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Graham B, Smith JE, Wei Y, Nelmes P, Latour JM. Psychometric validation of a patient-reported experience measure for older adults attending the emergency department: the PREM-ED 65 study. Emerg Med J 2024:emermed-2023-213521. [PMID: 38834289 DOI: 10.1136/emermed-2023-213521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 05/21/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Optimising emergency department (ED) patient experience is vital to ensure care quality. However, there are few validated instruments to measure the experiences of specific patient groups, including older adults. We previously developed a draft 82-item Patient Reported Experience Measure (PREM-ED 65) for adults ≥65 attending the ED. This study aimed to derive a final item list and provide initial validation of the PREM-ED 65 survey. METHODS A cross-sectional study involving patients in 18 EDs in England. Adults aged 65 years or over, deemed eligible for ED discharge, were recruited between May and August 2021 and asked to complete the 82-item PREM at the end of the ED visit and 7-10 days post discharge. Test-retest reliability was assessed 7-10 days following initial attendance. Analysis included descriptive statistics, including per-item proportions of responses, hierarchical item reduction, exploratory factor analysis (EFA), reliability testing and assessment of criterion validity. RESULTS Five hundred and ten initial surveys and 52 retest surveys were completed. The median respondent age was 76. A similar gender mix (men 47.5% vs women 50.7%) and reason for attendance (40.3% injury vs 49.0% illness) was observed. Most participants self-reported their ethnicity as white (88.6%).Hierarchical item reduction identified 53/82 (64.6%) items for exclusion, due to inadequate engagement (n=33), ceiling effects (n=5), excessive inter-item correlation (n=12) or significant differential validity (n=3). Twenty-nine items were retained.EFA revealed 25 out of the 29 items demonstrating high factor loadings (>0.4) across four scales with an Eigenvalue >1. These scales were interpreted as measuring 'relational care', 'the ED environment', 'staying informed' and 'pain assessment'. Cronbach alpha for the scales ranged from 0.786 to 0.944, indicating good internal consistency. Test-retest reliability was adequate (intraclass correlation coefficient 0.67). Criterion validity was fair (r=0.397) when measured against the Friends and Families Test question. CONCLUSIONS Psychometric testing demonstrates that the 25-item PREM-ED 65 is suitable for administration to adults ≥65 years old up to 10 days following ED discharge.
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Affiliation(s)
- Blair Graham
- Faculty of Health and Human Sciences, University of Plymouth Faculty of Health and Human Sciences, Plymouth, UK
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Yinghui Wei
- School of Engineering, Computing and Mathematics, Plymouth University, Plymouth, UK
| | - Pamela Nelmes
- Faculty of Health and Human Sciences, University of Plymouth Faculty of Health and Human Sciences, Plymouth, UK
| | - Jos M Latour
- Faculty of Health, University of Plymouth, Plymouth, UK
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
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Ruhe MM, Veldhuis LI, Azijli-Abdelloui K, Schepers T, Ridderikhof ML. Prehospital analgesia in suspected hip fracture patients: adherence to national prehospital pain management guidelines. Eur J Trauma Emerg Surg 2024; 50:937-943. [PMID: 37957364 DOI: 10.1007/s00068-023-02385-8] [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: 06/25/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE Patients with hip fractures frequently present at the emergency department (ED). Despite high pain scores, prehospital pain management is often inadequate and insufficient. In the Netherlands, the emergency medical services (EMS) exhibit a high level of training, supported by a comprehensive pain treatment protocol. This study aimed to assess adherence to the protocol and hypothesized that prehospital pain management in hip fracture patients was both sufficient and adequate. METHODS This was a retrospective observational cohort study of patients with suspected hip fractures. The median differences in numerical rating scale (NRS) pain scores between the initial score in the ambulance and upon arrival at the ED were compared. Furthermore, adherence to the ambulance pain protocol was studied. RESULTS From September 2016 to March 2021, 436 ambulance-transported hip fracture patients were included, of whom 81% received analgesics by EMS. The median initial pain score measured by EMS was 8; this number decreased to 5 at ED presentation, a significant decrease (ρ < 0.001). In case a prehospital NRS pain score was assessed, 66.5% of the patients were treated according to the protocol. In 80% of patients, the protocol was not followed correctly, primarily due to missing NRS pain scores. CONCLUSION In suspected hip fracture patients, initial prehospital pain scores were high and most patients received analgesics from EMS. This resulted in a significant decrease in pain. In nearly 67% of patients in whom an NRS pain score was assessed in the prehospital phase, pain management was according to protocol. However, in 80% of the total population the pain protocol was not adhered to, mainly due to missing NRS pain scores.
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Affiliation(s)
- Michelle Manon Ruhe
- Department of Emergency Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Lars I Veldhuis
- Department of Emergency Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Kaoutar Azijli-Abdelloui
- Department of Emergency Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Tim Schepers
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Milan L Ridderikhof
- Department of Emergency Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
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3
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Smith J, Soo D, Celenza A. Triage-initiated intranasal fentanyl for hip fractures in an Emergency Department - Results from introduction of an analgesic guideline. Int Emerg Nurs 2024; 74:101445. [PMID: 38579496 DOI: 10.1016/j.ienj.2024.101445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Pain relief is a priority for patients with hip fractures who present to Emergency Departments (EDs). Intranasal fentanyl (INF) is an ideal option for nurse initiated analgesia as it does not require intravenous access and can expedite care prior to examination by a physician. LOCAL PROBLEM Pain relief in patients with hip fractures is delayed during episodes of ED crowding. METHODS A retrospective medical record review was conducted following introduction of an INF guideline in an adult ED in 2018. Patients were included over a 4-month period during which the guideline was introduced. Historical and concurrent control groups receiving usual care were compared to patients receiving INF. INTERVENTIONS This quality improvement initiative investigated whether an INF analgesia at triage guideline would decrease time to analgesic administration in adults with hip fracture in ED. RESULTS This study included 112 patients diagnosed with fractured hips of which 16 patients received INF. Background characteristics were similar between groups. Mean time to analgesic administration (53 v 110 minutes), time to x-ray (46 v 75 minutes), and ED length of stay (234 v 298 minutes) were significantly decreased in the intervention group. Inadequate documentation was a limiting factor in determining improved efficacy of analgesia. CONCLUSION Use of triage-initiated INF significantly decreased time to analgesic administration, time to imaging and overall length of stay in ED.
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Affiliation(s)
- Jennifer Smith
- Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia
| | - Danny Soo
- Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia
| | - Antonio Celenza
- Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia; Division of Emergency Medicine, University of Western Australia, Stirling Highway, Nedlands, Western Australia, Australia.
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Labmayr V, Rief M, Reinbacher P, Gebauer D, Smigaj J, Sandner-Kiesling A, Papamargaritis V, Michaeli K, Bornemann-Cimenti H, Schittek GA. Simplified Pain Management Including Fentanyl TTS in PACU Patients With Hip Fracture Surgery to Improve Patients' Well-Being: A Double-Blind Randomized Trial. J Perianesth Nurs 2024; 39:461-467. [PMID: 38085188 DOI: 10.1016/j.jopan.2023.10.004] [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: 02/27/2023] [Revised: 08/16/2023] [Accepted: 10/10/2023] [Indexed: 06/03/2024]
Abstract
PURPOSE Adequate pain management is eminently relevant for elderly and more vulnerable patients with hip fractures in the setting of pre and postoperative pain. This study compares postoperative hip fracture patients treated with standard pain management with a variety of medications or an approach with only one option in each medication category (nonopioid: acetaminophen; opioid: fentanyl TTS 12,5 mcg/hour; rescue medication: piritramide) to simplify the treatment algorithm for nurses and improve patient well-being. DESIGN Double-blind randomized controlled trial. METHODS The sample was cognitively intact patients (N = 141) with hip fractures in a tertiary university hospital. Administration of fentanyl 12 mcg/hour transdermal therapeutic system was administered by the nurses in the postanesthesia care unit (PACU) to address basal wound pain to improve patient well-being and patient treatment in the PACU for 24 hours to better control for early complications. FINDINGS Well-being was equally increased in both groups in comparison to our preintervention data from 35.7% to over 60% and did not differ significantly between the intervention and control group. No statistically significant differences in numeric rating scale scores, rescue opioid dosage (piritramide i.v.) or in complications were present. CONCLUSIONS This one-size-fits-all simplified pain management approach did not improve patient well-being or any other outcome but highlighted the importance of adequate pain management and a sufficient nurse-to-patient ratio.
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Affiliation(s)
- Viktor Labmayr
- Department of Orthopedic Surgery, Medical University of Graz, Graz, Austria
| | - Martin Rief
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Patrick Reinbacher
- Department of Orthopedic Surgery, Medical University of Graz, Graz, Austria
| | - David Gebauer
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Jana Smigaj
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Sandner-Kiesling
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Vasileios Papamargaritis
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Kristina Michaeli
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Helmar Bornemann-Cimenti
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Gregor A Schittek
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria.
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Parvaresh-Masoud M, Cheraghi MA, Imanipour M. Nurses' perception of emergency department overcrowding: A qualitative study. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2024; 12:449. [PMID: 38464660 PMCID: PMC10920764 DOI: 10.4103/jehp.jehp_1789_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/28/2023] [Indexed: 03/12/2024]
Abstract
INTRODUCTION One of the most important wards of the hospital is the emergency department (ED). Due to the increasing number of referrals, overcrowding has become a significant problem. It means an increase in patients' referrals and swarms at the ED, limiting their medical staff access. This study investigates the nurses' experiences and perceptions about the reasons for ED overcrowding. MATERIALS AND METHODS Twelve emergency nurses were purposefully selected to take part in this study. Data collection was through face-to-face semi-structured interviews until data saturation was finalized. Data analysis was conducted using Graneheim and Lundman's conventional content analysis. RESULTS Nurses' experiences with the reasons for ED overcrowding came into two main categories. The first was "increased referral to the emergency department," which had three subcategories: "increased referral due to health system reform plan," "increased referral due to corona pandemic," and "improper triage." The second was "increased patients' length of stay at the ED" with seven subcategories including "shortage of bed," "shortage of nursing staff," "lack of physical space," "turtle para-clinic," "on-call specialists' delay," "timely medical record documentation requirements," and "delaying in patients' transfer from the ED to the ward." CONCLUSION The results showed ED overcrowding is inevitable. Intentional or unintentional changes in the health system, such as implementing the health system reform plan or the corona pandemic, can also increase overcrowding. Findings showed ED overcrowding increased referrals and patients' length of stay. This study suggests the health system authorities pay more attention to this phenomenon and look for solutions.
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Affiliation(s)
- Mohammad Parvaresh-Masoud
- Department of Emergency Medicine, Paramedical Faculty, Qom University of Medical Sciences, Qom, Iran
- Department of Critical Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Cheraghi
- Department of Nursing Management, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoomeh Imanipour
- Department of Critical Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
- Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
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Chary AN, Cameron-Comasco L, Shankar KN, Samuels-Kalow ME. Diversity, Equity, and Inclusion: Considerations in the Geriatric Emergency Department Patient. Clin Geriatr Med 2023; 39:673-686. [PMID: 37798072 PMCID: PMC10775156 DOI: 10.1016/j.cger.2023.04.009] [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] [Indexed: 10/07/2023]
Abstract
This article introduces core topics in health equity scholarship and provides examples of how diversity, equity, and inclusion impact the aging population and emergency care of older adults. It offers strategies for promoting diversity, equity, and inclusion to both strengthen the patient-clinician therapeutic relationship and to address operations and systems that impact care of the geriatric emergency department patient.
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Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Baylor College of Medicine, 2450 Holcombe Boulevard, Suite 01Y, Houston, TX 77021, USA; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, 2450 Holcombe Boulevard, Suite 01Y, Houston, TX 77021, USA.
| | - Lauren Cameron-Comasco
- Department of Emergency Medicine, Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA
| | - Kalpana N Shankar
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA
| | - Margaret E Samuels-Kalow
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 9206, Boston, MA 02114, USA
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7
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Thiam CN, Khor HM, Pang GHM, Lim WC, Shanmugam T, Chandrasekaran CSK, Singh S, Zakaria MIB, Ong T. Hip fracture management in the emergency department and its impact on hospital outcomes: a retrospective cross-sectional analysis. Eur Geriatr Med 2022; 13:1081-1088. [PMID: 35567676 DOI: 10.1007/s41999-022-00654-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The emergency department (ED) plays an important role in initiating early treatment for hip fractures and ensuring prompt transfer to orthopaedic wards. This study reported on the care delivered in a tertiary centre ED in Malaysia and the association between time spent in ED with hospital outcomes. METHODS Patients aged ≥ 65 years with fragility hip fractures and seen by the geriatric team were recruited. Data were collected on patient characteristics, key time points for treatment and hospital outcomes. Median time in ED was used to dichotomise long and short waiting time. RESULTS 447 patients were recruited. The mean (SD) age was 80.5 (7.0) years and 69.8% were women. 74.9% were prescribed analgesia within 30 min. Median (Q1,Q3) time to diagnostic imaging was 27.0 (24.0-43.0) minutes, clinician confirmation of fracture was 83.0 (49.0-129.0) minutes, and time in ED was 4.8 (3.5-6.9) h. A weekday, weekend, in-hour or out-of-hour admission did not demonstrate a difference in the time important care was delivered. Patients who spent ≥ 5 h in ED had more cardiac events (4.6 vs 10.1%, p = 0.023) and more spent ≥ 14 days in hospital (17.5 vs 29.0%, p = 0.004) compared to those < 5 h. No significant increase in inpatient complications (43.5 vs 34.6%, p = 0.054), length of stay (median, 8 vs 7 days, p = 0.119), care home discharge (5.3 vs 4.6%, p = 0.772), or in-hospital death (6.3 vs 4.2%, p = 0.313) were observed. CONCLUSION Time to early hip fracture pain relief and diagnosis was adequate in this ED. Time ≥ 5 h in ED was associated with cardiac events and 2 weeks or more inpatient stay.
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Affiliation(s)
- Chiann Ni Thiam
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of General Medicine, Hospital Kuala Lumpur, Ministry of Health, Jalan Pahang, 50586, Kuala Lumpur, Malaysia
| | - Hui Min Khor
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of Medicine, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Gordon Hwa Mang Pang
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of General Medicine, Hospital Kuala Lumpur, Ministry of Health, Jalan Pahang, 50586, Kuala Lumpur, Malaysia
| | - Wan Chieh Lim
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of General Medicine, Hospital Kuala Lumpur, Ministry of Health, Jalan Pahang, 50586, Kuala Lumpur, Malaysia
| | - Tharshne Shanmugam
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia
| | - C Sankara Kumar Chandrasekaran
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of Orthopaedic Surgery, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Simmrat Singh
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of Orthopaedic Surgery, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Mohd Idzwan Bin Zakaria
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Academic Unit Trauma and Emergency, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Terence Ong
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia. .,Department of Medicine, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia.
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Savioli G, Ceresa IF, Gri N, Bavestrello Piccini G, Longhitano Y, Zanza C, Piccioni A, Esposito C, Ricevuti G, Bressan MA. Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions. J Pers Med 2022; 12:279. [PMID: 35207769 PMCID: PMC8877301 DOI: 10.3390/jpm12020279] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 12/14/2022] Open
Abstract
It is certain and established that overcrowding represents one of the main problems that has been affecting global health and the functioning of the healthcare system in the last decades, and this is especially true for the emergency department (ED). Since 1980, overcrowding has been identified as one of the main factors limiting correct, timely, and efficient hospital care. The more recent COVID-19 pandemic contributed to the accentuation of this phenomenon, which was already well known and of international interest. Considering what would appear to be a trivial definition of overcrowding, it may seem simple for the reader to hypothesize solutions for what seems to be one of the most avoidable problems affecting the hospital system. However, proposing solutions to overcrowding, as well as their implementation, cannot be separated from a correct and precise definition of the issue, which must consider the main causes and aggravating factors. In light of the need of finding solutions that can put an end to hospital overcrowding, this review aims, through a review of the literature, to summarize the triggering factors, as well as the possible solutions that can be proposed.
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Affiliation(s)
- Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy; (G.S.); (M.A.B.)
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | | | - Nicole Gri
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy; (N.G.); (G.B.P.)
| | - Gaia Bavestrello Piccini
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy; (N.G.); (G.B.P.)
- School of Master in Emergency Medicine, Université Libre de Bruxelles, 1050 Brussels, Belgium
| | - Yaroslava Longhitano
- Foundation “Ospedale Alba-Bra Onlus”, Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital, 12060 Verduno, Italy;
- Research Training Innovation Infrastructure, Research and Innovation Department, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Christian Zanza
- Foundation “Ospedale Alba-Bra Onlus”, Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital, 12060 Verduno, Italy;
- Research Training Innovation Infrastructure, Research and Innovation Department, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy;
| | - Andrea Piccioni
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy;
| | - Ciro Esposito
- Unit of Nephrology and Dialysis, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Giovanni Ricevuti
- School of Pharmacy, Department of Drug Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Maria Antonietta Bressan
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy; (G.S.); (M.A.B.)
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Badr S, Nyce A, Awan T, Cortes D, Mowdawalla C, Rachoin JS. Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:5-14. [PMID: 35018125 PMCID: PMC8742612 DOI: 10.2147/oaem.s338079] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.
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Affiliation(s)
- Samer Badr
- Division of Hospital Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Andrew Nyce
- Department of Emergency Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Taha Awan
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Dennise Cortes
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Cyrus Mowdawalla
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jean-Sebastien Rachoin
- Division of Hospital Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA.,Division of Critical Care, Cooper University Health Care, Camden, NJ, USA
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10
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Lvovschi VE, Hermann K, Lapostolle F, Joly LM, Tavolacci MP. Bedside Evaluation of Early VAS/NRS Based Protocols for Intravenous Morphine in the Emergency Department: Reasons for Poor Follow-Up and Targeted Practices. J Clin Med 2021; 10:jcm10215089. [PMID: 34768612 PMCID: PMC8584399 DOI: 10.3390/jcm10215089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
Intravenous (IV) morphine protocols based on patient-reported scores, immediately at triage, are recommended for severe pain in Emergency Departments. However, a low follow-up is observed. Scarce data are available regarding bedside organization and pain etiologies to explain this phenomenon. The objective was the real-time observation of motivations and operational barriers leading to morphine avoidance. In a single French hospital, 164 adults with severe pain at triage were included in a cross-sectional study of the prevalence of IV morphine titration; caregivers were interviewed by real-time questionnaires on “real” reasons for protocol avoidance or failure. IV morphine prevalence was 6.1%, prescription avoidance was mainly linked to “Pain reassessment” (61.0%) and/or “alternative treatment prioritization” (49.3%). To further evaluate the organizational impact on prescription decisions, a parallel assessment of “simulated” prescription conditions was simultaneously performed for 98/164 patients; there were 18 titration decisions (18.3%). Treatment prioritization was a decision driver in the same proportion, while non-eligibility for morphine was more frequently cited (40.6% p = 0.001), with higher concerns about pain etiologies. Anticipation of organizational constraints cannot be excluded. In conclusion, IV morphine prescription is rarely based on first pain scores. Triage assessment is used for screening by bedside physicians, who prefer targeted practices to automatic protocols.
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Affiliation(s)
- Virginie Eve Lvovschi
- Emergency Department, UNIROUEN, INSERM U 1073, Rouen University Hospital, INSERM CIC-CRB 1404, F-76031 Rouen, France
- Correspondence:
| | - Karl Hermann
- Rouen University Hospital, INSERM CIC-CRB 1404, F-76000 Rouen, France;
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, INSERM U 942, Hôpital Avicenne, F-93009 Bobigny, France;
| | - Luc-Marie Joly
- Emergency Department, Rouen University Hospital, F-76031 Rouen, France;
| | - Marie-Pierre Tavolacci
- Normandie University, UNIROUEN, INSERM U 1073, Rouen University Hospital, INSERM CIC-CRB 1404, F-76031 Rouen, France;
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11
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Stryckman B, Kuhn D, Gingold DB, Fischer KR, Gatz JD, Schenkel SM, Browne BJ. Balancing Efficiency and Access: Discouraging Emergency Department Boarding in a Global Budget System. West J Emerg Med 2021; 22:1196-1201. [PMID: 34546898 PMCID: PMC8463045 DOI: 10.5811/westjem.2021.5.51889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/12/2021] [Indexed: 11/15/2022] Open
Abstract
Reducing cost without sacrificing quality of patient care is an important yet challenging goal for healthcare professionals and policymakers alike. This challenge is at the forefront in the United States, where per capita healthcare costs are much higher than in similar countries around the world. The state of Maryland is unique in the hospital financing landscape due to its “capitation” payment system (also known as “global budget”), in which revenue for hospital-based services is set at the beginning of the year. Although Maryland’s system has yielded many benefits, including reduced Medicare spending, it also has had unintentional adverse consequences. These consequences, such as increased emergency department boarding and ambulance diversion, constrain Maryland hospitals’ ability to fulfill their role as emergency care providers and act as a safety net for vulnerable patient populations. In this article, we suggest policy remedies to mitigate the unintended consequences of Maryland’s model that should also prove instructive for a variety of emerging alternative payment mechanisms.
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Affiliation(s)
- Benoit Stryckman
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Diane Kuhn
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Daniel B Gingold
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Kyle R Fischer
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - J David Gatz
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Stephen M Schenkel
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Brian J Browne
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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12
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Keister LA, Stecher C, Aronson B, McConnell W, Hustedt J, Moody JW. Provider Bias in prescribing opioid analgesics: a study of electronic medical Records at a Hospital Emergency Department. BMC Public Health 2021; 21:1518. [PMID: 34362330 PMCID: PMC8344207 DOI: 10.1186/s12889-021-11551-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background Physicians do not prescribe opioid analgesics for pain treatment equally across groups, and such disparities may pose significant public health concerns. Although research suggests that institutional constraints and cultural stereotypes influence doctors’ treatment of pain, prior quantitative evidence is mixed. The objective of this secondary analysis is therefore to clarify which institutional constraints and patient demographics bias provider prescribing of opioid analgesics. Methods We used electronic medical record data from an emergency department of a large U.S hospital during years 2008–2014. We ran multi-level logistic regression models to estimate factors associated with providing an opioid prescription during a given visit while controlling for ICD-9 diagnosis codes and between-patient heterogeneity. Results A total of 180,829 patient visits for 63,513 unique patients were recorded during the period of analysis. Overall, providers were significantly less likely to prescribe opioids to the same individual patient when the visit occurred during higher rates of emergency department crowding, later times of day, earlier in the week, later years in our sample, and when the patient had received fewer previous opioid prescriptions. Across all patients, providers were significantly more likely to prescribe opioids to patients who were middle-aged, white, and married. We found no bias towards women and no interaction effects between race and crowding or between race and sex. Conclusions Providers tend to prescribe fewer opioids during constrained diagnostic situations and undertreat pain for patients from high-risk and marginalized demographic groups. Potential harms resulting from previous treatment decisions may accumulate by informing future treatment decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11551-9.
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Affiliation(s)
- Lisa A Keister
- Department of Sociology, Duke Network Analysis, Sanford School of Public Policy, Duke University, Durham, NC, 27705, USA.
| | - Chad Stecher
- College of Health Solutions, Arizona State University, Phoenix, AZ, 85004, USA
| | - Brian Aronson
- The Adecco Group, 10151 Deerwood Park Blvd bldg 200 ste 101, Jacksonville, FL, 32256, USA
| | - William McConnell
- Department of Sociology, Florida Atlantic University, 777 Glades Road
- CU 97 Rm 253, Boca Raton, FL, 33431, USA
| | - Joshua Hustedt
- Department of Orthopedics, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, 85004, USA
| | - James W Moody
- Department of Sociology, Duke Network Analysis, Duke University, Durham, NC, 27705, USA
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13
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Lee JS, Bhandari T, Simard R, Emond M, Topping C, Woo M, Perry J, Eagles D, McRae AD, Lang E, Wong C, Sivilotti M, Newbigging J, Borgundvaag B, McLeod SL, Melady D, Chernoff L, Kiss A, Chenkin J. Point-of-care ultrasound-guided regional anaesthesia in older ED patients with hip fractures: a study to test the feasibility of a training programme and time needed to complete nerve blocks by ED physicians after training. BMJ Open 2021; 11:e047113. [PMID: 34226222 PMCID: PMC8258568 DOI: 10.1136/bmjopen-2020-047113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Point-of-care ultrasound-guided regional anaesthesia (POCUS-GRA) provides safe, rapid analgesia for older people with hip fractures but is rarely performed in the emergency department (ED). Self-perceived inadequate training and time to perform POCUS-GRA are the two most important barriers. Our objective is to assess the feasibility of a proposed multicentre, stepped-wedge cluster randomised clinical trial (RCT) to assess the impact of a knowledge-to-practice (KTP) intervention on delirium. DESIGN Open-label feasibility study. SETTING An academic tertiary care Canadian ED (annual visits 60 000). PARTICIPANTS Emergency physicians working at least one ED shift per week, excluding those already performing POCUS-GRA more than four times per year. INTERVENTION A KTP intervention, including 2-hour structured training sessions with procedure bundle and email reminders. PRIMARY AND SECONDARY OUTCOME MEASURES The primary feasibility outcome is the proportion of eligible physicians that completed training and subsequently performed POCUS-GRA. Secondary outcome is the time needed to complete POCUS-GRA. We also test the feasibility of the enrolment, consent and randomisation processes for the future stepped-wedge cluster RCT (NCT02892968). RESULTS Of 36 emergency physicians, 4 (12%) were excluded or declined participation. All remaining 32 emergency physicians completed training and 31 subsequently treated at least one eligible patient. Collectively, 27/31 (87.1%) performed 102 POCUS-GRA blocks (range 1-20 blocks per physician). The median (IQR) time to perform blocks was 15 (10-20) min, and reduction in pain was 6/10 (3-7) following POCUS-GRA. There were no reported complications. CONCLUSION Our KTP intervention, consent process and randomisation were feasible. The time to perform POCUS-GRA rarely exceeded 30 min, Our findings reinforce the existing data on the safety and effectiveness of POCUS-GRA, mitigate perceived barriers to more widespread adoption and demonstrate the feasibility of trialling this intervention for the proposed stepped-wedge cluster RCT. TRIAL REGISTRATION NUMBER Clinicaltrials.gov #02892968.
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Affiliation(s)
- Jacques Simon Lee
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tina Bhandari
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Robert Simard
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Marcel Emond
- Axe Santé des populations et pratiques optimales en santé, Universite Laval, Quebec, Québec, Canada
- Departément de medécine d'urgence, Universite Laval, Quebec, Québec, Canada
| | - Claude Topping
- Axe Santé des populations et pratiques optimales en santé, Universite Laval, Quebec, Québec, Canada
- Department of Family and Emergency Medicine, Universite Laval, Quebec, Québec, Canada
| | - Michael Woo
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andrew D McRae
- Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Charles Wong
- Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marco Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Joseph Newbigging
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Donald Melady
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lan Chernoff
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alex Kiss
- Department of Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jordan Chenkin
- Division of Emergency Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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14
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Inhaled methoxyflurane for the management of trauma related pain in patients admitted to hospital emergency departments: a randomised, double-blind placebo-controlled trial (PenASAP study). Eur J Emerg Med 2021; 27:414-421. [PMID: 32282467 DOI: 10.1097/mej.0000000000000686] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Oligo-analgesia is common in the emergency department (ED). This study aimed at reporting, when initiated by triage nurse, the superior efficacy of inhaled methoxyflurane plus standard of care (m-SoC) analgesia versus placebo plus SoC (p-SoC) for moderate-to-severe trauma-related pain in the hospital ED. METHODS A randomised, double-blind, placebo-controlled trial was conducted at eight EDs. Adults with pain score ≥4 (11-point numerical rate scale, NRS) at admission were randomised to receive one or two inhalers containing m-SoC or p-SoC. Primary outcome measure was time until pain relief ≤30 mm, assessed on the 100-mm Visual Analogic Scale (VAS). RESULTS A total of 351 patients were analysed (178 m-SoC; 173 p-SoC). Median pain prior to first inhalation was 66 mm, 75% had severe pain (NRS 6-10). Median time to pain relief was 35 min [95% confidence interval (CI), 28-62] for m-SoC versus not reached in p-SoC (92 - not reached) [hazard ratio), 1.93 (1.43-2.60), P < 0.001]. Pain relief was most pronounced in the severe pain subgroup: hazard ratio, 2.5 (1.7-3.7). As SoC, 24 (7%) patients received weak opioids (6 versus 8%), 4 (1%) strong opioid and 44 (13%) escalated to weak or strong opioids (8 versus 17%, respectively, P = 0.02). Most adverse events were of mild (111/147) intensity. CONCLUSIONS In this study, we report that methoxyflurane, initiated at triage nurse as part of a multimodal analgesic approach, is effective in achieving pain relief for trauma patients. This effect was particularly pronounced in the severe pain subgroup.
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15
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Hoot NR, Banuelos RC, Chathampally Y, Robinson DJ, Voronin BW, Chambers KA. Does crowding influence emergency department treatment time and disposition? J Am Coll Emerg Physicians Open 2021; 2:e12324. [PMID: 33521777 PMCID: PMC7819268 DOI: 10.1002/emp2.12324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/21/2020] [Accepted: 10/28/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The objective of this study was to determine whether crowding influences treatment times and disposition decisions for emergency department (ED) patients. METHODS We conducted a retrospective cohort study at 2 hospitals from January 1, 2014, to July 1, 2014. Adult ED visits with dispositions of discharge, admission, or transfer were included. Treatment times were modeled by linear regression with log-transformation; disposition decisions (admission or transfer vs discharge) were modeled by logistic regression. Both models adjusted for chief complaint, Emergency Severity Index (ESI), and 4 crowding metrics in quartiles: waiting count, treatment count, boarding count, and National Emergency Department Overcrowding Scale. RESULTS We included 21,382 visits at site A (12.9% excluded) and 29,193 at site B (15.0% excluded). Respective quartiles of treatment count increased treatment times by 7.1%, 10.5%, and 13.3% at site A (P < 0.001) and by 4.0%, 6.5%, and 10.2% at site B (P < 0.001). The fourth quartile of treatment count increased estimates of treatment time for patients with chest pain and ESI level 2 from 2.5 to 2.9 hours at site A (20 minutes) and from 3.0 to 3.3 hours at site B (18 minutes). Treatment times decreased with quartiles of waiting count by 5.6%, 7.2%, and 7.3% at site B (P < 0.001). Odds of admission or transfer increased with quartiles of waiting count by 8.7%, 9.6%, and 20.3% at site A (P = 0.011) and for the third (11.7%) and fourth quartiles (27.3%) at site B (P < 0.001). CONCLUSIONS Local crowding influenced ED treatment times and disposition decisions at 2 hospitals after adjusting for chief complaint and ESI.
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Affiliation(s)
- Nathan R. Hoot
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Rosa C. Banuelos
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Yashwant Chathampally
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - David J. Robinson
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Benjamin W. Voronin
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Kimberly A. Chambers
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
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16
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Turner AJ, Anselmi L, Lau YS, Sutton M. The effects of unexpected changes in demand on the performance of emergency departments. HEALTH ECONOMICS 2020; 29:1744-1763. [PMID: 32978879 DOI: 10.1002/hec.4167] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 08/13/2020] [Accepted: 09/07/2020] [Indexed: 06/11/2023]
Abstract
Crowding in emergency departments (EDs) is increasing in many health systems. Previous studies of the relationship between crowding and care quality are limited by the use of data from single hospitals, a focus on particular patient groups, a focus on a narrow set of quality measures, and use of crowding measures which induce bias from unobserved hospital and patient characteristics. Using data from 139 hospitals covering all major EDss in England, we measure crowding using quasi-exogenous variation in the volume of EDs attendances and examine its impacts on indicators of performance across the entire EDs care pathway. We exploit variations from expected volume estimated using high-dimensional fixed effects capturing hospital-specific variation in attendances by combinations of month and hour-of-the-week. Unexpected increases in attendance volume result in substantially longer waiting times, lower quantity and complexity of care, more patients choosing to leave without treatment, changes in referral and discharge decisions, but only small increases in reattendances and no increase in mortality. Causal bounds under potential omitted variable bias are narrow and exclude zero for the majority of outcomes. Results suggest that physician and patient responses may largely mitigate the impacts of demand increases on patient outcomes in the short-run.
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Affiliation(s)
- Alex J Turner
- Health Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, The University of Manchester, Manchester, UK
| | - Laura Anselmi
- Health Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, The University of Manchester, Manchester, UK
| | - Yiu-Shing Lau
- Health Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, The University of Manchester, Manchester, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, The University of Manchester, Manchester, UK
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17
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Sheehan JR, Wilson S, Quinlan J, Beer S, Darwent M, Dainty JR, Ezra M, Keating L. Prescription Of analgesia in Emergency Medicine (POEM): a multicentre observational survey of pain relief in patients presenting with an isolated limb fracture and/or dislocation. Br J Pain 2020; 14:211-220. [PMID: 33194185 DOI: 10.1177/2049463719858513] [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] [Indexed: 11/15/2022] Open
Abstract
Background Acute pain is one of the most commonly cited reasons for attendance to the emergency department (ED), and the Royal College of Emergency Medicine (RCEM) Best Practice Guideline (2014) acknowledged that the current management of acute pain in UK EDs is inadequate and has a poor evidence base. Methods The Prescription Of analgesia in Emergency Medicine (POEM) survey is a cross-sectional observational survey of consecutive patients presenting to 12 National Health Service (NHS) EDs with limb fracture and/or dislocation in England and Scotland and was carried out between 2015 and 2017. The primary outcome was to assess the adequacy of pain management in the ED against the recommendations in the RCEM Best Practice Guidelines. Results In all, 8346 patients were identified as attending the ED with a limb fracture and/or dislocation but adherence to RCEM guidelines could only be evaluated for the 4160 (49.8%) patients with a recorded pain score. Of these, 2409/4160 (57.9%) patients received appropriate pain relief, but only 1347 patients were also assessed within 20 minutes of their arrival in the ED. Therefore, according to the RCEM guidelines, only 16.1% (1347/8346) of all patients were assessed and had satisfactory pain management in the ED. Conclusions The POEM survey has identified that pain relief for patients with an isolated limb fracture remains inadequate when strictly compared to the RCEM Best Practice Guidelines. However, we have found that some patients receive analgesia despite having no pain score recorded, while other analgesic modalities are provided that are not currently encompassed by the Best Practice Guidelines. Future iterations of these guidelines may wish to encompass the breadth of available modalities of pain relief and the whole patient journey. In addition, more work is needed to improve timely and repeated assessment of pain and its recording, which has been better achieved in some EDs than others.
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Affiliation(s)
- James Robert Sheehan
- Department of Anaesthesia, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sarah Wilson
- Emergency Department, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Jane Quinlan
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sally Beer
- Emergency Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Melanie Darwent
- Emergency Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jack R Dainty
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Martyn Ezra
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Liza Keating
- Emergency Department, Royal Berkshire Hospital NHS Foundation Trust, Reading, UK
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18
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Savioli G, Ceresa IF, Maggioni P, Lava M, Ricevuti G, Manzoni F, Oddone E, Bressan MA. Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care. MEDICINES 2020; 7:medicines7100060. [PMID: 32987644 PMCID: PMC7598623 DOI: 10.3390/medicines7100060] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/07/2020] [Accepted: 09/11/2020] [Indexed: 02/07/2023]
Abstract
Background: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients’ characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient’s clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients’ management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusions: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-340-9070-001
| | - Iride Francesca Ceresa
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
| | - Paolo Maggioni
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
| | - Massimiliano Lava
- Neuro Radiodiagnostic, Irccs Policlinico San Matteo, 27100 Pavia, Italy;
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, Italy, Saint Camillus International University of Health Sciences, 00131 Rome, Italy;
| | - Federica Manzoni
- Clinical Epidemiology and Biometry Unit, Irccs Policlinico San Matteo, 27100 Pavia, Italy;
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy;
| | - Maria Antonietta Bressan
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
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Bahl A, Jamali AM, Ramesh G. Impact of Early Urine Specimen Collection on Emergency Department Time to Disposition: A Randomized Controlled Trial. Cureus 2020; 12:e10495. [PMID: 33083194 PMCID: PMC7567408 DOI: 10.7759/cureus.10495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Diagnostic testing in the ED increases the length of stay (LOS). Urinalysis testing is highlighted specifically as a source of delays. We aim to determine whether a triage-initiated urine specimen collection process decreases ED time to disposition (TTD) in ambulatory patients with abdominal pain. Methods This prospective, randomized controlled study was implemented at a Suburban Level One trauma ED with greater than 120,000 annual visits. A convenience sample of patients was recruited. Adult, non-ambulance patients presenting with abdominal pain were eligible. Participants were randomized into experimental and control groups. Patients in the control group provided a urine sample after physician evaluation, if ordered by the provider. Patients in the experimental group were prompted to provide a urine sample in the triage restrooms immediately after screening at the greeter desk. The UA sample was transported to the treatment area and sent to the laboratory after physician evaluation. Results A total of 125 control patients and 124 experimental patients were enrolled. Forty-two patients were excluded because they were unable to provide a urine sample. Patients who had a urinalysis ordered were included in statistical analysis. Final data set included 65 patients in the experimental group and 96 patients in the control group. No significant difference (p=0.5072) in disposition time between subjects in the experimental group (n=65, mean=5:17 [hours:min]) and subjects in the control group (n=96, mean=5:30) was found. Conclusions The triage protocol for urine specimen collection did not significantly reduce ED TTD. Further research in overcrowded EDs with long patient waiting room times may benefit from implementing a triage protocol for urine specimen collection.
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Affiliation(s)
- Amit Bahl
- Emergency Medicine, Beaumont Hospital, Royal Oak, USA
| | - Ameen M Jamali
- Emergency Medicine, Medical Center Health System, Odessa, USA
| | - Gautam Ramesh
- Emergency Medicine, Michigan State University College of Human Medicine, Lansing, USA
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20
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Fascia Iliaca Regional Anesthesia in Hip Fracture Patients Revisited: Which Fractures and Surgical Procedures Benefit Most? J Orthop Trauma 2020; 34:469-475. [PMID: 32815833 DOI: 10.1097/bot.0000000000001774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Perioperative fascia iliaca regional anesthesia (FIRA) decreases pain in hip fracture patients. The purpose of this study is to determine which hip fracture types and surgical procedures benefit most. DESIGN Prospective observational study compared with a retrospective historical control. PATIENTS/PARTICIPANTS Patients older than 60 years who received perioperative FIRA were compared with a historical cohort not receiving FIRA. SETTING This study was conducted at a Level 1 trauma center. MAIN OUTCOME MEASUREMENTS The primary outcome was morphine milliequivalents (MME) consumed during the index hospitalization. Fracture pattern-specific preoperative and postoperative MME consumption and surgical procedure-specific postoperative MME consumption was compared between the FIRA and non-FIRA groups. RESULTS A total of 949 patients were included in this study, with 194 (20.4%) patients in the prospective protocol group. There were no baseline differences between cohorts. Preoperatively, only femoral neck fracture patients receiving FIRA used fewer MME (P < 0.001). Postoperatively, femoral neck fracture patients receiving FIRA used fewer MME on postoperative day (POD) 1 (P = 0.027) and intertrochanteric fracture patients used fewer MME on POD1 and POD2 (P = 0.013; P = 0.002). Cephalomedullary nail patients receiving FIRA used fewer MME on POD1 and POD2 (P = 0.004; P = 0.003). Hip arthroplasty patients receiving FIRA used fewer MME on POD1 (P = 0.037). Percutaneous pinning and sliding hip screw patients had no significant MME reduction from FIRA. CONCLUSIONS Preoperatively, patients with femoral neck fractures benefit most from FIRA. Postoperatively, both patients with femoral neck fractures and intertrochanteric fractures benefit from FIRA. Patients undergoing cephalomedullary nail fixation or hip arthroplasty benefit most from FIRA postoperatively. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Schuijt HJ, Kusen J, van Hernen JJ, van der Vet P, Geraghty O, Smeeing DPJ, van der Velde D. Orthogeriatric Trauma Unit Improves Patient Outcomes in Geriatric Hip Fracture Patients. Geriatr Orthop Surg Rehabil 2020; 11:2151459320949476. [PMID: 32864179 PMCID: PMC7430081 DOI: 10.1177/2151459320949476] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Introduction: An aging population in developed countries has increased the number of
osteoporotic hip fractures and will continue to grow over the next decades.
Previous studies have investigated the effect of integrated orthogeriatric
trauma units and care model on outcomes of hip fracture patients. Although
all of the models perform better than usual care, there is no conclusive
evidence which care model is superior. More confirmative studies reporting
the efficacy of orthogeriatric trauma units are needed. The objective of
this study was to evaluate outcomes of hip fracture patients admitted to the
hospital before and after implementation of an orthogeriatric trauma
unit. Materials and methods: This retrospective cohort study was conducted at a level 2 trauma center
between 2016 and 2018. Patients aged 70 years or older with a hip fracture
undergoing surgery were included to evaluate the implementation of an
orthogeriatric trauma unit. The main outcomes were postoperative
complications, patient mortality, time spent at the emergency department,
time to surgery, and hospital length of stay. Results: A total of 806 patients were included. After implementation of the
orthogeriatric trauma unit, there was a significant decrease in
postoperative complications (42% vs. 49% in the historical cohort,
p = 0.034), and turnaround time at the emergency
department was reduced by 38 minutes. Additionally, there was significantly
less missing data after implementation of the orthogeriatric trauma unit.
After correcting for covariates, patients in the orthogeriatric trauma unit
cohort had a lower chance of complications (OR 0.654, 95% CI 0.471-0.908,
p = 0.011) and a lower chance of 1-year mortality (OR
0.656, 95% CI 0.450-0.957, p = 0.029). Conclusions: This study showed that implementation of an orthogeriatric trauma unit leads
to a decrease in postoperative complications, 1-year mortality, and time
spent at the emergency department, while also improving the quality of data
registration for clinical studies. Level of Evidence: Level III.
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Affiliation(s)
- Henk Jan Schuijt
- Department of Surgery, Sint Antonius Hospital, Utrecht, the Netherlands.,Department of Surgery, University Medical Center Utrecht, the Netherlands
| | - Jip Kusen
- Department of Surgery, Sint Antonius Hospital, Utrecht, the Netherlands.,Department of Surgery, University Medical Center Utrecht, the Netherlands
| | | | - Puck van der Vet
- Department of Surgery, Sint Antonius Hospital, Utrecht, the Netherlands.,Department of Surgery, University Medical Center Utrecht, the Netherlands
| | - Olivia Geraghty
- Department of Internal Medicine and Geriatrics, Sint Antonius Hospital, Utrecht, the Netherlands
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Garlich JM, Pujari A, Debbi EM, Yalamanchili DR, Moak ZB, Stephenson SK, Stephan SR, Polakof LS, Johnson CR, Noorzad AS, Little MTM, Moon CN, Black JT, Anand KK, Lin CA. Time to Block: Early Regional Anesthesia Improves Pain Control in Geriatric Hip Fractures. J Bone Joint Surg Am 2020; 102:866-872. [PMID: 32195685 DOI: 10.2106/jbjs.19.01148] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Fascia iliaca nerve blocks (FIBs) anesthetize the thigh and provide opioid-sparing analgesia for geriatric patients with hip fracture awaiting a surgical procedure. FIBs are recommended for preoperative pain management; yet, block administration is often delayed for hours after admission, and delays in pain management lead to worse outcomes. Our objective was to determine whether opioid consumption and pain following a hip fracture are affected by the time to block (TTB). We also examined length of stay and opioid-related adverse events. METHODS This prospective cohort study included patients who were ≥60 years of age, presented with a hip fracture, and received a preoperative FIB from March 2017 to December 2017. Individualized care timelines, including the date and time of admission, block placement, and surgical procedure, were created to evaluate the effect that TTB and time to surgery (TTS) had on outcomes. Patterns among TTB, TTS, and morphine milligram equivalents (MME) were investigated using the Spearman rho correlation. For descriptive purposes, we divided patients into 2 groups based on the median TTB. Multivariable regression for preoperative MME and length of stay was performed to assess the effect of TTB. RESULTS There were 107 patients, with a mean age of 83.3 years, who received a preoperative FIB. The median TTB was 8.5 hours. Seventy-two percent of preoperative MME consumption occurred before block placement (pre-block MME). A longer TTB was most strongly correlated with pre-block MME (rho = 0.54; p < 0.001), and TTS was not correlated. Patients with a faster TTB consumed fewer opioids preoperatively (12.0 compared with 33.1 MME; p = 0.015), had lower visual analog scale scores for pain on postoperative day 1 (2.8 compared with 3.5 points; p = 0.046), and were discharged earlier (4.0 compared with 5.5 days; p = 0.039). There were no differences in preoperative pain scores, postoperative opioid consumption, delirium, or opioid-related adverse events. Multivariate regression showed that every hour of delay in TTB was associated with a 2.8% increase in preoperative MME and a 1.0% increase in the length of stay. CONCLUSIONS Faster TTB in geriatric patients with hip fracture may reduce opioid use, pain, and length of stay. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- John M Garlich
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Amit Pujari
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Eytan M Debbi
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | | | - Zachary B Moak
- Department of Anesthesiology, Cedars Sinai Medical Center, Los Angeles, California
| | - Samuel K Stephenson
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Stephen R Stephan
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Landon S Polakof
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Christopher R Johnson
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Ali S Noorzad
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Milton T M Little
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Charles N Moon
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Jeanne T Black
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Kapil K Anand
- Department of Anesthesiology, Cedars Sinai Medical Center, Los Angeles, California
| | - Carol A Lin
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
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23
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Hansen K, Boyle A, Holroyd B, Phillips G, Benger J, Chartier LB, Lecky F, Vaillancourt S, Cameron P, Waligora G, Kurland L, Truesdale M. Updated framework on quality and safety in emergency medicine. Emerg Med J 2020; 37:437-442. [PMID: 32404345 PMCID: PMC7413575 DOI: 10.1136/emermed-2019-209290] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/03/2020] [Accepted: 02/08/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Quality and safety of emergency care is critical. Patients rely on emergency medicine (EM) for accessible, timely and high-quality care in addition to providing a 'safety-net' function. Demand is increasing, creating resource challenges in all settings. Where EM is well established, this is recognised through the implementation of quality standards and staff training for patient safety. In settings where EM is developing, immense system and patient pressures exist, thereby necessitating the availability of tiered standards appropriate to the local context. METHODS The original quality framework arose from expert consensus at the International Federation of Emergency Medicine (IFEM) Symposium for Quality and Safety in Emergency Care (UK, 2011). The IFEM Quality and Safety Special Interest Group members have subsequently refined it to achieve a consensus in 2018. RESULTS Patients should expect EDs to provide effective acute care. To do this, trained emergency personnel should make patient-centred, timely and expert decisions to provide care, supported by systems, processes, diagnostics, appropriate equipment and facilities. Enablers to high-quality care include appropriate staff, access to care (including financial), coordinated emergency care through the whole patient journey and monitoring of outcomes. Crowding directly impacts on patient quality of care, morbidity and mortality. Quality indicators should be pragmatic, measurable and prioritised as components of an improvement strategy which should be developed, tailored and implemented in each setting. CONCLUSION EDs globally have a remit to deliver the best care possible. IFEM has defined and updated an international consensus framework for quality and safety.
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Affiliation(s)
- Kim Hansen
- Emergency Department, Prince Charles Hospital, Chermside, Queensland, Australia .,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Adrian Boyle
- Emergency Department, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Brian Holroyd
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Georgina Phillips
- Emergency Department, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Jonathan Benger
- Academic Department of Emergency Care, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Lucas B Chartier
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Emergency Department, University Health Network, Toronto, Ontario, Canada
| | - Fiona Lecky
- Health Services Research, University of Sheffield, Sheffield, UK.,Emergency Department /TARN, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | | | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Emergency Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Grzegorz Waligora
- Emergency Department, Wroclaw Medical University, Wroclaw, Dolnoslaskie, Poland
| | - Lisa Kurland
- Medical Sciences, Orebro Universitet, Orebro, Sweden
| | - Melinda Truesdale
- Emergency Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Emergency Department, Royal Women's Hospital, Parkville, Victoria, Australia
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Body R, Morris N, Collinson P. Single test rule-out of acute myocardial infarction using the limit of detection of a new high-sensitivity troponin I assay. Clin Biochem 2020; 78:4-9. [PMID: 32135083 DOI: 10.1016/j.clinbiochem.2020.02.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 02/27/2020] [Accepted: 02/29/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To determine the diagnostic accuracy of a high-sensitivity cardiac troponin I (hs-cTnI) assay in patients presenting to the Emergency Department (ED) with suspected acute coronary syndromes. Specifically, we evaluated the use of a single blood test at the time of arrival in the ED, using low hs-cTnI cut-offs. METHODS In a prospective diagnostic test accuracy study at 14 centers, we included patients presenting to the ED with suspected ACS within 12 h of symptom onset. We drew blood for hs-cTnI (Siemens ADVIA Centaur, overall 99th percentile 47 ng/L, limit of quantification [LoQ] 2.50 ng/L) on arrival. Patients underwent serial cardiac troponin testing over 3-6 h. The primary outcome was an adjudicated diagnosis of acute myocardial infarction (AMI). We evaluated the incidence of major adverse cardiac events (MACE: death, AMI or revascularization) after 30 days. Test characteristics for hs-cTnI were calculated using previously reported cut-offs set at the LoQ and 5 ng/L. RESULTS We included 999 patients, including 131 (13.1%) with an adjudicated diagnosis of AMI. Compared to the LoQ (100.0% sensitivity [95% CI 95.9-100.0%]), 99.7% negative predictive value [NPV; 95% CI 97.6-100.0%]), a 5 ng/L cut-off had slightly lower sensitivity (99.2%; 95% CI 95.8-100.0%) and similar NPV (99.8%; 95% CI 98.6-100.0%) but would rule out more patients (28.6% at the LoQ vs 50.4% at 5 ng/L). MACE occurred in 2 (0.7%) patients with hs-cTnI below the LoQ and 7 (1.4%) patients with hs-cTnI < 5 ng/L. Accounting for time from symptom onset or ECG ischemia did not further improve sensitivity. CONCLUSION The Siemens ADVIA Centaur hs-cTnI assay has high sensitivity and NPV to rule out AMI with a single blood test in the ED. At the LoQ cut-off a sensitivity > 99% can be achieved. At a 5 ng/L cut-off it may be possible to rule out AMI for over 50% patients.
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Affiliation(s)
- Richard Body
- Emergency Department, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, United Kingdom; Cardiovascular Sciences Research Group, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester M13 9PL, United Kingdom; Healthcare Sciences Department, Manchester Metropolitan University, Oxford Road, Manchester, United Kingdom.
| | - Niall Morris
- Emergency Department, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, United Kingdom; Cardiovascular Sciences Research Group, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester M13 9PL, United Kingdom
| | - Paul Collinson
- Department of Chemical Pathology, St George's NHS Foundation Trust, Blackshaw Road, Totting, London SW17 0QT, United Kingdom
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25
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Noble J, Zarling B, Geesey T, Smith E, Farooqi A, Yassir W, Sethuraman U. Analgesia Use in Children with Acute Long Bone Fractures in the Pediatric Emergency Department. J Emerg Med 2020; 58:500-505. [DOI: 10.1016/j.jemermed.2019.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 01/30/2023]
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France DJ, Levin S, Ding R, Hemphill R, Han J, Russ S, Aronsky D, Weinger M. Factors Influencing Time-Dependent Quality Indicators for Patients With Suspected Acute Coronary Syndrome. J Patient Saf 2020; 16:e1-e10. [PMID: 26756723 PMCID: PMC4940339 DOI: 10.1097/pts.0000000000000242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Rapid risk stratification and timely treatment are critical to favorable outcomes for patients with acute coronary syndrome (ACS). Our objective was to identify patient and system factors that influence time-dependent quality indicators (QIs) for patients with unstable angina/non-ST elevation myocardial infarction (NSTEMI) in the emergency department (ED). METHODS A retrospective, cohort study was conducted during a 42-month period of all patients 24 years or older suspected of having ACS as defined by receiving an electrocardiogram and at least 1 cardiac biomarker test. Cox regression was used to model the effects of patient characteristics, ancillary service use, staffing provisions, equipment availability, and ED and hospital crowding on ACS QIs. RESULTS Emergency department adherence rates to national standards for electrocardiogram readout time and biomarker turnaround time were 42% and 37%, respectively. Cox regression models revealed that chief complaints without chest pain and the timing of stress testing and medication administration were associated with the most significant delays. CONCLUSIONS Patient and system factors both significantly influenced QI times in this cohort with unstable angina/NSTEMI. These results illustrate both the complexity of diagnosing patients with NSTEMI and the competing effects of clinical and system factors on patient flow through the ED.
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Affiliation(s)
- Daniel J France
- From the Department of Anesthesiology, Vanderbilt Medical Center, Nashville, Tennessee
| | - Scott Levin
- Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ru Ding
- Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Robin Hemphill
- National Center for Patient Safety, Veterans Affairs, Ann Arbor, Michigan
| | - Jin Han
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Stephan Russ
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Dominik Aronsky
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Matt Weinger
- From the Department of Anesthesiology, Vanderbilt Medical Center, Nashville, Tennessee
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27
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Topal FE, Bilgin S, Yamanoglu A, Karakaya Z, Payza U, Akyol PY, Aslan C, Aksun M. The Feasibility of the Ultrasound-Guided Femoral Nerve Block Procedure with Low-Dose Local Anesthetic in Intracapsular and Extracapsular Hip Fractures. J Emerg Med 2020; 58:553-561. [PMID: 32070647 DOI: 10.1016/j.jemermed.2019.12.033] [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: 10/12/2019] [Revised: 12/25/2019] [Accepted: 12/25/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The local anesthetic dosages used in the current literature in regional applications of local anesthetics are frequently high for surgical purposes, and there are no sufficient dosage studies for emergency department (ED) management. OBJECTIVES The aim of this study was to determine the success of lower local anesthetic dosages capable of reducing costs and excessive exposure to drugs in pain control in patients with femoral neck fractures (FNFs) in the ED. METHODS Patients ≥65 years of age with FNFs and reporting Wong-Baker Pain Rating Scales scores ≥8 were included in this prospective, interventional study. Patients underwent ultrasound-guided regional femoral block with 5 mL 2% prilocaine. Pain scores before the procedure and at 30 min and 2 h postprocedure were compared with the Friedman test and Wilcoxon test with Bonferroni correction. RESULTS Forty patients, 20 with intracapsular and 20 with extracapsular FNFs, were enrolled. The initial pain scores of patients with both intra- and extracapsular fractures were 8 (range 8-10). A statistically significant 50% decrease in pain scores was observed in both groups 30 min after the regional block procedure (p < 0.001). A statistically significant 75% decrease in pain scores was observed in both groups 2 h after the regional block procedure (p < 0.001). No statistically significant difference was determined in the change in 30-min and 2-h pain scores between the groups. CONCLUSIONS The administration of 5 mL 2% prilocaine for pain control in FNFs in elderly patients in the ED can reduce systemic analgesic requirements by establishing effective analgesia in both intracapsular and extracapsular fractures.
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Affiliation(s)
- Fatih Esad Topal
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Serkan Bilgin
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Adnan Yamanoglu
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Zeynep Karakaya
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Umut Payza
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Pınar Yesim Akyol
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Cihan Aslan
- Department of Orthopaedics and Traumatology, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Murat Aksun
- Department of Anesthesiology, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
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Stahley L, O'Brien PB, Lowe M, Porteous P, Austin S. The Impact of Bed Traffic Control and Improved Flow Process on Throughput Measures in a Metropolitan Emergency Department. J Emerg Nurs 2020; 46:682-692. [PMID: 31955924 DOI: 10.1016/j.jen.2019.10.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/23/2019] [Accepted: 10/27/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION ED crowding is a complex phenomenon that presents many challenges to patients, hospitals, and staff. Using Lewin's change model, we implemented an ED improvement plan, including an innovative bed traffic control and improved flow system. We hypothesized that this plan would reduce door-to-provider time and emergency medical service-offloading time, decrease the length of stay and number of patients leaving without being seen by a physician, and increase overall patient satisfaction. METHODS We examined the ED improvement plan's impact on institutional throughput metrics over a 4-year period (2015-2019). Data on door-to-provider time, door-to-discharge time, patient volume, leaving without being seen by a physician, and patient satisfaction by Press Ganey were analyzed. RESULTS Between 2015 and 2018, the median door-to-provider time decreased 56.9% and the median door-to-discharge time decreased 29.6%. Percentage of patients who left without being seen by a physician decreased 73.8%. In 2018, the patient satisfaction rank increased by 16 points (84.2% increase). Emergency medical services-offloading time decreased significantly, prompting a change of the 30-minute cutoff to 20 minutes. In 2018, 0.84% of patients had an offloading time of more than 20 minutes. Preliminary 2019 data show maintenance of this trend for all hospital metrics. DISCUSSION Implementing a pod system, with flow and bed placement managed by bed traffic control, reduced door-to-provider time, door-to-discharge time, leaving without being seen by a physician, emergency medical service-offload time, and increased patient satisfaction. Our results may provide a model for other emergency departments to effectively manage the challenges of crowding.
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Emergency department overcrowding : Analysis and strategies to manage an international phenomenon. Wien Klin Wochenschr 2020; 133:229-233. [PMID: 31932966 DOI: 10.1007/s00508-019-01596-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/10/2019] [Indexed: 10/25/2022]
Abstract
Overcrowding in emergency departments is a common and worldwide phenomenon, which is widely reported even in the lay press. Strategies to address this incriminating situation for patients, nurses, physicians and hospital administrators are urgently needed. The current review presents an analysis of the overcrowding problem as well as strategies to answer overcrowding situations.
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30
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Larsson G, Strömberg U, Rogmark C, Nilsdotter A. Cognitive status following a hip fracture and its association with postoperative mortality and activities of daily living: A prospective comparative study of two prehospital emergency care procedures. Int J Orthop Trauma Nurs 2019; 35:100705. [PMID: 31324592 DOI: 10.1016/j.ijotn.2019.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 06/12/2019] [Accepted: 07/01/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Early assessment of hip fracture patients' cognitive function is important for preventing pre- and postoperative complications. The aim of this study was twofold: (1) to assess prehospital cognitive function in hip fracture patients and establish whether cognitive status differs pre- and postoperatively between prehospital fast track care (PFTC) and the traditional emergency department (ED) pathway and (2) whether preoperative cognitive function is associated with postoperative mortality and activities of daily living (ADL) ability. METHODS Three hundred and ninety one hip fracture patients were prospectively included. The Short Portable Mental Status Questionnaire (SPMSQ) was used prehospital, at the orthopaedic ward and three days postoperatively. ADL was followed up after four months. RESULTS No difference in patients' cognitive function was observed between PFTC and ED. Four-month mortality was 37% for patients with dementia, 21% for those with cognitive impairment and 10% for patients without cognitive impariment. Only 26% of patients with dementia and 47% with cognitive impairment had full ADL ability, compared with 70% of patients with intact cognitive function (p < 0.001). CONCLUSION PFTC did not influence hip fracture patients' cognitive function. Patients with prehospital cognitive impairment had a poor outcome in terms of mortality and ADL, indicating the need for special care interventions.
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Affiliation(s)
- Glenn Larsson
- Department of Ambulance and Prehospital Care, Region Halland, Sweden; Department of Orthopaedics, Lund University, Sweden.
| | - Ulf Strömberg
- Department of R&D, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Cecilia Rogmark
- Department of Orthopaedics, Lund University, Sweden; Skane University Hospital, Malmö, Sweden
| | - Anna Nilsdotter
- Department of Orthopaedics, Lund University, Sweden; Department of R&D, Sahlgrenska University Hospital, Göteborg, Sweden
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Chrusciel J, Fontaine X, Devillard A, Cordonnier A, Kanagaratnam L, Laplanche D, Sanchez S. Impact of the implementation of a fast-track on emergency department length of stay and quality of care indicators in the Champagne-Ardenne region: a before-after study. BMJ Open 2019; 9:e026200. [PMID: 31221873 PMCID: PMC6588991 DOI: 10.1136/bmjopen-2018-026200] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the effect of the implementation of a fast-track on emergency department (ED) length of stay (LOS) and quality of care indicators. DESIGN Adjusted before-after analysis. SETTING A large hospital in the Champagne-Ardenne region, France. PARTICIPANTS Patients admitted to the ED between 13 January 2015 and 13 January 2017. INTERVENTION Implementation of a fast-track for patients with small injuries or benign medical conditions (13 January 2016). PRIMARY AND SECONDARY OUTCOME MEASURES Proportion of patients with LOS ≥4 hours and proportion of access block situations (when patients cannot access an appropriate hospital bed within 8 hours). 7-day readmissions and 30-day readmissions. RESULTS The ED of the intervention hospital registered 53 768 stays in 2016 and 57 965 in 2017 (+7.8%). In the intervention hospital, the median LOS was 215 min before the intervention and 186 min after the intervention. The exponentiated before-after estimator for ED LOS ≥4 hours was 0.79; 95% CI 0.77 to 0.81. The exponentiated before-after estimator for access block was 1.19; 95% CI 1.13 to 1.25. There was an increase in the proportion of 30 day readmissions in the intervention hospital (from 11.4% to 12.3%). After the intervention, the proportion of patients leaving without being seen by a physician decreased from 10.0% to 5.4%. CONCLUSIONS The implementation of a fast-track was associated with a decrease in stays lasting ≥4 hours without a decrease in access block. Further studies are needed to evaluate the causes of variability in ED LOS and their connections to quality of care indicators.
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Affiliation(s)
- Jan Chrusciel
- Department of Medical Information and Performance Evaluation, Centre Hospitalier de Troyes, Troyes, France
- Department of Research and Public Health, University Hospitals of Reims, Reims, France
| | - Xavier Fontaine
- Emergency Department, Manchester Hospital, Charleville-Mézières, France
| | - Arnaud Devillard
- Emergency Department, Centre Hospitalier de Troyes, Troyes, France
| | - Aurélien Cordonnier
- Department of Medical Information, Manchester Hospital, Charleville-Mézières, France
| | - Lukshe Kanagaratnam
- Department of Research and Public Health, University Hospitals of Reims, Reims, France
- Faculty of Medicine, Université de Reims Champagne-Ardenne, Reims, France
| | - David Laplanche
- Department of Medical Information and Performance Evaluation, Centre Hospitalier de Troyes, Troyes, France
| | - Stéphane Sanchez
- Department of Medical Information and Performance Evaluation, Centre Hospitalier de Troyes, Troyes, France
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Not missing the opportunity: Strategies to promote cultural humility among future nursing faculty. J Prof Nurs 2019; 36:28-33. [PMID: 32044049 DOI: 10.1016/j.profnurs.2019.06.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 05/13/2019] [Accepted: 06/03/2019] [Indexed: 12/19/2022]
Abstract
As the demographics in the United States continue to change, nurses must deliver care to patients from diverse cultural backgrounds. Cultural humility is a lifelong process of self-reflection which is also defined by that individual. It allows an individual to be open to other people's identities, which is core to the nursing standard of providing holistic care. Embracing and incorporating cultural humility is essential for creating a comprehensive and individualized plan of care. One of the ways to achieve cultural humility in nursing is to train future faculty to become agents of cultural humility. This also helps to create a pipeline of nurses who have respect and empathy for the patients they serve. The aims of this paper include: 1) define cultural humility and its importance to healthcare professionals; 2) explore the intrapersonal, interpersonal, and system levels of cultural humility; 3) provide insight on how to promote cultural humility; 4) reflect on best practices across a variety of healthcare disciplines; and 5) provide suggestions for practice.
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Naamany E, Reis D, Zuker-Herman R, Drescher M, Glezerman M, Shiber S. Is There Gender Discrimination in Acute Renal Colic Pain Management? A Retrospective Analysis in an Emergency Department Setting. Pain Manag Nurs 2019; 20:633-638. [PMID: 31175043 DOI: 10.1016/j.pmn.2019.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 03/02/2019] [Accepted: 03/31/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pain is a widespread problem, affecting both men and women; studies have found that women in the emergency department receive analgesic medication and opioids less often compared with men. AIMS The aim of this study was to examine the administration and management of analgesics by the medical/paramedical staff in relation to the patients' gender, and thereby to examine the extent of gender discrimination in treating pain. DESIGN This is a single-center retrospective cohort study that included 824 patients. SETTINGS Emergency department of tertiary hospital in Israel. PARTICIPANTS/SUBJECTS The patients stratified by gender to compare pain treatments and waiting times between men and women in renal colic complaint. METHODS As an acute pain model, we used renal colic with a nephrolithiasis diagnosis confirmed by imaging. We recorded pain level by Visual Analog Scale (VAS) scores and number of VAS examinations. Time intervals were calculated between admissions to different stations in the emergency department. We recorded the number of analgesic drugs administered, type of drugs prescribed, and drug class (opioids or others). RESULTS A total of 824 patients (414 women and 410 men) participated. There were no significant differences in age, ethnicity, and laboratory findings. VAS assessments were higher in men than in women (6.43 versus 5.90, p = .001, respectively). More men than women received analgesics (68.8% versus 62.1%, p = .04, respectively) and opioids were prescribed more often for men than for women (48.3 versus 35.7%, p = .001). The number of drugs prescribed per patient was also higher in men compared with women (1.06 versus 0.93, p = .03). A significant difference was found in waiting time length from admission to medical examination between non-Jewish women and Jewish women. CONCLUSIONS We found differences in pain management between genders, which could be interpreted as gender discrimination. Yet these differences could also be attributed to other factors not based on gender discrimination but rather on gender differences.
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Affiliation(s)
- Eviatar Naamany
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Reis
- Department of Emergency Medicine, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
| | - Rona Zuker-Herman
- Department of Emergency Medicine, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
| | - Michael Drescher
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Emergency Medicine, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
| | - Marek Glezerman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Research Institute for Gender Medicine, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
| | - Shachaf Shiber
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Emergency Medicine, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel.
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Jones J, Sim TF, Parsons R, Hughes J. Influence of cognitive impairment on pain assessment and management in the emergency department: A retrospective cross-sectional study. Emerg Med Australas 2019; 31:989-996. [PMID: 30953419 DOI: 10.1111/1742-6723.13294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 01/22/2019] [Accepted: 03/17/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To quantify the impact of cognitive impairment on pain assessment and management practices in the ED. METHODS A retrospective, cross-sectional study of patient records was conducted for all elderly patients (65 years or older) who presented to the ED of a large Western Australian tertiary hospital with a fracture because of a fall between 6 February and 14 December 2015. Of 327 records identified, 318 were suitable for data extraction. Of these, 120 patients had a cognitive impairment. Primary outcome measures were the method and frequency of pain assessment, and the delay to the administration of a pain intervention after pain was first assessed for patients with and without a cognitive impairment. RESULTS Patients with a cognitive impairment were less likely to have their pain assessed with a standardised pain assessment tool (55% vs 91.4%, P < 0.001), and 9.4 times more likely to have their pain assessed using ad hoc assessments only (95% confidence interval 4.6-19.1). The median time between ED presentation and a patient's first pain assessment was longer for patients with cognitive impairment (28 vs 17 min; P < 0.001), as was the time between repeat assessments (81 vs 62 min; P < 0.004). The median times to receive a pain intervention following pain assessment were 51 and 50 min for cognitively intact and impaired patients, respectively (P = 0.209, after adjustment for the first pain score). CONCLUSION Pain is inadequately and inappropriately assessed for elderly patients with a cognitive impairment in the ED, resulting in delays in initiation of pain management.
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Affiliation(s)
- Joshua Jones
- School of Pharmacy and Biomedical Sciences, Curtin University, Perth, Western Australia, Australia
| | - Tin Fei Sim
- School of Pharmacy and Biomedical Sciences, Curtin University, Perth, Western Australia, Australia
| | - Richard Parsons
- School of Pharmacy and Biomedical Sciences, Curtin University, Perth, Western Australia, Australia
| | - Jeff Hughes
- School of Pharmacy and Biomedical Sciences, Curtin University, Perth, Western Australia, Australia
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Bouida W, Beltaief K, Msolli MA, Ben Marzouk M, Boubaker H, Grissa MH, Zorgati A, Methamem M, Boukef R, Belguith A, Nouira S. Effect on Morphine Requirement of Early Administration of Oral Acetaminophen vs. Acetaminophen/Tramadol Combination in Acute Pain. Pain Pract 2019; 19:275-282. [PMID: 30303612 DOI: 10.1111/papr.12736] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 08/29/2018] [Accepted: 09/18/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the effect on opioid requirement of pain treatment starting at triage, and to evaluate satisfaction in emergency department (ED) patients with acute pain. METHODS This is a single-blind, randomized, prospective study conducted in the ED. The included patients were randomly assigned to single oral doses of placebo, acetaminophen, or a tramadol/acetaminophen combination. Protocol treatment was given at triage. The primary outcome was the need for rescue morphine during ED stay. The secondary outcome included patient satisfaction, ED length of stay, and percentage of patients discharged from the ED with a VAS score of <30. RESULTS We included 1,485 patients: 496 patients in the placebo group, 497 in the acetaminophen group, and 492 in the tramadol/acetaminophen combination group. The groups were similar regarding demographic and clinical characteristics and baseline VAS pain scores. Rescue morphine was significantly decreased in the tramadol/acetaminophen combination group compared to that in the placebo and acetaminophen groups (11.5%, 23.2%, and 18.9%, respectively; P = 0.03). Patient satisfaction was higher in the tramadol/acetaminophen combination group (77% vs. 69% in the acetaminophen group and 68% in the placebo group). A VAS score of <30 was observed in 84% of patients in the placebo group, 83% in the acetaminophen group, and 87% in the tramadol/acetaminophen combination group (P = 0.01 between the acetaminophen group and tramadol/acetaminophen combination group). The ED length of stay was 60 minutes for the acetaminophen group and tramadol/acetaminophen combination group and 71 minutes for the placebo group (P = 0.04). CONCLUSION Oral tramadol/acetaminophen combination administered early in triage was associated with a decrease in intravenous morphine requirement and increase in satisfaction among ED patients with acute pain when compared with patients taking acetaminophen. No significant increase in side effects was found. This intervention may be considered in EDs with an aim of similar benefits.
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Affiliation(s)
- Wahid Bouida
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
| | - Kaouthar Beltaief
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
| | - Mohamed Amine Msolli
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
| | - Maryem Ben Marzouk
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
| | - Hamdi Boubaker
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
| | - Mohamed Habib Grissa
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
| | - Asma Zorgati
- Emergency Department, Sahloul University Hospital, Sousse, Tunisia
| | - Mehdi Methamem
- Emergency Department, Farhat Hached University Hospital, Sousse, Tunisia
| | - Riadh Boukef
- Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia.,Emergency Department, Sahloul University Hospital, Sousse, Tunisia
| | - Asma Belguith
- Department of Preventive Medicine, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Semir Nouira
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, Monastir, Tunisia
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Abir M, Goldstick JE, Malsberger R, Williams A, Bauhoff S, Parekh VI, Kronick S, Desmond JS. Evaluating the impact of emergency department crowding on disposition patterns and outcomes of discharged patients. Int J Emerg Med 2019; 12:4. [PMID: 31179922 PMCID: PMC6354348 DOI: 10.1186/s12245-019-0223-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Crowding is a major challenge faced by EDs and is associated with poor outcomes. OBJECTIVES Determine the effect of high ED occupancy on disposition decisions, return ED visits, and hospitalizations. METHODS We conducted a retrospective analysis of electronic health records of patients evaluated at an adult, urban, and academic ED over 20 months between the years 2012 and 2014. Using a logistic regression model predicting admission, we obtained estimates of the effect of high occupancy on admission disposition, adjusted for key covariates. We then stratified the analysis based on the presence or absence of high boarder patient counts. RESULTS Disposition decisions during a high occupancy hour decreased the odds of admission (OR = 0.93, 95% CI: [0.89, 0.98]). Among those who were not admitted, high occupancy was not associated with increased odds of return in the combined (OR = 0.94, 95% CI: [0.87, 1.02]), with-boarders (OR = 0.96, 95% CI: [0.86, 1.09]), and no-boarders samples (OR = 0.93, 95% CI: [0.83, 1.04]). Among those who were not admitted and who did return within 14 days, disposition during a high occupancy hour on the initial ED visit was not associated with a significant increased odds of hospitalization in the combined (OR = 1.04, 95% CI: [0.87, 1.24]), the with-boarders (OR = 1.12, 95% CI: [0.87, 1.44]), and the no-boarders samples (OR = 0.98, 95% CI: [0.77, 1.24]). CONCLUSION ED crowding was associated with reduced likelihood of hospitalization without increased likelihood of 2-week return ED visit or hospitalization. Furthermore, high occupancy disposition hours with high boarder patient counts were associated with decreased likelihood of hospitalization.
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Affiliation(s)
- Mahshid Abir
- Department of Emergency Medicine, Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, NCRC Bldg. 10 Rm G016, 2800 Plymouth Road, Ann Arbor, MI, 48109-2800, USA. .,RAND Corporation, Santa Monica, CA, USA.
| | - Jason E Goldstick
- Department of Emergency Medicine, Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, NCRC Bldg. 10 Rm G016, 2800 Plymouth Road, Ann Arbor, MI, 48109-2800, USA
| | | | | | - Sebastian Bauhoff
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Vikas I Parekh
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Steven Kronick
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey S Desmond
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
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Mataloni F, Pinnarelli L, Perucci CA, Davoli M, Fusco D. Characteristics of ED crowding in the Lazio Region (Italy) and short-term health outcomes. Intern Emerg Med 2019; 14:109-117. [PMID: 29802522 PMCID: PMC6329731 DOI: 10.1007/s11739-018-1881-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 05/18/2018] [Indexed: 11/29/2022]
Abstract
The effect of emergency department (ED) crowding on patient care has been studied for several years in the scientific literature. We evaluate the association between ED crowding and short-term mortality and hospitalization in the Lazio region (Italy) using two different measures. A cohort of visits in the Lazio region ED during 2012-2014 was enrolled. Only discharged patients were selected. ED crowding was estimated using two measures, length of stay (LOS), and Emergency Department volume (EDV). LOS was defined as the interval of time from entrance to discharge; EDV was defined at the time of each new entrance in ED. The outcomes under study were mortality and hospitalization within 7 days from ED discharge. A multivariate logistic model was performed (Odds Ratios, ORs, 95% CI). The cohort includes 2,344,572 visits. ED crowding is associated with an increased risk of short-term hospitalization using both LOS and EDV as exposures (LOS 1-2 h: OR = 1.71, 95% CI 1.66-1.76, LOS 2-5 h: OR = 1.38, 95% CI 1.34-1.43, LOS > 5 h OR = 1.45 95% CI 1.40-1.50 compared to patients with 1 h of LOS; EDV 75°-95° percentile: OR = 1.02, 95% CI 0.99-1.05 and EDV > 95° percentile: OR = 1.06, 95% CI 1.01-1.11 compared to patients with a EDV < 75° percentile upon arrival). Increased risk of short-term mortality is found with increasing level of LOS. High levels of EDV at the time of patients' arrival and longer LOS in ED are associated with greater risks of hospitalization for patients discharged 7 days before. LOS in ED is also associated with an increased risk of mortality.
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Affiliation(s)
- Francesca Mataloni
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy.
| | - Luigi Pinnarelli
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy
| | | | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy
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Pasiorowski A, Olson K, Ghosh S, Ray L. Oligoanalgesia in Adult Colles Fracture Patients Admitted to the Emergency Department. Clin Nurs Res 2018; 30:23-31. [PMID: 30585090 DOI: 10.1177/1054773818820175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Pain is a complex symptom to assess properly and it is often poorly managed in the Emergency Department. The majority of research has focused on exploring oligoanalgesia in samples of patients with heterogeneous injuries. The occurrence of oligoanalgesia in a homogeneous injury, such as Colles fracture, has yet to be explored. A retrospective chart review was conducted to determine the incidence of oligoanalgesia in adults with Colles fractures admitted to two urban Emergency Departments in Western Canada. Data were collected from one hundred fifty charts from a 5-year period (2009-2014). Age and gender predicted of pain assessment (p = .019), but were not significantly associated with receipt of an opioid or pain reassessment. Pain reassessment was only completed in 47% of patients who received an initial pain assessment; this was significantly different from current best practice standards (p = .0002).
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Affiliation(s)
| | | | - Sunita Ghosh
- Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Lynne Ray
- University of Alberta, Edmonton, Canada
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Abstract
Hip fractures are associated with significant morbidity and mortality and a major health problem in the United States (). Eighty percent of hip fractures are experienced by 80-year-old women. Plain radiographs usually confirm the diagnosis, but if there is a high level of suspicion of an occult hip fracture, magnetic resonance imaging or bone scan is the next step to confirm the diagnosis. Areas of the hip bone have varied bone strength and blood supply, making the femoral neck one of the most vulnerable areas for fracture. A consultation to an orthopedic surgeon will determine surgical interventions.
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Gao LL, Yang LS, Zhang JJ, Wang YL, Feng K, Ma L, Yu YY, Li Q, Wang QH, Bao JT, Dai YL, Liu Q, Li YX, Yu QJ. A fixed nitrous oxide/oxygen mixture as an analgesic for trauma patients in emergency department: study protocol for a randomized, controlled trial. Trials 2018; 19:527. [PMID: 30268163 PMCID: PMC6162929 DOI: 10.1186/s13063-018-2899-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 09/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute pain is always the most common complaint in Emergency Department admissions and options for analgesia are limited. Nitrous oxide/oxygen possess many properties showing it may be an ideal analgesic method for the Emergency Department; it is quick-acting, well-tolerated, and does not mask signs and symptoms. The aim of this study is to evaluate the safety and analgesic effect of the fixed nitrous oxide/oxygen mixture for trauma patients in a busy emergency environment. METHODS The randomized, double-blind, prospective, placebo-controlled study will be carried out in the Emergency Department of General Hospital of Ningxia Medical University. The target research objects are trauma patients who present to the Emergency Department and report moderate to severe intensities of acute pain. A total of 90 patients will be recruited and randomly assigned into the treatment and control group. The treatment group will receive conventional pain treatment plus nitrous oxide/oxygen mixture and the control group will receive conventional pain treatment plus oxygen. Neither patients, nor investigators, nor data collectors will know the nature of the gas mixture in each cylinder and the randomization list. Outcomes will be monitored at baseline(T0), 5 min (T1), and 15 min (T2) after the beginning of intervention and at 5 min post intervention (T3) for each group. The primary outcome is the level of pain relief after the initial administering of the intervention at T1, T2, and T3. Secondary outcomes include adverse events, physiological parameters, total time of the gas administration, satisfaction from both patients and healthcare professionals, and the acceptance of patients. DISCUSSION Our previous studies suggested that a fixed nitrous oxide/oxygen mixture was an efficacious analgesic for the management of burning dressing pain and breakthrough cancer pain. The results of this study will provide a more in-depth understanding of the effect of this gas. If this treatment proves successful, it could help to generate preliminary guidelines and be implemented widely in trauma patients with pain in Emergency Departments. TRIAL REGISTRATION Chinese Clinical Trial Register, ChiCTR-INR-16007807 . Registered on 21 January 2016.
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Affiliation(s)
- Lu-Lu Gao
- School of Nursing, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004 China
| | - Li-Shan Yang
- Emergency Department, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Jun-Jun Zhang
- School of Nursing, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004 China
| | - Yi-Ling Wang
- School of Nursing, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004 China
| | - Ke Feng
- Emergency Department, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Lei Ma
- Emergency Department, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Yuan-Yuan Yu
- Emergency Department, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Qiang Li
- Emergency Department, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Qing-Huan Wang
- Emergency Department, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Jin-Tao Bao
- Emergency Department, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Ya-Liang Dai
- School of Nursing, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004 China
| | - Qiang Liu
- School of Basic Medical Sciences, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004 China
| | - Yu-Xiang Li
- School of Nursing, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004 China
- Institute of Nursing Research, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004 China
| | - Qiang-Jian Yu
- Department of Pharmacology, Pharmaceutical Institute of Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004 China
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Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS One 2018; 13:e0203316. [PMID: 30161242 PMCID: PMC6117060 DOI: 10.1371/journal.pone.0203316] [Citation(s) in RCA: 592] [Impact Index Per Article: 98.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/17/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Emergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions. AIM The aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding. METHOD The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A structured search of four databases (Medline, CINAHL, EMBASE and Web of Science) was undertaken to identify peer-reviewed research publications aimed at investigating the causes or consequences of, or solutions to, emergency department crowding, published between January 2000 and June 2018. Two reviewers used validated critical appraisal tools to independently assess the quality of the studies. The study protocol was registered with the International prospective register of systematic reviews (PROSPERO 2017: CRD42017073439). RESULTS From 4,131 identified studies and 162 full text reviews, 102 studies met the inclusion criteria. The majority were retrospective cohort studies, with the greatest proportion (51%) trialling or modelling potential solutions to emergency department crowding. Fourteen studies examined causes and 40 investigated consequences. Two studies looked at both causes and consequences, and two investigated causes and solutions. CONCLUSIONS The negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. This review identified a mismatch between causes and solutions. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Solutions aimed at the introduction of whole-of-system initiatives to meet timed patient disposition targets, as well as extended hours of primary care, demonstrated promising outcomes. While the review identified increased presentations by the elderly with complex and chronic conditions as an emerging and widespread driver of crowding, more research is required to isolate the precise local factors leading to ED crowding, with system-wide solutions tailored to address identified causes.
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Affiliation(s)
- Claire Morley
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Maria Unwin
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
| | - Gregory M. Peterson
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Jim Stankovich
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
| | - Leigh Kinsman
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
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Singh N, Robinson RD, Duane TM, Kirby JJ, Lyell C, Buca S, Gandhi R, Mann SM, Zenarosa NR, Wang H. Role of ED crowding relative to trauma quality care in a Level 1 Trauma Center. Am J Emerg Med 2018; 37:579-584. [PMID: 30139579 DOI: 10.1016/j.ajem.2018.06.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Trauma Quality Improvement Program participation among all trauma centers has shown to improve patient outcomes. We aim to identify trauma quality events occurring during the Emergency Department (ED) phase of care. METHODS This is a single-center observational study using consecutively registered data in local trauma registry (Jan 1, 2016-Jun 30, 2017). Four ED crowding scores as determined by four different crowding estimation tools were assigned to each enrolled patient upon arrival to the ED. Patient related (age, gender, race, severity of illness, ED disposition), system related (crowding, night shift, ED LOS), and provider related risk factors were analyzed in a multivariate logistic regression model to determine associations relative to ED quality events. RESULTS Total 5160 cases were enrolled among which, 605 cases were deemed ED quality improvement (QI) cases and 457 cases were ED provider related. Similar percentages of ED QI cases (10-12%) occurred across the ED crowding status range. No significant difference was appreciated in terms of predictability of ED QI cases relative to different crowding status after adjustment for potential confounders. However, an adjusted odds ratio of 1.64 (95% CI, 1.17-2.30, p < 0.01) regarding ED LOS ≥2 h predictive of ED related quality issues was noted when analyzed using multivariate logistic regression. CONCLUSION Provider related issues are a common contributor to undesirable outcomes in trauma care. ED crowding lacks significant association with poor trauma quality care. Prolonged ED LOS (≥2 h) appears to be linked with unfavorable outcomes in ED trauma care.
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Affiliation(s)
- Natasha Singh
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Richard D Robinson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Therese M Duane
- Department of Surgery, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Jessica J Kirby
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Cassie Lyell
- Department of Surgery, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Stefan Buca
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Rajesh Gandhi
- Department of Surgery, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Shaynna M Mann
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Nestor R Zenarosa
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Hao Wang
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
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Larsson G, Strömberg U, Rogmark C, Nilsdotter A. Patient satisfaction with prehospital emergency care following a hip fracture: a prospective questionnaire-based study. BMC Nurs 2018; 17:38. [PMID: 30127665 PMCID: PMC6097315 DOI: 10.1186/s12912-018-0307-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/31/2018] [Indexed: 11/18/2022] Open
Abstract
Background Older patients with a hip fracture require specialized emergency care and their first healthcare encounter before arriving at the hospital is often with the ambulance service. Since 2005 there has been a registered nurse on the crew of every ambulance in Sweden in order to provide prehospital emergency care and to prepare the patients for hospitalization. It is important to investigate patient satisfaction with prehospital emergency care following a hip fracture to ensure that their expectations of good care are met. The aim of this study was to investigate patient satisfaction with prehospital emergency care following a hip fracture by comparing two similar emergency care contexts. Methods The study was conducted using the Consumer Emergency Care Satisfaction Scale (CECSS) on patients treated for hip fracture in prehospital emergency care. The data were collected within a randomized controlled study for the purpose of comparing prehospital fast track care (PFTC) and the traditional type of transport to an accident and emergency department (A&E). Results Questionnaire data from 287 patients, 188 women (66%) and 99 men (34%) with a mean age of 80.9 years, were analysed. More than 80% of the patients selected the most positive response alternatives, but 16% were dissatisfied with the nursing information provided. Patients in PFTC responded more positively on specific caring behaviour than those transported to the A&E department in the traditional way. Conclusion Patient satisfaction with prehospital emergency care following a hip fracture is an important outcome and this study highlights the fact that patients expressed a high level of satisfaction with the prehospital emergency care provided by ambulance nurses in both care contexts under study. However, some areas need to be improved in terms of nursing information.
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Affiliation(s)
- Glenn Larsson
- Department of Ambulance and Prehospital Care, Region Halland, Health Centre Nyhem, 302 49 Halmstad, Sweden.,2Department of Orthopaedics, Lund University, Lund, Sweden
| | - Ulf Strömberg
- 4Department of R&D, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Cecilia Rogmark
- 2Department of Orthopaedics, Lund University, Lund, Sweden.,3Skane University Hospital, Malmö, Sweden
| | - Anna Nilsdotter
- 2Department of Orthopaedics, Lund University, Lund, Sweden.,4Department of R&D, Sahlgrenska University Hospital, Göteborg, Sweden
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Huang D, Bastani A, Anderson W, Crabtree J, Kleiman S, Jones S. Communication and bed reservation: Decreasing the length of stay for emergency department trauma patients. Am J Emerg Med 2018; 36:1874-1879. [PMID: 30104090 DOI: 10.1016/j.ajem.2018.08.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 08/07/2018] [Accepted: 08/07/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Prolonged emergency department (ED) length of stay (LOS) is associated with poorer clinical outcomes and patient experience. At our community hospital, trauma patients were experiencing extended ED LOS incommensurate with their clinical status. Our objective was to determine if operational modifications to patient flow would reduce the LOS for trauma patients. METHOD We conducted a retrospective chart review of admitted trauma patients from January 1, 2015 to June 30, 2016 to study two interventions. First, a communication intervention [INT1], which required the ED provider to directly notify the trauma service, was studied. Second, a bed intervention [INT2], which reserved two temporary beds for trauma patients, was added. The primary outcome was the average ED LOS change across three time periods: (1) Baseline data [BASE] collected from January 1, 2015 to June 30, 2015, (2) INT1 data collected from July 1, 2015 to October 18, 2015, and (3) INT2 data collected from October 19, 2015 to June 30, 2016. Data was analyzed using descriptive statistics, two-sample t-tests, and multivariate linear regression. RESULTS A total of 777 trauma patients were reviewed, with 151, 150 and 476 reviewed during BASE, INT1, and INT2 time periods, respectively. BASE LOS for trauma patients was 389 min. After INT1, LOS decreased by 74.35 min (±31.92; p < 0.0001). After INT2 was also implemented, LOS decreased by 164.56 min (±22.97; p < 0.0001) from BASE LOS. CONCLUSION Direct communication with the trauma service by the ED provider and reservation of two temporary beds significantly decreased the LOS for trauma patients.
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Affiliation(s)
- Derrick Huang
- Oakland University William Beaumont School of Medicine, 586 Pioneer Dr, Rochester, MI 48309, United States of America.
| | - Aveh Bastani
- Department of Emergency Medicine, Troy Beaumont Hospital, 44201 Dequindre Rd, Troy, MI 48085, United States of America
| | - William Anderson
- Department of Emergency Medicine, Troy Beaumont Hospital, 44201 Dequindre Rd, Troy, MI 48085, United States of America
| | - Janice Crabtree
- Management Engineering, Beaumont Health System, 44201 Dequindre Rd, Troy, MI 48085, United States of America
| | - Scott Kleiman
- Department of Emergency Medicine, Troy Beaumont Hospital, 44201 Dequindre Rd, Troy, MI 48085, United States of America
| | - Shanna Jones
- Department of Emergency Medicine, Troy Beaumont Hospital, 44201 Dequindre Rd, Troy, MI 48085, United States of America
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Ward MJ, Kc D, Jenkins CA, Liu D, Padaki A, Pines JM. Emergency department provider and facility variation in opioid prescriptions for discharged patients. Am J Emerg Med 2018; 37:851-858. [PMID: 30077493 DOI: 10.1016/j.ajem.2018.07.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/09/2018] [Accepted: 07/30/2018] [Indexed: 12/19/2022] Open
Abstract
STUDY OBJECTIVE To study the variation in opioid prescribing among emergency physicians and facilities for discharged adult ED patients. METHODS We conducted a retrospective analysis of ED visits from five U.S. hospitals between January and May 2014 using records from Data to Intelligence (D2i). We examined physician- and facility-level variation in opioid prescription rates for discharged ED patients. We calculated unadjusted opioid prescription rates at the physician and facility levels and used a multivariable mixed-effect logistic regression model to examine within-facility physician variation in opioid prescription adjusting for patient and situational factors including time of presentation, ED census, and physician workload. RESULTS In 47,304 visits across five EDs, median patient age was 40 years old (IQR 28,55), and 89% had some form of insurance. There were 17,098 (36%) ED discharges with at least one opioid prescription. The unadjusted facility-level opioid prescription rate ranged from 24%-46%. Among 253 ED physicians, the adjusted opioid prescription rate varied from 22%-76%. Increased physician workload is related to decreased odds of opioid prescription at ED discharge for the lowest (<3 patients) and moderate (6-9 patients) physician workload levels, while the association weakened with increasing levels of workload. CONCLUSION There was substantial physician and facility variation in opioid prescription for discharged adult ED patients. Emergency physicians were less likely to prescribe opioids when their workload was lower, and this effect diminished at high workload levels. Understanding situational and other factors that explain this variation is important given the rising U.S. opioid epidemic and the need for urgent intervention.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University School of Medicine, United States of America.
| | - Diwas Kc
- Information Systems & Operations Management, Goizueta Business School, Emory University, United States of America
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, United States of America
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, United States of America
| | - Amit Padaki
- Department of Emergency Medicine, Christiana Care Health System, United States of America
| | - Jesse M Pines
- Department of Emergency Medicine, Department Health Policy & Management, George Washington University School of Medicine and Health Sciences, United States of America
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Abdolrazaghnejad A, Banaie M, Tavakoli N, Safdari M, Rajabpour-Sanati A. Pain Management in the Emergency Department: a Review Article on Options and Methods. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2018; 2:e45. [PMID: 31172108 PMCID: PMC6548151 DOI: 10.22114/ajem.v0i0.93] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CONTEXT The aim of this review is to recognizing different methods of analgesia for emergency medicine physicians (EMPs) allows them to have various pain relief methods to reduce pain and to be able to use it according to the patient's condition and to improve the quality of their services. EVIDENCE ACQUISITION In this review article, the search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane for emergency pain management methods were reviewed. Among the findings, high quality articles were eventually selected from 2000 to 2018, and after reviewing them, we have conducted a comprehensive comparison of the usual methods of pain control in the emergency department (ED). RESULTS For better understanding, the results are reported in to separate subheadings including "Parenteral agents" and "Regional blocks". Non-opioids analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are commonly used in the treatment of acute pain. However, the relief of acute moderate to severe pain usually requires opioid agents. Considering the side effects of systemic drugs and the restrictions on the use of analgesics, especially opioids, regional blocks of pain as part of a multimodal analgesic strategy can be helpful. CONCLUSION This study was designed to investigate and identify the disadvantages and advantages of using each drug to be able to make the right choices in different clinical situations for patients while paying attention to the limitations of the use of these analgesic drugs.
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Affiliation(s)
- Ali Abdolrazaghnejad
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Banaie
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Nader Tavakoli
- Trauma and Injury research center, Iran university of medical sciences, Tehran, Iran
| | - Mohammad Safdari
- Department of Neurosurgery, Khatam-Al-Anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
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Ivarsson B, Hommel A, Sandberg M, Sjöstrand D, Johansson A. The experiences of pre- and in-hospital care in patients with hip fractures: A study based on Critical incidents. Int J Orthop Trauma Nurs 2018; 30:8-13. [PMID: 29929886 DOI: 10.1016/j.ijotn.2018.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/20/2018] [Accepted: 05/14/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Hip fractures are described to have a significant impact on patients' well-being and different fast-track concepts could result in a reduction of the patient's psychological and emotional reactions before pre- and intrahospital care. AIMS AND OBJECTIVES This study aimed to elucidate perceived situations of significance experienced by patients with hip fracture during the prehospital- and in-hospital care. DESIGN The study used a qualitative approach using a critical incident technique (CIT), 14 patients with hip fractures were included. METHODS All informants had undergone surgery for a hip fracture, were able to communicate in Swedish and had no cognitive impairment. RESULTS The main area Oscillating between being satisfied and to endure a new demanding situation emerged from five categories: Pain and pain management, Feeling fear and satisfaction in perioperative care, Experiencing continuity in care, Considering information and Felling confirmed. CONCLUSION Experiences of prehospital care shows a positive impact though the patients experienced this part of the pathway professionally. However, the patients described critical incidents according to their experiences of pain seems to have significant damagingly impact on the patients' well-being. The patient also describe a sense of uncertainty in their individual involvement of care.
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Affiliation(s)
- Bodil Ivarsson
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Ami Hommel
- Department of Care Sciences, Malmö University, Malmö, Sweden
| | - Magnus Sandberg
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Desirée Sjöstrand
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Anders Johansson
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
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Kim KH, Lee JY, Lee WS, Sung WY, Seo SW. Changes in medical care due to the absence of internal medicine physicians in emergency departments. Clin Exp Emerg Med 2018; 5:120-130. [PMID: 29706056 PMCID: PMC6039368 DOI: 10.15441/ceem.17.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 01/08/2018] [Indexed: 11/29/2022] Open
Abstract
Objective Especially in emergency departments (EDs), a lack of internal medicine (IM) residents in charge causes difficulties in medical care and ED overcrowding. Thus, protocols without IM residents in EDs is needed. This study aimed to investigate changes in medical care when emergency medicine residents replaced the roles of IM residents. Methods This study was conducted at a single-site ED of a university medical center. The study group contained patients admitted to the IM department between September and December 2015, during which IM residents were absent in the ED. The control group contained patients admitted to the IM department between September and December 2014, during which IM residents were present in the ED. Changes in medical care between the presence and absence of IM residents in the ED were studied by comparing admission rates from the ED, length of ED stay, duration of hospitalization, and concordance of diagnoses between admission and discharge by the IM department. Results The study group contained 2,341 patients; the control group contained 2,215 patients. Admission rates from the ED increased by 53.4% (95% confidence interval [CI], P<0.001); lengths of stay decreased by 15.1% (95% CI, P<0.001); and durations of hospitalization in the pulmonology department decreased by 38.4% (95% CI, P=0.001). Concordance of diagnoses between admission and discharge decreased by 14.2% in the cardiology department (95% CI, P=0.021). Conclusion Lengths of stay were reduced without critical declines in diagnostic concordance rates when emergency medicine physicians, instead of IM residents in the ED, decided upon admissions of IM patients.
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Affiliation(s)
- Kyoung Ho Kim
- Department of Emergency Medicine, Eulji University Hospital, Daejeon, Korea
| | - Jang Young Lee
- Department of Emergency Medicine, Eulji University Hospital, Daejeon, Korea.,Department of Emergency Medicine, Eulji University College of Medicine, Daejeon, Korea
| | - Won Suk Lee
- Department of Emergency Medicine, Eulji University Hospital, Daejeon, Korea.,Department of Emergency Medicine, Eulji University College of Medicine, Daejeon, Korea
| | - Won Young Sung
- Department of Emergency Medicine, Eulji University Hospital, Daejeon, Korea.,Department of Emergency Medicine, Eulji University College of Medicine, Daejeon, Korea
| | - Sang Won Seo
- Department of Emergency Medicine, Eulji University Hospital, Daejeon, Korea.,Department of Emergency Medicine, Eulji University College of Medicine, Daejeon, Korea
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Charbonneau V, Kwok E, Boyle L, Stiell IG. Impact of emergency department surge and end of shift on patient workup and treatment prior to referral to internal medicine: a health records review. Emerg Med J 2018. [PMID: 29523720 DOI: 10.1136/emermed-2017-207149] [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: 11/04/2022]
Abstract
BACKGROUND The goal of this study was to determine if ED surge and end-of-shift assessment of patients affect the extent of diagnostic tests, therapeutic interventions and accuracy of diagnosis prior to referral to internal medicine. METHODS This study was a health records review of consecutive patients referred to the internal medicine service with an ED diagnosis of heart failure, chronic obstructive pulmonary disease (COPD) or sepsis starting 1 December 2013 until 100 cases for each condition had been obtained. We developed a scoring system in consultation with emergency and internal medicine physicians to uniformly assess the completeness of treatments and investigations performed. These scores, expressed as percentage of possible points, were compared at high and low surge levels and at middle and end of shift at time of patient referral. End of shift was defined as 7:30-8:30, 15:30-16:30 and 23:30-00:30 as our shift changes occur at 8:00, 16:00 and 24:00. Rate of admission, diversion to other services and diagnosis disagreements were also assessed. RESULTS We included 308 patients (101 heart failure, 101 COPD, 106 sepsis) with a mean age of 74.7. Comparing middle of shift to end of shift, the mean scores were 91.9% versus 91.8% (difference 0.1% (95% CI -2.4 to 3.0)) for investigations and 73.0% versus 70.4% (difference 2.6% (95% CI -1.8 to 7.4)) for treatments. Comparing low to high surge times, the mean scores were 92.1% versus 91.7% (difference 0.4% (95% CI -1.2 to 2.4)) for investigations and 71.4% versus 73.6% (difference -2.2% (95% CI -5.6 to 1.3)) for treatments. We found low rates of diversion to alternate services (8.9% heart failure, 0% COPD, 6.6% sepsis) and low rates of diagnosis disagreement (4.0% heart failure, 10.9% COPD, 8.5% sepsis). CONCLUSIONS We found no evidence that surge levels and end of shift impact the extent of investigations and treatments provided to patients diagnosed in the ED with heart failure, COPD or sepsis and referred to internal medicine.
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Affiliation(s)
- Valerie Charbonneau
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Edmund Kwok
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Loree Boyle
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Lee JH, Cho SH. Effect of Crowding and Nurse Staffing on Time to Antibiotic Administration for Patients with Pneumonia in an Emergency Department. ACTA ACUST UNITED AC 2018. [DOI: 10.11111/jkana.2018.24.2.107] [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)
- Joo Hyun Lee
- College of Nursing, Seoul National University, Korea
| | - Sung-Hyun Cho
- College of Nursing, Research Institute of Nursing Science, Seoul National University, Korea
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