Defining and measuring successful emergency care networks: a research agenda

Consensus-based recommendations for strengthening emergency care at primary health care level: a Delphi study

BACKGROUND

Emergency care at a primary health care (PHC) level must be strengthened to reduce overall mortality and morbidity in any country. Developing recommendations for improvement in this area should take into consideration the context and nuances of the current emergency care system and primary health care context. Contribution to policy from the experts in the cross-cutting fields of PHC and emergency care is lacking.

OBJECTIVES

This study aims to evaluate the strengths and weaknesses of emergency care in primary health settings and develop consensus-based recommendations for the strengthening of emergency care at this level.

METHODS

Using a modified Delphi technique, data were collected from various data sources to evaluate the strengths and weaknesses of emergency care at PHC level, from which recommendation statements were developed. These recommendations were proposed to a panel of experts using a Delphi survey to build consensus on 14 recommendations to strengthen emergency care at PHC level.

RESULTS

Ten experts were recruited to participate (n = 10) with a response rate of 90% in round II and 80% in round III of Delphi. Recommendations broadly addressed the areas of education and training in emergency care, the role and placement of various actors, leadership in emergency care and the development of a national plan for emergency care. Consensus was reached in round II for 97.61% of the statements and after modification based on open-ended comments, 98.21% consensus was reached in round III.

CONCLUSION

Strengthening emergency care at primary and subsequent levels of health care requires a coordinated effort and mandate from authority in order to effect real change.

Social network analysis of nationwide interhospital emergency department transfers in Taiwan

Transferring patients between emergency departments (EDs) is a complex but important issue in emergency care regionalization. Social network analysis (SNA) is well-suited to characterize the ED transfer pattern. We aimed to unravel the underlying transfer network structure and to identify key network metrics for monitoring network functions. This was a retrospective cohort study using the National Electronic Referral System (NERS) database in Taiwan. All interhospital ED transfers from 2014 to 2016 were included and transfer characteristics were retrieved. Descriptive statistics and social network analysis were used to analyze the data. There were a total of 218,760 ED transfers during the 3-year study period. In the network analysis, there were a total of 199 EDs with 9516 transfer ties between EDs. The network demonstrated a multiple hub-and-spoke, regionalized pattern, with low global density (0.24), moderate centralization (0.57), and moderately high clustering of EDs (0.63). At the ED level, most transfers were one-way, with low reciprocity (0.21). Sending hospitals had a median of 5 transfer-out partners [interquartile range (IQR) 3-7), while receiving hospitals a median of 2 (IQR 1-6) transfer-in partners. A total of 16 receiving hospitals, all of which were designated base or co-base hospitals, had 15 or more transfer-in partners. Social network analysis of transfer patterns between hospitals confirmed that the network structure largely aligned with the planned regionalized transfer network in Taiwan. Understanding the network metrics helps track the structure and process aspects of regionalized care.

Emergency Medical Services Stroke Care Performance Variability in Michigan: Analysis of a Statewide Linked Stroke Registry

Background Emergency medical services (EMS) compliance with recommended prehospital care for patients with acute stroke is inconsistent; however, sources of variability in compliance are not well understood. The current analysis utilizes a linkage between a statewide stroke registry and EMS information system data to explore patient and EMS agency-level contributions to variability in prehospital care. Methods and Results This is a retrospective analysis of a cohort of confirmed stroke cases transported by EMS to hospitals participating in a statewide stroke registry. Using EMS information system data, the authors quantified EMS compliance with 6 performance measures derived from national guidelines for prehospital stroke care: prehospital stroke scale performance, glucose check, stroke recognition, on-scene time ≤15 minutes, time last known well documentation, and hospital prenotification. Multilevel multivariable logistic regression analysis was then used to examine associations between patient-level demographic and clinical characteristics and EMS compliance while accounting for and quantifying the variation attributable to agency of transport and recipient hospital. Over an 18-month period, EMS and stroke registry records were linked for 5707 EMS-transported stroke cases. Compliance ranged from 24% of cases for last known well documentation to 82% for documentation of a glucose check. The other measures were documented in approximately half of cases. Older age, higher National Institutes of Health Stroke Scale, and earlier presentation were associated with more compliant prehospital care. EMS agencies accounted for more than half of the variation in EMS prehospital stroke scale documentation and last known well documentation and 27% of variation in glucose check but <10% of stroke recognition and prenotification variability. Conclusions EMS stroke care remains highly variable across different performance measures and EMS agencies. EMS agency and electronic medical record type are important sources of variability in compliance with key prehospital performance metrics for stroke.

An Analysis of Ambulance Transport and Out-of-Network Emergency Department Utilization in an Accountable Care Organization

For hospital-affiliated accountable care organizations (ACOs), emergency care represents a unique challenge for coordination of care and a major source of ACO leakage. The authors analyzed emergency department (ED) visits among ACO members to assess the potential impact of ambulance transport on the use of in-network versus out-of-network EDs. To better understand factors influencing the use of in-network versus out-of-network EDs, 2018 claims data from members of a regional subset of a large ACO in the greater Boston area were analyzed. Within this population, multivariable logistic regression was used to assess the relationship between ambulance transport as well as demographic factors, insurance type, and hospital distance on the use of in-network versus out-of-network EDs. Arrival to an ED via ambulance was found to be significantly associated with reduced odds of presenting to an in-network ED compared to arriving by private transportation (odds ratio 0.70, 95% confidence interval: 0.58-0.85). Age older than 65 years, commercial insurance (relative to Medicare), proximity to an in-network ED, and distance from an out-of-network ED also were significantly associated with use of in-network EDs relative to out-of-network EDs. Given the central role of the ED as a primary source of hospital admissions in the United States, emergency care represents a key potential target for interventions aimed at reducing patient leakage. Future efforts should aim to identify and evaluate new ways that emergency medical services can be leveraged to promote effective care coordination.

Impact of ST-Segment-Elevation Myocardial Infarction Regionalization Programs on the Treatment and Outcomes of Patients Diagnosed With Non-ST-Segment-Elevation Myocardial Infarction

Background Many communities have implemented systems of regionalized care to improve access to timely care for patients with ST-segment-elevation myocardial infarction. However, patients who are ultimately diagnosed with non-ST-segment-elevation myocardial infarctions (NSTEMIs) may also be affected, and the impact of regionalization programs on NSTEMI treatment and outcomes is unknown. We set out to determine the effects of ST-segment-elevation myocardial infarction regionalization schemes on treatment and outcomes of patients diagnosed with NSTEMIs. Methods and Results The cohort included all patients receiving care in emergency departments diagnosed with an NSTEMI at all nonfederal hospitals in California from January 1, 2005 to September 30, 2015. Data were analyzed using a difference-in-differences approach. The main outcomes were 1-year mortality and angiography within 3 days of the index admission. A total of 293 589 patients with NSTEMIs received care in regionalized and nonregionalized communities. Over the study period, rates of early angiography increased by 0.5 and mortality decreased by 0.9 percentage points per year among the overall population (95% CI, 0.4-0.6 and -1.0 to -0.8, respectively). Regionalization was not associated with early angiography (-0.5%; 95% CI, -1.1 to 0.1) or death (0.2%; 95% CI, -0.3 to 0.8). Conclusions ST-segment-elevation myocardial infarction regionalization programs were not statistically associated with changes in guideline-recommended early angiography or changes in risk of death for patients with NSTEMI. Increases in the proportion of patients with NSTEMI who underwent guideline-directed angiography and decreases in risk of mortality were accounted for by secular trends unrelated to regionalization policies.

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

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

Quality Through Coopetition: An Empiric Approach to Measure Population Outcomes for Emergency Care-Sensitive Conditions

STUDY OBJECTIVE

We develop a novel approach for measuring regional outcomes for emergency care-sensitive conditions.

METHODS

We used statewide inpatient hospital discharge data from the Pennsylvania Healthcare Cost Containment Council. This cross-sectional, retrospective, population-based analysis used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes to identify admissions for emergency care-sensitive conditions (ischemic stroke, ST-segment elevation myocardial infarction, out-of-hospital cardiac arrest, severe sepsis, and trauma). We analyzed the origin and destination patterns of patients, grouped hospitals with a hierarchical cluster analysis, and defined boundary shapefiles for emergency care service regions.

RESULTS

Optimal clustering configurations determined 10 emergency care service regions for Pennsylvania.

CONCLUSION

We used cluster analysis to empirically identify regional use patterns for emergency conditions requiring a communitywide system response. This method of attribution allows regional performance to be benchmarked and could be used to develop population-based outcome measures after life-threatening illness and injury.

Funding global emergency medicine research-from seed grants to NIH support

BACKGROUND

Funding for global health has grown significantly over the past two decades. Numerous funding opportunities for international development and research work exist; however, they can be difficult to navigate. The 2013 Academic Emergency Medicine consensus conference on global health and emergency care identified the need to strengthen global emergency care research funding, solidify existing funding streams, and expand funding sources.

RESULTS

This piece focuses on the various federal funding opportunities available to support emergency physicians conducting international research from seed funding to large institutional grants. In particular, we focus on the application and review processes for the Fulbright and Fogarty programs, National Institutes of Health (NIH) Career development awards, and the Medical Education Partnership Initiative (MEPI), including tips and pathways through each application process.

CONCLUSIONS

Lastly, the paper provides an index that may be used as a guide in determining whether the amount of funding provided by a grant is worth the effort in applying.

Specialist availability in emergencies: contributions of response times and the use of ad hoc coverage in New York State

OBJECTIVES

Nationwide, hospitals struggle to maintain specialist on-call coverage for emergencies. We seek to further understand the issue by examining reliability of scheduled coverage and the role of ad hoc coverage when none is scheduled.

METHODS

An anonymous electronic survey of all emergency department (ED) directors of a large state. Overall and for 10 specialties, respondents were asked to estimate on-call coverage extent and "reliability" (frequency of emergency response in a clinically useful time frame: 2 hours), and use and effect of ad hoc emergency coverage to fill gaps. Descriptive statistics were performed using Fisher exact and Wilcoxon sign rank tests for significance.

RESULTS

Contact information was obtained for 125 of 167 ED directors. Sixty responded (48%), representing 36% of EDs. Forty-six percent reported full on-call coverage scheduled for all specialties. Forty-six percent reported consistent reliability. Coverage and reliability were strongly related (P<.01; 33% reported both), and larger ED volume correlated with both (P<.01). Ninety percent of hospitals that had gaps in either employed ad hoc coverage, significantly improving coverage for 8 of 10 specialties. For all but 1 specialty, more than 20% of hospitals reported that specialists are "Never", "Rarely" or "Sometimes" reliable (more than 50% for cardiovascular surgery, hand surgery and ophthalmology).

CONCLUSIONS

Significant holes in scheduled on-call specialist coverage are compounded by frequent unreliability of on-call specialists, but partially ameliorated by ad hoc specialist coverage. Regionalization may help because a 2-tiered system may exist: larger hospitals have more complete, reliable coverage. Better understanding of specialists' willingness to treat emergencies ad hoc without taking formal call will suggest additional remedies.

County-Level Effects of Prehospital Regionalization of Critically Ill Patients: A Simulation Study

OBJECTIVE

Regionalization may improve critical care delivery, yet stakeholders cite concerns about its feasibility. We sought to determine the operational effects of prehospital regionalization of nontrauma, nonarrest critical illness.

SETTING

King County, Washington.

DESIGN

Discrete event simulation study.

PATIENTS

All 2006 hospital discharge data, linked to all adult, eligible patients transported by county emergency medical services agencies.

INTERVENTIONS

We simulated active triage of high-risk patients to designated referral centers using a validated prehospital risk score; we studied three regionalization scenarios: 1) up triage, 2) up and down triage, and 3) up and down triage after reducing ICU beds by 25%. We determined the effect on patient routing, ICU occupancy at referral and nonreferral hospitals, and emergency medical services transport times.

MEASUREMENTS AND MAIN RESULTS

A total of 119,117 patients were hospitalized at 11 nonreferral centers and 76,817 patients were hospitalized at three referral centers. Among 20,835 emergency medical services patients, 7,817 patients (43%) were eligible for up triage and 10,242 patients (57%) were eligible for down triage. At baseline, mean daily ICU bed occupancy was 61% referral and 47% at nonreferral hospitals. Up triage increased referral ICU occupancy to 68%, up and down triage to 64%, and up and down triage with bed reduction to 74%. Mean daily nonreferral ICU occupancy did not exceed 60%. Total emergency medical services transport time increased by less than 3% with up and down triage.

CONCLUSIONS

Regionalization based on prehospital triage of the critically ill can allocate high-risk patients to referral hospitals without adversely affecting ICU occupancy or prehospital travel time.

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Background

In 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.

Objective

The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.

Data sources

MEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.

Methods

We have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.

Results

The review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.

Limitations

Although there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.

Conclusions

The evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.

Funding

The National Institute for Health Research Health Services and Delivery Research Programme.

Variation in childbirth services in California: a cross-sectional survey of childbirth hospitals

OBJECTIVE

The objective of the study was to describe the resources and activities associated with childbirth services.

STUDY DESIGN

We adapted models for assessing the quality of healthcare to generate a conceptual framework hypothesizing that childbirth hospital resources and activities contributed to maternal and neonatal outcomes. We used this framework to guide development of a survey, which we administered by telephone to hospital labor and delivery nurse managers in California. We describe the findings by hospital type (ie, integrated delivery system [IDS], teaching, and other [community] hospitals).

RESULTS

Of 248 nonmilitary childbirth hospitals in California, 239 (96%)responded; 187 community, 27 teaching, and 25 IDS hospitals reported. The context of services varied across hospital types, with community hospitals more likely to have for-profit ownership, be in a rural or isolated location, and have fewer annual deliveries per hospital. Results included the findings of the following: (1) 24 hour anesthesia availability in 50% of community vs 100% of IDS and teaching hospitals (P < .001); (2) 24 hour in-house labor and delivery physician coverage in 5% of community vs 100% of IDS and 48% of teaching hospitals (P < .001); (3) 24 hour blood bank availability in 88% of community vs 96% of IDS and 100% of teaching hospitals (P = .092); (4) adult subspecialty intensive care unit availability in 33% of community vs 36% of IDS and 82% of teaching hospitals (P < .001); (5) ability to perform emergency cesarean delivery in 30 minutes 100% of the time in 56% of community vs 100% of IDS and 85% of teaching hospitals (P < .001); (6) pediatric care available both day and night in 54% of community vs 63% of IDS vs 76% of teaching hospitals (P = .087); and (7) no neonatal intensive care unit in 44% of community vs 12% of IDS and 4% of teaching hospitals (P < .001).

CONCLUSION

Childbirth services varied widely across California hospitals. Cognizance of this variation and linkage of these data to childbirth outcomes should assist in the identification of key resources and activities that optimize the hospital environment for pregnant women and set the groundwork for identifying criteria for the provision of maternal risk-appropriate care.

The relationship between survival after out-of-hospital cardiac arrest and process measures for emergency medical service ambulance team performance

OBJECTIVE

International institutes have developed their own clinical performance indicators for ambulance services. It is unknown whether these process measures are related to survival of patients after out-of-hospital cardiac arrest (OHCA). We aimed to determine whether Emergency Medical Service (EMS)-related ambulance team process measures correlate with patient survival.

METHODS

Four years of observational data were collected from an urban EMS OHCA registry. The two process measures were achieving an EMS response time ≤4 min and prehospital ROSC (return of spontaneous circulation). The outcome measure was survival to discharge. We used the GLMM (generalised linear mixed model) with stepwise selection to examine this process-outcome link at the patient and EMS team levels, respectively.

RESULTS

We analyzed 3856 OHCA patients distributed across forty-three EMS ambulance teams. Survival to discharge was observed in 193 (5%) patients. The two EMS team process measures were positively associated with an improvement in survival at the patient level after case-mix adjustment. However, they were not associated with improvement in the risk-adjusted survival rate.

CONCLUSIONS

The EMS team-level process measures proposed by international institutes may not predict the risk-adjusted survival rate. Using these measures to motivate EMS teams to improve their quality performance would be questionable. Increased efforts should be devoted to constructing more pivotal EMS team-level process measures that are tightly linked to survival.

Is There an Increasing Regionalization of Surgical Repair of Craniosynostosis Procedures Into Teaching Hospitals? Implications of Regionalization

Objective The objective of the present study is to examine whether surgical repairs for craniosynostosis have been regionalized to teaching hospitals over the 8-year period from 2003 to 2010. Design Retrospective analysis of hospital discharge database. Setting Nationwide Inpatient Sample for years 2003 to 2010. All patients aged up to 3 years who had a surgical repair for craniosynostosis were selected. Interventions Surgical repair for craniosynostosis. Main Outcome Measures Performance of surgery in a teaching hospital. Results During the study period (years 2003 to 2010), a total of 19,417 patients aged up to 3 years underwent a surgical repair for craniosynostosis. The number of surgical procedures increased during the study period. It ranged from 1628 procedures in year 2003 to 3001 procedures during 2010. Data show that 83.3% of all procedures in 2003 were performed in teaching hospitals; whereas, 97.5% of procedures in 2010 were performed in teaching hospitals. Following adjustment for patient-level factors, year 2010 was associated with increased odds of having the surgical procedures performed in a teaching hospital as opposed to a nonteaching hospital when compared with year 2003 (odds ratio = 10.43, 95% confidence interval, 1.10 to 98.98; P = .04). Conclusions An increasing proportion of surgical repairs of craniosynostosis are performed in teaching hospitals, suggesting there is an increasing concentration of these complex surgical procedures in select centers. As more longitudinal data become available, the relative benefits and drawbacks associated with regionalization of surgical repairs of craniosynostosis should be examined.

System-level planning, coordination, and communication: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

System-level planning involves uniting hospitals and health systems, local/regional government agencies, emergency medical services, and other health-care entities involved in coordinating and enabling care in a major disaster. We reviewed the literature and sought expert opinions concerning system-level planning and engagement for mass critical care due to disasters or pandemics and offer suggestions for system-planning, coordination, communication, and response. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The American College of Chest Physicians (CHEST) consensus statement development process was followed in developing suggestions. Task Force members met in person to develop nine key questions believed to be most relevant for system-planning, coordination, and communication. A systematic literature review was then performed for relevant articles and documents, reports, and other publications reported since 1993. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS

Suggestions were developed and grouped according to the following thematic elements: (1) national government support of health-care coalitions/regional health authorities (HC/RHAs), (2) teamwork within HC/RHAs, (3) system-level communication, (4) system-level surge capacity and capability, (5) pediatric patients and special populations, (6) HC/RHAs and networks, (7) models of advanced regional care systems, and (8) the use of simulation for preparedness and planning.

CONCLUSIONS

System-level planning is essential to provide care for large numbers of critically ill patients because of disaster or pandemic. It also entails a departure from the routine, independent system and involves all levels from health-care institutions to regional health authorities. National government support is critical, as are robust communication systems and advanced planning supported by realistic exercises.

A cross-sectional retrospective analysis of the regionalization of complex surgery

Background

The Veterans Health Administration (VHA) system has assigned a surgical complexity level to each of its medical centers by specifying requirements to perform standard, intermediate or complex surgical procedures. No study to similarly describe the patterns of relative surgical complexity among a population of United States (U.S) civilian hospitals has been completed.

Methods

Design: single year, retrospective, cross-sectional.

Setting/Participants: the study used Florida Inpatient Discharge Data from short-term acute hospitals for calendar year 2009. Two hundred hospitals with 2,542,920 discharges were organized into four quartiles (Q 1, 2, 3, 4) based on the number of complex procedures per hospital. The VHA surgical complexity matrix was applied to assign relative complexity to each procedure. The Clinical Classification Software (CCS) system assigned complex procedures to clinically meaningful groups. For outcome comparisons, propensity score matching methods adjusted for the surgical procedure, age, gender, race, comorbidities, mechanical ventilator use and type of admission.

Main Outcome Measures: in-hospital mortality and length-of-stay (LOS).

Results

Only 5.2% of all inpatient discharges involve a complex procedure. The highest volume complex procedure hospitals (Q4) have 49.8% of all discharges but 70.1% of all complex procedures. In the 133,436 discharges with a primary complex procedure, 374 separate specific procedures are identified, only about one third of which are performed in the lowest volume complex procedure (Q1) hospitals. Complex operations of the digestive, respiratory, integumentary and musculoskeletal systems are the least concentrated and proportionately more likely to occur in the lower volume hospitals. Operations of the cardiovascular system and certain technology dependent miscellaneous diagnostic and therapeutic procedures are the most concentrated in high volume hospitals. Organ transplants are only done in Q4 hospitals. There were no significant differences in in-hospital mortality rates and the longest lengths of stay were found in higher volume hospitals.

Conclusions

Complex surgery in Florida is effectively regionalized so that small volume hospitals operating within the range of complex procedures appropriate to their capabilities provide no increased risk of post surgical mortality.

Emergency care and health systems: consensus-based recommendations and future research priorities

The theme of the 14th annual Academic Emergency Medicine consensus conference was "Global Health and Emergency Care: A Research Agenda." The goal of the conference was to create a robust and measurable research agenda for evaluating emergency health care delivery systems. The concept of health systems includes the organizations, institutions, and resources whose primary purpose is to promote, restore, and/or maintain health. This article further conceptualizes the vertical and horizontal delivery of acute and emergency care in low-resource settings by defining specific terminology for emergency care platforms and discussing how they fit into broader health systems models. This was accomplished through discussion surrounding four principal questions touching upon the interplay between health systems and acute and emergency care. This research agenda is intended to assist countries that are in the early stages of integrating emergency services into their health systems and are looking for guidance to maximize their development and health systems planning efforts.

Emergency care research funding in the global health context: trends, priorities, and future directions

Over the past few decades there has been a steady growth in funding for global health, yet generally little is known about funding for global health research. As part of the 2013 Academic Emergency Medicine consensus conference, a session was convened to discuss emergency care research funding in the global health context. Overall, the authors found a lack of evidence available to determine funding priorities or quantify current funding for acute care research in global health. This article summarizes the initial preparatory research and reports on the results of the consensus conference focused on identifying challenges and strategies to improve funding for global emergency care research. The consensus conference meeting led to the creation of near- and long-term goals to strengthen global emergency care research funding and the development of important research questions. The research questions represent a consensus view of important outstanding questions that will assist emergency care researchers to better understand the current funding landscape and bring evidence to the debate on funding priorities of global health and emergency care. The four key areas of focus for researchers are: 1) quantifying funding for global health and emergency care research, 2) understanding current research funding priorities, 3) identifying barriers to emergency care research funding, and 4) using existing data to quantify the need for emergency services and acute care research. This research agenda will enable emergency health care scientists to use evidence when advocating for more funding for emergency care research.

Strategies to improve clinical research in surgery through international collaboration

More than 235 million patients undergo surgery every year worldwide, but less than 1% are enrolled in surgical clinical trials--few of which are international collaborations. Several levels of action are needed to improve this situation. International research collaborations in surgery between developed and developing countries could encourage capacity building and quality improvement, and mutually enhance care for patients with surgical disorders. Low-income and middle-income countries increasingly report much the same range of surgical diseases as do high-income countries (eg, cancer, cardiovascular disease, and the surgical sequelae of metabolic syndrome); collaboration is therefore of mutual interest. Large multinational trials that cross cultures and levels of socioeconomic development might have faster results and wider applicability than do single-country trials. Surgeons educated in research methods, and aided by research networks and trial centres, are needed to foster these international collaborations. Barriers to collaboration could be overcome by adoption of global strategies for regulation, health insurance, ethical approval, and indemnity coverage for doctors.

Changes in Interhospital Transfer Patterns of Acute Ischemic Stroke Patients in the Regional Stroke Care System After Designation of a Cerebrovascular-specified Center

The Ministry of Health and Welfare of Korea recently designated cerebrovascularspecified centers (CSCs) to improve the regional stroke care system for acute ischemic stroke (AIS) patients. This study was performed to evaluate the changes in the flow of AIS patients between hospitals and to describe the role of the Emergency Medical Information Center (EMIC) after the designation of the CSCs. Data for coordination of interhospital transfers by the EMIC were reviewed for 6 months before and after designation of the CSCs. The data included the success or failure rate, the time used for coordination of interhospital transfer, and the changes in the interhospital transfer pattern between transfer-requesting and transfer-accepting hospitals. The total number of requests for interhospital transfer increased from 198 to 244 after designation of the CSCs. The median time used for coordination decreased from 8.0 minutes to 4.0 minutes (p<0.001). The success rate of coordination increased from 88.9% to 96.7% (p<0.001). The proportion of requests by CSCs decreased from 3.5% to 0.4% (p=0.017). However, the proportion of acceptance by non-CSC hospitals increased from 15.9% to 25.8% (p=0.015). With the designation of CSCs, the EMIC could coordinate interhospital transfers more quickly. However, AIS patients are more dispersed to CSC and non-CSC hospitals, which might be because the CSCs still do not have sufficient resources to cover the increasing volume of AIS patients and non-CSC hospitals have changed their policies. Further studies based on patients' outcome are needed to determine the adequate type of interhospital transfer for AIS patients.

The incomplete infrastructure for interhospital patient transfer

OBJECTIVE

Interhospital transfer of critically ill patients is a common part of their care. This article sought to review the data on the current patterns of use of interhospital transfer and identify systematic barriers to optimal integration of transfer as a mechanism for improving patient outcomes and value of care.

DATA SOURCE

Narrative review of medical and organizational literature.

SUMMARY

Interhospital transfer of patients is common, but not optimized to improve patient outcomes. Although there is a wide variability in quality among hospitals of nominally the same capability, patients are not consistently transferred to the highest quality nearby hospital. Instead, transfer destinations are selected by organizational routines or non-patient-centered organizational priorities. Accomplishing a transfer is often quite difficult for sending hospitals. But once a transfer destination is successfully found, the mechanics of interhospital transfer now appear quite safe.

CONCLUSION

Important technological advances now make it possible to identify nearby hospitals best able to help critically ill patients, and to successfully transfer patients to those hospitals. However, organizational structures have not yet developed to insure that patients are optimally routed, resulting in potentially significant excess mortality.

Is emergency department closure resulting in increased distance to the nearest emergency department associated with increased inpatient mortality?

STUDY OBJECTIVE

We seek to determine whether patients living in areas affected by emergency department (ED) closure, with subsequent increased distance to the nearest ED, have a higher risk of inpatient death from time-sensitive conditions.

METHODS

Using the California Office of Statewide Health and Planning Development database, we performed a nonconcurrent cohort study of hospital admissions in California between 1999 and 2009 for patients admitted for acute myocardial infarction, stroke, sepsis and asthma or chronic obstructive pulmonary disease. We used generalized linear mixed-effects models comparing adjusted inpatient mortality for patients experiencing increased distance to the nearest ED versus no change in distance.

RESULTS

Of 785,385 patient admissions, 67,577 (8.6%) experienced an increase in distance to ED care because of an ED closure. The median change for patients experiencing an increase in distance to the nearest ED was only 0.8 miles, with a range of 0.1 to 33.4 miles. Patients with an increase did not have a significantly higher mortality (adjusted odds ratio 1.04; 95% confidence interval 0.99 to 1.09). In subgroups, we also observed no statistically significant differences in adjusted mortality among patients with acute myocardial infarction, stroke, asthma or chronic obstructive pulmonary disease, and sepsis. We did not observe any significant variations in mortality for time-sensitive conditions in sensitivity analyses that incorporated a lag effect of time after change in distance, allowance for a larger affected population, or removal of ST-segment elevation myocardial infarction from the acute myocardial infarction subgroup.

CONCLUSION

In this large population-based sample, less than 10% of the patients experienced an increase in distance to the nearest ED, and of that group, the majority had less than a 1-mile increase. These small increased distances to the nearest ED were not associated with higher inpatient mortality among time-sensitive conditions.

Bedside sonographic measurement of the inferior vena cava caval index is a poor predictor of fluid responsiveness in emergency department patients

OBJECTIVES

Sonographic measurement of the inferior vena cava (IVC) caval index predicts central venous pressure in ED patients. Fluid responsiveness (FR) is a measure of preload dependence defined as an increase in cardiac output secondary to volume expansion. We sought to determine if the caval index is an accurate measurement of FR in ED patients.

METHODS

We conducted a prospective, observational trial at an urban, academic, adult ED with an annual census >105 000. Included patients were clinically suspected of eu- and hypovolemia. Excluded patients were <18 years old, pregnant, incarcerated, sustained significant trauma or unable to consent. Supine IVC diameter was measured by bedside ultrasonography (M-Turbo; Sonosite, Bothwell, WA, USA). Caval index = [(expiratory IVC diameter - inspiratory IVC diameter)/expiratory IVC diameter] × 100. FR was defined as an increase in the cardiac index by >10% by impedance cardiography (BioZ; Sonosite) following passive leg raise. The primary outcome was analysed using Spearman correlations for non-parametric data and the area under the receiver operating characteristics curve by Wilcoxon method.

RESULTS

Thirty patients were enrolled; four were excluded because of incomplete data collection. Thirty-one per cent (95% CI 13-48) of the patients were FR. The mean initial caval and cardiac index were 15.8% (95% CI 9.5-22) and 2.9 L/min/m(2) (95% CI 2.6-3.2), respectively. Caval index did not predict FR (receiver operating curve = 0.46, 95% CI 0.21-0.71, P = 0.63).

CONCLUSION

Bedside sonographic measurement of IVC caval index does not predict FR in a heterogeneous ED patient population. Further research using this technique in targeted patient subsets and a variety of shock etiologies is needed.

Change of inter-facility transfer pattern in a regional trauma system after designation of trauma centers

Purpose

The Ministry of Health and Welfare recently designated 35 major trauma-specified centers (MTSC). The purpose of this study is to determine changes in patient flow and designated hospitals, and to describe the role of the emergency medical information center (EMIC) in a regional trauma care system.

Methods

Data of trauma patient inter-facility transfer arrangement by one EMIC were reviewed for 2 months before and after the designation of MTSC. The data included success or failure rates of the arrangement, time used for arrangement, and inquiring and accepting facility.

Results

At pre- and post-designation study period, there were 540 and 433 trauma patient inter-facility transfers arranged by EMIC, respectively. The median time used for arrangement decreased from 9.3 to 7.7 minutes (P = 0.007). Arrangement failure rate was 3.5% and 2.5%, respectively, with no significant interval change (P = 0.377). The percentage of inquiring MTSC decreased from 49.1 to 36.9% (P < 0.001). The percentage of accepting MTSC increased from 20.2 to 37.4% (P < 0.001).

Conclusion

With the designation of MTSC, EMIC could arrange inter-facility transfers more quickly. The hospitals wanted more trauma patients after the designation. There would be a concentration of trauma patients to MTSCs in our region. Further studies are needed for scientific evidence on patient outcome.

Assessment of temporal trends in mortality with implementation of a statewide ST-segment elevation myocardial infarction (STEMI) regionalization program

STUDY OBJECTIVE

Although regionalized care for ST-segment elevation myocardial infarction (STEMI) has improved the use of timely reperfusion therapy, its effect on patient outcomes has been difficult to assess. Our objective is to explore temporal trends in STEMI mortality with the implementation of a statewide STEMI regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments [RACE]).

METHODS

We compared trends in inpatient mortality among STEMI patients treated at North Carolina (NC) hospitals participating in the RACE program, relative to those not participating, using state inpatient claims data. Using Medicare claims data, we compared trends in 30-day mortality among Medicare beneficiaries in NC with those nationally. Logistic models with random effects were used to evaluate the association of the program with mortality.

RESULTS

From 2005 to 2007, inpatient mortality for 6,565 STEMI patients treated at NC hospitals participating in RACE decreased from 11.6% to 10.1% (risk difference -1.5%; 95% confidence interval [CI] -3.0% to 0.04%), whereas inpatient mortality among 5,850 STEMI patients treated at NC nonparticipating hospitals decreased from 10.2% to 8.6% (risk difference -1.6%; 95% CI -3.1% to 0.10%); (adjusted odds ratio 1.28; 95% CI 0.88 to 1.85 for temporal differences between groups). During the same period, 30-day STEMI mortality among Medicare beneficiaries decreased from 22.7% to 21.4% in NC (risk difference -1.28%; 95% CI -3.60% to 1.03%) and from 22.3% to 21.6% nationally (risk difference -0.71%, 95% CI -1.13% to -0.29%; adjusted odds ratio 0.99, 95% CI 0.85 to 1.15 for temporal differences between regions).

CONCLUSION

The initiation of a statewide STEMI collaborative care model was associated with a reduction in mortality rates according to claims data, yet these changes were similar to those seen nationally. Further study is needed to evaluate regionalized systems of STEMI care and to determine the role of claims data to evaluate population-based STEMI outcomes.