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Hughes JA, Hazelwood S, Lyrstedt AL, Jones L, Brown NJ, Jarugula R, Douglas C, Chu K. Enhancing pain care with the American Pain Society Patient Outcome Questionnaire for use in the emergency department (APS-POQ-RED): validating a patient-reported outcome measure. BMJ Open Qual 2024; 13:e002295. [PMID: 38448040 PMCID: PMC10916172 DOI: 10.1136/bmjoq-2023-002295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 12/02/2023] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND In general, the quality of pain care in emergency departments (ED) is poor, despite up to 80% of all ED patients presenting with pain. This may be due to the lack of well-validated patient-reported outcome measures (PROMs) of pain care in the ED setting. The American Pain Society-Patient Outcome Questionnaire-Revised Edition (APS-POQ-R), with slight modification for ED patients, is a potentially useful PROM for the adult ED, however it is yet to be completely validated. METHODS Adult patients, who had presented with moderate to severe acute pain, were recruited at two large inner-city EDs in Australia. A modified version of the APS-POQ-R was administered at the completion of their ED care. Responses were randomly split into three groups and underwent multiple rounds of exploratory and confirmatory factor analysis with testing for construct, convergent, divergent validity and internal consistency. RESULTS A total of 646 ED patients (55.6% female), with a median age of 48.3 years, and moderate to severe pain on arrival, completed the ED-modified APS-POQ-R. Psychometric evaluation resulted in a reduced nine-question tool, which measures three constructs (pain relief and satisfaction (α=0.891), affective distress (α=0.823) and pain interference (α=0.908)) and demonstrated construct, convergent, divergent validity, and internal consistency. CONCLUSIONS This new tool, which we refer to as the American Pain Society-Patient Outcome Questionnaire-Revised for the ED (APS-POQ-RED), should form the basis for reporting patient-reported outcomes of ED pain care in future quality improvement and research.
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Affiliation(s)
- James A Hughes
- School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Sarah Hazelwood
- Emergency Department, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Anna-Lisa Lyrstedt
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Lee Jones
- Queensland University of Technology, Brisbane, Queensland, Australia
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Nathan J Brown
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Medicine, University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, Queensland, Australia
| | - Rajeev Jarugula
- Emergency Department, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Clint Douglas
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Kevin Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Medicine, University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, Queensland, Australia
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Hutchinson CL, Curtis K, McCloughen A. Characteristics of patients who return unplanned to the ED, and factors that contribute to their decision to return: Integrated results from an explanatory sequential mixed methods inquiry. Australas Emerg Care 2024; 27:71-77. [PMID: 37741746 DOI: 10.1016/j.auec.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 09/25/2023]
Abstract
AIM To identify common characteristics of patients who return to the ED unplanned and factors that may contribute to their decision to return. BACKGROUND Return visits to the Emergency Department (ED) have been associated with adverse events and deficits in initial care provided. There is increasing evidence to suggest that many return visits may be preventable. METHODS The results of primary quantitative measures (QUAN) followed by qualitative measures (qual) were integrated to build on and explain the quantitative data found in the initial phase of the research. RESULTS Integration of results produced three new findings. 1) Most return visits occurred beyond 48 hrs because patients intentionally delayed going back to the ED despite their persisting symptoms; 2) Clinical urgency and deterioration were rarely evident in patients who made return visits in patients and 3) Ineffective communication between the clinician and the patient at discharge may have contributed to patients making the decision to return to the ED. CONCLUSION The decision to return unplanned to the ED is not an immediate response for most patients, and several potentially avoidable factors may influence their decision-making process. Future research should focus on strategies which contribute to the avoidance of unplanned return visits.
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Affiliation(s)
- Claire L Hutchinson
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Emergency Department, Canterbury Hospital, Campsie, Sydney, NSW, Australia; Faculty of Health. Southern Cross University, Coffs Harbour Campus, NSW, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia
| | - Andrea McCloughen
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW, Australia
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Eccleston C, Marsden E, Craswell A, Sweeny A, Howell N, Wallis M, Crilly J. Impact of COVID-19 state-wide lockdown on older adult presentations to Queensland emergency departments. Emerg Med Australas 2023; 35:799-808. [PMID: 37160322 DOI: 10.1111/1742-6723.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/25/2023] [Accepted: 04/14/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To determine the impact of the COVID-19 state-wide lockdown on ED presentations for older adults in Queensland, Australia. METHODS A retrospective cohort study pertaining to adults aged 70+ years who presented to Queensland public hospital EDs across three separate time periods; 11 March to 30 June 2018 and 2019 (pre-pandemic average), 2020 (COVID-19 state-wide lockdown) and 2021 (post-state-wide lockdown). The primary outcome was change in presentation rates to ED. Secondary outcomes included change in triage category rates, length of stay (LOS), diagnosis and disposition. RESULTS There was 380 854 older adult presentations. During the COVID-19 state-wide lockdown, ED presentation rates decreased by 12.5% (incidence rate ratio 0.875 [95% confidence interval 0.867-0.883]). All triage category presentation rates decreased, as did ED LOS and reasons for presentation, except sepsis and disorders of the nervous system. In the post-state-wide lockdown period a 22% (incidence rate ratio 1.22 [95% confidence interval 1.21-1.23]) increase in the presentation rate was observed and presentations in all triage categories increased. ED LOS increased to longer than pre-pandemic (P < 0.001). Respiratory presentations increased by 346%. Patients who 'did not wait' increased by 212% and ED mortality rose by 42% compared to during the lockdown. CONCLUSION There was a significant decrease in presentation rates to EDs during the COVID-19 state-wide lockdown for the older population, followed by an increase in presentation rates, longer ED LOS, and an increased ED mortality rate, in the post-state-wide lockdown period. It is important to ensure older adults continue to seek appropriate, timely medical care, during a pandemic.
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Affiliation(s)
- Cassanne Eccleston
- Sunshine Coast University Hospital, Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia
| | - Elizabeth Marsden
- RADAR Metro North, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Alison Craswell
- School of Health, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Amy Sweeny
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- Faculty of Medicine, Griffith University, Brisbane, Queensland, Australia
- School of Dentistry and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Naomi Howell
- School of Health, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Marianne Wallis
- Faculty of Health, Southern Cross University, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
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Gale J, Varndell W, James S, Perry L. Unscheduled emergency department presentations with diabetes: Identifying high risk characteristics. Australas Emerg Care 2023; 26:205-210. [PMID: 36528482 DOI: 10.1016/j.auec.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Unscheduled emergency department (ED) presentation by patients with diabetes has seldom been examined. This study aimed to determine the frequency and associated characteristics of presentations in this population. METHODS Using a prospective cross-sectional design, data were collected from patients with diabetes presenting and/or admitted to a tertiary metropolitan hospital in New South Wales, Australia (December 2016-September 2017). A screening interview including brief measures of cognitive and executive function, and clinical details from healthcare records were utilised; details around unscheduled presentations within 90 days were extracted. Independent associations with ED presentation were determined. RESULTS Unscheduled ED presentations were common; 35.4% had at least one within 90 days, and for 20.1% this occurred within 28 days. The screening tool contributed little towards identifying risk of unscheduled presentation. Those attending any community or outpatient follow-up appointment within the first 28 (OR 0.42, 95% CI 0.23-0.76; p = 0.004) or 90 days (OR 0.25; 0.13-0.47; p < 0.001) from the index presentation were less likely to present within that same period. CONCLUSIONS Findings indicated the magnitude of unscheduled ED presentation, care complexity and the value of targeted and timely follow-up. Alternative service support may help maintain and improve diabetes self-management and will require effectiveness and cost-effectiveness evaluation.
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Affiliation(s)
- Julie Gale
- Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Wayne Varndell
- Prince of Wales Hospital, Randwick, New South Wales, Australia; University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Steven James
- University of the Sunshine Coast, Petrie, Queensland, Australia; University of Melbourne, Parkville, Victoria, Australia.
| | - Lin Perry
- Prince of Wales Hospital, Randwick, New South Wales, Australia; University of Technology Sydney, Ultimo, New South Wales, Australia
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Hospital presentations with diabetic ketoacidosis: A retrospective review. Australas Emerg Care 2023; 26:1-6. [PMID: 35817716 DOI: 10.1016/j.auec.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/21/2022] [Accepted: 06/26/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a significant source of preventable episodes of care and cost. This study aimed to describe the demographic and clinical characteristics of people with type 1 diabetes (T1D) presenting to the Emergency Department (ED) with DKA in an area of socio-economic deprivation in metropolitan Queensland, Australia, and to describe factors associated with hospital admission and re-presentation in this population. METHODS This was a retrospective descriptive analysis of routine healthcare record data for January 2015-December 2019. People with T1D were identified through hospital discharge codes. RESULTS More than half (n = 165) the estimated local T1D population (n = 317) experienced an index ED presentation for DKA; mean±SD age at ED presentation was 31.1 + /- 19.3 years, 126 (76.4%) were aged ≥ 16 years and 20 (12.1%) were newly diagnosed. Index DKA presentation was significantly associated with female sex (p = 0.04) but no other demographic or geographic variables. More than half the presentations (n = 92, 55.8%) occurred outside regular business hours. Twenty-three representations occurred within 90 days, associated with older age (p = 0.045) and lower residential socio-economic score (p = 0.02). CONCLUSION Findings highlight the frequent problem of DKA and the importance of socio-economic influences. This flags the need and opportunity to improve support to people with T1D to promote diabetes self-care.
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Factors Contributing to Leaving against Medical Advice (LAMA): A Consideration of the Patients' Perspective. Healthcare (Basel) 2023; 11:healthcare11040506. [PMID: 36833040 PMCID: PMC9956126 DOI: 10.3390/healthcare11040506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/21/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023] Open
Abstract
It is essential to understand why patients choose to leave the hospital in direct opposition to medical advice. This understanding could help to identify individuals who are at risk of adverse outcomes. In realizing this need, this study aimed to explore the factors contributing to the decision of patients to leave the hospital against medical advice. MATERIALS AND METHODS This research employed a descriptive-analytical approach. It was conducted in the city of Hail, Kingdom of Saudi Arabia. The participants were 13 patients who had opted to leave against medical advice from the Emergency Department of the government-subsidized hospitals. The researchers employed both purposive and snowball sampling. In snowball sampling, the researchers used referrals from initial participants to generate additional participants. Moreover, purposive sampling was used to find the individual that would best contribute to addressing the research issue. The data gathering was conducted from April to June 2022. RESULTS Five themes emerged based on the accounts of the 13 participant patients. These included (1) health literacy, (2) self-diagnosing, (3) unclear explanations regarding their condition, (4) prolonged waiting times, and (5) communication issues. CONCLUSION The factors contributing to patients leaving against medical advice resulted in the five themes mentioned above. While interactions between patients and healthcare professionals may be challenging, pertinent health information must still be handed down clearly to patients.
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Zhang J, Qian S, Su G, Deng C, Reid D, Curtis K, Sinclair B, Yu P. Emergency department presentations of patients with alcohol use disorders in an Australian regional health district. Subst Abus 2022; 43:1126-1138. [DOI: 10.1080/08897077.2022.2060427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Jingxiang Zhang
- Centre for Digital Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, Australia
| | - Siyu Qian
- Centre for Digital Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, Australia
- Drug and Alcohol Service, Illawarra Shoalhaven Local Health District, Wollongong, Australia
| | - Guoxin Su
- School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, Australia
| | - Chao Deng
- School of Medicine and Molecular Horizons, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
| | - David Reid
- Drug and Alcohol Service, Illawarra Shoalhaven Local Health District, Wollongong, Australia
| | - Kate Curtis
- Illawarra Health and Medical Research Institute, Wollongong, Australia
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Barbara Sinclair
- Drug and Alcohol Service, Illawarra Shoalhaven Local Health District, Wollongong, Australia
| | - Ping Yu
- Centre for Digital Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
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Julie G, James S, Varndell W, Perry L. UNPLANNED REPRESENTATION TO HOSPITAL BY PATIENTS WITH DIABETES: DEVELOPMENT AND PILOT FEASIBILITY TESTING OF A SCREENING TOOL. Contemp Nurse 2022; 57:439-449. [PMID: 35021961 DOI: 10.1080/10376178.2022.2029517] [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: 10/19/2022]
Abstract
BackgroundUnplanned representation of patients with diabetes recently discharged from emergency department or in-patient hospitals is a common but complex problem worldwide. This study set out to examine the feasibility of a risk screening interview and whether component characteristics may be associated with unplanned representation of patients with diabetes to a tertiary metropolitan hospital.MethodsA screening interview comprised of demographic, social and clinical characteristics was developed and piloted using prospective cross-sectional survey design. A convenience sample of 55 patients was recruited and screened. Outcomes were the occurrence of unplanned representation to hospital within 28 or 90 days of hospital discharge from the index presentation.ResultsThe screening interview was shown to be broadly feasible and acceptable for use by staff and patients, with identified areas for modification. Seventeen participants (30.9%) experienced unplanned representation within 90 days of hospital discharge; for 13 participants (23.6%) this occurred within 28 days. Characteristics linked with unplanned representation to hospital were identified.ConclusionsPreliminary data indicated the feasibility of tool use and informed refinement for future testing of the ability of the screening interview to predict those patients with diabetes at high risk of unplanned representation to hospital to enhance effective care planning.
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Affiliation(s)
- Gale Julie
- South East Sydney Local Health District, Prince of Wales Hospital, Randwick, New South Wales, 2031, Australia
| | - Steven James
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Petrie, Queensland, 4502, Australia
| | - Wayne Varndell
- South East Sydney Local Health District, Prince of Wales Hospital, Randwick, New South Wales, 2031, Australia
| | - Lin Perry
- South East Sydney Local Health District, Prince of Wales Hospital, Randwick, New South Wales, 2031, Australia.,Faulty of Health, University of Technology Sydney, Ultimo, New South Wales, 2007, Australia
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Kuehl S, Stanley J, Nelson K, Collings S. The Serious Self-Harm Risk of "Mixed Presenters," People Who Presented to New Zealand Emergency Departments for Self-Harm and Other Reasons: A Cohort Study. Arch Suicide Res 2021; 25:475-490. [PMID: 32065083 DOI: 10.1080/13811118.2020.1715904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The objective of this study was to investigate if "Mixed Presenters," people who present to emergency departments at least twice within 28 days, once for self-harm and once for another reason (any order), have an increased risk of subsequent serious self-harm compared to self-harm only repeat presenters. Self-harm coded emergency department data from the Multi-level Intervention for Suicide Prevention (MISP) study was utilized to identify people with at least two presentations to one of eight District Health Boards between 2010 and 2012. First eligible presentation pairs determined their "Mixed Presenter" or "Self-harm Only Presenter" status. The sample was linked to admission and mortality datasets. Survival analysis over the 30-month timeframe was used to determine which presenter group was at higher risk of serious self-harm. Mixed Presenters (n = 1,544), four times more common than Self-harm Only Presenters (n = 377), had an estimated 60% reduced risk of serious self-harm compared to Self-harm Only Presenters. Compared to men, women had a 3.5 times (HR 3.53, 95% CI 2.47-5.06) increased risk. Having an urgent triage code allocated at the index presentation and being admitted at that index presentation were associated with increased serious self-harm risk for Self-harm Only Presenters compared to Mixed Presenters. This study confirms that two presentations for self-harm within a short timeframe indicate high risk of serious self-harm in the future. As men often die following single attempts, and Mixed Presenters may transition to being Self-harm Only Presenters, each presentation for self-harm requires serious attention.
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Knights E, Gorman V, Mitra B, Gray R. Emergency department nurse call back: A quality improvement project. Int Emerg Nurs 2021; 56:101001. [PMID: 33848792 DOI: 10.1016/j.ienj.2021.101001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 02/18/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Early detection of clinical deterioration after discharge from the Emergency Department may facilitate timely intervention and improve patient outcomes. METHODS A quality improvement project to evaluate nurse call back offered to all patients within 72 h of discharge to community (usual residence) from an Emergency Department. All patients of all ages that were assessed, managed by a physician and discharged to their home from an Emergency Department were eligible. A standard algorithm and flow chart was used for all call backs. Call back refers to the follow up phone call by a Registered Nurse from the Emergency Department following patient discharge. The aim of call back is to enhance the early recognition of deteriorating patients. Project outcomes were the proportion of patients who were contacted by phone by a nurse post discharge and the proportion of patients that met deterioration criteria. The project was conducted over a six month period. RESULTS There were 1139 patients eligible. Call back was attempted for 893 patients of which 716 (80%) were contacted. Deterioration was identified in 34 of 716 (5%) patients, two were advised to attend their general practitioner, and 32 were directed to present to an Emergency Department. Of the 32 recalled patients, 26 represented to the original Emergency Department and 12 were admitted following the call back, an admission rate of 46% (95% CI:28.7-64.5) of those that represented. CONCLUSIONS It was feasible to implement a nurse call back in an Emergency Department. Nurse call back has the potential to reduce times to re-presentation of an emergency, thereby mitigating adverse events, preventing complications. Further evaluation is warranted.
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Affiliation(s)
- Emily Knights
- Northpark Private Hospital, 10 Greenhills Road, Bundoora, Melbourne, Australia; School of Nursing and Midwifery, La Trobe University, Corner Plenty Road and Kingsbury Drive, Bundoora, Melbourne, Australia
| | - Vanessa Gorman
- The Royal Womens Hospital, 20 Flemington Road, Parkville, Melbourne, Australia
| | - Biswadev Mitra
- Northpark Private Hospital, 10 Greenhills Road, Bundoora, Melbourne, Australia; School of Public Health & Preventive Medicine, Monash University, Wellington Road, Clayton, Melbourne, Australia
| | - Richard Gray
- School of Nursing and Midwifery, La Trobe University, Corner Plenty Road and Kingsbury Drive, Bundoora, Melbourne, Australia.
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Discharge against medical advice from the emergency department in a university hospital. BMC Emerg Med 2021; 21:31. [PMID: 33726692 PMCID: PMC7962258 DOI: 10.1186/s12873-021-00422-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 02/24/2021] [Indexed: 11/22/2022] Open
Abstract
Background Patients discharged against medical advice (DAMA) act as a high-risk population for the Emergency Department (ED), regardless of their presentations, and can pose a serious burden for the hospital. This study examines the prevalence, demographic and clinical characteristics, reasons, and clinical outcomes of a small sample of DAMA patients in a teaching university hospital, including readmission, morbidity, and mortality. Methods A prospective, descriptive cross-sectional study was conducted in the ED of King Hamad University Hospital (KHUH) with 98,992 patient visits during a 1-year period from June 2018 to June 2019. Consenting DAMA patients were asked to complete a data collection form. Results Patients (n = 413) had a mean age of 44.1 years with a female majority (57.1%). The majority were categorized as triage level-3 (87.7%). The main reasons for DAMA included refusal of the procedure/operation (23.2%), long ED waiting time (22.2%), subjective improvement with treatment (17.7%), and children at home (14.8%), whereas the least selected reason was dissatisfaction with medical care (1.2%). Follow-up of DAMA patients revealed that 86 cases (20.8%) were readmitted to the ED within 72 h of which 41 (47.7%) cases were morbidity and 2 (2.3%) were mortality. Marital status was a predictor of DAMA patients who revisit the ED within 72 h. Conclusion The results act as a pilot study to examine a small sample of DAMA patients’ characteristics, diagnosis, and ED revisits. Hospitals should investigate further the DAMA population on a larger scale, reasons for refusing procedures, and utilize this knowledge to improve the healthcare process.
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Hutchinson CL, Curtis K, McCloughen A, Qian S, Yu P, Fethney J. Identifying return visits to the Emergency Department: A multi-centre study. Australas Emerg Care 2020; 24:34-42. [PMID: 32593525 DOI: 10.1016/j.auec.2020.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/27/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Patients who return to the Emergency Department (ED) for the same complaint are known to be at risk of adverse events. Monitoring of return visits is considered a way to measure the quality of care provided in the ED, although the most commonly used benchmark of 48h lacks evidence. This study aimed to describe the incidence, characteristics and outcomes of patients with unplanned return visits. The study also aimed to determine the capture rate of the 48-h benchmark using an all-inclusive method of return visit identification. METHODS A retrospective cross-sectional study was conducted across three EDs in Sydney, New South Wales from July 1st, 2017 to June 30th, 2018. Visits that occurred within 28 days with the same or similar presenting complaint following discharge from the ED were classified as a return visit. Data were grouped by index and return visit. Descriptive statistics were used to summarise incidence, patient characteristics and outcomes for all presentations. Categorical data were analysed using Chi square tests. Continuous data were analysed using Mann-Whitney when data were not normally distributed and t-tests when normally distributed. RESULTS Of all ED presentations (n=164,598), 5860 (3.6%) were identified as a return visit. Return patients were younger than non-return patients, but those that required admission were older (43 vs 33 years, p=<0.01). Abdominal problems were the most common reason for return followed by urological and mental health. The median time to return was 64:51h (IQR 20:35-226:37). Only 43% of return visits occurred within 48h. Return visits to a different ED accounted for 13.2% of return visits. CONCLUSION More than half of ED return visits are missed when the existing benchmark of 48h is used. Current policy makers should consider increasing the 48-h benchmark to more accurately reflect the incidence of return visits. Further investigation into the causal factors for return visits is warranted, particularly in patients with abdominal, urological or mental health complaints.
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Affiliation(s)
- Claire L Hutchinson
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia
| | - Andrea McCloughen
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
| | - Siyu Qian
- Centre for IT-enabled Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia
| | - Ping Yu
- Centre for IT-enabled Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia
| | - Judith Fethney
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
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13
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Whitaker AS, Cottrell WN. What proportion of unplanned re‐presentations to an emergency department are medication related and preventable? JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - W. Neil Cottrell
- Pharmacy Australia Centre of Excellence The University of Queensland School of Pharmacy Brisbane Australia
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Millhouse MGE, Davies MJ, Tankel AS. Characteristics of short‐term re‐presentations to a regional emergency department. Emerg Med Australas 2019; 31:961-966. [DOI: 10.1111/1742-6723.13286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/23/2019] [Accepted: 02/24/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Madison GE Millhouse
- St George and Sutherland Clinical School, Faculty of Medicine, The University of New South Wales Sydney New South Wales Australia
| | - Matthew J Davies
- St George and Sutherland Clinical School, Faculty of Medicine, The University of New South Wales Sydney New South Wales Australia
| | - Alan S Tankel
- St George and Sutherland Clinical School, Faculty of Medicine, The University of New South Wales Sydney New South Wales Australia
- Emergency DepartmentCoffs Harbour Base Hospital Coffs Harbour New South Wales Australia
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15
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Incidence, characteristics and outcomes of patients that return to Emergency Departments. An integrative review. Australas Emerg Care 2019; 22:47-68. [PMID: 30998872 DOI: 10.1016/j.auec.2018.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Unplanned return visits account for up to 5% of Emergency Department presentations in Australia and have been associated with adverse events and increased costs. A large number of studies examine the incidence, characteristics and outcomes of unplanned return visits but few studies examine the reasons for return from a patient perspective. The objective of this integrative review was to determine the incidence, characteristics, outcomes and reasons for unplanned return visits to Emergency Departments. METHOD An integrative literature review design was employed to conduct a structured search of the literature using the databases CINAHL, MEDLINE, PubMed, ProQuest and EMBASE (inception to June 2018). Results were screened using predefined criteria and final studies collated and appraised using a quality assessment tool. RESULTS Fifty-two primary research articles were included in the review. The timeframe used to capture unplanned return visits varied and the incidence ranged between 0.07% and 33%. The majority of patients who return unplanned to the Emergency Department are subsequently discharged (51% and 90%) without an adverse event. CONCLUSION There is no consensus on the timeframe employed to classify unplanned return visits to the Emergency Department and the commonly used 72h lacks evidence. Routine statewide data linkage to capture return visits to other facilities is needed to ensure accurate data about this vulnerable patient group. Further research that focuses on patient and clinician perspectives is required to facilitate the development of local strategies to reduce the incidence of avoidable unplanned return visits.
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Hayward J, Hagtvedt R, Ma W, Gauri A, Vester M, Holroyd BR. Predictors of Admission in Adult Unscheduled Return Visits to the Emergency Department. West J Emerg Med 2018; 19:912-918. [PMID: 30429921 PMCID: PMC6225947 DOI: 10.5811/westjem.2018.8.38225] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/26/2018] [Accepted: 08/11/2018] [Indexed: 11/24/2022] Open
Abstract
Introduction The 72-hour unscheduled return visit (URV) of an emergency department (ED) patient is often used as a key performance indicator in emergency medicine. We sought to determine if URVs with admission to hospital (URVA) represent a distinct subgroup compared to unscheduled return visits with no admission (URVNA). Methods We performed a retrospective cohort study of all 72-hour URVs in adults across 10 EDs in the Edmonton Zone (EZ) over a one-year period (January 1, 2015 - December 31, 2015) using ED information-system data. URVA and URVNA populations were compared, and a multivariable analysis identified predictors of URVA. Results Analysis of 40,870 total URV records, including 3,363 URVAs, revealed predictors of URVA on the index visit including older age (>65 yrs, odds ratio [OR] 3.6), higher disease acuity (Canadian Emergency Department Triage and Acuity Scale [CTAS] 2, OR 2.6), gastrointestinal presenting complaint (OR 2.2), presenting to a referral hospital (OR 1.4), fewer annual ED visits (<4 visits, OR 2.0), and more hours spent in the ED (>12 hours, OR 2.0). A decrease in CTAS score (increase in disease acuity) upon return visit also increased the risk of admission (-1 CTAS level, OR 2.6). ED crowding at the index visit, as indicated by occupancy level, was not a predictor. Conclusion We demonstrate that URVA patients comprise a distinct subgroup of 72-hour URV patients. Risk factors for URVA are present at the index visit suggesting that patients at high risk for URVA may be identifiable prior to admission.
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Affiliation(s)
- Jake Hayward
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Reidar Hagtvedt
- University of Alberta, Alberta School of Business, Edmonton, Alberta, Canada
| | - Warren Ma
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Aliyah Gauri
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Michael Vester
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Brian R. Holroyd
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
- Alberta Health Services, Emergency Strategic Clinical Network, Edmonton, Alberta, Canada
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Hayward J, Hagtvedt R, Ma W, Gauri A, Vester M, Holroyd B. Predictors of Admission in Adult Unscheduled Return Visits to the Emergency Department. West J Emerg Med 2018. [DOI: 10.5811/westjem.2018.38225] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jake Hayward
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Reidar Hagtvedt
- University of Alberta, Alberta School of Business, Edmonton, Alberta, Canada
| | - Warren Ma
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Aliyah Gauri
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Michael Vester
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Brian Holroyd
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada; Alberta Health Services, Emergency Strategic Clinical Network, Edmonton, Alberta, Canada
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18
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Dinh MM, Berendsen Russell S, Bein KJ, Chalkley D, Muscatello D, Paoloni R, Ivers R. Trends and characteristics of short-term and frequent representations to emergency departments: A population-based study from New South Wales, Australia. Emerg Med Australas 2016; 28:307-12. [DOI: 10.1111/1742-6723.12582] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 03/07/2016] [Accepted: 03/28/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Michael M Dinh
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
- Discipline of Emergency Medicine; The University of Sydney; Sydney New South Wales Australia
| | - Saartje Berendsen Russell
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
- School of Nursing; The University of Sydney; Sydney New South Wales Australia
| | - Kendall J Bein
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Dane Chalkley
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - David Muscatello
- School of Public Health and Community Medicine; University of New South Wales; Sydney New South Wales Australia
| | - Richard Paoloni
- Discipline of Emergency Medicine; The University of Sydney; Sydney New South Wales Australia
| | - Rebecca Ivers
- The George Institute for Global Health; The University of Sydney; Sydney New South Wales Australia
- School of Nursing and Midwifery; Flinders University; Adelaide South Australia Australia
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19
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Sayed ME, Jabbour E, Maatouk A, Bachir R, Dagher GA. Discharge Against Medical Advice From the Emergency Department: Results From a Tertiary Care Hospital in Beirut, Lebanon. Medicine (Baltimore) 2016; 95:e2788. [PMID: 26871837 PMCID: PMC4753933 DOI: 10.1097/md.0000000000002788] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients who leave the emergency department against medical advice are at high risk for complications. Against medical advice (AMA) discharges are also considered high-risk events potentially leading to malpractice litigation.Our aim was to characterize patients who leave AMA in a payment prior to service emergency department (ED) model and to identify predictors for return visits to ED after leaving AMA.We conducted a retrospective review study of charts of ED patients who were discharged AMA between January 1, 2012 and January 1, 2013 at a tertiary care center in Beirut Lebanon. We carried out a descriptive analysis and a bivariate analysis comparing AMA patients without and with return visit within 72 hours. This was followed by a Logistic regression to identify predictors of return visits after leaving AMA.A total of 1213 ED patients were discharged AMA during the study period. Mean age was 46.9 years (±20.9). There were 654 men (53.9%), 737 married (60.8%). The majority (1059 patients (87.3%)) had an emergency severity index of 3 or less (1 or 2). ED average length of stay was 3.8 hours (±6.8). Self payers accounted for 53.9%. Reasons for leaving AMA were: no reason mentioned (44.1%), incomplete workup (30.5%), refusing admission (12.4%), financial reasons (7.9%), long wait times (2.9%), and others (2.2%). Discharge diagnoses were mainly cardiac (23.4%), gastrointestinal (16.4%), infectious (10.1%), and trauma (9.8%).One hundred nineteen returned to ED within 72 hours (9.8%). Predictors of returning to ED after leaving AMA were: older age (OR 1.02 95% CI (1.01-1.03)), private insurance status (OR 4.64 95% (CI 2.89-7.47) within network insurance status (OR 7.20 95% CI (3.86-13.44), longer ED length of stay during the first visit (OR 1.03 95% CI (1.01-1.05).In our setting, the rate of return visit to ED after leaving AMA was 9.8%. Reasons for leaving AMA, high-risk discharge diagnoses and predictors of return visit were identified. Financial status was a strong predictor of return to ED after leaving AMA.
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Affiliation(s)
- Mazen El Sayed
- From the Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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20
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Elder E, Johnston ANB, Crilly J. Improving emergency department throughput: An outcomes evaluation of two additional models of care. Int Emerg Nurs 2015. [PMID: 26208424 DOI: 10.1016/j.ienj.2015.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to explore the impact of incorporating a physician at triage (PAT) and the implementation of a medical assessment unit (MAU) on emergency department (ED) patient throughput. METHODS A retrospective comparative analysis of two additional models of care (standard care, T1; PAT, T2 and PATplusMAU, T3) was undertaken. Patient presentations to a large public teaching hospital in South-East Queensland between 10th January 2013 and 25th February 2013, and the same time period in 2012, were included. The impact of these care models on ED length of stay and other outcomes (time to be seen by a clinician, time from bed request to ward transfer, meeting 4 hour transit targets, admission rates and the proportion of patients who did not wait) were compared. RESULTS Compared to standard care, ED length of stay appeared to decrease with the introduction of both models, but was only significantly decreased after PATplusMAU was implemented (2013; T1, 186 min; T2, 181 min; T3, 175 min: T1 vs T3, P < 0.001). Outcomes that improved included: time to be seen by a clinician, proportion of patients who did not wait; increase in meeting 4-hour length of stay target for both admitted and not-admitted patients. CONCLUSION Placing a physician at triage and implementing a medical assessment unit were viable models of care that promoted patient flow and helped meet several time-sensitive health service targets.
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Affiliation(s)
- Elizabeth Elder
- School of Nursing & Midwifery, Griffith Health, Gold Coast Campus, Griffith University, QLD 4222, Australia.
| | - Amy N B Johnston
- Department of Emergency Medicine & Griffith Health Institute, Gold Coast Hospital and Health Service & Griffith University, Southport, QLD 4215, Australia
| | - Julia Crilly
- Department of Emergency Medicine & Griffith Health Institute, Gold Coast Hospital and Health Service & Griffith University, Southport, QLD 4215, Australia
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van der Linden MC, Lindeboom R, de Haan R, van der Linden N, de Deckere ER, Lucas C, Rhemrev SJ, Goslings JC. Unscheduled return visits to a Dutch inner-city emergency department. Int J Emerg Med 2014; 7:23. [PMID: 25045407 PMCID: PMC4100563 DOI: 10.1186/s12245-014-0023-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 05/23/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unscheduled return visits to the emergency department (ED) may reflect shortcomings in care. This study characterized ED return visits with respect to incidence, risk factors, reasons and post-ED disposition. We hypothesized that risk factors for unscheduled return and reasons for returning would differ from previous studies, due to differences in health care systems. METHODS All unscheduled return visits occurring within 1 week and related to the initial ED visit were selected. Multivariable logistic regression was conducted to determine independent factors associated with unscheduled return, using patient information available at the initial visit. Reasons for returning unscheduled were categorized into illness-, patient- or physician-related. Post-ED disposition was compared between patients with unscheduled return visits and the patients who did not return. RESULTS Five percent (n = 2,492) of total ED visits (n = 49,341) were unscheduled return visits. Patients with an urgent triage level, patients presenting during the night shift, with a wound or local infection, abdominal pain or urinary problems were more likely to return unscheduled. Reasons to revisit unscheduled were mostly illness-related (49%) or patient-related (41%). Admission rates for returning patients (16%) were the same as for the patients who did not return (17%). CONCLUSIONS Apart from abdominal complaints, risk factors for unscheduled return differ from previous studies. Short-term follow-up at the outpatient clinic or general practitioner for patients with urgent triage levels and suffering from wounds or local infections, abdominal pain or urinary problem might prevent unscheduled return.
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Affiliation(s)
| | - Robert Lindeboom
- Division of Clinical Methods and Public Health, Master Evidence Based Practice, Academic Medical Centre, University of Amsterdam, Amsterdam 1100 DD, The Netherlands
| | - Rob de Haan
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, J1b-118, Amsterdam 1100 DD, The Netherlands
| | - Naomi van der Linden
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam 3000 DR, The Netherlands
| | - Ernie Rjt de Deckere
- Accident and Emergency Department, Medical Centre Haaglanden, The Hague 2501 CK, The Netherlands
| | - Cees Lucas
- Division of Clinical Methods and Public Health, Master Evidence Based Practice, Academic Medical Centre, University of Amsterdam, Amsterdam 1100 DD, The Netherlands
| | - Steven J Rhemrev
- Accident and Emergency Department, Medical Centre Haaglanden, The Hague 2501 CK, The Netherlands
| | - J Carel Goslings
- Department of Surgery, Trauma Unit, Academic Medical Centre, University of Amsterdam, Amsterdam 1100 DD, The Netherlands
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Blom MC, Jonsson F, Landin-Olsson M, Ivarsson K. Associations between in-hospital bed occupancy and unplanned 72-h revisits to the emergency department: a register study. Int J Emerg Med 2014; 7:25. [PMID: 25045408 PMCID: PMC4080705 DOI: 10.1186/s12245-014-0025-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 06/11/2014] [Indexed: 11/21/2022] Open
Abstract
Background A possible downstream effect of high in-hospital bed occupancy is that patients in the emergency department (ED) who would benefit from in-hospital care are denied admission. The present study aimed at evaluating this hypothesis through investigating associations between in-hospital bed occupancy at the time of presentation in the ED and the probability for unplanned 72-hour (72-h) revisits to the ED among patients discharged at index. A second outcome was unplanned 72-h revisits resulting in admission. Methods All visits to the ED of a 420-bed emergency hospital in southern Sweden between 1 January 2011 and 31 December 2012, which did not result in admission, death, or transfer to another hospital were included. Revisiting fractions were computed for in-hospital occupancy intervals <85%, 85% to 90%, 90% to 95%, 95% to 100%, 100% to 105%, and ≥105%. Multivariate models were constructed in an attempt to take confounding factors from, e.g., presenting complaints, age, referral status, and triage priority into account. Results Included in the study are 81,878 visits. The fraction of unplanned 72-h revisits/unplanned 72-h revisits resulting in admission was 5.8%/1.4% overall, 6.2%/1.4% for occupancy <85%, 6.4%/1.5% for occupancy 85% to 90%, 5.8%/1.4% for occupancy 90% to 95%, 6.0%/1.6% for occupancy 95% to 100%, 5.4%/1.6% for occupancy 100% to 105%, and 4.9%/1.4% for occupancy ≥105%. In the multivariate models, a trend to lower probability of unplanned 72-h revisits was observed at occupancy ≥105% compared to occupancy <95% (OR 0.88, CI 0.76 to 1.01). No significant associations between in-hospital occupancy at index and the probability of making unplanned 72-h revisits resulting in admission were observed. Conclusions The lack of associations between in-hospital occupancy and unplanned 72-h revisits does not support the hypothesis that ED patients are inappropriately discharged when in-hospital beds are scarce. The results are reassuring as they indicate that physicians are able to make good decisions, also while resources are constrained.
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Affiliation(s)
- Mathias C Blom
- Department of Clinical Science Lund, Lund University, Hs 32, EA-blocket, Plan 2, Lund 22185, Sweden
| | - Fredrik Jonsson
- Department of Emergency, Helsingborg Hospital, S Vallgatan 5, Helsingborg 25187, Sweden
| | - Mona Landin-Olsson
- Department of Clinical Science Lund, Lund University, Hs 32, EA-blocket, Plan 2, Lund 22185, Sweden
| | - Kjell Ivarsson
- Department of Clinical Science Lund, Lund University, Hs 32, EA-blocket, Plan 2, Lund 22185, Sweden
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