International perspectives on emergency department crowding

Improving emergency department flow by introducing four interventions simultaneously. A quality improvement project

BACKGROUND

Emergency department (ED) crowding is a widespread issue with adverse effects on patient care and outcomes.

LOCAL PROBLEM

ED crowding exacerbates wait times and compromises patient care, prompting opportunities for internal process improvement.

METHOD

Over one week, the ED flow project team implemented four interventions, including an additional triage station, to optimize patient flow. We compared triage times, length of stay, crowding levels, and patient experiences with two control periods.

RESULTS

During peak hours, waiting times to triage decreased significantly with a median of 20 min (IQR 15-30) in the project week and 26 min (IQR 18-37) in the control weeks. Self-referrals decreased, while general practitioner referrals remained unchanged. Individual patient length of stay was unaffected, but crowding reduced notably during the project week. We found no difference in patient experiences between the periods.

CONCLUSION

The interventions contributed to reduced crowding and improved patient flow. The dedication of the ED flow project team and the ED nurses was crucial to these outcomes. An additional triage station during peak hours in the ED was established as a structural change.

Diagnostic Performance of Point-of-Care High-Sensitivity Troponin in the Exclusion of Non-ST-Elevation Myocardial Infarction in the Emergency Department

BACKGROUND

This study evaluates the diagnostic performance of high-sensitivity troponin using point-of-care testing (POCT) devices compared with main laboratory measurements for ruling out non-ST-elevation myocardial infarction (NSTEMI) in emergency department (ED) patients presenting with non-traumatic chest pain.

METHODS

This multicenter, observational, prospective, non-interventional study was conducted in two Spanish hospitals from 1 June to 31 December 2023 and included adult patients presenting with non-traumatic chest pain admitted to the ED. High-sensitivity troponin levels were measured using both the Siemens Atellica® VTLi POCT device and main laboratory testing, with data collected on analytical results and measurement times.

RESULTS

Of the 201 patients who met the inclusion criteria, a significant correlation was observed between the POCT and laboratory assays. The area under the curve (AUC) of the ROC curve was consistently greater than 0.9, indicating a high diagnostic accuracy for ruling out NSTEMI. In addition, measurement times were significantly reduced using POCT compared to the core laboratory.

CONCLUSION

These results suggest that high-sensitivity troponin POCT devices offer comparable diagnostic performance to traditional laboratory methods for the diagnosis of NSTEMI in the emergency department, potentially speeding up clinical decisions and optimizing resource utilization.

Non-emergency department (ED) interventions to reduce ED utilization: a scoping review

BACKGROUND

Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs.

METHODS

This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population.

RESULTS

Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions.

CONCLUSION

A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.

Factors associated with hospital revisitation within 7 days among patients discharged at triage: a case-control study

BACKGROUND AND IMPORTANCE

Existing data are limited for determining the medical conditions best suited for an emergency department (ED) redirection strategy in a heterogeneous, nonurgent patient population.

OBJECTIVE

The aim was to establish factors associated with hospital revisits within 7 days among patients discharged or redirected by a triage team.

DESIGN, SETTINGS, AND PARTICIPANTS

An observational single-center case-control study was conducted at the Tampere University Hospital ED for the full calendar year of 2019. The cases comprised unplanned hospital revisits within 7 days of being discharged or redirected by triage, while the controls were discharged or redirected but did not revisit.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was an unplanned hospital revisit within 7 days. A subgroup analysis was conducted for revisits leading to hospitalization. Basic demographics, comorbidities before triage, and triage visit characteristics were considered as predictive factors for the revisit. A backward stepwise conditional logistic regression analysis was performed.

MAIN RESULTS

During the calendar year of 2019, there were a total of 92 406 ED visits. Of these, 7216 (7.8%) visits were discharged or redirected by triage, and 6.5% (n = 467) of all these patients revisited. Of the revisiting patients, 25% (n = 117) were hospitalized. In multivariable analysis, higher age was associated with both revisitation [odds ratio (OR): 1.01, 95% confidence interval (CI): 1.00-1.02] and hospitalization (OR: 1.02, 95% CI: 1.00-1.04). Furthermore, using other visits as a reference, abdominal pain was associated with revisitation and hospitalization (OR: 3.70, 95% CI: 2.24-6.11 and OR: 5.28, 95% CI: 2.08-13.4, respectively).

CONCLUSION

Higher age and abdominal pain were associated with hospital revisitation and hospitalization within 7 days among patients directly discharged or redirected by the triage team. Regardless of the triage system in use, there might be patient groups that should be evaluated more cautiously if a triage-based discharge or redirection strategy is to be considered.

An explainable machine learning framework for predicting the risk of buprenorphine treatment discontinuation for opioid use disorder among commercially insured individuals

OBJECTIVES

Buprenorphine is an effective evidence-based medication for opioid use disorder (OUD). Yet premature discontinuation undermines treatment effectiveness, increasing the risk of mortality and overdose. We developed and evaluated a machine learning (ML) framework for predicting buprenorphine care discontinuity within 12 months following treatment initiation.

METHODS

This retrospective study used United States (US) 2018-2021 MarketScan commercial claims data of insured individuals aged 18-64 who initiated buprenorphine between July 2018 and December 2020 with no buprenorphine prescriptions in the previous six months. We measured buprenorphine prescription discontinuation gaps of ≥30 days within 12 months of initiating treatment. We developed predictive models employing logistic regression, decision tree classifier, random forest, extreme gradient boosting, Adaboost, and random forest-extreme gradient boosting ensemble. We applied recursive feature elimination with cross-validation to reduce dimensionality and identify the most predictive features while maintaining model robustness. For model validation, we used several statistics to evaluate performance, such as C-statistics and precision-recall curves. We focused on two distinct treatment stages: at the time of treatment initiation and one and three months after treatment initiation. We employed SHapley Additive exPlanations (SHAP) analysis that helped us explain the contributions of different features in predicting buprenorphine discontinuation. We stratified patients into risk subgroups based on their predicted likelihood of treatment discontinuation, dividing them into decile subgroups. Additionally, we used a calibration plot to analyze the reliability of the models.

RESULTS

A total of 30,373 patients initiated buprenorphine and 14.98% (4551) discontinued treatment. C-statistic varied between 0.56 and 0.76 for the first-stage models including patient-level demographic and clinical variables. Inclusion of proportion of days covered (PDC) measured after one month and three months following treatment initiation significantly increased the models' discriminative power (C-statistics: 0.60 to 0.82). Random forest (C-statistics: 0.76, 0.79 and 0.82 with baseline predictors, one-month PDC and three-months PDC, respectively) outperformed other ML models in discriminative performance in all stages (C-statistics: 0.56 to 0.77). Most influential risk factors of discontinuation included early stage medication adherence, age, and initial days of supply.

CONCLUSION

ML algorithms demonstrated a good discriminative power in identifying patients at higher risk of buprenorphine care discontinuity. The proposed framework may help healthcare providers optimize treatment strategies and deliver targeted interventions to improve buprenorphine care continuity.

Application of a Human Factors Systems Approach to Healthcare Control Centres for Managing Patient Flow: A Scoping Review

Over the past decade, healthcare systems have started to establish control centres to manage patient flow, with a view to removing delays and increasing the quality of care. Such centres-here dubbed Healthcare Capacity Command/Coordination Centres (HCCCs)-are a challenge to design and operate. Broad-ranging surveys of HCCCs have been lacking, and design for their human users is only starting to be addressed. In this review we identified 73 papers describing different kinds of HCCCs, classifying them according to whether they describe virtual or physical control centres, the kinds of situations they handle, and the different levels of Rasmussen's [1] risk management framework that they integrate. Most of the papers (71%) describe physical HCCCs established as control centres, whereas 29% of the papers describe virtual HCCCs staffed by stakeholders in separate locations. Principal functions of the HCCCs described are categorised as business as usual (BAU) (48%), surge management (15%), emergency response (18%), and mass casualty management (19%). The organisation layers that the HCCCs incorporate are classified according to the risk management framework; HCCCs managing BAU involve lower levels of the framework, whereas HCCCs handling the more emergent functions involve all levels. Major challenges confronting HCCCs include the dissemination of information about healthcare system status, and the management of perspectives and goals from different parts of the healthcare system. HCCCs that take the form of physical control centres are just starting to be analysed using human factors principles that will make staff more effective and productive at managing patient flow.

Experiences of implementing and working with obstetric emergency triage: A qualitative study among Swedish midwifes, auxiliary nurses, and obstetricians

INTRODUCTION

Obstetric emergency triage is a relatively new form of emergency triage and is not yet implemented in Sweden. Adaptations enables safe assessment of the childbearing woman, fetus and labor status. Failure to identify severely ill childbearing women and women post childbirth has repeatedly led to adverse outcomes. Introducing obstetric emergency triage constitutes a profound alteration in management that may challenge preconceived notions on how to provide best care. This study aimed at exploring and describing obstetric staff's experiences of working with obstetric emergency triage.

MATERIALS AND METHODS

Thirteen obstetricians, midwives and auxiliary nurses at an obstetric emergency department in eastern Sweden were recruited by purposeful sampling. Individual qualitative interviews underwent inductive qualitative content analysis according to Graneheim and Lundman.

RESULTS

An overarching theme - A new mindset - emerged from the analysis, comprising the four categories: Implications for the individual caregiver's own work, An improved organization, Improved patient care. Initial skepticism to triage changed towards a positive attitude during implementation, identifying barriers and facilitators for successful implementation.

CONCLUSIONS

This first study exploring Swedish obstetric staff's perception of obstetric emergency triage as a working method suggests that, given time for implementation, a new mindset in obstetric emergency care might develop. Triage provides structure and a sense of control through a clear and quick overview of childbearing women seeking emergency care and enhances teamwork by improving communication. Triage directs attention toward aberrations and promotes reflection and action, improving patient safety.

Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing

STUDY OBJECTIVE

Boarding admitted patients in emergency departments (EDs) is a national crisis that is worsening despite potential financial disadvantages. The objective of this study was to assess costs associated with boarding.

METHODS

We conducted a prospective, observational investigation of patients admitted through an ED for management of acute stroke at a large, urban, academic, comprehensive stroke center hospital. We employed time-driven activity-based costing methodology to estimate cost for patient care activities during admission and aggregated results to estimate the total cost of boarding versus inpatient care. Primary outcomes were total daily costs per patient for medical-surgical (med/surg) boarding, med/surg inpatient care, ICU boarding, and ICU inpatient care.

RESULTS

The total daily cost per patient with acute stroke was US$1856, for med/surg boarding versus US$993 for med/surg inpatient care and US$2267, for ICU boarding versus US$2165, for ICU inpatient care. These differences were even greater when accounting for costs associated with traveler nurses. ED nurses spent 293 min/d (mean) caring for each med/surg boarder; inpatient nurses spent 313 min/d for each med/surg inpatient. ED nurses spent 419 min/d caring for each ICU boarder; inpatient nurses spent 787 min/d for each ICU inpatient. Neurology attendings and residents spent 25 and 52 min/d caring for each med/surg boarder versus 62 minutes and 90 minutes for each med/surg inpatient, respectively.

CONCLUSION

Using advanced cost-accounting methods, our investigation provides novel evidence that boarding of admitted patients is financially costly, adding greater urgency for elimination of this practice.

"I do not know the advantages of having a general practitioner" - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care

BACKGROUND

Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP.

METHOD

Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis.

RESULTS

Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity.

CONCLUSION

Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00023480; date: 2020/11/27.

Patients' pathways to the emergency department: a scoping review

BACKGROUND

Emergency department (ED) crowding is a common healthcare issue with multiple causes. One important knowledge area is understanding where patients arrived from and what care they received prior to ED admission. This information could be used to inform strategies to provide care for low acuity patients outside of the hospital and reduce unnecessary ED admissions. The aim of this scoping review was to provide a comprehensive overview of global published research examining the acute care trajectory of all ED patients.

METHODS

The scoping review was performed according to the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive literature search was performed to identify studies describing where patients arrived from and/or whose pathway of care was before an ED visit. The search was conducted in MEDLINE, Embase, and the Cochrane Library from inception through December 5th, 2022. Two reviewers independently screened the records.

RESULTS

Out of the 6,465 records screened, 14 studies from Australia, Canada, Haiti, Norway, Sweden, Switzerland, Belgium, Indonesia, and the UK met the inclusion criteria. Four studies reported on where patients physically arrived from, ten reported how patients were transported, six reported who referred them, and six reported whether medical care or advice was sought prior to visiting an ED.

CONCLUSION

This scoping review revealed a lack of studies describing patients' pathways to the ED. However, studies from some countries indicate that a relatively large proportion of patients first seek care or guidance from a primary care physician (PCP) before visiting an ED. However, further research and published data are needed. To improve the situation, we recommend the development and implementation of a template for the uniform reporting of factors outside the ED, including where the patient journey began, which healthcare facilities they visited, who referred them to the ED, and how they arrived.

[Redirection of patients from the emergency department to ambulatory care: a feasibility study]

BACKGROUND

§ 120 para. 3b SGB V mandates the Federal Joint Committee to define guidelines for the initial assessment of self-referred walk-in patients as well as for the redirection of patients who can be treated by office-based physicians. A corresponding streaming and redirection process was tested in a feasibility study at the RoMed Clinic Rosenheim.

MATERIALS AND METHODS

For the duration of the study, triage nurses of the emergency department (ED) first assessed self-referred walk-in patients with the Manchester Triage System (MTS). Patients in categories green and blue who did not obviously need the ED's resources were additionally assessed by health professionals of the Association of Statutory Health Insurance Physicians of Bavaria using the software Structured Initial Medical Assessment in Germany (SmED). Patients with a recommendation for non-hospital medical treatment were streamed to the out-of-hours practice on campus or were redirected to a physician office after video consultation with an office-based physician. Patient pathways were documented and a qualitative survey using semistructured guided interviews of all stakeholder groups was carried out.

RESULTS

1,091 self-referred walk-in patients were included. Direct streaming to the ED occurred in 525 cases,13 refused to participate. Based on SmED, 24 additional patients were referred to the ED, 514 patients were streamed to the out-of-hours practice, 23 received a video consultation and five left the ED. After video consultation, eight patients were redirected to a physician's office, 10 were discharged, and five referred to the ED of which one did not want an office-based physician. No returnees from practices to the ED were identified. Generally, the redirection process was evaluated positively in the interviews (n=18). In particular, potential for technical improvement was identified.

CONCLUSION

Overall, the results indicate the feasibility of the redirection process and high acceptance levels. Using SmED in addition to MTS appeared useful before redirection but not necessary for streaming on campus. Redirection to physician offices can help reduce strain on the ED when the out-of-hours practice is not operating. In addition to arranging acute care appointments, video consultations offer an additional potential to treat patients. In a follow-up study, a broader range of patients should be included and appropriateness of redirection decisions should be evaluated.

Diagnosing an overcrowded emergency department from its Electronic Health Records

Emergency department overcrowding is a complex problem that persists globally. Data of visits constitute an opportunity to understand its dynamics. However, the gap between the collected information and the real-life clinical processes, and the lack of a whole-system perspective, still constitute a relevant limitation. An analytical pipeline was developed to analyse one-year of production data following the patients that came from the ED (n = 49,938) at Uppsala University Hospital (Uppsala, Sweden) by involving clinical experts in all the steps of the analysis. The key internal issues to the ED were the high volume of generic or non-specific diagnoses from non-urgent visits, and the delayed decision regarding hospital admission caused by several imaging assessments and lack of hospital beds. Furthermore, the external pressure of high frequent re-visits of geriatric, psychiatric, and patients with unspecified diagnoses dramatically contributed to the overcrowding. Our work demonstrates that through analysis of production data of the ED patient flow and participation of clinical experts in the pipeline, it was possible to identify systemic issues and directions for solutions. A critical factor was to take a whole systems perspective, as it opened the scope to the boundary effects of inflow and outflow in the whole healthcare system.

Emergency department crowding: An examination of older adults and vulnerability

Emergency departments in many nations worldwide have been struggling for many years with crowding and the subsequent provision of care in hallways and other unconventional spaces. While this issue has been investigated and analyzed from multiple perspectives, the ethical dimensions of the place of emergency department care have been underexamined. Specifically, the impacts of the place of care on patients and their caregivers have not been robustly explored in the literature. In this article, a feminist ethics and human geography framing is utilized to argue that care provision in open and unconventional spaces in the emergency department can be unethical, as vulnerability can be amplified by the place of care for patients and their caregivers. The situational and pathogenic vulnerability of patients can be heightened by the place of the emergency department and by the constraints to healthcare providers' capacity to promote patient comfort, privacy, communication, and autonomy in this setting. The arrangements of care in the emergency department are of particular concern for older adults given the potential increased risks for vulnerability in this population. As such, hallway healthcare can reflect the normalized inequities of structural ageism. Recommendations are provided to address this complicated ethical issue, including making visible the moral experiences of patients and their caregivers, as well as those of healthcare providers in the emergency department, advocating for a systems-level accounting for the needs of older adults in the emergency department and more broadly in healthcare, as well as highlighting the need for further research to examine how to foster autonomy and care in the emergency department to reduce the risk for vulnerabilities.

An explainable machine learning approach for hospital emergency department visits forecasting using continuous training and multi-model regression

BACKGROUND AND OBJECTIVE

In the last years, the Emergency Department (ED) has become an important source of admissions for hospitals. Since late 90s, the number of ED visits has been steadily increasing, and since Covid19 pandemic this trend has been much stronger. Accurate prediction of ED visits, even for moderate forecasting time-horizons, can definitively improve operational efficiency, quality of care, and patient outcomes in hospitals.

METHODS

In this paper we propose two different interpretable approaches, based on Machine Learning algorithms, to accurately forecast hospital emergency visits. The proposed approaches involve a first step of data segmentation based on two different criteria, depending on the approach considered: first, a threshold-based strategy is adopted, where data is divided depending on the value of specific predictor variables. In a second approach, a cluster-based ensemble learning is proposed, in such a way that a clustering algorithm is applied to the training dataset, and ML models are then trained for each cluster.

RESULTS

The two proposed methodologies have been evaluated in real data from two hospital ED visits datasets in Spain. We have shown that the proposed approaches are able to obtain accurate ED visits forecasting, in short-term and also long-term prediction time-horizons up to one week, improving the efficiency of alternative prediction methods for this problem.

CONCLUSIONS

The proposed forecasting approaches have a strong emphasis on providing explainability to the problem. An analysis on which variables govern the problem and are pivotal for obtaining accurate predictions is finally carried out and included in the discussion of the paper.

Emergency department overcrowding and its associated factors at HARME medical emergency center in Eastern Ethiopia

Introduction

Emergency department (ED) overcrowding has become a significant concern as it can lead to compromised patient care in emergency settings. Various tools have been used to evaluate overcrowding in ED. However, there is a lack of data regarding this issue in resource-limited countries, including Ethiopia. This study aimed to validate NEDOCS, assess level of ED overcrowding and identify associated factors at HARME Medical Emergency Center, located in Hiwot Fana Comprehensive Specialized Hospital, Harar, Ethiopia.

Methods

A cross-sectional study was conducted at the HARME Medical Emergency Center, Hiwot Fana Comprehensive Specialized Hospital, involving a total of 899 patients during 120 sampling intervals. The area under the receiver operating characteristic curves (AUC) was calculated to evaluate the agreement between objective and subjective assessments of ED overcrowding. A multivariable logistic regression analysis was employed to identify factors associated with ED overcrowding and statistically significant association was declared using 95 % confidence level and a p-value < 0.05.

Results

The interrater agreement showed a strong correlation with a Cohen's kappa (κ) of 0.80. The National Emergency Department Overcrowding Study Score demonstrated a strong association with subjective assessments from residents and case team nurses, with an AUC of 0.81 and 0.79, respectively. According to residents' perceptions, ED were considered overcrowded 65.8 % of the time. Factors significantly associated with ED overcrowding included waiting time for triage (AOR: 2.24; 95 % CI: 1.54-3.27), working time (AOR: 2.23; 95 % CI: 1.52-3.26), length of stay (AOR: 2.40; 95 % CI: 1.27-4.54), saturation level (AOR: 2.35; 95 % CI: 1.31-4.20), chronic illness (AOR: 2.19; 95 % CI: 1.37-3.53), and abnormal pulse rate (AOR: 1.52; 95 % CI: 1.06-2.16).

Conclusion

The study revealed that ED were overcrowded approximately two-thirds of the time.

Emergency physician personnel crisis: a survey on attitudes of new generations in Slovenia

BACKGROUND

Emergency departments globally are overburdened, and emergency medicine residency is losing popularity among students and physicians. This raises concerns about the collapse of a life-saving system. Our goal was to identify the key workforce reasoning and question medical staff employment behavior.

METHODS

This was a prospective cross-sectional study. In December 2022, medical students and pre-residency doctors in Slovenia were invited to complete a web-based questionnaire. The data were analyzed using T-test, chi-square test, Mann‒Whitney-Wilcoxon tests, and principal component analysis. Open-ended questions were hand-categorized.

RESULTS

There were 686 participatns who clicked on the first page and 436 of those finished the survey. 4% of participants gave a clear positive response, while 11% responded positively regarding their decision to pursue emergency medicine residency. The popularity of emergency medicine decreases significantly among recent medical school graduates upon their initial employment. People who choose emergency medicine are less concerned about its complexity and pressure compared to others. Most respondents preferred 12-hour shift lengths. The preferred base salary range for residents was I$ 3623-4529, and for specialists, it was I$ 5435-6341. The sample's primary personal priorities are achieving a satisfactory work-life balance, earning respect from colleagues, and engaging in academic activities. Factors that attract individuals to choose emergency medicine include high hourly wages, establishment of standards and norms, and reduced working hours.

CONCLUSIONS

Our findings indicate that enhancing compensation, establishing achievable standards and norms, facilitating a beneficial work-life equilibrium, providing assistance with initial property acquisition, stimulating participation in deficit residency programs, fostering collegiality among peers, restricting the duration of shifts, and enabling pension accrual may be imperative in attracting more individuals to pursue emergency medicine residency.

Appropriateness of the Emergency Referrals Made by Primary Care Clinicians: A cross-sectional review of referral notes

Objectives

This study aimed to evaluate the appropriateness of the emergency referrals made by primary care clinicians and determine the factors contributing to inappropriate referrals.

Methods

This cross-sectional study utilises referral notes review between October 2019 and March 2020. Patients referred to Khawla Hospital's emergency department by a primary care clinician in Muscat Governorate were randomly selected; their referral notes were reviewed by five family physicians. The appropriateness of the referrals was evaluated according to the primary care referral protocol. Any referral that deviated from the protocol was classified as inappropriate. The prevalence and characteristics of inappropriate referrals were identified, and the factors contributing to inappropriate referral were determined using multivariable logistic regression.

Results

In total, 591 referrals were reviewed; 354 (59.9%) of them were classified as inappropriate due to inadequate medical notes (291, 82.2%), lack of provisional diagnosis (176, 49.7%), misdirected to a non-concerned emergency (30, 8.4%) or misclassification of urgency (107 [30.2%] were classified as urgent and 45 [12.7%] as routine). After adjusting for multiple variables, insufficient clinical notes, unavailability of referral guidelines and lack of expertise were found to be strong determinants of inappropriate referral, with an odds ratio of 62.52 (95% confidence interval [CI]: 32.04-121.96), 2.88 (95% CI: 1.40-5.92) and 9.37 (95% CI: 4.09-21.43), respectively.

Conclusion

While most of the referrals required emergency management, the majority were inappropriate, mainly due to insufficient clinical documentation. Inadequate clinical notes and lack of national guidelines and expertise were found to be strong predictors of inappropriate emergency referrals.

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

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

[Motives of patients presenting independently at the emergency department-a prospective monocentric observational study]

BACKGROUND

In the ongoing professional, societal, and political discussion, the hypothesis is repeatedly put forward that a large portion of patients who independently visit the emergency department could also be treated in other care settings such as by a general practitioner, the statutory medical on-call service, or in emergency clinics. Various reasons are cited for why these alternative care settings are not utilized in these cases.

OBJECTIVES

This study investigates the motives of patients who presented independently at the emergency department, as well as the socio-demographic parameters of this study cohort.

MATERIALS AND METHODS

The survey was carried out as part of a prospective monocentric observational study of internal medicine patients at a university emergency department.

RESULTS

A total of 1086 patients were included in the study. In total, 33% of the study participants visited the emergency department based on a physician's recommendation or referral instead of opting for an alternative care option. The main reason for visiting the emergency department was the subjectively assessed urgency of their symptoms. Among the patients who presented independently at the emergency department, 28% required further inpatient care during the course of treatment. Awareness of alternative care pathways, such as utilizing emergency medical services, seeking care from the statutory medical on-call service, or visiting an emergency clinic, was low.

CONCLUSIONS

Emergency departments remain an important point of contact for patients who present there independently, without being brought by emergency medical services. The motives behind why patients choose a visit to the emergency department over treatment in an alternative care setting vary. If alternatives are to be used instead of emergency departments, structures first need to be established or expanded.

Lifting the curtain on the emergency department crisis: a multi-method reception study of Larry Saves the Canadian Healthcare System

BACKGROUND

Despite growing evidence of the potential of arts-based modalities to translate knowledge and spark discussion on complex issues, applications to health policy are rare. This study explored the potential of a research-based theatrical video to increase public capacity and motivation to engage with the complex issues that make Emergency Department wait times such an intractable problem.

METHODS

Larry Saves the Canadian Healthcare System is a digital musical micro-series developed from extensive research examining system-level causes of Emergency crowding and the ineffectiveness of prevailing approaches. We released individual episodes and a revised full-length version on YouTube, using organic promotion strategies and paid advertising. We used YouTube Analytics to track views, engagement and viewer demographics, and content-analyzed viewer comments. We also conducted five university-based screenings; 92 students completed questionnaires, rating Larry on 16 descriptors using a 7-point Likert scale.

RESULTS

From June 2022 through May 2023, Larry garnered over 100,000 views (76,752 of the full-length version, 35,535 of episodes), 1329 likes, 2780 shares, and 139 comments. Views and watch time were higher among women and positively associated with age. Among YouTube comments, the predominating themes were praise for the video and criticism of the healthcare system. Many commenters applauded the show's accuracy, humor, and/or resonance with their experience; several shared healthcare horror stories. Students overwhelmingly agreed with all positive and disagreed with all negative descriptors, and nearly unanimously deemed the video informative, thought-provoking, and entertaining. Most also affirmed that it had increased their knowledge, interest, and confidence to participate in discussions about healthcare issues. Neither gender, primary language, nor employment in healthcare predicted ratings, but graduate students and those 25+ years old evaluated the video most positively.

DISCUSSION

These findings highlight the promise of research-informed musical satire to inform and invigorate discourse on an urgent health policy problem. Larry has reached tens of thousands of viewers, garnered excellent feedback, and received high student ratings. Further research should directly assess educational and behavioural outcomes and explore what facilitative strategies could maximize this knowledge translation product's potential to foster informed, impactful policy dialogue.

Emergency department crowding increases 10-day mortality for non-critical patients: a retrospective observational study

The current evidence suggests that higher levels of crowding in the Emergency Department (ED) have a negative impact on patient outcomes, including mortality. However, only limited data are available about the association between crowding and mortality, especially for patients discharged from the ED. The primary objective of this study was to establish the association between ED crowding and overall 10-day mortality for non-critical patients. The secondary objective was to perform a subgroup analysis of mortality risk separately for both admitted and discharged patients. An observational single-centre retrospective study was conducted in the Tampere University Hospital ED from January 2018 to February 2020. The ED Occupancy Ratio (EDOR) was used to describe the level of crowding and it was calculated both at patient's arrival and at the maximum point during the stay in the ED. Age, gender, Emergency Medical Service transport, triage acuity, and shift were considered as confounding factors in the analyses. A total of 103,196 ED visits were included. The overall 10-day mortality rate was 1.0% (n = 1022). After controlling for confounding factors, the highest quartile of crowding was identified as an independent risk factor for 10-day mortality. The results were essentially similar whether using the EDOR at arrival (OR 1.31, 95% CI 1.07-1.61, p = 0.009) or the maximum EDOR (OR 1.27, 95% CI 1.04-1.56, p = 0.020). A more precise, mortality-associated threshold of crowding was identified at EDOR 0.9. The subgroup analysis did not yield any statistically significant findings. The risk for 10-day mortality increased among non-critical ED patients treated during the highest EDOR quartile.

Perceived treatment urgency of common mental disorders in the German population

Perceived treatment urgency of mental disorders are important as they determine utilization of health care. The aim was to analyze variations in perceived treatment urgency in cases of psychosis (adolescents), alcoholism (adults), and depression (older adults) with two levels of severity each by characteristics of the case and the respondents. A telephone survey (N = 1200) with vignettes describing cases of psychosis, alcoholism, and depression was conducted in Hamburg, Germany. Vignettes varied by symptom severity and sex. Perceived treatment urgency was assessed by three items. A sum scale was calculated. Linear regression models were computed to analyze differences in perceived urgency by characteristics of the case (severity, sex) and the respondents (sex, age, education, migration background, illness recognition, personal affliction). Perceived treatment urgency was significantly higher in severe cases and varied by education. Additionally, regarding psychosis, estimated urgency varied significantly by correct illness recognition. With regard to depression, perceived urgency differed significantly by age and correct illness recognition. Interaction effects between case severity and sociodemographic characteristics of the respondents, personal affliction, and correct recognition of the disorder were found. The identified differences should be considered in the development of interventions on mental health literacy with regard to adequate urgency assessment.

The pattern of emergency department length of stay in Saudi Arabia: an epidemiological Nationwide analyses of secondary surveillance data

Background

Emergency department length of stay is a vital performance indicator for quality and efficiency in healthcare. This research aimed to evaluate the length of stay patterns in emergency departments across Saudi Arabia and to identify predictors for extended stays. The study used secondary data from the Ministry of Health's Ada'a program.

Methods

Using a retrospective approach, the study examined data from the Ada'a program on emergency department length of stay from September 2019 to December 2021. These data covered 1,572,296 emergency department visits from all regions of Saudi Arabia. Variables analyzed included quality indicators, year of visit, shift time, hospital type, and data entry method. The analysis was conducted using multiple linear regression.

Results

The study found that the median length of stay was 61 min, with significant differences among related predictors. All associations were significant with a value of p of less than 0.001. Compared to 2019, the length of stay was notably shorter by 28.5% in 2020 and by 44.2% in 2021. Evening and night shifts had a shorter length of stay by 5.9 and 7.8%, respectively, compared to the morning shift. Length of stay was lower in winter, summer, and fall compared to spring. Patients in levels I and II of the Canadian Triage and Acuity Scales had longer stays than those in level III, with those in level I reaching an increase of 20.5% in length of stay. Clustered hospitals had a longer length of stay compared to the non-clustered ones. Pediatric hospitals had a 15.3% shorter stay compared to general hospitals. Hospitals with data entered automatically had a 14.0% longer length of stay than those entered manually. Patients admitted to the hospital had a considerably longer length of stay, which was 54.7% longer compared to non-admitted patients. Deceased patients had a 20.5% longer length of stay than patients discharged alive.

Conclusion

Data at the national level identified several predictors of prolonged emergency department length of stay in Saudi Arabia, including shift time, season, severity level, and hospital type. These results underline the necessity of continuous monitoring and improvement efforts in emergency departments, in line with policy initiatives aiming to enhance patient outcomes in Saudi Arabia.

Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic

STUDY OBJECTIVE

We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022.

METHODS

We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states.

RESULTS

Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day.

CONCLUSION

ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

Motives behind low-acuity geriatric emergency medicine attenders: a picture from free healthcare system

BACKGROUND

Current evidence about the low-acuity ED visits of old patients has been generated in various healthcare systems; however, this is not a well-researched area in middle-income countries by patients' perspectives.

METHODS

A study of 231 patients attending the ED of a tertiary public hospital was conducted using a structured questionnaire from June to August 2021. Eligible patients were community-dwelling, aged > 65 years, who presented with lower clinical urgency. The questionnaire tool was developed using questions from available studies on health service utilization. Additional commentary was obtained from the patients regarding on the reasons for attending the ED and was administered on weekdays between 8:00 am and 5:30 pm.

RESULTS

The study included 221 patients over 65 years of age, with a mean age of 72.21 ± 4.2. A total of 58.4% of the patients thought that they should be examined urgently, 15.4% had symptoms that had lasted more than one month, and 59% requested emergency imaging. Patients preferred the ED via treatment, imaging, transportation opportunities of emergency department, past negative experiences, and access problems with family medicines or appointment problems with specialist outpatient clinics with expectations of continuity of care.

CONCLUSION

Old individuals have unique healthcare needs, and the motives behind this group of patients with low-acuity problems to apply to the ED is complex. As one of the key objectives of healthcare policies is to make sure that patients are assessed at proper time and place, studies that consider patient perspectives might lead to accurate conclusions for this aim.

Fast track to stroke unit for patients not eligible for acute intervention, a case-control register study on 1066 patients

Stroke patients not eligible for acute intervention often have low priority and may spend long time at the emergency department (ED) waiting for admission. The aim of this retrospective case-control register study was to evaluate outcomes for such "low priority" stroke patients who were transported via Fast Track directly to the stroke unit, according to pre-specified criteria by emergency medical service (EMS). The outcomes of Fast Track patients, transported directly to stroke unit (cases) were compared with the outcomes of patients who fulfilled these critera for Fast Track, but instead were transported to the ED (controls). In all, 557 cases and 509 controls were identified. The latter spent a mean time of 237 min in the ED before admission. The 90-day mortality rate was 12.9% for cases and 14.7% for controls (n.s.). None of the secondary outcome events differed significantly between the groups: 28-day mortality rate; death rate during hospitalisation; proportion of pneumonias, falls or pressure ulcers; or health-related outcomes according to the EQ-5D-5L questionnaire. These findings indicates that the Fast Track to the stroke unit by an EMS is safe for selected stroke patients and could avoid non-valuable time in the ED.

Applying Andersen's healthcare utilization model to assess factors influencing patients' expectations for diagnostic tests at emergency department visits during the COVID-19 pandemic

Background

The uncertainties surrounding the COVID-19 pandemic led to a surge in non-urgent emergency department (ED) attendance among people presenting with upper respiratory tract infection (URTI) symptoms. These non-urgent visits, often manageable in primary care, exacerbated ED overcrowding, which could compromise the quality of ED services. Understanding patients' expectations and the reasons for these ED visits is imperative to mitigate the problem of ED overcrowding. Hence, we assessed the factors influencing patients' expectations for diagnostic tests during their ED visits for uncomplicated URTI during different phases of the pandemic.

Methods

We conducted a cross-sectional study on adults with URTI symptoms seeking care at four public EDs in Singapore between March 2021 and March 2022. We segmented the study period into three COVID-19 pandemic phases-containment, transition, and mitigation. The outcome variables are whether patients expected (1) a COVID-19-specific diagnostic test, (2) a non-COVID-19-specific diagnostic test, (3) both COVID-19-specific and non-COVID-19-specific diagnostic tests, or (4) no diagnostic test. We built a multinomial regression model with backward stepwise selection and classified the findings according to Andersen's healthcare utilization model.

Results

The mean age of participants was 34.5 (12.7) years. Factors (adjusted odds ratio [95% confidence interval]) influencing expectations for a COVID-19-specific diagnostic test in the ED include younger age {21-40 years: (2.98 [1.04-8.55])}, no prior clinical consultation (2.10 [1.13-3.89]), adherence to employer's health policy (3.70 [1.79-7.67]), perceived non-severity of illness (2.50 [1.39-4.55]), being worried about contracting COVID-19 (2.29 [1.11-4.69]), and during the transition phase of the pandemic (2.29 [1.15-4.56]). Being non-employed influenced the expectation for non-COVID-19-specific diagnostic tests (3.83 [1.26-11.66]). Factors influencing expectations for both COVID-19-specific and non-COVID-19-specific tests include younger age {21-40 years: (3.61 [1.26-10.38]); 41-60 years: (4.49 [1.43-14.13])}, adherence to employer's health policy (2.94 [1.41-6.14]), being worried about contracting COVID-19 (2.95 [1.45- 5.99]), and during the transition (2.03 [1.02-4.06]) and mitigation (2.02 [1.03-3.97]) phases of the pandemic.

Conclusion

Patients' expectations for diagnostic tests during ED visits for uncomplicated URTI were dynamic across the COVID-19 pandemic phases. Expectations for COVID-19-specific diagnostic tests for ED visits for uncomplicated URTI were higher among younger individuals and those worried about contracting COVID-19 during the COVID-19 pandemic. Future studies are required to enhance public communications on the availability of diagnostic services in primary care and public education on self-management of emerging infectious diseases such as COVID-19.

How Emergency Medicine Residents Have Conversations About Life-Sustaining Treatments in Critical Illness: A Qualitative Study Using Inductive Thematic Analysis

STUDY OBJECTIVE

The inherent pressures of high-acuity, critical illness in the emergency department create a unique environment whereby acute goals-of-care discussions must be had with patients or substitute decision makers to rapidly decide between divergent treatment paths. Among university-affiliated hospitals, resident physicians are often conducting these highly consequential discussions. This study aimed to use qualitative methods to explore how emergency medicine residents make recommendations regarding life-sustaining treatments during acute goals-of-care discussions in critical illness.

METHODS

Using qualitative methods, semistructured interviews were conducted with a purposive sample of emergency medicine residents in Canada from August to December 2021. Inductive thematic analysis of the interview transcripts was conducted using line-by-line coding, and key themes were identified through comparative analysis. Data collection continued until thematic saturation was reached.

RESULTS

Seventeen emergency medicine residents from 9 Canadian universities were interviewed. Two factors guided residents' treatment recommendations (a duty to provide a recommendation and the balance between disease prognosis and patient values). Three factors influenced residents' comfort when making recommendations (time constraints, uncertainty, and moral distress).

CONCLUSION

While conducting acute goals-of-care discussions with critically ill patients or their substitute decision makers in the emergency department, residents felt a sense of duty to provide a recommendation informed by an intersection between the patient's disease prognosis and the patient's values. Their comfort in making these recommendations was limited by time constraints, uncertainty, and moral distress. These factors are important for informing future educational strategies.

Age in addition to RETTS triage priority substantially improves 3-day mortality prediction in emergency department patients: a multi-center cohort study

BACKGROUND

Previous studies have shown varying results on the validity of the rapid emergency triage and treatment system (RETTS), but have concluded that patient age is not adequately considered as a risk factor for short term mortality. Little is known about the RETTS system's performance between different chief complaints and on short term mortality. We therefore aimed to evaluate how well a model including both RETTS triage priority and patient age (TP and age model) predicts 3-day mortality compared to a univariate RETTS triage priority model (TP model). Secondarily, we aimed to evaluate the TP model compared to a univariate age model (age model) and whether these three models' predictive performance regarding 3-day mortality varies between patients with different chief complaints in an unsorted emergency department patient population.

METHODS

This study was a prospective historic observational cohort study, using logistic regression on a cohort of patients seeking emergency department care in Stockholm during 2012-2016. Patient visits were stratified into the 10 chief complaint categories (CCC) with the highest number of deceased patients within 3 days of arrival, and to "other chief complaints". Patients with priority 1 were excluded.

RESULTS

The studied cohort contained 1,690,981 visits by 788,046 different individuals. The TP and age model predicted 3-day mortality significantly and substantially better than both univariate models in the total population and in each studied CCC. The age model predicted 3-day mortality significantly and substantially better than the TP model in the total population and for all but three CCCs and was not inferior in any CCC. There were substantial differences between the studied CCCs in the predictive ability of each of the three models.

CONCLUSIONS

Adding patient age to the RETTS triage priority system significantly and substantially improves 3-day mortality prediction compared to RETTS priority alone. Age alone is a non-inferior predictor of 3-day mortality compared to RETTS priority. The impact on 3-day mortality prediction of adding patient age to RETTS priority varies between CCCs but is substantial for all CCCs and for the total population. Including age as a variable in future revisions of RETTS could substantially improve patient safety.

Who, When, Why?-Traumatological Patients in the Emergency Department of a Maximum Care Provider

Nationwide, there is an annual increase in the number of patients in German emergency departments resulting in a growing workload for the entire emergency department staff. Several studies have investigated the situation in emergency departments, most of which were interdisciplinary, but there are no data on a solely traumatological patient population. The present study therefore aims to investigate the situation in a university-based trauma surgery emergency department. A total of 8582 traumatological patients attending a university hospital from 1 January 2019 to 31 December 2019 were studied. Various variables, such as reason for presentation, time of accident, diagnosis, and diagnostic as well as therapeutic measures performed were analyzed from the admission records created. The mean age was 36.2 years, 60.1% were male, 63.3% presented on their own to the emergency department, and 41.2% presented during regular working hours between 8:00 a.m. and 6:00 p.m., Monday through Friday. The most common reason for presentation was outdoor falls at 17.4%, and 63.3% presented to the emergency department within the first 12 h after the sustained trauma. The most common diagnosis was bruise (27.6%), and 14.2% of patients were admitted as inpatients. Many of the emergency room patients suffered no relevant trauma sequelae. In order to reduce the number of patients in emergency rooms in the future, existing institutions in the outpatient emergency sector must be further expanded and effectively advertised to the public. In this way, the emergency medical resources of clinics, including staff, can be relieved to provide the best possible care for actual emergency patients.

Strategies to mitigate emergency department crowding and its impact on cardiovascular patients

Emergency department (ED) crowding is a worsening global problem caused by hospital capacity and other health system challenges. While patients across a broad spectrum of illnesses may be affected by crowding in the ED, patients with cardiovascular emergencies-such as acute coronary syndrome, malignant arrhythmias, pulmonary embolism, acute aortic syndrome, and cardiac tamponade-are particularly vulnerable. Because of crowding, patients with dangerous and time-sensitive conditions may either avoid the ED due to anticipation of extended waits, leave before their treatment is completed, or experience delays in receiving care. In this educational paper, we present the underlying causes of crowding and its impact on common cardiovascular emergencies using the input-throughput-output process framework for patient flow. In addition, we review current solutions and potential innovations to mitigate the negative effect of ED crowding on patient outcomes.

Bidirectional referral system between National Taiwan University Hospital medical center and Zhongxiao Branch community hospital of Taipei City Hospital: focus on patient satisfaction

The policy of bidirectional referral between National Taiwan University Hospital and Taipei City Hospital has been launched due to the over-crowding of the emergency department at National Taiwan University Hospital. This research aims to evaluate patient satisfaction with the bidirectional referral. Sixty-six patients have been referred from the emergency department of National Taiwan University Hospital to Taipei City Hospital, Zhongxiao campus from April 2015 to December 2017. The selection criteria of the subjects for bidirectional referral include the management of patients classified as triage classification 2 or 3. Exclusion criteria are as follows: incomplete patient records and patients who chose hospice care. Sixty-six patients completed the questionnaires. Multivariate regression was used to evaluate the determinants of overall satisfaction scores of the bidirectional referral. The two overall satisfaction scores of patients were high (> 7). Three independent variables, (1) overall satisfaction scores of medical care at Taipei City Hospital, Zhongxiao campus, (2) waiting times for examination, treatment, and test, and (3) a positive question regarding quality improvement of delivered care for patients and family explained 69.3% adjusted variability of the overall satisfaction scores of bidirectional referrals. Therefore, the policy of bidirectional referrals and direct admission into the wards of Taipei City Hospital, Zhongxiao campus, from the emergency department of National Taiwan University Hospital met the criteria for patient satisfaction and public accountability.

Practice of Pre-Hospital Emergency Care and Associated Factors in Addis Ababa, Ethiopia: Facility-Based Cross-Sectional Study Design

Background

Medical emergencies require quick field interventions and stabilization before transport, while rapid transportation to definitive healthcare with fewer field interventions improves trauma outcomes. Poor prehospital healthcare practices negatively impact patients' health, and limited studies exist on providers' practices in resource-limited areas like Ethiopia. This study aimed to assess the practice of pre-hospital emergency care and associated factors at pre-hospital health facilities in Addis Ababa, Ethiopia.

Methods

A facility-based cross-sectional study was conducted 191 pre-hospital healthcare providers, of which 20 randomly selected participants were participated in the observational study from October 2021 to February 2022 in Addis Ababa Ethiopia. Data was collected using a checklist and self-administered questionnaire. Data was cleaned, entered into Epi data version 4.4, and exported to SPSS software for analysis. Binary and multivariable logistic regression analyses were performed, with a P-value of 0.05 considered statistically significant.

Results

The study found that 43% (82) of pre-hospital healthcare providers in Addis Ababa, Ethiopia, had good practice in pre-hospital emergency care. The identified factors that increased the odds of good practice in pre-hospital emergency care were: being able to provide advanced life support (AOR = 88.99; 95% CI: 27.143-291.603); adequate monitoring and defibrillators (AOR = 5.829; 95% CI: 1.430-23.765); having work experience of 4-5 years (AOR = 5.86; 95% CI: 1.424-24.109); and having the opportunity to continue education (AOR = 31.953; 95% 6.479-157.591).

Conclusions and Recommendations

The study found high levels of poor practice among pre-hospital healthcare providers in Addis Ababa, Ethiopia. Factors contributing to good practice include being trained in advanced Life Support, adequate monitoring, defibrillators, work experience, and having the opportunity to continue education. Therefore, policymakers and health planners should establish teaching and training centres based on Ministry of Health and Education guidelines.

Existing Data Sources in Clinical Epidemiology: Database of Community Acquired Infections Requiring Hospital Referral in Eastern Denmark (DCAIED) 2018-2021

Infectious diseases are major health care challenges globally and a prevalent cause of admission to emergency departments. Epidemiologic characteristics and outcomes based on population level data are limited. The Database of Community Acquired Infections in Eastern Denmark (DCAIED) 2018-2021 was established with the aim to explore and estimate the population characteristics, and outcomes of patients suffering from community acquired infections at the emergency departments in the Capital Region and the Zealand Region of Denmark using data from electronic medical records. Adult patients (≥18 years) presenting to the emergency department with suspected or confirmed infection are included in the cohort. Presence of sepsis and organ failure are assessed using modified criteria from the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). During the inclusion period from January 2018 to January 2022, 2,241,652 adult emergency department visits have been registered. Of these, 451,825 were unique encounters of which 60,316 fulfilled criteria of suspected infection and 28,472 fulfilled sepsis criteria and 8,027 were defined as septic shock. The database covers the entire Capital and Zealand Region of Denmark with an uptake area of 2.6 million inhabitants and includes demographic, laboratory and outcome indicators, with complete follow-up. The database is well-suited for epidemiological research for future national and international collaborations.

Predictive indicators for determining red blood cell transfusion strategies in the emergency department

BACKGROUND AND IMPORTANCE

Appropriate decision-making is critical for transfusions to prevent unnecessary adverse outcomes; however, transfusion in the emergency department (ED) can only be decided based on sparse evidence in a limited time window.

OBJECTIVES

This study aimed to identify factors associated with appropriate red blood cell (RBC) transfusion in the ED by analyzing retrospective data of patients who received transfusions at a single center.

OUTCOME MEASURES AND ANALYSIS

This study analyzed associations between transfusion appropriateness and sex, age, initial vital signs, an ED triage score [the Korean Triage and Acuity Scale (KTAS)], the length of stay, and the hemoglobin (Hb) concentration.

MAIN RESULTS

Of 10 490 transfusions, 10 109 were deemed appropriate, and 381 were considered inappropriate. A younger age ( P  < 0.001) and a KTAS level of 3-5 ( P  = 0.028) were associated with inappropriate transfusions, after adjusting for O 2 saturation and the Hb level.

CONCLUSIONS

In this single-center retrospective study, younger age and higher ED triage scores were associated with the appropriateness of RBC transfusions.

Emergency department crowding and mortality: an observational multicenter study in Sweden

Background

Emergency department (ED) crowding is a serious problem worldwide causing decreased quality of care. It is reasonable to assume that the negative effects of crowding are at least partially due to high staff workload, but previous crowding metrics based on high workload have not been generalisable to Swedish EDs and have not been associated with increased mortality, in contrast to, e.g., occupancy rate. We recently derived and validated the modified Skåne Emergency Department Assessment of Patient Load model (mSEAL) that measures crowding based on staff workload in Swedish EDs, but its ability to identify situations with increased mortality is unclear. In this study, we aimed to investigate the association between ED crowding measured by mSEAL model, or occupancy rate, and mortality.

Methods

All ED patients from 2017-01-01 to 2017-06-30 from two regional healthcare systems (Skåne and Östergötland Counties with a combined population of approximately 1.8 million) in Sweden were included. Exposure was ED- and hour-adjusted mSEAL or occupancy rate. Primary outcome was mortality within 7 days of ED arrival, with one-day and 30-day mortality as secondary outcomes. We used Cox regression hazard ratio (HR) adjusted for age, sex, arrival by ambulance, hospital admission and chief complaint.

Results

We included a total of 122,893 patients with 168,900 visits to the six participating EDs. Arriving at an hour with a mSEAL score above the 95th percentile for that ED and hour of day was associated with an non-significant HR for death at 7 days of 1.04 (95% CI 0.96-1.13). For one- and 30-day mortality the HR was non-significant at 1.03 (95% CI 0.9-1.18) and 1.03 (95% CI 0.97-1.09). Similarly, occupancy rate above the 95th percentile with a HR of 1.04 (95% CI 0.9-1.19), 1.03 (95%CI 0.95-1.13) and 1.04 (95% CI 0.98-1.11) for one-, 7- and 30-day mortality, respectively.

Conclusion

In this multicenter study in Sweden, ED crowding measured by mSEAL or occupancy rate was not associated with a significant increase in short-term mortality.

Synergism of an Urgent Care Walk-in Clinic With an Emergency Department

BACKGROUND

The overutilization of hospital emergency departments by low-urgency patients is seen as a growing problem in health-care delivery, and a variety of solutions are under discussion. We studied the change in utilization of a hospital emergency department (ED) by low-urgency patients after an urgent care walk-in clinic (WIC) was opened in the immediate vicinity.

METHODS

A prospective, single-center pre-post comparative study was carried out at the University Medical Center Hamburg-Eppendorf (UKE). The ED patient collective consisted of adult walk-in patients who presented to the ED between 4 pm and midnight. The "pre" period consisted of August and September 2019, and the "post" period was from November 2019 (after the opening of the WIC) to January 2020.

RESULTS

The study patients consisted of 4765 ED walk-in patients and 1201 WIC patients. 956 (80.5%) of the WIC patients had been referred onward to the WIC after initially presenting to the ED; from this group, 790 patients (82.6%) received definitive care in the WIC. The number of outpatients treated in the ED fell by 37.3% (95% confidence interval [30.9; 43.8]), from 851.5 to 536.7 per month. The most marked decreases were in the areas of dermatology (from 62.5 to 14.3 patients per month), neurology (45.5 to 25), ophthalmology (115 to 64.7), and trauma surgery (211 to 128.7). No decrease was seen in urology, psychiatry, or gynecology. For patients presenting without any referral document, the mean length of stay fell by a mean of 17.6 [7.4; 27.8] minutes from its "pre" value of 172.3 minutes. The rate of patients who left during treatment fell from 76.5 to 28.3 patients per month (p < 0.001).

CONCLUSION

A GP-led urgent care walk-in clinic next door to an interdisciplinary hospital emergency department is a resource-saving treatment option for walk-in patients who present to the emergency department. Most of the patients referred from the ED to the WIC were able to receive definitive care there.

The impact of alternate level of care on access block and operational strategies to reduce emergency wait times: a multi-center simulation study

OBJECTIVES

Lengthy emergency department (ED) wait times caused by hospital access block is a growing concern for the Canadian health care system. Our objective was to quantify the impact of alternate-level-of-care on hospital access block and evaluate the likely effects of multiple interventions on ED wait times.

METHODS

Discrete-event simulation models were developed to simulate patient flows in EDs and acute care of six Canadian hospitals. The model was populated with administrative data from multiple sources (April 2017-March 2018). We simulated and assessed six different intervention scenarios' impact on three outcome measures: (1) time waiting for physician initial assessment, (2) time waiting for inpatient bed, and (3) patients who leave without being seen. We compared each scenario's outcome measures to the baseline scenario for each ED.

RESULTS

Eliminating 30% of medical inpatients' alternate-level-of-care days reduced the mean time waiting for inpatient bed by 0.25 to 4.22 h. Increasing ED physician coverage reduced the mean time waiting for physician initial assessment (∆ 0.16-0.46 h). High-quality care transitions targeting medical patients lowered the mean time waiting for inpatient bed for all EDs (∆ 0.34-6.85 h). Reducing ED visits for family practice sensitive conditions or improving continuity of care resulted in clinically negligible reductions in wait times and patients who leave without being seen rates.

CONCLUSIONS

A moderate reduction in alternate-level-of-care hospital days for medical patients could alleviate access block and reduce ED wait times, although the magnitude of reduction varies by site. Increasing ED physician staffing and aligning physician capacity with inflow demand could also decrease wait time. Operational strategies for reducing ED wait times should prioritize resolving output and throughput factors rather than input factors.

Qualitative study on the use of emergency services by people with serious mental disorder in Spain

BACKGROUND

The population with severe mental disorders (SMD) is a frequent user of emergency services. Situations of psychiatric decompensation can have devastating consequence and can cause problems in getting urgent medical care. The objective was to study the experiences and needs of these patients and their caregivers regarding the demand for emergency care in Spain.

METHODS

Qualitative methodology involving patients with SMD and their informal caregivers. Purposive sampling by key informants in urban and rural areas. Paired interviews were carried out until data saturation. A discourse analysis was conducted, obtaining a codification in categories by means of triangulation.

RESULTS

Forty-two participants in twenty-one paired interviews (19 ± 7.2 min as mean duration). Three categories were identified. 1º Reasons for urgent care: poor self-care and lack of social support, as well as difficulties in accessibility and continuity of care in other healthcare settings. 2º Urgent care provision: trust in the healthcare professional and the information patients receive from the healthcare system is crucial, telephone assistance can be a very useful resource. 3º Satisfaction with the urgent care received: they request priority care without delays and in areas separated from the other patients, as well as the genuine interest of the professional who attends them.

CONCLUSIONS

The request for urgent care in patients with SMD depends on different psychosocial determinants and not only on the severity of the symptoms. There is a demand for care that is differentiated from the other patients in the emergency department. The increase in social networks and alternative systems of care would avoid overuse of the emergency departments.

Are Short-Stay Units Safe and Effective in the Treatment of Non-Variceal Upper Gastrointestinal Bleeding?

Introduction: Emergency Department (ED) overcrowding is a health, political, and economic problem of concern worldwide. The causes of overcrowding are an aging population, an increase in chronic diseases, a lack of access to primary care, and a lack of resources in communities. Overcrowding has been associated with an increased risk of mortality. The establishment of a Short Stay Unit (SSU) for conditions that cannot be treated at home but require treatment and hospitalization for up to 72 h may be a solution. SSU can significantly reduce hospital length of stay (LOS) for certain conditions but does not appear to be useful for other diseases. Currently, there are no studies addressing the efficacy of SSU in the treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). Our study aims to evaluate the efficacy of SSU in reducing the need for hospitalization, LOS, hospital readmission, and mortality in patients with NVUGIB compared with admission to the regular ward. Materials and Methods: This was a retrospective, single-center observational study. Medical records of patients presenting with NVUGIB to ED between 1 April 2021, and 30 September 2022, were analyzed. We included patients aged >18 years who presented to ED with acute upper gastrointestinal tract blood loss. The test population was divided into two groups: Patients admitted to a normal inpatient ward (control) and patients treated at SSU (intervention). Clinical and medical history data were collected for both groups. The hospital LOS was the primary outcome. Secondary outcomes were time to endoscopy, number of blood units transfused, readmission to the hospital at 30 days, and in-hospital mortality. Results: The analysis included 120 patients with a mean age of 70 years, 54% of whom were men. Sixty patients were admitted to SSU. Patients admitted to the medical ward had a higher mean age. The Glasgow-Blatchford score, used to assess bleeding risk, mortality, and hospital readmission were similar in the study groups. Multivariate analysis after adjustment for confounders found that the only factor independently associated with shorter LOS was admission to SSU (p < 0.0001). Admission to SSU was also independently and significantly associated with a shorter time to endoscopy (p < 0.001). The only other factor associated with a shorter time to EGDS was creatinine level (p = 0.05), while home treatment with PPI was associated with a longer time to endoscopy. LOS, time to endoscopy, number of patients requiring transfusion, and number of units of blood transfused were significantly lower in patients admitted to SSU than in the control group. Conclusions: The results of the study show that treatment of NVUGIB in SSU can significantly reduce the time required for endoscopy, the hospital LOS, and the number of transfused blood units without increasing mortality and hospital readmission. Treatment of NVUGIB at SSU may therefore help to reduce ED overcrowding but multicenter randomized controlled trials are needed to confirm these data.

Emergency department crowding negatively influences outcomes for adults presenting for chronic obstructive pulmonary disease

OBJECTIVES

Emergency department (ED) crowding leads to poor outcomes. Patients with respiratory conditions like chronic obstructive pulmonary disease (COPD) are especially vulnerable to crowding-related delays in care. We aimed to assess the associations of ED crowding metrics with outcomes for patients presenting with COPD.

METHODS

We conducted a population-based cohort study of adult patients presenting with a diagnosis of COPD to 18 high-volume EDs between 2014 and 2019 in Alberta, Canada. Administrative databases provided date and time data on key stages of the presentation including physician initial assessment and disposition decision. Crowding metrics were calculated using facility-specific median physician initial assessment and length of stay. Patient presentations were grouped by acuity and mixed-effects regression models were fit to adjust for the clustering at the facility level.

RESULTS

There were 49,085 presentations for COPD made by 25,734 patients (median age = 73 years). A 1-h increase in the physician initial assessment metric was associated with an increase in physician initial assessment for COPD patients by 23, 53, and 59 min for the high, moderate, and low acuity groups, respectively, adjusted for other predictors. For the low acuity group, this metric was associated with an increased length of stay of 73 min for admitted individuals. Similarly, an increase in the length of stay metric was also associated with an increased likelihood of being admitted for all acuity groups.

CONCLUSIONS

For patients with COPD, ED crowding results in delays in assessment increased length of stay, and increased proportion of patients admitted. These results suggest that ED crowding mitigation efforts to provide timely care for patients with COPD are urgently needed.

TRIAL REGISTRATION

N/A.

Exploring the views of low-acuity emergency department consulters on an educational intervention and general practitioner appointment service: a qualitative study in Berlin, Germany

OBJECTIVES

Low-acuity patients presenting to emergency departments (EDs) frequently have unmet ambulatory care needs. This qualitative study explores the patients' views of an intervention aimed at education about care options and promoting primary care (PC) attachment.

DESIGN

Qualitative telephone interviews were conducted with a subsample of participants of an interventional pilot study, based on a semi-structured interview guide. The data were analysed through qualitative content analysis.

SETTING

The study was carried out in three EDs in the city centre of Berlin, Germany.

PARTICIPANTS

Thirty-two low-acuity ED consulters with no connection to a general practitioner (GP) who had participated in the pilot study were interviewed; (f/m: 15/17; mean age: 32.9 years).

INTERVENTION

In the pilot intervention, ED patients with low-acuity complaints were provided with an information leaflet on appropriate ED usage and alternative care paths and they were offered an optional GP appointment scheduling service. Qualitative interviews explored the views of a subsample of the participants on the intervention.

RESULTS

Interviewees perceived both parts of the intervention as valuable. Receiving a leaflet about appropriate ED use and alternatives to the ED was viewed as helpful, with participants expressing the desire for additional online information and a wider distribution of the content. The GP appointment service was positively assessed by the participants who had made use of this offer and seen as potentially helpful in establishing a long-term connection to GP care. The majority of patients declining a scheduled GP appointment expected no personal need for further medical care in the near future or preferred to choose a GP independently.

CONCLUSIONS

Low-acuity ED patients seem receptive to information on alternative acute care options and prevailingly appreciate measures to encourage and facilitate attachment to a GP. Promoting PC integration could contribute to a change in future usage behaviour.

TRIAL REGISTRATION NUMBER

DRKS00023480.

Appropriateness of frequent use of emergency departments: A retrospective analysis in Rome, Italy

Background

Frequent users (FUs) are patients who repeatedly and inappropriately visit the emergency department (ED) for low-grade symptoms that could be treated outside the hospital setting. This study aimed to investigate the phenomenon of the FU in Rome by profiling such users and analyzing ED attendance by FUs.

Methods

The analysis was carried out for attendance in 2021 at 15 EDs in the Local Health Authority Roma 1 geographical area. A digital app collected data, including information on the following variables: number of attendance, demographic characteristics, emergency medical service (EMS) usage, triage code, and appropriateness of attendance. COVID-19 diagnosis was also studied to analyze any possible influence on ED attendance. Differences between FUs and non-FUs were investigated statistically by t-test and chi-square test. Univariate analysis and multivariable logistic regression were performed to analyze the associated factors.

Results

A total of 122,762 ED attendance and 89,036 users were registered. The FU category represented 2.9% of all users, comprising 11.9% of total ED attendance. There was a three times higher frequency of non-urgent codes in attendance of FU patients (FU: 9.7%; non-FU: 3.2%). FUs were slightly more likely to have used the EMS (13.6% vs. 11.4%) and had a lower frequency of appropriate ED attendance (23.8% vs. 27.0%). Multivariate logistic analysis confirmed a significant effect of triage code, gender, age, EMS usage, and COVID-19 diagnosis for the appropriateness of attendance. The results were statistically significant (p &lt; 0.001).

Conclusion

The FU profile describes mostly non-urgent and inappropriate attendance at the ED, including during the COVID-19 pandemic. This study represents an important tool for strengthening preventive policies outside the hospital setting. The Italian National Recovery and Resilience Plan represents an excellent opportunity for the development of new strategies to mitigate the phenomenon of FUs.

The Causal Effect of Community Hospitals on General Hospital Admissions. Evaluation of a Natural Experiment Using Register Data

Background

To reduce overall healthcare costs, several countries have attempted to shift services from specialist to primary care. This was also the main strategy of the Coordination Reform introduced in Norway in 2012. An important part of the reform was the introduction of Municipal Acute Wards (MAWs), a type of community hospital aimed at reducing admissions to general hospitals. The main objective of this paper is to investigate whether the implementation of MAWs had a causal effect on hospital admissions.

Methods

Monthly admission rates in total and by age groups for patients admitted with acute or elective conditions at internal medicine or surgical departments were analyzed using panel data regression techniques. We identified causal effects by exploiting the sequential roll out of the MAWs within fixed effect analyses. Our data covered all municipalities from start of 2010 until the end of 2017.

Results

The sequential implementation of the MAWs started during the summer of 2012. By the beginning of 2016 close to all municipalities had an operative MAW. The introduction of MAWs significantly reduced acute hospital admissions. The effect was strongest for patients ≥80 years admitted acutely to internal medicine departments. The effects were even stronger if the MAW had a physician on site 24/7 or was located close to a local emergency center.

Conclusion

Our findings suggest that this type of intermediate care unit is a viable option to alleviate the burden on hospitals by reducing acute secondary care admission volumes.

CEU 2023 Florence: an appointment with the future of the emergency system

The Academy of Emergency Medicine and Care is one of the more than 20 scientific societies promoting the 3rd National Congress of Emergency/Urgency (CEU2023), planned in Florence from March 30th to April 1st.1 This will be a fundamental appointment for update on all clinical and organizing aspects of the Italian emergency system. More that 2500 people will participated to the CEU2023 meeting and courses with the possibility to attend more than 50 sessions with approximately 500 national and international speakers. This organization will ensure elevate quality of updating for specific themes by covering the point of view of hospital and pre-hospital medical doctors and nurses, emergency medicine trainees, but other professionals (drivers, rescuers, technicians, and volunteers). [...]

A Disease-Prediction Protocol Integrating Triage Priority and BERT-Based Transfer Learning for Intelligent Triage

Large hospitals can be complex, with numerous discipline and subspecialty settings. Patients may have limited medical knowledge, making it difficult for them to determine which department to visit. As a result, visits to the wrong departments and unnecessary appointments are common. To address this issue, modern hospitals require a remote system capable of performing intelligent triage, enabling patients to perform self-service triage. To address the challenges outlined above, this study presents an intelligent triage system based on transfer learning, capable of processing multilabel neurological medical texts. The system predicts a diagnosis and corresponding department based on the patient’s input. It utilizes the triage priority (TP) method to label diagnostic combinations found in medical records, converting a multilabel problem into a single-label one. The system considers disease severity and reduces the “class overlapping” of the dataset. The BERT model classifies the chief complaint text, predicting a primary diagnosis corresponding to the complaint. To address data imbalance, a composite loss function based on cost-sensitive learning is added to the BERT architecture. The study results indicate that the TP method achieves a classification accuracy of 87.47% on medical record text, outperforming other problem transformation methods. By incorporating the composite loss function, the system’s accuracy rate improves to 88.38% surpassing other loss functions. Compared to traditional methods, this system does not introduce significant complexity, yet substantially improves triage accuracy, reduces patient input confusion, and enhances hospital triage capabilities, ultimately improving the patient’s medical experience. The findings could provide a reference for intelligent triage development.