany
- Institut für Medizinmanagement und Gesundheitswissenschaften,
Universität Bayreuth, Bayreuth, Germany
| | - Sarah Oslislo
- Zentralinstitut für die kassenärztliche Versorgung in
der Bundesrepublik Deutschland, Berlin, Germany
| | - Michael Bayeff-Filloff
- Notaufnahme, RoMed Klinikum Rosenheim, Rosenheim, Germany
- Ärztlicher Landesbeauftragter Rettungsdienst, Bayerisches
Staatsministerium des Innern für Bau und Verkehr, München,
Germany
| | - Reno Thoß
- Notdienste, Vermittlungs- und Beratungszentrale,
Kassenärztliche Vereinigung Bayerns, München,
Germany
| | - Eckhardt Nagel
- Institut für Medizinmanagement und Gesundheitswissenschaften,
Universität Bayreuth, Bayreuth, Germany
| | - Sebastian Carnarius
- Zentralinstitut für die kassenärztliche Versorgung in
der Bundesrepublik Deutschland, Berlin, Germany
| | - Dominik Stillfried
- Zentralinstitut für die kassenärztliche Versorgung in
der Bundesrepublik Deutschland, Berlin, Germany
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Davies F, Edwards M, Price D, Anderson P, Carson-Stevens A, Choudhry M, Cooke M, Dale J, Donaldson L, Evans BA, Harrington B, Harris S, Hepburn J, Hibbert P, Hughes T, Hussain F, Islam S, Pockett R, Porter A, Siriwardena AN, Snooks H, Watkins A, Edwards A, Cooper A. Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-152. [PMID: 38687611 DOI: 10.3310/jwqz5348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Background Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models. Objectives To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models. Design Mixed-methods realist evaluation. Methods Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development. Results General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models. Limitations The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored. Conclusion Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services. Future work The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy. Study registration This study is registered as PROSPERO CRD42017069741. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Freya Davies
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Delyth Price
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Bangor Institute for Health and Medical Research, Bangor University, Wales, UK
| | | | - Mazhar Choudhry
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Matthew Cooke
- Professor of Clinical Systems Design, Warwick Medical School, Warwick, UK
| | - Jeremy Dale
- Professor of Clinical Systems Design, Warwick Medical School, Warwick, UK
| | | | - Bridie Angela Evans
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Shaun Harris
- Swansea Centre for Health Economics, School of Health and Social Care, Swansea University, Swansea, UK
| | - Julie Hepburn
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | - Faris Hussain
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Saiful Islam
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Rhys Pockett
- Swansea Centre for Health Economics, School of Health and Social Care, Swansea University, Swansea, UK
| | - Alison Porter
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Helen Snooks
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | - Alan Watkins
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | - Adrian Edwards
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Alison Cooper
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
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Marx T, Moore L, Talbot D, Guertin JR, Lachapelle P, Blais S, Singbo N, Simonyan D, Lavallée J, Zada N, Shahrigharahkoshan S, Huard B, Olivier P, Mallet M, Létourneau M, Lafrenière M, Archambault PM, Berthelot S. A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments. CAN J EMERG MED 2023; 25:394-402. [PMID: 37004679 DOI: 10.1007/s43678-023-00481-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/04/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVES Our aim was to compare some of the health outcomes and costs associated with value of care in emergency departments (ED) and walk-in clinics for ambulatory patients presenting with an acute respiratory disease. METHODS A health records review was conducted from April 2016 through March 2017 in one ED and one walk-in clinic. Inclusion criteria were: (i) ambulatory patients at least 18 years old, (ii) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Primary outcome was the proportion of patients returning to any ED or walk-in clinic within three and seven days of the index visit. Secondary outcomes were the mean cost of care and the incidence of antibiotic prescription for URTI patients. The cost of care was estimated from the Ministry of Health's perspectives using time-driven activity-based costing. RESULTS The ED group included 170 patients and the walk-in clinic group 326 patients. The return visit incidences at three and seven days were, respectively, 25.9% and 38.2% in the ED vs. 4.9% and 14.7% in the walk-in clinic (adjusted relative risk (arr) of 4.7 (95% CI 2.6-8.6) and 2.7 (1.9-3.9)). The mean cost ($Cdn) of the index visit care was 116.0 (106.3-125.7) in the ED vs. 62.5 (57.7-67.3) in the walk-in clinic (mean difference of 56.4 (45.7-67.1)). Antibiotic prescription for URTI was 5.6% in the ED vs. 24.7% in the walk-in clinic (arr 0.2, 0.01-0.6). CONCLUSIONS This study is the first in a larger research program to compare the value of care between walk-in clinics and the ED. The potential advantages of walk-in clinics over EDs (lower costs, lower incidence of return visits) for ambulatory patients with respiratory diseases should be considered in healthcare planning.
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Affiliation(s)
- Tania Marx
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Lynne Moore
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Denis Talbot
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Jason R Guertin
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Philippe Lachapelle
- Clinical and Organizational Performance Department of the CHU de Québec-Université Laval, Québec, QC, Canada
| | - Sébastien Blais
- Clinical and Organizational Performance Department of the CHU de Québec-Université Laval, Québec, QC, Canada
| | - Narcisse Singbo
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - David Simonyan
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Jeanne Lavallée
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Nawid Zada
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Shaghayegh Shahrigharahkoshan
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Benoit Huard
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Pascale Olivier
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Myriam Mallet
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Mélanie Létourneau
- Clinical and Organizational Performance Department of the CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Patrick M Archambault
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- Centre de Recherche du Centre Intégré de Santé et de Services Sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- VITAM - Centre de Recherche en Santé Durable, Université Laval, Québec, QC, Canada
| | - Simon Berthelot
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada.
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada.
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Lau T, Maltby A, Ali S, Moran V, Wilk P. Does the definition of preventable emergency department visit matter? An empirical analysis using 20 million visits in Ontario and Alberta. Acad Emerg Med 2022; 29:1329-1337. [PMID: 36043233 DOI: 10.1111/acem.14587] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/11/2022] [Accepted: 08/28/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study had two objectives: (1) to estimate the prevalence of preventable emergency department (ED) visits during the 2016-2020 time period among those living in 19 large urban centers in Alberta and Ontario, Canada, and (2) to assess if the definition of preventable ED visits matters in estimating the prevalence. METHODS A retrospective, population-based study of ED visits that were reported to the National Ambulatory Care Reporting System from April 1, 2016, to March 31, 2020, was conducted. Preventable ED visits were operationalized based on the following approaches: (1) Canadian Triage and Acuity Scale (CTAS), (2) ambulatory care-sensitive conditions (ACSC), (3) family practice-sensitive conditions (FPSC), and (4) sentinel nonurgent conditions (SNC). The overall proportion of ED visits that were preventable was estimated. We also estimated the adjusted relative risks of preventable ED visits by patients' sex and age, fiscal year, province of residence, and census metropolitan area (CMA) of residence. RESULTS There were 20,171,319 ED visits made by 8,919,618 patients ages 1 to 74 who resided in one of the 19 CMAs in Alberta or Ontario. On average, there were 2.26 visits per patient over the period of 4 fiscal years; most patients made one (44.22%) or two ED visits (20.72%). The overall unadjusted prevalence of preventable ED visits varied by definition; 35.33% of ED visits were defined as preventable based on CTAS, 12.88% based on FPSC, 3.41% based on SNC, and 2.33% based on ACSC. CONCLUSIONS There is a substantial level of variation in prevalence estimates across definitions of preventable ED visits, and care should be taken when interpreting these estimates as each has a different meaning and may lead to different conclusions. The conceptualization and measurement of preventable ED visits is complex and multifaceted and may not be adequately captured by a single definition.
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Affiliation(s)
- Tammy Lau
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Alana Maltby
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Shehzad Ali
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Valérie Moran
- Department of Precision Health, Luxembourg Institute of Health, Strassen, Luxembourg.,Luxembourg Institute of Socio-Economic Research, Living Conditions, Esch-sur-Alzette, Luxembourg
| | - Piotr Wilk
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Department of Paediatrics, Western University, London, Ontario, Canada.,Child Health Research Institute, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,ICES, London, Ontario, Canada.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Oslislo S, Kümpel L, Resendiz Cantu R, Heintze C, Möckel M, Holzinger F. Redirecting emergency medical services patients with unmet primary care needs: the perspective of paramedics on feasibility and acceptance of an alternative care path in a qualitative investigation from Berlin, Germany. BMC Emerg Med 2022; 22:103. [PMID: 35690710 PMCID: PMC9187922 DOI: 10.1186/s12873-022-00660-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background Against the backdrop of emergency department (ED) overcrowding, patients’ potential redirection to outpatient care structures is a subject of current political debate in Germany. It was suggested in this context that suitable lower-urgency cases could be transported directly to primary care practices by emergency medical services (EMS), thus bypassing the ED. However, practicality is discussed controversially. This qualitative study aimed to capture the perspective of EMS personnel on potential patient redirection concepts. Methods We conducted qualitative, semi-structured phone interviews with 24 paramedics. Interviews were concluded after attainment of thematic saturation. Interviews were transcribed verbatim, and qualitative content analysis was performed. Results Technical and organizational feasibility of patients’ redirection was predominantly seen as limited (theme: “feasible, but only under certain conditions”) or even impossible (theme: “actually not feasible”), based on a wide spectrum of potential barriers. Prominently voiced reasons were restrictions in personnel resources in both EMS and ambulatory care, as well as concerns for patient safety ascribed to a restricted diagnostic scope. Concerning logistics, alternative transport options were assessed as preferable. Regarding acceptance by stakeholders, the potential for releasing ED caseload was described as a factor potentially promoting adoption, while doubt was raised regarding acceptance by EMS personnel, as their workload was expected to conversely increase. Paramedics predominantly did not consider transporting lower-urgency cases as their responsibility, or even as necessary. Participants were markedly concerned of EMS being misused for taxi services in this context and worried about negative impact for critically ill patients, as to vehicles and personnel being potentially tied up in unnecessary transports. As to acceptance on the patients’ side, interview participants surmised a potential openness to redirection if this would be associated with benefits like shorter wait times and accompanied by proper explanation. Conclusions Interviews with EMS staff highlighted considerable doubts about the general possibility of a direct redirection to primary care as to considerable logistic challenges in a situation of strained EMS resources, as well as patient safety concerns. Plans for redirection schemes should consider paramedics’ perspective and ensure a provision of EMS with the resources required to function in a changing care environment. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00660-2.
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Affiliation(s)
- Sarah Oslislo
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany
| | - Lisa Kümpel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany
| | - Rebecca Resendiz Cantu
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine, Campus Mitte and Virchow, Charitéplatz 1, 10117, Berlin, Germany
| | - Christoph Heintze
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Möckel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine, Campus Mitte and Virchow, Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Holzinger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany.
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7
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Gilbert A, Brasseur E, Petit M, Donneau AF, D’Orio V, Ghuysen A. Advanced triage to redirect non-urgent Emergency Department visits to alternative care centers: the PERSEE algorithm. Acta Clin Belg 2022; 77:571-578. [PMID: 33856271 DOI: 10.1080/17843286.2021.1914948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Primary care treatable visits in the Emergency Department (ED) are part of the different factors leading to the overcrowding. Their triage and diversion to alternative care centers could potentially help manage the increasing inflow provided the establishment of an advanced triage to ensure patients' safety. We aim to suggest a new triage tool, PERSEE, and prove its feasibility, safety and performance. METHODS All self-referrals presented to the ED were triaged with the PERSEE algorithm: first, patients were classified with a five-level ED acuity scale and then evaluated by algorithms to determine their appropriate category (ED or Primary Care). Patients were eligible for a redirection if they were triaged by the acuity scale as level 3 or lower, considered as ambulatory patients and finally categorized as primary care patients. We defined appropriate redirections as patients requiring less than three emergency resources, no emergency-specific treatment and no hospitalization. RESULTS During the study, 1999 patients were admitted to the ED. Among those, 1333 patients were self-referred (66.9%) of whom 1167 patients were triaged as level 3 or below (58.6%) and 775 patients triaged as ambulatory (39.0%). Among the 775 patients, 200 patients were categorized as primary care treatable (10.0%) and thereby, as potentially eligible for a redirection. We noticed an error rate of 7%, sensitivity of 24.06% and specificity of 97.6%. The redirection rate reached 15% of the self-referrals. CONCLUSION These results indicate that PERSEE triage could lead to a safe redirection and could be an efficient tool to reduce ED crowding provided several adjustments.
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Affiliation(s)
- Allison Gilbert
- Emergency Department, University Hospital Center, Liège, Belgium
| | - Edmond Brasseur
- Emergency Department, University Hospital Center, Liège, Belgium
| | - Mérédith Petit
- Emergency Department, University Hospital Center, Liège, Belgium
| | - Anne Françoise Donneau
- Biostatistics Unit, University of Liège, Liège, Belgium
- Public Health Department, University of Liège, Liège, Belgium
| | - Vincent D’Orio
- Emergency Department, University Hospital Center, Liège, Belgium
| | - Alexandre Ghuysen
- Emergency Department, University Hospital Center, Liège, Belgium
- Public Health Department, University of Liège, Liège, Belgium
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Feral-Pierssens AL, Morris J, Marquis M, Daoust R, Cournoyer A, Lessard J, Berthelot S, Messier A. Safety assessment of a redirection program using an electronic application for low-acuity patients visiting an emergency department. BMC Emerg Med 2022; 22:71. [PMID: 35488215 PMCID: PMC9052637 DOI: 10.1186/s12873-022-00626-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Emergency departments (EDs) are operating at or above capacity, which has negative consequences on patients in terms of quality of care and morbi-mortality. Redirection strategies for low-acuity ED patients to primary care practices are usually based on subjective eligibility criteria that sometimes necessitate formal medical assessment. Literature investigating the effect of those interventions is equivocal. The aim of the present study was to assess the safety of a redirection process using an electronic clinical support system used by the triage nurse without physician assessment. Methods A single cohort observational study was performed in the ED of a level 1 academic trauma center. All low-acuity patients redirected to nearby clinics through a clinical decision support system (February–August 2017) were included. This system uses different sets of medical prerequisites to identify patients eligible to redirection. Data on safety and patient experience were collected through phone questionnaires on day 2 and 10 after ED visit. The primary endpoint was the rate of redirected patients returning to any ED for an unexpected visit within 48 h. Secondary endpoints were the incidence of 7-day return visit and satisfaction rates. Results A total of 980 redirected low-acuity patients were included over the period: 18 patients (2.8%) returned unexpectedly to an ED within 48 h and 31 patients (4.8%) within 7 days. No hospital admission or death were reported within 7 days following the first ED visit. Among redirected patients, 81% were satisfied with care provided by the clinic staff. Conclusion The implementation of a specific electronic-guided decision support redirection protocol appeared to provide safe deferral to nearby clinics for redirected low-acuity patients. EDs are pivotal elements of the healthcare system pathway and redirection process could represent an interesting tool to improve the care to low-acuity patients.
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Affiliation(s)
- Anne-Laure Feral-Pierssens
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada. .,CR-CSIS, Sherbrooke University, Longueuil, Québec, Canada. .,Health Educations and Promotion Laboratory (LEPS EA3412), University Sorbonne Paris Nord, Bobigny, France. .,SAMU 93 - Emergency Department, Avicenne Hospital, Assistance Publique Hôpitaux de Paris, Bobigny, France.
| | - Judy Morris
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Martin Marquis
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada
| | - Raoul Daoust
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Alexis Cournoyer
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada.,Hôpital Maisonneuve-Rosemont, CIUSSS-EIM, Montréal, Québec, Canada.,Corporation d'Urgences-santé, Montréal, Québec, Canada
| | - Justine Lessard
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Simon Berthelot
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada.,Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Alexandre Messier
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
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9
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Eagles D, Cheung WJ, Avlijas T, Yadav K, Ohle R, Taljaard M, Molnar F, Stiell IG. Barriers and facilitators to nursing delirium screening in older emergency patients: a qualitative study using the theoretical domains framework. Age Ageing 2022; 51:6509750. [PMID: 35061872 DOI: 10.1093/ageing/afab256] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND delirium is common in older emergency department (ED) patients, but vastly under-recognised, in part due to lack of standardised screening processes. Understanding local context and barriers to delirium screening are integral for successful implementation of a delirium screening protocol. OBJECTIVES we sought to identify barriers and facilitators to delirium screening by nurses in older ED patients. METHODS we conducted 15 semi-structured, face-to-face interviews based on the Theoretical Domains Framework with bedside nurses, nurse educators and managers at two academic EDs in 2017. Two research assistants independently coded transcripts. Relevant domains and themes were identified. RESULTS a total of 717 utterances were coded into 14 domains. Three dominant themes emerged: (i) lack of clinical prioritisation because of competing demands, lack of time and heavy workload; (ii) discordance between perceived capabilities and knowledge and (iii) hospital culture. CONCLUSION this qualitative study explored nursing barriers and facilitators to delirium screening in older ED patients. We found that delirium was recognised as an important clinical problem; however, it was not clinically prioritised; there was a false self-perception of knowledge and ability to recognise delirium and hospital culture was a strong influencer of behaviour. Successful adoption of a delirium screening protocol will only be realised if these issues are addressed.
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Affiliation(s)
- Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Warren J Cheung
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Tanja Avlijas
- Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Robert Ohle
- Department of Emergency Medicine, Health Science North Research Institute, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Frank Molnar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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10
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Strum RP, Tavares W, Worster A, Griffith LE, Costa AP. Emergency department interventions that could be conducted in subacute care settings for patients with nonemergent conditions transported by paramedics: a modified Delphi study. CMAJ Open 2022; 10:E1-E7. [PMID: 35017171 PMCID: PMC8758169 DOI: 10.9778/cmajo.20210148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND As the number of patients with nonemergent conditions who are transported by paramedics continues to increase in Ontario, redirecting specific patients to subacute settings may be more beneficial and suitable for both patients and emergency departments. We aimed to evaluate whether emergency department interventions conducted on patients with nonemergent conditions who are transported by paramedics could be conducted in subacute health centres. METHODS We conducted a RAND/UCLA modified Delphi study in Ontario between Oct. 13 and Dec. 19, 2020. We used purposive sampling to recruit practising emergency and primary care physicians for an expert panel. We abstracted interventions given to adult patients with nonemergent conditions (18 yr of age or older) who were transported by paramedics to an emergency department from the National Ambulatory Care Reporting System (NACRS) database (Jan. 1, 2014, to Mar. 31, 2018). Participants in the expert panel rated the suitability of the 150 most frequently recorded emergency department interventions from the NACRS database, for completion in subacute health care centres. We set consensus at 70% agreement. RESULTS We invited 25 physician experts, 21 of whom consented to participate; 20 physicians completed round 1, and 18 physicians completed both rounds. After 2 rounds, consensus was reached on 146 (97.3%) interventions; 103 interventions (68.7%) were suitable for subacute centres, 43 (28.7%) for only the emergency department and 4 (2.6%) did not receive consensus. For subacute centres, all 103 interventions were rated for urgent care centres; walk-in medical centres were applicable for 46 (30.6%) interventions and clinics led by nurse practitioners for 47 (31.3%) interventions. INTERPRETATION Most interventions provided to patients with nonemergent conditions transported by paramedics to emergency departments were identified as suitable for urgent care clinics, with one-third being suitable for either walk-in medical centres or clinics led by nurse practitioners. This study has potential to inform a patient classification model for paramedic-initiated redirection of patients from emergency departments, although further contextualization is required for this to be implemented in clinical practice. STUDY REGISTRATION ID ISRCTN22901977.
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Affiliation(s)
- Ryan P Strum
- Department of Health Research Methods, Evidence, and Impact (Strum, Worster, Griffith, Costa), McMaster Institute for Research and Aging (Griffith), Emergency Medicine Division (Worster), Department of Medicine, and Department of Medicine (Costa), McMaster University, Hamilton, Ont.; The Wilson Centre (Tavares), University of Toronto, Toronto, Ont.; York Region Paramedic and Senior Services (Tavares), Regional Municipality of York, Newmarket, Ont.
| | - Walter Tavares
- Department of Health Research Methods, Evidence, and Impact (Strum, Worster, Griffith, Costa), McMaster Institute for Research and Aging (Griffith), Emergency Medicine Division (Worster), Department of Medicine, and Department of Medicine (Costa), McMaster University, Hamilton, Ont.; The Wilson Centre (Tavares), University of Toronto, Toronto, Ont.; York Region Paramedic and Senior Services (Tavares), Regional Municipality of York, Newmarket, Ont
| | - Andrew Worster
- Department of Health Research Methods, Evidence, and Impact (Strum, Worster, Griffith, Costa), McMaster Institute for Research and Aging (Griffith), Emergency Medicine Division (Worster), Department of Medicine, and Department of Medicine (Costa), McMaster University, Hamilton, Ont.; The Wilson Centre (Tavares), University of Toronto, Toronto, Ont.; York Region Paramedic and Senior Services (Tavares), Regional Municipality of York, Newmarket, Ont
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact (Strum, Worster, Griffith, Costa), McMaster Institute for Research and Aging (Griffith), Emergency Medicine Division (Worster), Department of Medicine, and Department of Medicine (Costa), McMaster University, Hamilton, Ont.; The Wilson Centre (Tavares), University of Toronto, Toronto, Ont.; York Region Paramedic and Senior Services (Tavares), Regional Municipality of York, Newmarket, Ont
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact (Strum, Worster, Griffith, Costa), McMaster Institute for Research and Aging (Griffith), Emergency Medicine Division (Worster), Department of Medicine, and Department of Medicine (Costa), McMaster University, Hamilton, Ont.; The Wilson Centre (Tavares), University of Toronto, Toronto, Ont.; York Region Paramedic and Senior Services (Tavares), Regional Municipality of York, Newmarket, Ont
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11
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Berthelot S, Breton M, Guertin JR, Archambault PM, Berger Pelletier E, Blouin D, Borgundvaag B, Duhoux A, Harvey Labbé L, Laberge M, Lachapelle P, Lapointe-Shaw L, Layani G, Lefebvre G, Mallet M, Matthews D, McBrien K, McLeod S, Mercier E, Messier A, Moore L, Morris J, Morris K, Ovens H, Pageau P, Paquette JS, Perry J, Schull M, Simon M, Simonyan D, Stelfox HT, Talbot D, Vaillancourt S. A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study. JMIR Res Protoc 2021; 10:e25619. [PMID: 33616548 PMCID: PMC7939947 DOI: 10.2196/25619] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. OBJECTIVE The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. METHODS A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. RESULTS Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. CONCLUSIONS The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/25619.
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Affiliation(s)
- Simon Berthelot
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
| | - Mylaine Breton
- Department of Community Health sciences, Université de Sherbrooke, Campus de Longueuil, Longueuil, QC, Canada
- Centre de recherche Charles-Le Moyne - Saguenay-Lac-Saint-Jean sur les innovations en santé, Longueuil, QC, Canada
| | - Jason Robert Guertin
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Patrick Michel Archambault
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Elyse Berger Pelletier
- Ministère de la santé et des services sociaux, Gouvernement du Québec, Québec, QC, Canada
| | - Danielle Blouin
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Bjug Borgundvaag
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada
| | - Laurie Harvey Labbé
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Maude Laberge
- Operations and Decision Systems Department, Faculty of Administrative Sciences, Université Laval, Québec, QC, Canada
| | - Philippe Lachapelle
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Géraldine Layani
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Gabrielle Lefebvre
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Myriam Mallet
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Deborah Matthews
- Ministry of Health and Long Term Care, Government of Ontario, Toronto, ON, Canada
| | - Kerry McBrien
- Departments of Family Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Shelley McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Eric Mercier
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
| | - Alexandre Messier
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Lynne Moore
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Judy Morris
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
- Hôpital du Sacré-Coeur-de-Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de Montréal, Montréal, QC, Canada
| | - Kathleen Morris
- Canadian Institute for Health Information, Ottawa, ON, Canada
| | - Howard Ovens
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
| | - Paul Pageau
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jean-Sébastien Paquette
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Laboratoire ARIMED, GMF-U de Saint-Charles-Borromée, Québec, QC, Canada
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Michael Schull
- Department of Emergency Medicine, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Mathieu Simon
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, Canada
| | - David Simonyan
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Denis Talbot
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Samuel Vaillancourt
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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Leite H. The impact of non-urgent patients in emergency departments' operations. INTERNATIONAL JOURNAL OF QUALITY & RELIABILITY MANAGEMENT 2020. [DOI: 10.1108/ijqrm-01-2020-0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeGlobally, the presence of non-urgent patients in emergency departments (EDs) is considered one of the main reasons for creating excessive waiting times and overcrowding in units. This paper aims to understand the impact of non-urgent patients in EDs' operations.Design/methodology/approachThis study is based on qualitative case studies conducted within two Brazilian EDs, and uses interviews and observations to access the data.FindingsFrom a thematic analysis, three key themes emerged: characteristics of non-urgent demands in EDs, negative aspects of non-urgent patients in EDs, and the impact of the healthcare system model on EDs. These themes bring to light the impact that non-urgent patients have in EDs' operations, and provide theoretical and practical implications.Research limitations/implicationsThe limitation of this work is bound by the understanding of the non-urgent demands in EDs. Therefore, a benchmarking approach (investigating state-of-the-art practices to avoid such impact) was not applied but was suggested for future research instead.Practical implicationsThe research provides significant contributions to practitioners and policymakers, aiding future discussions to improve healthcare coverage and performance.Social implicationsThe research provides significant contributions for managers and policymakers, aiding future discussions to improve healthcare. For instance, the use of well-known techniques (e.g. lean, six sigma) are discussed and suggested to enhance healthcare capacity and performance. Furthermore, the policymakers are called upon to evaluate the healthcare access and provide regulations that involve innovative approaches to widen healthcare access.Originality/valueBased upon empirical data, this research extends the discussions related to non-urgent patient in EDs and is not limited merely to descriptive analysis, but by providing practical propositions and discussions related to the impact of these patients' presence in EDs' operations. Finally, the research provides a range of suggestions for future research related to the EDs' operational performance.
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Lehto M, Mustonen K, Kantonen J, Raina M, Heikkinen AMK, Kauppila T. A Primary Care Emergency Service Reduction Did Not Increase Office-Hour Service Use: A Longitudinal Follow-up Study. J Prim Care Community Health 2020; 10:2150132719865151. [PMID: 31354021 PMCID: PMC6664635 DOI: 10.1177/2150132719865151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study, conducted in a Finnish city, examined whether decreasing emergency
department (ED) services in an overcrowded primary care ED and corresponding
direction to office-hour primary care would guide patients to office-hour visits
to general practitioners (GP). This was an observational retrospective study
based on a before-and-after design carried out by gradually decreasing ED
services in primary care. The interventions were (a)
application of ABCDE-triage combined with public guidance on the proper use of
EDs, (b) cessation of a minor supplementary ED, and finally
(c) application of “reverse triage” with enhanced direction
of the public to office-hour services from the remaining ED. The numbers of
visits to office-hour primary care GPs in a month were recorded before applying
the interventions fully (preintervention period) and in the postintervention
period. The putative effect of the interventions on the development rate of
mortality in different age groups was also studied as a measure of safety. The
total number of monthly visits to office-hour GPs decreased slowly over the
whole study period without difference in this rate between pre- and
postintervention periods. The numbers of office-hour GP visits per 1000
inhabitants decreased similarly. The rate of monthly visits to office-hour
GP/per GP did not change in the preintervention period but decreased in the
postintervention period. There was no increase in the mortality in any of the
studied age groups (0-19, 20-64, 65+ years) after application of the ED
interventions. There is no guarantee that decreasing activity in a primary care
ED and consecutive enhanced redirecting of patients to the office-hour primary
care systems would shift patients to office-hour GPs. On the other hand, this
decrease in the ED activity does not seem to increase mortality either.
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Affiliation(s)
| | - Katri Mustonen
- 2 Department of General Practice, University of Helsinki, Helsinki, Finland
| | | | | | | | - Timo Kauppila
- 1 City of Vantaa, Vantaa, Finland.,2 Department of General Practice, University of Helsinki, Helsinki, Finland.,3 University of Tampere, Tampere, Finland
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Aubrion A, Morin M, Roupie E, Macrez R. Pertinence des hospitalisations posturgences de moins de 24 heures en dehors des unités d’hospitalisation de courte durée. ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2019-0131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectifs : L’overcrowding — ou surcharge — des services d’urgence hospitaliers est un problème de santé international, qui impacte la qualité des soins et la durée moyenne de séjour (DMS). Cette surpopulation est liée majoritairement au manque d’accès aux lits d’hospitalisation. Notre objectif principal était d’étudier la pertinence des admissions hors unité d’hospitalisation de courte durée (UHCD) ayant une DMS inférieure à 24 heures.
Méthode : Notre étude observationnelle descriptive rétrospective sur l’année 2016 concernait les patients hospitalisés hors UHCD de DMS de moins de 24 heures. La grille AEPf (Appropriateness Evaluation Protocole adaptée en France par la Haute Autorité de santé) utilisée permet de les séparer en trois groupes : hospitalisations pertinentes (gravité clinique ou soins), non pertinentes mais justifiées (organisationnelles), non pertinentes et non justifiées (hébergement). Les comparaisons étaient réalisées par test de Chi2.
Résultats : Sur 1 006 admissions, selon la grille AEPf, 786 (78 %) sont pertinentes (sévérité clinique, actes diagnostiques ou thérapeutiques, surveillance, etc.). Pour les 220 hospitalisations non pertinentes, 210 (95 %) sont justifiées par des contraintes organisationnelles (avis spécialisés, actes d’imagerie, procédures). Quatre-vingt-dix-neuf (47 %) d’entre eux auraient pu rentrer à domicile si l’organisation des soins l’avait permis. Pour 83 (39 %) de ces hospitalisations non pertinentes, la structure la plus adaptée reste l’hôpital. Seulement dix (1 %) de ces 1 006 hospitalisations sont non pertinentes et non justifiées. Le service d’hospitalisation était adéquat pour 805 patients (80 %).
Conclusion : Le taux d’hospitalisations pertinentes ou justifiées, de DMS de moins de 24 heures, depuis notre service est élevé. Il existerait quelques leviers organisationnels permettant d’éviter le recours à une hospitalisation.
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Cooper A, Davies F, Edwards M, Anderson P, Carson-Stevens A, Cooke MW, Donaldson L, Dale J, Evans BA, Hibbert PD, Hughes TC, Porter A, Rainer T, Siriwardena A, Snooks H, Edwards A. The impact of general practitioners working in or alongside emergency departments: a rapid realist review. BMJ Open 2019; 9:e024501. [PMID: 30975667 PMCID: PMC6500276 DOI: 10.1136/bmjopen-2018-024501] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 12/14/2018] [Accepted: 01/24/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%-43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are 'free to care for the sickest patients'. However, the research evidence to support this initiative is weak. DESIGN Rapid realist literature review. SETTING Emergency departments. INCLUSION CRITERIA Articles describing general practitioners working in or alongside emergency departments. AIM To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system. RESULTS Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes. CONCLUSIONS Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research. PROSPERO REGISTRATION NUMBER CRD42017069741.
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Affiliation(s)
- Alison Cooper
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Freya Davies
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Centre for Health Economics, Swansea University, Swansea, UK
| | | | | | - Liam Donaldson
- London School of Hygiene and Tropical Medicine, London, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Peter D Hibbert
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Thomas C Hughes
- Emergency Department, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Alison Porter
- College of Medicine, Swansea University, Swansea, UK
| | - Tim Rainer
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | - Helen Snooks
- College of Medicine, Swansea University, Swansea, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
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Alsabbagh MW, Houle SKD. The proportion, conditions, and predictors of emergency department visits that can be potentially managed by pharmacists with expanded scope of practice. Res Social Adm Pharm 2018; 15:1289-1297. [PMID: 30545614 DOI: 10.1016/j.sapharm.2018.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pharmacists have been shown to be beneficial for inclusion in emergency department (ED) services; however, little has been done to assess these benefits with pharmacists having even wider scopes of practice, including limited prescribing authority. OBJECTIVES The aims of this study were to determine the proportion of ED visits that can potentially be managed by pharmacists, the most prevalent conditions within these cases, and the factors associated with patients presenting with such cases to the ED. METHODS This was a retrospective quantitative cohort study using administrative databases from 2010 to 2017. Among all unscheduled ED visits in Ontario, all visits with a Family Practice Sensitive Condition and Canadian Triage and Acuity Scale score of IV or V were identified, in addition to conditions that can be managed by pharmacists with expanded scope. Logistic regression was performed to identify determinants of having a potentially pharmacist-manageable condition. RESULTS Of 34,550,020 ED visits identified, 12.4% (n = 4,293,807) were considered FPSC with CTAS IV or V. Of these, 1,494,887 (34.8%) were for conditions considered to be potentially manageable by pharmacists, representing 4.3% of all ED visits. The most frequent diagnoses observed were: acute pharyngitis, conjunctivitis, rash and other nonspecific skin eruption, otitis externa, cough, acute sinusitis, and dermatitis. Female gender, having a family physician or presenting with a CTAS of IV were associated with higher odds of presenting to the ED, while increased age and income were associated with lower odds. CONCLUSIONS Under an expanded scope, pharmacists could potentially have managed nearly 1.5 million cases presenting to the ED over the study period. The introduction of ED-based or community pharmacists practicing under an expanded scope may have a positive impact on overcrowding in EDs.
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Affiliation(s)
- Mhd Wasem Alsabbagh
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, N2G 1C5, ON, Canada; Ontario Pharmacy Evidence Network (OPEN), School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, N2G 1C5, ON, Canada. https://uwaterloo.ca/pharmacy/people-profiles/wasem-alsabbagh
| | - Sherilyn K D Houle
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, N2G 1C5, ON, Canada; Ontario Pharmacy Evidence Network (OPEN), School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, N2G 1C5, ON, Canada
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Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) Guidelines 2016. CAN J EMERG MED 2018; 19:S18-S27. [PMID: 28756800 DOI: 10.1017/cem.2017.365] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Mustonen K, Kantonen J, Kauppila T. The effect on the patient flow in local health care services after closing a suburban primary care emergency department: a controlled longitudinal follow-up study. Scand J Trauma Resusc Emerg Med 2017; 25:116. [PMID: 29183366 PMCID: PMC5706306 DOI: 10.1186/s13049-017-0460-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 11/20/2017] [Indexed: 11/10/2022] Open
Abstract
Background It has not been studied what happens to patient flow to EDs and other parts of local health care system if distances to ED services are manipulated as a part of health policy in urban areas. Methods The present work was an observational and quasi-experimental study with a control and it was based on before-after comparisons. The impact of terminating a geographically distant suburban primary care ED on patient flow to doctors in local public primary care EDs, office-hour primary care, secondary care EDs and in private primary care was studied. The effect of this intervention was compared with a primary care system where no similar intervention was performed. The number of monthly visits to doctors in different departments of health care was scored as the main measure of the study in each department studied (e.g. in primary care EDs, secondary care ED, office-hour public primary care and private primary care). Monthly mortality rates were also recorded. Results Increasing the distance to ED services by terminating a peripheral ED did not cause an increase in the use of local office-hour services in those areas whose local ED was terminated, although use of ED services decreased by 25% in these areas (P < 0.001). The total use of primary care doctor services rather decreased - if anything - after this intervention while use of doctor services in secondary care ED remained unaffected. Doctor visits to the complementary private primary care increased but this was probably not associated with the intervention because a simultaneous increase in this parameter was observed in the control. There was no increased mortality in any age groups. Conclusion Manipulating distances to ED services can be used to direct patient flows to different parts of the health care system. The correlation between distance to ED and the tendency to use ED by inhabitants is negative. If secondary care ED was available there were no life-threatening side-effects at the level of general public health when a minor ED was closed in a primary care ED system.
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Affiliation(s)
- Katri Mustonen
- Department of Primary Health Care Laboratory Services, Helsinki University Central Hospital, Laboratory Services (HUSLAB), Topeliuksenkatu 32, 00029 HUS, Helsinki, Finland
| | - Jarmo Kantonen
- Primary Health Care, City of Vantaa, Peltolantie 2D, 01300, Vantaa, Finland
| | - Timo Kauppila
- Primary Health Care, City of Vantaa, Peltolantie 2D, 01300, Vantaa, Finland. .,Department of General Practice and Primary Health Care, Clinicum of Faculty of Medicine, University of Helsinki, (Tukholmankatu 8B), -00014, Helsinki, SF, Finland.
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Correlation of age and rurality with low-urgency use of emergency medical services (LUEMS): A geographic analysis. CAN J EMERG MED 2017; 20:874-881. [PMID: 28774350 DOI: 10.1017/cem.2017.364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Studies suggest that addressing the needs of the older population in rural areas may substantially reduce their low-urgency use of emergency medical services (LUEMS). It may ultimately also help improve the efficiency in our health system. There is, however, a dearth of evidence substantiating geographic patterns in LUEMS by different age cohorts. This exploratory study was aimed to clarify the understanding of emergency medical services (EMS) use in Nova Scotia through a geographic analysis. METHODS Records with Canadian Triage and Acuity Scale of 4 and 5 were considered as LUEMS. We assessed the distribution of LUEMS incidence rates (proportion of LUEMS out of all EMS uses) by age and rurality, using descriptive statistics and Geographic Information Systems mapping. RESULTS Nearly half of all EMS transports were individuals of 65+ years of age; 35% of those were LUEMS. The rates increased along with the level of rurality, and the older cohort had the highest incidence rates in non-metro communities. High rates were seen primarily in some rural communities farthest away from the capital/tertiary care centre. CONCLUSION High LUEMS incidence rates are rural phenomena but not specific to the older population. However, the absolute number of LUEMS by the older cohort is significant, and elder-specific interventions in rural regions could still lead to effective cost savings. Further investigation of other factors, such as distance to the emergency department, availability of public transportation, and socioeconomic conditions of EMS users, is needed.
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Ng CJ, Liao PJ, Chang YC, Kuan JT, Chen JC, Hsu KH. Predictive factors for hospitalization of nonurgent patients in the emergency department. Medicine (Baltimore) 2016; 95:e4053. [PMID: 27368040 PMCID: PMC4937954 DOI: 10.1097/md.0000000000004053] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Nonurgent emergency department (ED) patients are a controversial issue in the era of ED overcrowding. However, a substantial number of post-ED hospitalizations were found, which prompted for investigation and strategy management. The objective of this study is to identify risk factors for predicting the subsequent hospitalization of nonurgent emergency patients. This was a retrospective study of a database of adult nontrauma ED visits in a medical center for a period of 12 months from January 2013 to December 2013. Patient triages as either Taiwan Triage and Acuity Scale (TTAS) level 4 or 5 were considered "nonurgent." Basic demographic data, primary and secondary diagnoses, clinical parameters including blood pressure, heart rate, body temperature, and chief complaint category in TTAS were analyzed to determine if correlation exists between potential predictors and hospitalization in nonurgent patients.A total of 16,499 nonurgent patients were included for study. The overall hospitalization rate was 12.47 % (2058/16,499). In the multiple logistic regression model, patients with characteristics of males (odds ratio, OR = 1.37), age more than 65 years old (OR = 1.56), arrival by ambulance (OR = 2.40), heart rate more than 100/min (OR = 1.47), fever (OR = 2.73), and presented with skin swelling/redness (OR = 4.64) were predictors for hospitalization. The area under receiver-operator calibration curve (AUROC) for the prediction model was 0.70. Nonurgent patients might still be admitted for further care especially in male, the elderly, with more secondary diagnoses, abnormal vital signs, and presented with dermatologic complaints. Using the TTAS acuity level to identify patients for diversion away from the ED is unsafe and will lead to inappropriate refusal of care for many patients requiring hospital treatment.
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Affiliation(s)
- Chip-Jin Ng
- Emergency Department, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Tao-Yuan
| | - Pei-Ju Liao
- Department of Health Care Administration, Oriental Institute of Technology, New Taipei City
| | - Yu-Che Chang
- Emergency Department, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Tao-Yuan
- Department of Medical Education, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University
| | - Jen-Tze Kuan
- Emergency Department, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Tao-Yuan
| | - Jih-Chang Chen
- Emergency Department, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Tao-Yuan
| | - Kuang-Hung Hsu
- Laboratory for Epidemiology, Department of Health Care Management, and Healthy Aging Research Center, and Department of Urology, Chang Gung Memorial Hospital, Chang Gung University, Kwei-Shan, Tao-Yuan, Taiwan
- Correspondence: Kuang-Hung Hsu, PhD, Professor, Laboratory for Epidemiology, Department of Health Care Management, Chang Gung University, 259, Wen-Hwa 1st Rd, Kwei-Shan, Tao-Yuan, Taiwan (e-mail: )
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Mirhaghi A, Heydari A, Ebrahimi M, Noghani Dokht Bahmani M. Nonemergent Patients in the Emergency Department: An Ethnographic Study. Trauma Mon 2016; 21:e23260. [PMID: 28180119 PMCID: PMC5282938 DOI: 10.5812/traumamon.23260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 12/01/2014] [Accepted: 12/10/2014] [Indexed: 11/16/2022] Open
Abstract
Background Triage in the interactive atmosphere of the emergency department (ED) has been described as complex and challenging. Nonemergent ED visits have been accompanied by ethical and legal conflicts. Objectives The aim of this study was to gain an understanding of ED nurses’ practice regarding triage of nonemergent patients. Patients and Methods Focused micro-ethnography based on Spradley’s developmental research sequence (DRS) was used. This study was conducted in an emergency department. Data was collected through complete participant observations along with formal and informal interviews, and then analyzed using DRS. Results Nine key informants were interviewed formally. Four main categories emerged from the nurses’ culture: nonemergent patient as an uninvited guest, nonemergent patient as an elephant in a dark room, nonemergent patient as an aggressive client, and being nonemergency unless at risk of death. Conclusions Providing care in the emergency department is significantly affected by nonemergent patients, as the emergency department is a place for critically ill patients thus awareness training program is recommended.
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Affiliation(s)
- Amir Mirhaghi
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Abbas Heydari
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, IR Iran
- Corresponding author: Abbas Heydari, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, IR Iran. Tel: +98-513859151, Fax: +98-5138539775, E-mail:
| | - Mohsen Ebrahimi
- Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Mohsen Noghani Dokht Bahmani
- Department of Social Sciences, Faculty of Letters and Humanities, Ferdowsi University of Mashhad, Mashhad, IR Iran
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Évaluation d’un service d’urgence possédant une unité d’hospitalisation conventionnelle. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-015-0584-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Funakoshi H, Shiga T, Homma Y, Nakashima Y, Takahashi J, Kamura H, Ikusaka M. Validation of the modified Japanese Triage and Acuity Scale-based triage system emphasizing the physiologic variables or mechanism of injuries. Int J Emerg Med 2016; 9:1. [PMID: 26810318 PMCID: PMC4726641 DOI: 10.1186/s12245-015-0097-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 12/07/2015] [Indexed: 11/18/2022] Open
Abstract
Background The Canadian Triage and Acuity Scale is a valid triage system. The system was translated and implemented in the Japanese emergency departments (EDs) from 2012. This system was named the Japanese Triage and Acuity Scale; however, the validation studies of the Japanese Triage and Acuity Scale have been limited. In addition, for a patient with multiple complaints, it could become challenging, due to its requirement of a single complaint. Therefore, we hypothesized that a modified version of the Japanese Triage and Acuity Scale using first-order modifiers without chief complaint detection is accurate. Methods A retrospective cohort study evaluated a correlation between the modified triage scale level and outcomes of all adult emergency department patients at a Japanese hospital. Construct validity of the modified triage scale level was assessed based on comparisons of total admission rate (including hospitalizations, emergency department deaths) and length of stay between triage levels. Results The distributions of five levels of the triage scale (level 1 is the most urgent) among the 17,121 cases are as follows: 1:451, 2:1148, 3:7703, 4:7652, and 5:167. Total admission rates by each level were 1:89.8, 2:68.2, 3:26.4, 4:6.6, and 5:0.6 %, which progressively increased from level 5 to 1 and were significant (p < 0.01). Compared with patients in level 3, the odds of total admission rates were 14.4, 5.1, 0.27, and 0.030 for the patients in levels 1, 2, 4, and 5. The length of stay was longer in the patients with the more urgent levels except for those with level 1. Conclusions The modified version of the Japanese Triage and Acuity Scale is a valid predictor of total admission and length of stay and may enable the nurses to triage patients without detecting the chief complaints.
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Affiliation(s)
- Hiraku Funakoshi
- Department of Emergency Medicine, Tokyobay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu-shi, Chiba, 279-0001, Japan.
| | - Takashi Shiga
- Department of Emergency Medicine, Tokyobay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu-shi, Chiba, 279-0001, Japan.
| | - Yosuke Homma
- Department of Emergency Medicine, Tokyobay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu-shi, Chiba, 279-0001, Japan.
| | - Yoshiyuki Nakashima
- Department of Emergency Medicine, Tokyobay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu-shi, Chiba, 279-0001, Japan.
| | - Jin Takahashi
- Department of Emergency Medicine, Tokyobay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu-shi, Chiba, 279-0001, Japan.
| | - Hiroshi Kamura
- Department of Emergency Medicine, Tokyobay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu-shi, Chiba, 279-0001, Japan.
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan.
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Lin D, Worster A. Predictors of admission to hospital of patients triaged as nonurgent using the Canadian Triage and Acuity Scale. CAN J EMERG MED 2015; 15:353-8. [PMID: 24176459 DOI: 10.2310/8000.2013.130842] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To identify factors known prior to triage that might have predicted hospital admission for patients triaged by the Canadian Triage Acuity Scale (CTAS) as level 5 (CTAS 5, nonurgent) and to determine whether inappropriate triage occurred in the admitted CTAS 5 patients. METHODS We reviewed the triage records of patients triaged as CTAS 5 at the emergency departments (EDs) of three tertiary care hospitals between April 2002 and September 2009. Two triage nurses unaware of the study objective independently assigned the CTAS level in 20% of randomly selected CTAS 5 patients who were admitted. We used the kappa statistic (κ) to measure the agreement among the raters in CTAS level between the assessment of the research nurses and the original triage assessment and regression analysis to identify independent predictors of admission to hospital. RESULTS Of the 37,416 CTAS 5 patients included in this study, 587 (1.6%) were admitted. Agreement on CTAS assignment in CTAS 5 patients who were admitted was κ -0.9, (95% confidence interval [CI] -0.96 to -0.84). Age over 65 (odds ratio [OR] 5.46, 95% CI 4.57 to 6.53) and arrival by ambulance (OR 7.42, 95% CI 6.15 to 8.96) predicted hospital admission in CTAS 5 patients. CONCLUSIONS Most of the CTAS 5 patients who were subsequently admitted to hospital may have qualified for a higher triage category. Two potential modifiers, age over 65 and arrival by ambulance, may have improved the prediction of admission in CTAS 5 patients. However, the consistent application of existing CTAS criteria may also be important to prevent incorrect triage.
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Saghafian S, Austin G, Traub SJ. Operations research/management contributions to emergency department patient flow optimization: Review and research prospects. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/19488300.2015.1017676] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kantonen J, Lloyd R, Mattila J, Kauppila T, Menezes R. Impact of an ABCDE team triage process combined with public guidance on the division of work in an emergency department. Scand J Prim Health Care 2015; 33:74-81. [PMID: 25968180 PMCID: PMC4834506 DOI: 10.3109/02813432.2015.1041825] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To study the effects of applying an emergency department (ED) triage system, combined with extensive publicity in local media about the "right" use of emergency services, on the division of work between ED nurses and general practitioners (GPs). DESIGN An observational and quasi-experimental study based on before-after comparisons. SETTING Implementation of the ABCDE triage system in a Finnish combined ED where secondary care is adjacent, and in a traditional primary care ED where secondary care is located elsewhere. SUBJECTS GPs and nurses from two different primary care EDs. MAIN OUTCOME MEASURES Numbers of monthly visits to different professional groups before and after intervention in the studied primary care EDs and numbers of monthly visits to doctors in the local secondary care ED. RESULTS The beginning of the triage process increased temporarily the number of independent consultations and patient record entries by ED nurses in both types of studied primary care EDs and reduced the number of patient visits to a doctor compared with previous years but had no effect on doctor visits in the adjacent secondary care ED. No further decrease in the number of nurse or GP visits was observed by inhibiting the entrance of non-urgent patients. CONCLUSION The ABCDE triage system combined with public guidance may reduce non-urgent patient visits to doctors in different kinds of primary care EDs without increasing visits in the secondary care ED. However, the additional work to implement the ABCDE system is mainly directed to nurses, which may pose a challenge for staffing.
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Affiliation(s)
| | - Robert Lloyd
- Institute for Healthcare Improvement, Boston, MA, USA
| | - Juho Mattila
- Helsinki University Central Hospital, HUS, Helsinki, Finland
| | - Timo Kauppila
- Department of General Practice and Primary Healthcare, HUS, Institute of Clinical Medicine, and University of Helsinki, Finland
- Correspondence: Timo Kauppila, MD DMSc, Reader, Department of General Practice and Primary Healthcare, HUS, Institute of Clinical Medicine, and University of Helsinki, PO Box 20 (Tukholmankatu 8 B), 00014 University of Helsinki, Finland. Tel: + 358 9 1911, + 358 44 7684449. Fax: + 358 9 191 27536.
| | - Ricardo Menezes
- Emergency unit project, Jorvi Hospital, Puolarmetsä Hospital, Espoo, Medivida LTD, Helsinki, Finland
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Abstract
ABSTRACT
Introduction:
Many emergency department (ED) visits are non-urgent. Postulated reasons for these visits include lack of access to family physicians, convenience and 24/7 access, perceived need for investigations or treatment not available elsewhere, and as a mechanism for expedited referral to other specialists. We conducted a patient survey to determine why non-urgent patients use our tertiary care ED. Our primary objective was to determine how often the lack of a family physician was associated with non-urgent ED use.
Methods:
The survey was administered to Canadian Emergency Department Triage and Acuity Scale (CTAS) Level IV and V patients who attended the ED of the Queen Elizabeth II Health Sciences Centre in Halifax, NS, from March 7 to March 13, 2005.
Results:
Of the 352 eligible patients, 235 completed the survey (response rate, 67%). Fifty-six percent (132/235) had an acute medical problem of less than 48 hours, including 48% (114/235) with a recent injury. Thirty-four percent (82/235) had been referred to the ED, 49% (114/235) believed they required a specific service that was unavailable elsewhere (e.g., radiology, suturing, casting) and 43% (100/235) presented because of self-perceived urgency of their condition. Eighty-four percent (198/235) had a family physician; 23% (55/235) used the ED because of limited access to theirfamily physician and 3% (6/235) used the ED because they did not have a family physician.
Conclusions:
In this setting, most non-urgent ED visits involved patients who required a specific service offered by the ED, patients who believed their condition was urgent, or patients who were referred from the community to the ED. From a patient perspective, relatively few visits would be considered inappropriate. Lack of a family physician was not associated with non-urgent ED use; however, inability to obtain timely access to the FP was a factor in one-quarter of cases.
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Affiliation(s)
- Simon Field
- Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Engelbrecht A, du Toit FG, Geyser MM. A cross-sectional profile and outcome assessment of adult patients triaged away from Steve Biko Academic Hospital emergency unit. S Afr Fam Pract (2004) 2015. [DOI: 10.1080/20786190.2015.1024013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Reducing frequent visits to the emergency department: a systematic review of interventions. PLoS One 2015; 10:e0123660. [PMID: 25874866 PMCID: PMC4395429 DOI: 10.1371/journal.pone.0123660] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 02/21/2015] [Indexed: 11/23/2022] Open
Abstract
Objective The objective of this study was to establish the effectiveness of interventions to reduce frequent emergency department (ED) use among a general adult high ED-use population. Methods Systematic review of the literature from 1950-January 2015. Studies were included if they: had a control group (controlled trials or comparative cohort studies), were set in an ED or acute care facility, and examined the impact of an intervention to reduce frequent ED use in a general adult population. Studies reporting non-original data or focused on a specific patient population were excluded. Study design, patient population, intervention, the frequency of ED visits, and costs of frequent ED use and/or interventions were extracted and narratively synthesized. Results Among 17 included articles, three intervention categories were identified: case management (n = 12), individualized care plans (n = 3), and information sharing (n = 2). Ten studies examining case management reported reductions in mean (-0.66 to -37) or median (-0.1 to -20) number of ED visits after 12-months; one study reported an increase in mean ED visits (+2.79); and one reported no change. Of these, 6 studies also reported reduced hospital costs. Only 1 study evaluating individualized care plans examined ED utilization and found no change in median ED visits post-intervention. Costs following individualized care plans were also only evaluated in 1 study, which reported savings in hospital costs of $742/patient. Evidence was mixed regarding information sharing: 1 study reported no change in mean ED visits and did not examine costs; whereas the other reported a decrease in mean ED visits (-16.9) and ED cost savings of $15,513/patient. Conclusions The impact of all three frequent-user interventions was modest. Case management had the most rigorous evidence base, yielded moderate cost savings, but with variable reductions in ED use. Future studies evaluating non-traditional interventions, tailoring to patient subgroups or socio-cultural contexts, are warranted.
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Menser TL, Radcliff TA, Schuller KA. Implementing a medical screening and referral program for rural emergency departments. J Rural Health 2014; 31:126-34. [PMID: 25124750 DOI: 10.1111/jrh.12085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
CONTEXT Emergency Department (ED) overcrowding due to nonemergent use is an ongoing concern. In 2011, a regional health system that primarily serves rural communities in Texas instituted a new program to medically screen and refer nonemergent patients to nearby affiliated rural health clinics (RHCs). PURPOSE This formative evaluation describes the program goals, process, and early implementation experiences at 2 sites that adopted the program before wider implementation within the rural health system. METHODS Primary data collection including document review, internal stakeholder interviews, and direct observation of program processes were used for this formative evaluation of program implementation in light of program goals and objectives. Fourteen key informants were asked questions related to the program concept, structure, and implementation. RESULTS The program, as implemented, aligned with initial program goals, but it was dependent on ED screening staff and RHC availability. Some adjustments to the program were needed, including RHC hours, consistency among staff in making referrals, patient education, and improving patient uptake on the referral. Stakeholders reported lessons learned related to training, staff buy-in, Emergency Medical Treatment and Labor Act (EMTALA), and intraorganizational cooperation. DISCUSSION The system was able to leverage excess capacity of affiliated RHCs to accommodate low-acuity patients referred from the ED and may lead to improvements in Triple Aim goals of increased patient satisfaction, better population health and outcomes, and lower per capita costs. Lessons learned from this program may inform similar processes aimed to reduce nonemergency ED utilization by other rural health systems.
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Affiliation(s)
- Terri L Menser
- Department of Health Policy & Management, Center for Health Organization Transformation, Texas A&M Health Science Center, School of Public Health, College Station, Texas
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Delays in service for non-emergent patients due to arrival of emergent patients in the emergency department: a case study in Hong Kong. J Emerg Med 2013; 45:271-80. [PMID: 23759699 PMCID: PMC7126712 DOI: 10.1016/j.jemermed.2012.11.102] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 09/20/2012] [Accepted: 11/02/2012] [Indexed: 11/20/2022]
Abstract
Background In Hong Kong Emergency Departments (EDs), the timeliness of providing high-quality services has been compromised by the increasing attendance of non-emergent patients in addition to the unpredictable arrival of emergency patients. Objectives We sought to quantify the impact of the presence of emergent patients and other related factors on the delay in service for non-emergent patients. Methods We conducted a retrospective study in patients who visited the ED of a large hospital in Hong Kong from July 1, 2009 to June 30, 2010. We estimated waiting and length of stay (LOS) for individual non-emergent patients registered during day and evening shifts. Using multiple linear regression, we estimated waiting time and LOS as a function of the presence of emergent patients and other related factors such as patient demographics and clinical factors. In particular, we evaluated the influence of the arrival or presence of emergent patients on the odds of violating the 120-min waiting time target for semi-urgent patients. Results The arrival of a new emergent patient prolonged the waiting time and LOS of a non-emergent patient by 14.9% (95% confidence interval [CI] 14.2–15.5) and 10.8% (95% CI 10.6–11.0), respectively. An additional patient-hour needed for an emergent patient increased the probability of violating the waiting time target for non-emergent patients (odds ratio 2.3, 95% CI 2.2–2.4). Conclusions The arrival of an emergent patient significantly prolonged the waiting time and LOS for non-emergent patients. Discouraging non-urgent ED utilization and building a real-time decision-support system are critical methods needed to relieve staff pressure and guide contingent resource reallocation when emergent patients arrive.
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Balossini V, Zanin A, Alberti C, Freund Y, Decobert M, Tarantino A, La Rocca M, Lacroix L, Spiri D, Lejay E, Armoogum P, Wood C, Gervaix A, Zuccotti GV, Perilongo G, Bona G, Mercier JC, Titomanlio L. Triage of children with headache at the ED: a guideline implementation study. Am J Emerg Med 2013; 31:670-5. [DOI: 10.1016/j.ajem.2012.11.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 10/21/2012] [Accepted: 11/23/2012] [Indexed: 12/01/2022] Open
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Forero R, Hillman KM, McCarthy S, Fatovich DM, Joseph AP, Richardson DB. Access block and ED overcrowding. Emerg Med Australas 2012; 22:119-35. [PMID: 20534047 DOI: 10.1111/j.1742-6723.2010.01270.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20-30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998-1999) to 2.4 beds per 1000 (2002-2007) in 2002, and has remained steady at between 2.5-2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998-1999 rates, the number of available beds in 2006-2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.
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Affiliation(s)
- Roberto Forero
- Simpson Centre for Health Services Research Affiliated with The Australian Institute of Health Innovation, University of New South Wales, Kensington, New South Wales, Australia.
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Geelhoed GC, Klerk NH. Emergency department overcrowding, mortality and the 4‐hour rule in Western Australia. Med J Aust 2012; 196:122-6. [DOI: 10.5694/mja11.11159] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Gary C Geelhoed
- Emergency Department, Princess Margaret Hospital for Children, Perth, WA
- School of Paediatrics and Child Health and School of Primary and Aboriginal and Rural Health Care, University of Western Australia, Perth, WA
| | - Nicholas H Klerk
- Telethon Institute for Child Health Research, Perth, WA
- Centre for Child Health Research, University of Western Australia, Perth, WA
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Impact of the ABCDE triage in primary care emergency department on the number of patient visits to different parts of the health care system in Espoo City. BMC Emerg Med 2012; 12:2. [PMID: 22217300 PMCID: PMC3267646 DOI: 10.1186/1471-227x-12-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 01/04/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland. METHODS The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital). A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse). The introduction of this triage system was combined with information to the public on the "correct" use of emergency services. RESULTS After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month) as compared to the three previous years in the EDs. The Number of visits to public sector GPs during office hours did not alter. Implementation of ABCDE-triage combined with public guidance was associated with decreased total number of doctor visits in public health care. During same period, the number of patient visits in the private health care increased. Simultaneously, the number of doctor visits in secondary health care ED did not alter. CONCLUSIONS The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the secondary health care EDs. Limiting the access of less urgent patients to ED may redirect the demands of patients to private sector rather than office hours GP services.
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Elkum NB, Barrett C, Al-Omran H. Canadian Emergency Department Triage and Acuity Scale: implementation in a tertiary care center in Saudi Arabia. BMC Emerg Med 2011; 11:3. [PMID: 21310024 PMCID: PMC3042416 DOI: 10.1186/1471-227x-11-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 02/10/2011] [Indexed: 11/13/2022] Open
Abstract
Background The Canadian Emergency Department Triage and Acuity Scale (CTAS) is a well recognized and validated triage system that prioritizes patient care by severity of illness. The aim of this study was to describe the results of Emergency Department (ED) waiting times after the implementation of the CTAS in a major tertiary care hospital emergency department outside of Canada. Methods A total of 1206 charts were randomly selected and retrospectively reviewed for triage performance. The indicators were: time to triage, triage duration, waiting time to be evaluated by a physician, and proportion of patients who left without being seen by a physician. Waiting times were stratified by triage level and reported as fractile response rates. Results The approximate time to triage was ≤ 10 minutes for 71% and ≤ 15 minutes for 82.8% of the patients. Fifty-three percent (53.5%) completed their triage process within 5 minutes. Waiting times evaluated by a physician was 100% within CTAS time objectives in category I patients, however, this was not the case for the other 4 categories. The overall left without being seen (LWBS) rate was 9.8%; 11.9% were in Level III, 20.3% in Level IV, and 67.8% in Level V. Median length of stay (LOS) was 144 minutes for the study sample as a whole. Conclusion The CTAS may be adapted, with achievable objectives, in hospitals outside Canada as well. Time to see physician, total LOS, and LWBS are effective markers of ED performance and the quality of triage. Registration-to-physician time (RTP) and LOS profiles, stratified by triage level, are essential indicative markers for ED performance and should be used in improving patients flow through collaborative efforts.
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Affiliation(s)
- Naser B Elkum
- Department of Biostatistics & Epidemiology, Dasman Diabetes Institute, PO Box 1180, Dasman 15462, Kuwait.
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Tsai JCH, Liang YW, Pearson WS. Utilization of emergency department in patients with non-urgent medical problems: patient preference and emergency department convenience. J Formos Med Assoc 2010; 109:533-42. [PMID: 20654793 DOI: 10.1016/s0929-6646(10)60088-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 06/23/2009] [Accepted: 10/08/2009] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND/PURPOSE We investigated the factors associated with emergency department (ED) use among patients with non-urgent medical problems, with a focus on convenience and preference to use the ED instead of primary care clinics. METHODS A five-level triage system was adopted by research nurses to decide each patient's triage level and the maximum time to physician interview. Patients who had a maximum time to physician interview of more than 60 minutes were assumed to be non-urgent in this study. RESULTS More than half of ED visits were considered to be non-urgent. Non-urgent patients were more likely to be unmarried, government employees, visit the ED due to trauma, have a history of chronic illness, and present in the day time or at the weekend. ED visits were also more likely to occur in patients who took less than 15 minutes to reach the ED, chose the ED for its convenience, agreed that they could have chosen another facility for their visit, did not agree that the ED was convenient for receiving medical care. Multivariate logistic regression showed that marital status, time of presentation, time needed to get to the ED, and occupation were associated with non-urgent ED visits. CONCLUSION Preference for using EDs for medical care and their convenience might contribute to non-urgent ED visits. A five-level triage system reliably stratified patients with different admission rates and utilization of medical resources, and could be helpful for reserving limited medical resources for more urgent patients.
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Altmayer CA, Ardal S, Woodward GL, Schull MJ. Variation in emergency department visits for conditions that may be treated in alternative primary care settings. CAN J EMERG MED 2010; 7:252-6. [PMID: 17355682 DOI: 10.1017/s1481803500014391] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The purpose of this report is to examine Ontario's geographic variation in emergency department (ED) visits for conditions that may be treated in alternative primary care settings. We studied all visits to Ontario EDs in 2002/03 and calculated county-specific age-standardized rates. Overall in Ontario, there were 3174 ED visits per 100,000 population aged 1-74 for conditions that could be treated in alternate primary care settings, but rates varied widely across counties. They were higher in rural counties with rates up to 7-fold higher than the provincial average. Urban counties had lower rates, some were less than one-third of the provincial average. Further research is needed to determine the relationship between ED utilization and primary care capacity.
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Kantonen J, Kaartinen J, Mattila J, Menezes R, Malmila M, Castren M, Kauppila T. Impact of the ABCDE triage on the number of patient visits to the emergency department. BMC Emerg Med 2010; 10:12. [PMID: 20525299 PMCID: PMC2889933 DOI: 10.1186/1471-227x-10-12] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2009] [Accepted: 06/03/2010] [Indexed: 11/15/2022] Open
Abstract
Background Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care specialists are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to tertiary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for those patients who need it the most. Methods A face-to-face triage system based on the letters A (patient directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs was applied in the main ED in the City of Vantaa, Finland (Peijas Hospital) as an attempt to provide immediate treatment for the most acute patients. The first step was an initial patient assessment by a health care professional (triage nurse). If the patient was not considered to be in need of immediate care (i.e. A-D) he was allocated to group E and examined after the more urgent patients were treated. The introduction of this triage system was combined with information to the public on the "correct" use of emergency services. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the combined ED. To study the effect of the intervention on patient flow, numbers monthly visits to doctors were recorded before and after intervention in Peijas ED and, simultaneously, in control EDs (Myyrmäki in Vantaa, Jorvi and Puolarmetsä in Espoo). To study does the implementation of the triage system redirect patients to other health services, numbers of monthly visits to doctors were also scored in the private health care and public office hour services of Vantaa primary care. Results The number of patient visits to a primary care doctor in 2004 decreased by up to eight percent (340 visits/month) as compared to the previous year in the Peijas ED after implementation of the ABCDE-triage system. Simultaneously, doctor visits in tertiary health care ED increased by ten percent (125 visits/month). ABCDE-triage was not associated with a subsequent increase in the number of patient visits in the private health care or office hour services. The number of ED visits in the City of Espoo, used as a control where no triage was applied, remained unchanged. Conclusions The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the tertiary health care EDs.
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Ben-Isaac E, Schrager SM, Keefer M, Chen AY. National profile of nonemergent pediatric emergency department visits. Pediatrics 2010; 125:454-9. [PMID: 20123777 DOI: 10.1542/peds.2009-0544] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Emergency department (ED) crowding prevents the efficient and effective use of health services and compromises quality. Patients who use the ED for nonemergent health concerns may unnecessarily crowd ED services. In this article we describe characteristics of pediatric patients in the United States who use EDs for nonemergent visits. METHODS We analyzed data from the 2002-2005 Medical Expenditure Panel Survey. The Medical Expenditure Panel Survey is conducted by the Agency for Healthcare Research and Quality and consists of a nationally representative sample of the civilian noninstitutionalized population of the United States. Our study sample consisted of 5512 person-years of observation. We included only ED visits for children from birth to 17 years of age with a specified International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code. The main dependent variable for our multivariate logistic model was nonemergent ED use, which was constructed by using the New York University ED-classification algorithm. Independent variables were derived from Andersen's Behavioral Model of Health Services Utilization. RESULTS We found that from 2002 to 2005, a nationally representative sample of US children from birth to 17 years of age used EDs for various nonemergent or primary care-treatable diagnoses. Overall, children from higher-income families had higher ED expenditures than children from lower-income families. Children with private insurance had higher total ED expenditures than publicly insured or uninsured children, but uninsured children had the highest out-of-pocket expenditures. We found that children from birth to 2 years of age were less likely to use the ED for nonemergent diagnoses (odds ratio [OR]: 0.13; P < .01) compared with older children. Non-Hispanic black children were also less likely to use the ED for nonemergent diagnoses (OR: 0.40; P = .03) than were non-Hispanic white children. CONCLUSION Children's sociodemographic characteristics were predictors of nonemergent use of ED services.
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Affiliation(s)
- Eyal Ben-Isaac
- Childrens Hospital Los Angeles, 4650 Sunset Blvd, Mail Stop 30, Los Angeles, CA 90027, USA
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Bonk A, Siebert H, Seekamp A, Hoffmann R. [Triage systems in central emergency units]. Unfallchirurg 2009; 112:445-54. [PMID: 19347384 DOI: 10.1007/s00113-009-1617-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Central emergency units were established for medical and economic reasons in many German hospitals. The huge number of patients requiring treatment more or less urgent led to an implementation of triage-systems, which are known from abroad. Five of those triage-systems with different approaches are going to be presented below. The Manchester triage-system is the one of those, which can be transferred to German circumstances the best and is the most common clinical triage-system in Germany. Before implementing the above-mentioned systems to German emergency unit all of them need further development. Furthermore a scientific verification of the efficiency and the safety of triage-systems is necessary.
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Affiliation(s)
- A Bonk
- Abteilung Unfallchirurgie und Orthopädische Chirurgie, BG Unfallklinik Frankfurt/M., Friedberger Landstrasse 430, Frankfurt/M., Germany.
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van Veen M, Moll HA. Reliability and validity of triage systems in paediatric emergency care. Scand J Trauma Resusc Emerg Med 2009; 17:38. [PMID: 19712467 PMCID: PMC2747834 DOI: 10.1186/1757-7241-17-38] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 08/27/2009] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Triage in paediatric emergency care is an important tool to prioritize seriously ill children. Triage can also be used to identify patients who do not need urgent care and who can safely wait. The aim of this review was to provide an overview of the literature on reliability and validity of current triage systems in paediatric emergency care METHODS We performed a search in Pubmed and Cochrane on studies on reliability and validity of triage systems in children RESULTS The Manchester Triage System (MTS), the Emergency Severity Index (ESI), the Paediatric Canadian Triage and Acuity Score (paedCTAS) and the Australasian Triage Scale (ATS) are common used triage systems and contain specific parts for children. The reliability of the MTS is good and reliability of the ESI is moderate to good. Reliability of the paedCTAS is moderate and is poor to moderate for the ATS.The internal validity is moderate for the MTS and confirmed for the CTAS, but not studied for the most recent version of the ESI, which contains specific fever criteria for children. CONCLUSION The MTS and paedCTAS both seem valid to triage children in paediatric emergency care. Reliability of the MTS is good, moderate to good for the ESI and moderate for the paedCTAS. More studies are necessary to evaluate if one triage system is superior over other systems when applied in emergency care.
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Affiliation(s)
- Mirjam van Veen
- Department of Paediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Armagan E, Yilmaz Y, Olmez OF, Simsek G, Gul CB. Predictive value of the modified Early Warning Score in a Turkish emergency department. Eur J Emerg Med 2009; 15:338-40. [PMID: 19078837 DOI: 10.1097/mej.0b013e3283034222] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The modified Early Warning Score (mEWS) is a triage instrument that promises to predict patient disposition and clinical outcome in emergency departments (EDs). We investigated whether mEWS can predict death, hospital admission, intensive care unit (ICU) admission, and in-hospital deaths in a Turkish setting. METHODS We conducted an ED-based prospective study of 309 patients who presented to an academic medical center. The mEWS was recorded in all patients on ED admission. A mEWS >4 was used to define patients at high-risk for the study outcomes. RESULTS Patients categorized as being at high-risk either were admitted to ICU (n=23) or to hospital (n=37) 56.6% of the time, or died in ED (n=16) or in hospital (n=29) 42.4% of the time. Patients categorized as being at low-risk either were admitted to ICU (n=25) or to hospital (n=52) 37.4% of the time, or died in ED (n=1) or in hospital (n=4) 2.5% of the time. In multivariate regression analysis, patients with a mEWS of 5 or more were 1.95 times more likely to be admitted to ICU than those with a score less than 5. Patients with high-risk mEWS were 35 times more likely to die in ED and 14 times more likely to die in hospital than those presenting with a low-risk score. CONCLUSION We conclude that scores on the mEWS predict ICU admission as well as ICU and in-hospital deaths.
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Affiliation(s)
- Erol Armagan
- Department of Emergency Medicine, Uludag University Medical School, Bursa, Turkey
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Abstract
OBJECTIVE For a variety of reasons, many emergency department (ED) visits are classified as less- or nonurgent (Canadian Triage and Acuity Scale [CTAS] level IV and V). A recent survey in a tertiary care ED identified some of these reasons. The purpose of our study was to determine if these same reasons applied to patients presenting with problems triaged at a similar level at a low- volume rural ED. METHODS A 9-question survey tool was administered to 141 CTAS level IV and V patients who attended the South Huron Hospital ED, in Exeter, Ontario, over a 2-week period in December 2006. RESULTS Of the 141 eligible patients, 137 (97.2%) completed the study. One hundred and twenty-two patients (89.1%) reported having a family physician (FP) and 53 (38.7%) had already seen an FP before presenting to the ED. Just over one-half of all patients (51.1%) had their problem for more than 48 hours, and 42 (30.7%) stated that they were referred to the ED for care. Fifty-three (38.7%) of the respondents felt they needed treatment as soon as possible. Many patients reported coming to the ED because: 1) their FP office was closed (21.9%); 2) they could not get a timely appointment (16.8%); or 3) the walk-in clinic was closed (24.8%). Only 6 patients (4.4%) specifically stated that they came to the ED because they had no FP. One-third of patients attended the ED because they believed it offered specialized services. CONCLUSION In this rural setting, most less- or nonurgent ED patients had an FP yet they went to the ED because they did not have access to primary care, because they perceived their problem to be urgent or because they were referred for or sought specific services.
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Abstract
OBJECTIVES The objective was to determine effects of a modification in triage process on triage acuity distribution in general and among patients with conditions requiring time-sensitive therapy. METHODS The authors retrospectively reviewed triage acuity distributions before and after modification of their triage process that entailed conversion from the Canadian Triage and Acuity Scale (CTAS) to the Emergency Severity Index (ESI). The authors calculated the ratio of the odds of being triaged to a nonemergent level (3, 4, or 5) under ESI to the odds of being triaged as nonemergent under CTAS. The authors calculated sensitivity and specificity of triage to an emergent acuity level (1 or 2) for identifying patients with common presentations who required time-sensitive care. RESULTS There were shifts from higher to lower acuity levels for all subsets, with odds ratios ranging from 2.80 (95% confidence interval [CI] = 2.75 to 2.86) for all patients to 21.39 (95% CI = 14.66 to 31.21) for patients over 55 years of age with a chief complaint of chest pain. The sensitivity of triage for identifying abdominal pain patients requiring admission to an intensive care unit (ICU) or operating room (OR) or emergency department (ED) death was 80.7% (95% CI = 73.2 to 86.5) before versus 50.8% (95% CI = 43.5 to 58.1) following the transition to ESI. Specificity under CTAS, 55.2% (95% CI = 54.0 to 56.4), was significantly lower than under ESI, 83.6% (95% CI = 82.7 to 84.4). The authors found similar effects for patients presenting with chest pain. CONCLUSIONS Monitoring for changes in the sensitivity of the triage process for detecting patients with potentially time-sensitive conditions should be considered when modifying triage processes. Further work should be done to determine if the decreased sensitivity seen in this study occurs in other institutions converting to ESI, and potential causative factors should be explored.
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Affiliation(s)
- Phillip V Asaro
- Division of Emergency Medicine, Washington University in St. Louis, St. Louis, MO, USA.
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47
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Ting JYS. Emergency department presentations of patients with primary care complaints might engender negative staff attitudes that impact on quality of care. Emerg Med Australas 2008; 20:91-2. [DOI: 10.1111/j.1742-6723.2007.01054.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Thrasher C, Purc-Stephenson RJ. Integrating nurse practitioners into Canadian emergency departments: a qualitative study of barriers and recommendations. CAN J EMERG MED 2007; 9:275-81. [PMID: 17626692 DOI: 10.1017/s1481803500015165] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to identify the facilitators and barriers associated with integrating nurse practitioners (NPs) into Canadian emergency departments (EDs) from the perspectives of NPs and ED staff. METHODS We conducted 24 semi-structured interviews with key multidisciplinary stakeholders in 6 Ontario EDs to gain a broad range of perspectives on implementation issues. Data were analyzed using a grounded-theory approach. RESULTS Qualitative analysis of the interview data revealed 3 major issues associated with NP implementation: organizational context, role clarity and NP recruitment. Organizational context refers to the environment an NP enters and involves issues related to the ED culture, physician reimbursement system and patient volume. Role clarity refers to understanding the NP's function in the ED. Recruitment issues are associated with attracting and retaining NPs to work in EDs. Examples of each issue using respondent's own words are provided. CONCLUSIONS Our study identified 3 issues that illustrate the complex issues involved when implementing NPs in EDs. The findings may inform policy makers and health care professionals in the future development of the role of NPs in Canadian EDs.
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Howard M, Goertzen J, Hutchison B, Kaczorowski J, Morris K. Patient satisfaction with care for urgent health problems: a survey of family practice patients. Ann Fam Med 2007; 5:419-24. [PMID: 17893383 PMCID: PMC2000305 DOI: 10.1370/afm.704] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Patient satisfaction is an important health care outcome. This study compared patients' satisfaction with care received for an urgent health problem from their family physician, at an after-hours clinic in which their physician participated, at a walk-in clinic, at the emergency department, from telephone health advisory services, or from more than 1 of those services. METHODS We mailed a questionnaire to a random sample of patients from 36 family practices in Thunder Bay, Ontario. We elicited satisfaction with care for the most recent urgent health problem in the past 6 months on a 7-point scale (very dissatisfied to very satisfied). RESULTS The response rate was 62.3% (5,884 of 9,397). Of the 5,722 eligible patients 1,342 (23.4%) reported an urgent health problem, and data were available for both services used and satisfaction for 1,227 patients. After adjusting for sociodemographic characteristics and self-reported health status, satisfaction with care received for most recent urgent health problem was significantly higher among patients who visited or spoke to their family physician (mean 6.1; 95% confidence interval [CI], 5.8-6.4) compared with all other services (all P <.004, adjusted for multiple comparisons), with the exception of patients who used the after-hours clinic affiliated with their physician, whose satisfaction was not significantly different (mean 5.6; 95% CI, 5.2-6.0). CONCLUSIONS Satisfaction was highest for patients receiving care from their own family physician or their physician's after-hours clinic. These results are important for new primary care models that emphasize continuity and after-hours availability of family physicians.
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Affiliation(s)
- Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.
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50
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Schull MJ, Kiss A, Szalai JP. The Effect of Low-Complexity Patients on Emergency Department Waiting Times. Ann Emerg Med 2007; 49:257-64, 264.e1. [PMID: 17049408 DOI: 10.1016/j.annemergmed.2006.06.027] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Revised: 05/19/2006] [Accepted: 06/13/2006] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE The extent to which patients presenting to emergency departments (EDs) with minor conditions contribute to delays and crowding is controversial. To test this question, we study the effect of low-complexity ED patients on the waiting times of other patients. METHODS We obtained administrative records on all ED visits to Ontario hospitals from April 2002 to March 2003. For each ED, we determined the association between the number of new low-complexity patients (defined as ambulatory arrival, low-acuity triage level, and discharged) presenting in each 8-hour interval and the mean ED length of stay and time to first physician contact for medium- and high-complexity patients. Covariates were the number of new high- and medium-complexity patients, mean patient age, sex distribution, hospital teaching status, work shift, weekday/weekend, and total patient-hours. Autoregression modeling was used given correlation in the data. RESULTS One thousand ninety-five consecutive 8-hour intervals at 110 EDs were analyzed; 4.1 million patient visits occurred, 50.8% of patients were women, and mean age was 38.4 years. Low-, medium-, and high-complexity patients represented 50.9%, 37.1%, and 12% of all patients, respectively. Mean (median) ED length of stay was 6.3 (4.7), 3.9 (2.8), and 2.2 (1.6) hours for high-, medium-, and low-complexity patients, respectively, and mean (median) time to first physician contact was 1.1 (0.7), 1.3 (0.9), and 1.1 (0.8) hours. In adjusted analyses, every 10 low-complexity patients arriving per 8 hours was associated with a 5.4-minute (95% confidence interval [CI] 4.2 to 6.0 minutes) increase in mean length of stay and a 2.1-minute (95% CI 1.8 to 2.4 minutes) increase in mean time to first physician contact for medium- and high-complexity patients. Results were similar regardless of ED volume and teaching status. CONCLUSION Low-complexity ED patients are associated with a negligible increase in ED length of stay and time to first physician contact for other ED patients. Reducing the number of low-complexity ED patients is unlikely to reduce waiting times for other patients or lessen crowding.
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Affiliation(s)
- Michael J Schull
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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