Association between delays to patient admission from the emergency department and all-cause 30-day mortality

Transforming respiratory tract infection diagnosis in the kingdom of saudi arabia through point-of-care testing: A white paper for policy makers

With the evident increased prevalence of respiratory tract infections (RTIs) such as Respiratory Syncytial Virus (RSV), influenza, Group A Streptococcus (GAS), and COVID-19, the conventional diagnostic methods are considered sub-optimal in providing timely management to patients in the Kingdom of Saudi Arabia (KSA). Gaps in current diagnostics are magnified by the Kingdom's unique demographic composition, comprising 11.9 million foreign workers, and the annual influx of over 10 million pilgrims. Current gaps in timely diagnosis leads to delays in treatment, misuse of antibiotics, and protracted hospital stays, subsequently compromising patient care, and escalating healthcare costs. KSA healthcare stakeholders suggest that the integration of rapid molecular Point-of-Care Testing (POCT) into the Kingdom's healthcare infrastructure is an absolute necessity. This publication serves as an urgent call for action aimed at healthcare policymakers in Saudi Arabia, to review the existing diagnostic challenges and include rapid POCTs in the Saudi healthcare strategy for respiratory infections.

A need for systems thinking and the appliance of (complexity) science in healthcare

Hospitals represent complex adaptive systems where interactions and relationships of different components both affect and shape the way they work simultaneously. Pressures on hospitals determine how they behave and many of the problems seen in the NHS and indeed other health services can be viewed through the lens of complexity science and systems thinking. 'Flow' of patients through the hospital can be seen as an indicator of how well the hospital 'system' is working. The better flow is, the more patients can be treated and the less time is spent waiting in the various queues that accrue around the hospital, In this article, we explore the impact of these disciplines on patient flow and examine how short-term and overly simple solutions can exacerbate problems in the health service, despite the best intentions of those working in it. Many of today's problems can be described in terms of 'system archetypes' and 'game theory'. Understanding this may lead to improvement in how services are redesigned to solve these problems.

OrthoMortPred: Predicting one-year mortality following orthopedic hospitalization

OBJECTIVE

Predicting mortality risk following orthopedic surgery is crucial for informed decision-making and patient care. This study aims to develop and validate a machine learning model for predicting one-year mortality risk after orthopedic hospitalization and to create a personalized risk prediction tool for clinical use.

METHODS

We analyzed data from 3,132 patients who underwent orthopedic procedures at the Central Lisbon University Hospital Center from 2021 to 2023. Using the LightGBM algorithm, we developed a predictive model incorporating various clinical and administrative variables. We employed SHAP (SHapley Additive exPlanations) values for model interpretation and created a personalized risk prediction tool for individual patient assessment.

RESULTS

Our model achieved an accuracy of 93% and an area under the ROC curve of 0.93 for predicting one-year mortality. Notably, 'EMERGENCY ADMISSION DATE TIME' emerged as the most influential predictor, followed by age and pre-operative days. The model demonstrated robust performance across different patient subgroups and outperformed traditional statistical methods. The personalized risk prediction tool provides clinicians with real-time, patient-specific risk assessments and insights into contributing factors.

CONCLUSION

Our study presents a highly accurate model for predicting one-year mortality following orthopedic hospitalization. The significance of 'EMERGENCY ADMISSION DATE TIME' as the primary predictor highlights the importance of admission timing in patient outcomes. The accompanying personalized risk prediction tool offers a practical means of implementing this model in clinical settings, potentially improving risk stratification and patient care in orthopedic practice.

Experiences of the emergency department environment: a qualitative study with caregivers of people with dementia

ED crowding and boarding adversely impact older patients' care and outcomes. Little is known about how ED crowding impacts persons living with dementia, a vulnerable population. This study sought to explore ED experiences of caregivers of people with dementia during a period of ED crowding and boarding. We performed semi-structured interviews with caregivers of people with dementia with an ED visit during a period of ED crowding and boarding at two public hospitals experiencing a threefold increase in boarding from pre-pandemic levels. Participants were recruited via chart review. We coded data using an inductive approach. Three themes emerged from 29 caregiver interviews: (1) difficulty obtaining assistance, (2) patient harms, and (3) concerns about triage and rooming processes. First, caregivers described having to be proactive to obtain symptom control and assistance with mobility. Second, caregivers observed harms of noise and stimulation provoking agitation and delays in administration of routine medications. Third, caregivers felt it was inappropriate for people with dementia to receive care in waiting room chairs or to receive prolonged hallway care. Caregivers advocated for preferential considerations for rooming and rapid assessment to avoid agitation, facilitatd access to ED staff, and promote patient comfort. Caregivers of people with dementia associated ED environments with difficulty obtaining assistance, patient harms, and triage concerns. Strategies to mitigate the negative impacts of ED crowding on people with dementia should focus on environmental modifications, uptriage of people with dementia, supporting activities of daily living and mobility, and innovation around patient disposition.

A strategic solution to preventing the harm associated with ambulance handover delays

Ambulance handover delays arise when emergency departments become overcrowded as patients waiting prolonged periods for admission occupy clinical cubicles designed to facilitate the assessment and treatment of emergency arrivals. In response, many organisations become reliant on temporarily lodging acutely unwell patients awaiting admission in undesignated areas for care such as corridors, to provide additional space. This results in a significant risk of avoidable harm, indignity and psychological trauma for patients and has a negative effect on the well-being of healthcare professionals, since unacceptable standards of care become normalised. A two-phase strategic quality improvement project was implemented at the authors' acute trust. Ambulance handover data from between 2 November 2020 and 26 July 2021 provided a benchmark for the project. The first phase was implemented between 2 November 2021 and 26 July 2022 and aimed to reduce 60-minute ambulance handover delays. The second phase was implemented between 2 November 2022 and 26 July 2023 and aimed to eradicate 60-minute ambulance handover delays and improve overall performance. Phase one resulted in a 32% reduction in 60-minute ambulance handover delays. Phase two resulted in a 97% reduction in 60-minute ambulance handover delays. Over the course of the project there was a 24% increase in handovers completed within 15 minutes. This project demonstrates how strategic planning and collaboration between healthcare teams can reduce the potential for avoidable patient harm, while simultaneously promoting workforce well-being and retention.

Delayed admission of patients with hip fracture from the emergency department is associated with an increased mortality risk and increased length of hospital stay

BACKGROUND

The aims of this study were to assess whether delayed admission from the ED influenced mortality risk, length of acute hospital stay, risk of developing delirium and return to domicile for patients presenting with a hip fracture.

METHODS

A single centre service evaluation was undertaken including patients aged over 50 years who were admitted to a Scottish hospital through the ED with a hip fracture during a 42-month period (from January 2019 to June 2022). Delay was defined as spending >4 hours in the ED from arrival. Patient demographics and perioperative variables and mortality were collected. Cox regression analysis (adjusting for age, sex, season, socioeconomic status, American Society of Anesthesiologists grade, place of residence, fracture type, delirium and time from ward to theatre) was used to determine the independent association between delayed disposition from the ED and mortality (90 days and final follow-up) as recorded on a regional database.

RESULTS

The cohort consisted of 3266 patients with a mean age of 81 years, of which 2359 (72.2%) were female. 1261 (38.6%) patients stayed >4 hours in ED. The median follow-up was 529 days, during which time there were 1314 (40.2%) deaths. Survival at 90 days was significantly lower (hazard ratio [HR] 0.76, 95% CI 0.63 to 0.91) for patients who stayed >4 hours (92.9%) compared with those who stayed ≤4 hours (95.7%). Delayed disposition was independently associated with an increased mortality risk at 90 days (adjusted HR 1.36, 95% CI 1.12 to 1.63, p=0.001) and at final follow-up (adjusted HR 1.15, 95% CI 1.03 to 1.29, p=0.017). Delay was also associated with a longer length of hospital stay (difference in medians of 1 day, p<0.001). There were no differences in the risk of delirium on the ward (p=0.256) or return to place of residence (p≥0.315).

CONCLUSION

Delayed disposition from our ED was associated with an increased mortality risk and longer length of hospital stay in patients presenting with a hip fracture.

Variation in attendance at emergency departments in England across local areas: A system under unequal pressure

BACKGROUND

Crowding in Accident and Emergency Departments (AEDs) and long waiting times are critical issues contributing to adverse patient outcomes and system inefficiencies. These challenges are exacerbated by varying levels of AED attendance across different local areas, which may reflect underlying disparities in primary care provision and population characteristics.

METHOD

We used regression analysis to determine how much variation across local areas in England of attendance at emergency departments remained after controlling for population risk factors and alternative urgent care provision.

FINDINGS

There is substantial residual variation of the order of 3 to 1 (highest to lowest) in per person attendance rate across different areas. This is not related to in-hospital capacity as proxied by the per person number of hospital emergency doctors in an area.

CONCLUSION

Some areas in England have emergency departments that are under much greater pressure than others, and this cannot be explained in terms of their population characteristics or the availability of alternative treatment options. It is imperative to better understand the drivers of this variation so that effective interventions to address utilisation can be designed.

Ambulance offload performance, patient characteristics and disposition for patients offloaded to different areas of the emergency department

OBJECTIVE

Ambulance transfer of care (TOC) is a key performance indicator for New South Wales EDs, with 90% of ambulances to be offloaded within 30 min of arrival. Nepean Hospital ED has a number of strategies to improve TOC, including ambulatory areas where patients can be offloaded immediately. Offload data are supplied by ambulance and there is no study into its accuracy. The aim is to audit the accuracy of ambulance data of TOC compared to times recorded in the Nepean ED information system, and to examine TOC and patient demographics for different offload destinations.

METHODS

A retrospective observational study was performed for patients presenting by ambulance between 1 July and 31 December 2022. TOC was calculated from FirstNet and compared to ambulance data using a paired-sample t test. Patients were categorised by offload destination within the ED and examined for age, TOC, disposition and specialty team if admitted.

RESULTS

TOC for ambulance and ED data was 60.8% versus 64.1%, respectively (difference 3.33%, P < 0.001). Patients offloaded to acute care were older, with 61.9% being >65 years; had a TOC of 37.3% compared to the resuscitation and ambulatory areas with TOC close to 90%; and were likely to be admitted with a 63.8% admission rate and 24.1% of admissions being under the geriatric service.

CONCLUSION

Patients arriving by ambulance requiring an acute care bed were likely to be elderly and frail, and suffered substantial ambulance offload delays. Delays to ambulance offload for these patients is likely driven by acute care bed availability and access block.

Optimizing Emergency Department Length of Stay and Quality of Care: A Quality Improvement Project

Background Patients' long length of stay (LOS) in the emergency department (ED) is a common measure of quality of care that could be a cause of increased morbidity and mortality. This quality improvement project (QIP) aimed to identify causes of long LOS and to improve common causes such as long consultation times. Methodology Over two months, three plan, do, study, and act (PDSA) cycles were conducted aiming to identify causes of long ED LOS and improve common causes that extended ED LOS beyond four hours. Additionally, the project aimed to reduce the time taken from requesting a consultation from another specialty until it was completed and documented to an average of 60 minutes. Main interventions included raising awareness of staff and administration through video presentations, printed posters, direct contact, and optimizing the electronic health records system to audit performance. Results From PDSA cycle 1 through PDSA cycle 3, average consultation times decreased from 91 to 65 minutes. Common organization-related causes of long LOS included pending radiology or laboratory investigations, awaiting inpatient admission, and awaiting consultations from other specialties. Physician-related factors included delay in documentation likely resulting from heavy workload. Pending investigations and admissions were factors that could be amended with better administrative control. Conclusions A multifaceted approach that tackles physician-related and organization-related factors could be a necessity to improve LOS and the quality of care in the ED. Having staff and administration aware of targets and performance along with utilizing the electronic health records system to audit performance and increase efficiency are beneficial in improving the LOS in the ED.

Healthcare outcomes and dispositions in persons with obesity within emergency departments in Ontario, Canada: A cross-sectional analysis of the National Ambulatory Care Reporting System (NACRS), 2018-2022

INTRODUCTION

The experience of persons with obesity (PwO) in the Canadian healthcare setting has not been widely studied. The objective of this study was to assess care in PwO in emergency departments in Ontario, Canada.

METHODS

This secondary analysis made use of 2018-2022 Canadian Institute for Health Information's National Ambulatory Care Reporting System. The sample consisted of 4547 individuals with an obesity diagnosis, and 4547 controls who were matched for sex, age, and main diagnosis. Ordinal logistic and multiple linear regression analyses were used to assess triage scores, wait times, and length of stay.

RESULTS

PwO had 4.8 minutes longer wait time for a physician initial assessment (p<0.01), 3.56 hours longer length of stay in the emergency department (p<0.0001), and 55% greater odds (OR = 1.55, 95% CI: 1.43-1.68) of having a less urgent triage score compared to controls matched for main diagnosis. When further matched for triage score, PwO experienced over three hours longer length of stay for triage level 2 (emergent, p<0.01), five hours longer for triage level 3 (urgent, p<0.01), and nearly two hours longer for triage level 4 (less urgent, p<0.05) cases.

CONCLUSION

PwO were rated as less urgent and experienced longer wait times and length of stay, compared to controls matched by sex, age, and main diagnosis. Additional research is needed to confirm the consistency of these findings in other provinces/territories, and to examine clinical outcomes, and the underlying reasons for differences.

Exploring the effects of emergency department crowding on emergency nurses

Although the phenomenon of crowding in emergency departments (EDs) is not new, it remains a significant problem for patients, ED staff and the wider healthcare system. Crowding in EDs, which is also called overcrowding, has been widely explored in the literature, but there are relatively few studies of the subject from an emergency nurse perspective. This article reports the findings of a literature review that aimed to explore the effects of crowding on nurses working in EDs. Four key themes were identified from a synthesis of 16 articles included in the review: staffing and skill mix; inadequate care and the effect on nurses' well-being and stress levels; violence in the ED; and hospital metrics and patient flow. Further research is required to explore in more depth the effects of ED crowding on emergency nurses and to address the multiple factors that perpetuate the phenomenon.

Scoping review of the effectiveness of 10 high-impact initiatives (HIIs) for recovering urgent and emergency care services

INTRODUCTION

Prolonged ambulance response times and unacceptable emergency department (ED) wait times are significant challenges in urgent and emergency care systems associated with patient harm. This scoping review aimed to evaluate the evidence base for 10 urgent and emergency care high-impact initiatives identified by the National Health Service (NHS) England.

METHODS

A two-stage approach was employed. First, a comprehensive search for reviews (2018-2023) was conducted across PubMed, Epistemonikos and Google Scholar. Additionally, full-text searches using Google Scholar were performed for studies related to the key outcomes. In the absence of sufficient review-level evidence, relevant available primary research studies were identified through targeted MEDLINE and HMIC searches. Relevant reviews and studies were mapped to the 10 high-impact initiatives. Reviewers worked in pairs or singly to identify studies, extract, tabulate and summarise data.

RESULTS

The search yielded 20 771 citations, with 48 reviews meeting the inclusion criteria across 10 sections. In the absence of substantive review-level evidence for the key outcomes, primary research studies were also sought for seven of the 10 initiatives. Evidence for interventions improving ambulance response times was generally scarce. ED wait times were commonly studied using ED length of stay, with some evidence that same day emergency care, acute frailty units, care transfer hubs and some in-patient flow interventions might reduce direct and indirect measures of wait times. Proximal evidence existed for initiatives such as urgent community response, virtual hospitals/hospital at home and inpatient flow interventions (involving flow coordinators), which did not typically evaluate the NHS England outcomes of interest.

CONCLUSIONS

Effective interventions were often only identifiable as components within the NHS England 10 high-impact initiative groupings. The evidence base remains limited, with substantial heterogeneity in urgent and emergency care initiatives, metrics and reporting across different studies and settings. Future research should focus on well-defined interventions while remaining sensitive to local context.

Sex-specific high-sensitivity troponin T cut-points have similar safety but lower efficacy than overall cut-points in a multisite U.S. cohort

BACKGROUND

Data comparing the performance of sex-specific to overall (non-sex-specific) high-sensitivity cardiac troponin (hs-cTn) cut-points for diagnosing acute coronary syndrome (ACS) are limited. This study aims to compare the safety and efficacy of sex-specific versus overall 99th percentile high-sensitivity cardiac troponin T (hs-cTnT) cut-points.

METHODS

We conducted a secondary analysis of the STOP-CP cohort, which prospectively enrolled emergency department patients ≥ 21 years old with symptoms suggestive of ACS without ST-elevation on initial electrocardiogram across eight U.S. sites (January 25, 2017-September 6, 2018). Participants with both 0- and 1-h hs-cTnT measures less than or equal to the 99th percentile (sex-specific 22 ng/L for males, 14 ng/L for females; overall 19 ng/L) were classified into the rule-out group. The safety outcome was adjudicated cardiac death or myocardial infarction (MI) at 30 days. Efficacy was defined as the proportion classified to the rule-out group. McNemar's test and a generalized score statistic were used to compare rule-out and 30-day cardiac death or MI rates between strategies. Net reclassification improvement (NRI) index was used to further compare performance.

RESULTS

This analysis included 1430 patients, of whom 45.8% (655/1430) were female; the mean ± SD age was 57.6 ± 12.8 years. At 30 days, cardiac death or MI occurred in 12.8% (183/1430). The rule-out rate was lower using sex-specific versus overall cut-points (70.6% [1010/1430] vs. 72.5% [1037/1430]; p = 0.003). Among rule-out patients, the 30-day cardiac death or MI rates were similar for sex-specific (2.4% [24/1010]) vs. overall (2.3% [24/1037]) strategies (p = 0.79). Among patients with cardiac death or MI, sex-specific versus overall cut-points correctly reclassified three females and incorrectly reclassified three males. The sex-specific strategy resulted in a net of 27 patients being incorrectly reclassified into the rule-in group. This led to an NRI of -2.2% (95% CI -5.1% to 0.8%).

CONCLUSIONS

Sex-specific hs-cTnT cut-points resulted in fewer patients being ruled out without an improvement in safety compared to the overall cut-point strategy.

Overnight stay in Spanish emergency departments and mortality in older patients

To assess whether older adults who spend a night in emergency departments (ED) awaiting admission are at increased risk of mortality. This was a retrospective review of a multipurpose cohort that recruited all patients ≥ 75 years who visited ED and were admitted to hospital on April 1 to 7, 2019, at 52 EDs across Spain. Study groups were: patients staying in ED from midnight until 8:00 a.m. (ED group) and patients admitted to a ward before midnight (ward group). The primary endpoint was in-hospital mortality, truncated at 30 days, and secondary outcomes assessed length of stay for the index episode. The sample comprised 3,243 patients (median [IQR] age, 85 [81-90] years; 53% women), with 1,096 (34%) in the ED group and 2,147 (66%) in the ward group. In-hospital mortality for patients spending the night in the ED the ED group was 10.7% and 9.5% for patients transferred to a ward bed before midnight the ward group (adjusted OR: 1.12, 95%CI: 0.80-1.58). Sensitivity analyses rendered similar results (ORs ranged 1.06-1.13). Interaction was only detected for academic/non-academic hospitals (p < 0.001), with increased mortality risk for the latter (1.01, 0.33-3.09 vs 2.86, 1.30-6.28). There were no differences in prolonged hospitalization (> 7 days), with adjusted OR of 1.16 (0.94-1.43) and 1.15 (0.94-1.42) depending on whether time spent in the ED was or was not taken into consideration. No increased risk of in-hospital mortality or prolonged hospitalization was found in older patients waiting overnight in the ED for admission. Nonetheless, all estimations suggest a potential harmful effect of staying overnight, especially if a proper bedroom and hospitalist ward bed and hospitalized care are not provided.

Impact of off-hours admissions in STEMI-related cardiogenic shock managed with microaxial flow pump - insights from J-PVAD

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (STEMI-CS) is associated with high mortality rates. Patients admitted during off-hours, specifically on weekends and at night, show higher mortality rates, which is called the "off-hours effect". The off-hours effect in patients with STEMI-CS treated with mechanical circulatory support, especially Impella, has not been fully evaluated.

AIMS

We aimed to investigate whether off-hours admissions were associated with higher mortality rates in this population.

METHODS

We used large-scale Japanese registry data for consecutive patients treated with Impella between February 2020 and December 2021 and compared on- and off-hours admissions. On- and off-hours were defined as the time between 8:00 and 19:59 on weekdays and the remaining time, respectively. The Cox proportional hazards model was used to calculate the adjusted hazard ratios (aHRs) for 30-day mortality.

RESULTS

Of the 1,207 STEMI patients, 566 (46.9%) patients (mean age: 69 years; 107 females) with STEMI-CS treated with Impella were included. Of these, 300 (53.0%) were admitted during on-hours. During the follow-up period (median 22 days [interquartile range 13-38 days]), 112 (42.1%) and 91 (30.3%) deaths were observed among patients admitted during off- and on-hours, respectively. Off-hours admissions were independently associated with a higher risk of 30-day mortality than on-hours admissions (aHR 1.60, 95% confidence interval: 1.07-2.39; p=0.02).

CONCLUSIONS

Our findings indicated the persistence of the "off-hours effect" in STEMI-CS patients treated with Impella. Healthcare professionals should continue to address the disparities in cardiovascular care by improving the timely provision of evidence-based treatments and enhancing off-hours medical services.

Multimorbidity and adverse outcomes following emergency department attendance: population based cohort study

ABSTRACT

Objectives

To describe the effect of multimorbidity on adverse patient centred outcomes in people attending emergency department.

Design

Population based cohort study.

Setting

Emergency departments in NHS Lothian in Scotland, from 1 January 2012 to 31 December 2019.

Participants

Adults (≥18 years) attending emergency departments.

Data sources

Linked data from emergency departments, hospital discharges, and cancer registries, and national mortality data.

Main outcome measures

Multimorbidity was defined as at least two conditions from the Elixhauser comorbidity index. Multivariable logistic or linear regression was used to assess associations of multimorbidity with 30 day mortality (primary outcome), hospital admission, reattendance at the emergency department within seven days, and time spent in emergency department (secondary outcomes). Primary analysis was stratified by age (<65 v ≥65 years).

Results

451 291 people had 1 273 937 attendances to emergency departments during the study period. 43 504 (9.6%) had multimorbidity, and people with multimorbidity were older (median 73 v 43 years), more likely to arrive by emergency ambulance (57.8% v 23.7%), and more likely to be triaged as very urgent (23.5% v 9.2%) than people who do not have multimorbidity. After adjusting for other prognostic covariates, multimorbidity, compared with no multimorbidity, was associated with higher 30 day mortality (8.2% v 1.2%, adjusted odds ratio 1.81 (95% confidence interval (CI) 1.72 to 1.91)), higher rate of hospital admission (60.1% v 20.5%, 1.81 (1.76 to 1.86)), higher reattendance to an emergency department within seven days (7.8% v 3.5%, 1.41 (1.32 to 1.50)), and longer time spent in the department (adjusted coefficient 0.27 h (95% CI 0.26 to 0.27)). The size of associations between multimorbidity and all outcomes were larger in younger patients: for example, the adjusted odds ratio of 30 day mortality was 3.03 (95% CI 2.68 to 3.42) in people younger than 65 years versus 1.61 (95% CI 1.53 to 1.71) in those 65 years or older.

Conclusions

Almost one in ten patients presenting to emergency department had multimorbidity using Elixhauser index conditions. Multimorbidity was strongly associated with adverse outcomes and these associations were stronger in younger people. The increasing prevalence of multimorbidity in the population is likely to exacerbate strain on emergency departments unless practice and policy evolve to meet the growing demand.

Abated crowding by fast-tracking the Throughput component of the ED for patients in no need of hospitalization with competency managed personnel

BACKGROUND

Emergency department (ED) crowding is a major patient safety concern and has a negative impact on healthcare systems and healthcare providers. We hypothesized that it would be feasible to control crowding by employing a multifaceted approach consisting of systematically fast-tracking patients who are mostly not in need of a hospital stay as assessed by an initial nurse and treated by decision competent physicians.

METHODS

Data from 120,901 patients registered in a secondary care ED from the 4tth quarter of 2021 to the 1st quarter of 2024 was drawn from the electronic health record's data warehouse using the SAP Web Intelligence tool and processed in the Python programming language. Crowding was compared before and after ED transformation from a uniform department into a high flow (α) and a low flow (β) section with patient placement in gurneys/chairs or beds, respectively. Patients putatively not in need of hospitalization were identified by nurse, placed in in the α setting and assessed and treated by decision competent physicians. Incidence of crowding, number of patients admitted per day and readmittances within 72 h following ED admission before and after changes were determined. Values are number of patients, mean ± SEM and mean differences with 95% CIs. Statistical significance was ascertained using Student's two tailed t-test for unpaired values.

RESULTS

Before and after ED changes crowding of 130% amounted to 123.8 h and 19.3 h in the latter. This is a difference of -104.6 ± 23.9 h with a 95% CI of -159.9 to -49.3, Δ% -84 (p = 0.002). There was the same amount of patients / day amounting to 135.8 and 133.5 patients / day Δ% = -1.7 patients 95% CI -6.3 to 1.6 (p = 0.21). There was no change in readmittances within 72 h before and after changes amounting to 9.0% versus 9.5%, Δ% = 0.5, 95%, CI -0.007 to 1.0 (p > 0.052).

CONCLUSION

It appears feasible to abate crowding with unchanged patient admission and without an increase in readmittances by fast-track assessment and treatment of patients who are not in need of hospitalization.

Interventions to improve emergency department throughput and care delivery indicators: A systematic review and meta-analysis

BACKGROUND

Emergency department (ED) crowding has repercussions on acute care, contributing to prolonged wait times, length of stay, and left without being seen (LWBS). These indicators are regarded as systemic shortcomings, reflecting a failure to provide equitable and accessible acute care. The objective was to evaluate the effectiveness of interventions aimed at improving ED care delivery indicators.

METHODS

This was a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing ED interventions aimed at reducing key metrics of time to provider (TTP), time to disposition (TTD), and LWBS. We excluded disease-specific trials (e.g., stroke). We used Cochrane's revised tool to assess the risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations to rate the quality of evidence. The meta-analysis was performed using a random-effects model and Cochrane Q test for heterogeneity. Data were summarized as means (±SD) for continuous variables and risk ratios (RR) with 95% confidence intervals (CIs).

RESULTS

We searched MEDLINE, EMBASE, and other major databases. A total of 1850 references were scanned and 20 RCTs were selected for inclusion. The trials reported at least one of the three outcomes of TTD, TTP, or LWBS. Most interventions focused on triage liaison physician and point-of-care (POC) testing. Others included upfront expedited workup (ordering tests before full evaluation by a provider), scribes, triage kiosks, and sending notifications to consultants or residents. POC testing decreased TTD by an average of 5-96 min (high heterogeneity) but slightly increased TTP by a mean difference of 2 min (95% CI 0.6-4 min). Utilizing a triage liaison physician reduced TTD by 28 min (95% CI 19-37 min; moderate-quality evidence) and was more effective in reducing LWBS than routine triage (RR 0.76, 95% CI 0.66-0.88; moderate quality).

CONCLUSIONS

Operational strategies such as POC testing and triage liaison physicians could mitigate the impact of ED crowding and appear to be effective. The current evidence supports these strategies when tailored to the appropriate practice environment.

Being a patient in a crowded emergency department: a qualitative service evaluation

BACKGROUND

Emergency department (ED) crowding causes increased mortality. Professionals working in crowded departments feel unable to provide high-quality care and are predisposed to burnout. Awareness of the impact on patients, however, is limited to metrics and surveys rather than understanding perspectives. This project investigated patients' experiences and identified mitigating interventions.

METHODS

A qualitative service evaluation was undertaken in a large UK ED. Adults were recruited during periods of high occupancy or delayed transfers. Semi-structured interviews explored experience during these attendances. Participants shared potential mitigating interventions. Analysis was based on the interpretative phenomenological approach. Verbatim transcripts were read, checked for accuracy, re-read and discussed during interviewer debriefing. Reflections about positionality informed the interpretative process.

RESULTS

Seven patients and three accompanying partners participated. They were aged 24-87 with characteristics representing the catchment population. Participants' experiences were characterised by 'loss of autonomy', 'unmet expectations' and 'vulnerability'. Potential mitigating interventions centred around information provision and better identification of existing ED facilities for personal needs.

CONCLUSION

Participants attending a crowded ED experienced uncertainty, helplessness and discomfort. Recommendations included process and environmental orientation.

Mortality and its determinants among patients attending in emergency departments

BACKGROUND

Due to the high burden of mortality from acute communicable and non-communicable diseases, emergency department's mortality has become one of the major health indices in Ethiopia that should be evaluated regularly in every health institution. However, there are inconsistencies between studies, and there is no systematic review or meta-analysis study about the prevalence of mortality in the emergency department. Therefore, this study aimed to determine the pooled prevalence of mortality and identify its determinants in the emergency departments of Ethiopian hospitals.

METHODS

This systematic review was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and has been registered with PROSPERO. A structured search of databases (Medline/PubMed, Google Scholar, CINAHL, EMBASE, HINARI, and Web of Science) was undertaken. All observational studies reporting the prevalence of mortality of patients in emergency departments of Ethiopian hospitals, and published in English up to December 16, 2023, were considered for this review. Two reviewers independently assess the quality of the studies using the Joanna Briggs Institute (JBI) critical appraisal tool. A meta-analysis using a random-effects model was performed to estimate the pooled prevalence. The heterogeneity of studies was assessed using I2 statistics, and to identify the possible causes of heterogeneity, subgroup analysis and meta-regression were used. Egger's test and funnel plots were used to assess publication bias. STATA version 17.0 software was used for all the statistical analyses. A p-value less than 0.05 was used to declare statistical significance.

RESULTS

A total of 1363 articles were retrieved through electronic search databases. Subsequently, eighteen studies comprised 21,582 study participants were included for analysis. The pooled prevalence of mortality among patients in the Emergency Department (ED) was 7.71% (95% CI: 3.62, 11.80). Regional subgroup analysis showed that the pooled prevalence of mortality was 16.7%, 12.89%, 10.28%, and 4.35% in Dire Dawa, Amhara, Oromia, and Addis Ababa, respectively. Moreover, subgroup analysis based on patients' age revealed that the pooled prevalence of mortality among adults and children was 8.23% (95% CI: 3.51, 12.94) and 4.48% (95% CI: 2.88, 6.08), respectively. Being a rural resident (OR; 2.30, 95% CI: 1.48, 3.58), unconsciousness (OR; 3.86, 95% CI: 1.35, 11.04), comorbidity (OR; 2.82, 95% CI: 1.56, 5.09), and time to reach a nearby health facility (OR; 4.73, 95% CI: 2.19, 10.21) were determinants of mortality for patients in the emergency departments.

CONCLUSION AND RECOMMENDATIONS

This study found that the overall prevalence of mortality among patients in emergency departments of Ethiopian hospitals was high, which requires collaboration between all stakeholders to improve outcomes. Being a rural resident, unconsciousness, comorbidity, and time elapsed to reach health facilities were determinants of mortality. Improving pre-hospital care, training healthcare providers, early referral, and improving first-line management at referral hospitals will help to reduce the high mortality in our country.

Assessing the effectiveness of artificial intelligence (AI) in prioritising CT head interpretation: study protocol for a stepped-wedge cluster randomised trial (ACCEPT-AI)

INTRODUCTION

Diagnostic imaging is vital in emergency departments (EDs). Accessibility and reporting impacts ED workflow and patient care. With radiology workforce shortages, reporting capacity is limited, leading to image interpretation delays. Turnaround times for image reporting are an ED bottleneck. Artificial intelligence (AI) algorithms can improve productivity, efficiency and accuracy in diagnostic radiology, contingent on their clinical efficacy. This includes positively impacting patient care and improving clinical workflow. The ACCEPT-AI study will evaluate Qure.ai's qER software in identifying and prioritising patients with critical findings from AI analysis of non-contrast head CT (NCCT) scans.

METHODS AND ANALYSIS

This is a multicentre trial, spanning four diverse sites, over 13 months. It will include all individuals above the age of 18 years who present to the ED, referred for an NCCT. The project will be divided into three consecutive phases (pre-implementation, implementation and post-implementation of the qER solution) in a stepped-wedge design to control for adoption bias and adjust for time-based changes in the background patient characteristics. Pre-implementation involves baseline data for standard care to support the primary and secondary outcomes. The implementation phase includes staff training and qER solution threshold adjustments in detecting target abnormalities adjusted, if necessary. The post-implementation phase will introduce a notification (prioritised flag) in the radiology information system. The radiologist can choose to agree with the qER findings or ignore it according to their clinical judgement before writing and signing off the report. Non-qER processed scans will be handled as per standard care.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with the principles of Good Clinical Practice. The protocol was approved by the Research Ethics Committee of East Midlands (Leicester Central), in May 2023 (REC (Research Ethics Committee) 23/EM/0108). Results will be published in peer-reviewed journals and disseminated in scientific findings (ClinicalTrials.gov: NCT06027411) TRIAL REGISTRATION NUMBER: NCT06027411.

Code Stroke Alert: Focus on Emergency Department Time Targets and Impact on Door-to-Needle Time across Day and Night Shifts

BACKGROUND AND OBJECTIVES

To minimize stroke-related deaths and maximize the likelihood of cerebral reperfusion, medical professionals developed the "code stroke" emergency protocol, which allows for the prompt evaluation of patients with acute ischemic stroke symptoms in pre-hospital care and the emergency department (ED). This research will outline our experience in implementing the stroke code protocol for acute ischemic stroke patients and its impact on door-to-needle time (DTN) in the ED.

METHODS

Our study included patients with a "code stroke alert" upon arrival at the emergency department. The final sample of this study consisted of 258 patients eligible for intravenous (IV) thrombolysis with an onset-to-door time < 4.5 h. ED admissions were categorized into two distinct groups: "day shift" (from 8 a.m. to 8 p.m.) (n = 178) and "night shift" (from 8 p.m. to 8 a.m.) (n = 80) groups.

RESULTS

An analysis of ED time targets showed an increased median during the day shift for onset-to-ED door time of 310 min (IQR, 190-340 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3-9 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3-9 min), and for door-to-physician (neurologist) time of 7 min (IQR, 5-10 min), also during the day shift. During the night shift, an increased median was found for door-to-CT time of 21 min (IQR, 16.75-23 min), for door-to-CT results of 40 min (IQR, 38-43 min), and for door-to-needle time of 57.5 min (IQR, 46.25-60 min). Astonishingly, only 17.83% (n = 46) of these patients received intravenous thrombolysis, and the proportion of patients with thrombolysis was significantly higher during the night shift (p = 0.044). A logistic regression analysis considering the door-to-needle time (minutes) as the dependent variable demonstrated that onset-to-ED time (p < 0.001) and door-to-physician (emergency medicine physicians) time (p = 0.021) are predictors for performing thrombolysis in our study.

CONCLUSIONS

This study identified higher door-to-CT and door-to-emergency medicine physician times associated with an increased DTN, highlighting further opportunities to improve acute stroke care in the emergency department. Further, door-to-CT and door-to-CT results showed statistically significant increases during the night shift.

Boarding in the emergency department: challenges and mitigation strategies

PURPOSE OF REVIEW

Herein, we conducted a review of the literature to better understand the issue of prolonged emergency department (ED) boarding by providing an overview of the current evidence on the available causes, consequences, and mitigation strategies.

RECENT FINDINGS

Severely ill patients awaiting transfer to intensive care units (ICU) imposes additional burdens on the emergency care team from both a clinical and management perspective. The reasons for prolonged ED boarding are multifactorial. ED boarding compromises patients' safety and outcomes, and is associated with increased team burnout and dissatisfaction. Mitigation strategies include the optimization of patients' flow, the establishment of resuscitative care units, deployment of mobile critical care teams, and improvements in training. Staffing adjustments, changes in hospital operations, and quality improvement initiatives are required to improve this situation, while active bed management and implementation of capacity command centers may also help.

SUMMARY

Considering the characteristics of healthcare systems, such as funding mechanisms, organizational structures, delivery models, access and quality of care, the challenge of ED boarding of critically ill patients requires a nuanced and adaptable approach. Solutions are complex but must involve the entirety of the hospital system, emergency department, staff adjustment, and education.

An evaluation of the effectiveness of an advanced practice physiotherapist in the emergency department setting in Ireland

BACKGROUND

One of the means of easing increased pressure on emergency care worldwide has been the development of advanced musculoskeletal physiotherapy practice in the emergency department setting. This model of care is in its infancy in Ireland.

AIMS

To evaluate the effectiveness of an advanced practice physiotherapist working as a primary contact clinician in the emergency department at St. James's Hospital, Dublin.

METHODS

A three-month retrospective chart review was undertaken for patients assigned the advanced practice physiotherapist as their primary clinician during their emergency department attendance. Three widely accepted measures of quality in emergency medicine were used to evaluate effectiveness, namely, time from attendance to discharge, time from triage to assessment, and unplanned reattendance within seven days.

RESULTS

A total of 129 patients were included in this study. Time from attendance to discharge was significantly less in the APP group (mean 208.5 min, standard deviation 122.4 min) than in the ED group (mean 377.1 min, standard deviation 314.7 min) (mean difference - 168.61 (95% C.I - 191.24- - 145.98)) (p < 0.001). Time from triage to assessment was significantly less in the APP group (mean 72.1 min, standard deviation 51.9 min) than in the ED group (mean 94.1 min, standard deviation 96.5 min) (mean difference - 22.08 (95% C.I - 31.28- - 12.89)) (p < 0.001). The unplanned reattendance rate was 3.9%. No adverse events were identified.

CONCLUSIONS

The findings of this study indicate that an advanced practice physiotherapist can provide a timely, effective, and safe service for patients attending the emergency department with musculoskeletal complaints in Ireland.

Free-for-all: Does crowding impact outcomes because hospital emergency departments do not prioritise effectively?

Unexpected peaks in volumes of attendances at hospital emergency departments (EDs) have been found to affect waiting times, intensity of care and outcomes. We ask whether these effects of ED crowding on patients are caused by poor clinical prioritisation or a quality-quantity trade-off generated by a binding capacity constraint. We study the effects of crowding created by lower-severity patients on the outcomes of approximately 13 million higher-severity patients attending the 140 public EDs in England between April 2016 and March 2017. Our identification approach relies on high-dimensional fixed effects to account for planned capacity. Unexpected demand from low-severity patients has very limited effects on the care provided to higher-severity patients throughout their entire pathway in ED. Detrimental effects of crowding caused by low-severity patients materialise only at very high levels of unexpected demand, suggesting that binding resource constraints impact patient care only when demand greatly exceeds the ED's expectations. These effects are smaller than those caused by crowding induced by higher-severity patients, suggesting an efficient prioritisation of incoming patients in EDs.

Extremes of Emergency Department Boarding are Associated With Poorer Financial Performance Among Hospitals

GOAL

Boarding emergency department (ED) patients is associated with reductions in quality of care, patient safety and experience, and ED operational efficiency. However, ED boarding is ultimately reflective of inefficiencies in hospital capacity management. The ability of a hospital to accommodate variability in patient flow presumably affects its financial performance, but this relationship is not well studied. We investigated the relationship between ED boarding and hospital financial performance measures. Our objective was to see if there was an association between key financial measures of business performance and limitations in patient progression efficiency, as evidenced by ED boarding.

METHODS

Cross-sectional ED operational data were collected from the Emergency Department Benchmarking Alliance, a voluntarily self-reporting operational database that includes 54% of EDs in the United States. Freestanding EDs, pediatric EDs and EDs with missing boarding data were excluded. The key operational outcome variable was boarding time. We reviewed the financial information of these nonprofit institutions by accessing their Internal Revenue Service Form 990. We examined standard measures of financial performance, including return on equity, total margin, total asset turnover, and equity multiplier (EM). We studied these associations using quantile regressions of added ED volume, ED admission percentage, urban versus nonurban ED site location, trauma status, and percentage of the population receiving Medicare and Medicaid as covariates in the regression models.

PRINCIPAL FINDINGS

Operational data were available for 892 EDs from 31 states. Of those, 127 reported a Form 990 in the year corresponding to the ED boarding measures. Median boarding time across EDs was 148 min (interquartile range [IQR]: 100-216). A significant relationship exists between boarding and the EM, along with a negative association with the hospital's total profit margin in the highest-performing hospitals (by profit margin percentage). After adjusting for the covariates in the regression model, we found that for every 10 min above 90 min of boarding, the mean EM for the top quartile increased from 245.8% to 249.5% (p < .001). In hospitals in the top 90th percentile of total margin, every 10 min beyond the median ED boarding interval led to a decrease in total margin of 0.24%.

PRACTICAL APPLICATIONS

Using the largest available national registry of ED operational data and concordant nonprofit financial reports, higher boarding among the highest-profitability hospitals (i.e., top 10%) is associated with a drag on profit margin, while hospitals with the highest boarding are associated with the highest leverage (i.e., indicated by the EM). These relationships suggest an association between a key ED indicator of hospital capacity management and overall institutional financial performance.

From symptom onset to ED departure: understanding the acute care chain for patients with undifferentiated complaints: a prospective observational study

BACKGROUND

For most acute conditions, the phase prior to emergency department (ED) arrival is largely unexplored. However, this prehospital phase has proven an important part of the acute care chain (ACC) for specific time-sensitive conditions, such as stroke and myocardial infarction. For patients with undifferentiated complaints, exploration of the prehospital phase of the ACC may also offer a window of opportunity for improvement of care. This study aims to explore the ACC of ED patients with undifferentiated complaints, with specific emphasis on time in ACC and patient experience.

METHODS

This Dutch prospective observational study, included all adult (≥ 18 years) ED patients with undifferentiated complaints over a 4-week period. We investigated the patients' journey through the ACC, focusing on time in ACC and patient experience. Additionally, a multivariable linear regression analysis was employed to identify factors independently associated with time in ACC.

RESULTS

Among the 286 ED patients with undifferentiated complaints, the median symptom duration prior to ED visit was 6 days (IQR 2-10), during which 58.6% of patients had contact with a healthcare provider before referral. General Practitioners (GPs) referred 80.4% of the patients, with the predominant patient journey (51.7%) involving GP referral followed by self-transportation to the ED. The median time in ACC was 5.5 (IQR 4.0-8.4) hours of which 40% was spent before the ED visit. GP referral and referral to pulmonology were associated with a longer time in ACC, while referral during evenings was associated with a shorter time in ACC. Patients scored both quality and duration of the provided care an 8/10.

CONCLUSION

Dutch ED patients with undifferentiated complaints consulted a healthcare provider in over half of the cases before their ED visit. The median time in ACC is 5.5 h of which 40% is spent in the prehospital phase. Those referred by a GP and to pulmonology had a longer, and those in the evening a shorter time in ACC. The acute care journey starts hours before patients arrive at the ED and 6 days of complaints precede this journey. This timeframe could serve as a window of opportunity to optimise care.

Lower Limits for Reporting High-Sensitivity Cardiac Troponin Assays and Impact of Analytical Performance on Patient Misclassification

BACKGROUND

Cardiac troponin measurements are indispensable for the diagnosis of myocardial infarction and provide useful information for long-term risk prediction of cardiovascular disease. Accelerated diagnostic pathways prevent unnecessary hospital admission, but require reporting cardiac troponin concentrations at low concentrations that are sometimes below the limit of quantification. Whether analytical imprecision at these concentrations contributes to misclassification of patients is debated.

CONTENT

The International Federation of Clinical Chemistry Committee on Clinical Application of Cardiac Bio-Markers (IFCC C-CB) provides evidence-based educational statements on analytical and clinical aspects of cardiac biomarkers. This mini-review discusses how the reporting of low concentrations of cardiac troponins impacts on whether or not assays are classified as high-sensitivity and how analytical performance at low concentrations influences the utility of troponins in accelerated diagnostic pathways. Practical suggestions are made for laboratories regarding analytical quality assessment of cardiac troponin results at low cutoffs, with a particular focus on accelerated diagnostic pathways. The review also discusses how future use of cardiac troponins for long-term prediction or management of cardiovascular disease may require improvements in analytical quality.

SUMMARY

Clinical guidelines recommend using cardiac troponin concentrations as low as the limit of detection of the assay to guide patient care. Laboratories, manufacturers, researchers, and external quality assessment providers should extend analytical performance monitoring of cardiac troponin assays to include the concentration ranges applicable in these pathways.

Where's my med? Improving patient-specific medication storage for emergency department boarders

BACKGROUND

There have been an increased number of patients boarding in the emergency department (ED) who often experience delays in receiving nonurgent medications not typically stocked in the ED automated dispensing cabinets (ADC).

OBJECTIVES

To describe a quality improvement project designed to decrease the amount of time it takes nursing staff to obtain patient-specific medications for patients boarding in the ED at a community hospital.

PRACTICE DESCRIPTION

Prior to this quality improvement project, standard practice was for pharmacy staff to send all medications to the ED based on inpatient cart fill lists, resulting in a 24-hour supply being sent at 1 time. Medications that were not immediately due were often misplaced by ED staff as there was no standard location to store them.

PRACTICE INNOVATION

A separate location for each examination room in the ED was created in 1 central ADC to store patient-specific medications. Pharmacy staff were instructed to load medications directly into the ADC for expected long-term behavioral health boarders. Nursing staff were instructed to place future doses in the newly created locations and were educated on how to locate medications utilizing the electronic medication administration record.

EVALUATION METHODS

ED nursing staff timed how long it took them to obtain medications for 40 boarding patients before and after implementation of the quality improvement initiatives.

RESULTS

The postimprovement intervention decreased the amount of time it took to obtain medications for forty ED boarding patients by 66%, from an average of 37.7 minutes at baseline to 12.9 minutes postintervention. This was a statistically significant improvement via an unpaired t-test (P < 0.0001 with a 95% CI from 15.3 to 34.47). This was rechecked after 1 year and the improvement was sustained.

CONCLUSION

A multidisciplinary team-based quality improvement initiative was successful in reducing the time it took to obtain medications for ED boarding patients.

Rapid triage and transfer system for patients with proven Covid-19 at emergency department

BACKGROUND

COVID-19 is a viral disease notorious for frequent worldwide outbreaks. It is difficult to control, thereby resulting in overload of the healthcare system. A possible solution to prevent overcrowding is rapid triage of patients, which makes it possible to focus care on the high-risk patients and minimize the impact of crowding on patient prognosis.

METHODS

The triage algorithm assessed self-sufficiency, oximetry, systolic blood pressure, and the Glasgow coma scale. Compliance with the triage protocol was defined as fulfillment of all protocol steps, including assignment of the correct level of care. Triage was considered successful if there was no change in the scope of care (e.g., unscheduled hospital admission, transfer to different level of care) or if there was unexpected death within 48 hours.

RESULTS

A total of 929 patients were enrolled in the study. Triage criteria were fulfilled in 825 (88.8%) patients. Within 48 hours, unscheduled hospital admission, transfer to different level of care, or unexpected death occurred in 56 (6.0%), 6 (0.6%), and 5 (0.5%) patients, respectively. The risk of unscheduled hospital admission or transfer to different level of care was significantly increased if triage criteria were not fulfilled [13.1% vs. 76.1%, RR 5.8 (3.8-8.3), p < 0.001; 0.5% vs. 5.2%, RR 11.4 (2.3-57.7), p = 0.036, respectively].

CONCLUSION

The proposed algorithm for triage of patients with proven COVID-19 is a simple, fast, and reliable tool for rapid sorting for outpatient treatment, hospitalization on a standard ward, or assignment to an intensive care unit.

Impact of emergency department length of stay on in-hospital mortality: a retrospective cohort study

BACKGROUND AND IMPORTANCE

Emergency Department (ED) workload may lead to ED crowding and increased ED length of stay (LOS). ED crowding has been shown to be associated with adverse events and increasing mortality. We hypothesised that ED-LOS is associated with mortality.

OBJECTIVE

To study the relationship between ED-LOS and in-hospital mortality.

DESIGN

Observational retrospective cohort study.

SETTINGS AND PARTICIPANTS

From 1 January 2015 to 30 September 2018, all visits by patients aged 15 or older to one of the two ED at Toulouse University Hospital were screened. Patients admitted to the hospital after ED visits were included. Visits followed by ED discharge, in-ED death or transfer to ICU or another hospital were not included.

OUTCOME MEASURE AND ANALYSIS

The primary outcome was 30-day in-hospital mortality. ED-LOS was defined as time from ED registration to inpatient admission. ED-LOS was categorised according to quartiles [<303 min (Q1), between 303 and 433 minutes (Q2), between 434 and 612 minutes (Q3) and >612 min (Q4)]. A multivariable logistic regression tested the association between ED-LOS and in-hospital mortality.

MAIN RESULTS

A total of 49 913 patients were admitted to our hospital after ED visits and included in the study. ED-LOS was not independently associated with in-hospital mortality. Compared to ED-LOS < 303 min (Q1, reference), odd-ratios (OR) [95% CI] of in-hospital mortality for Q2, Q3, and Q4 were respectively 0.872 [0.747-1.017], 0.906 [0.777-1.056], and 1.137 [0.985-1.312]. Factors associated to in-hospital mortality were: aged over 75 years (OR [95% CI] = 4.3 [3.8-4.9]), Charlson Comorbidity Index score > 1 (OR [95% CI] = 1.3 [1.1-1.5], and 2.2 [1.9-2.5] for scores 2 and ≥ 3 respectively), high acuity at triage (OR [95% CI] = 3.9 [3.5-4.4]), ED visit at Hospital 1 (OR [95% CI] = 1.6 [1.4-1.7]), and illness diagnosis compared to trauma (OR [95% CI] = 2.1 [1.7-2.6]). Night-time arrival was associated with decreased in-hospital mortality (OR [95% CI] = 0.852 [0.767-0.947]).

CONCLUSION

In this retrospective cohort study, there was no independent association between ED-LOS before admission to general non-ICU wards and in-patient mortality.

Telemedicine in Nursing Home Residents Requiring a Call to an Emergency Medical Communication Center

OBJECTIVES

To compare the proportion of nursing home residents dispatched to an emergency department (ED) after a call to the emergency medical communication center (EMCC) according to the availability or nonavailability of telemedicine.

DESIGN

This prospective, observational trial was conducted in the EMCC and 74 nursing homes in a French county.

SETTING AND PARTICIPANTS

All nursing home residents who needed to contact the EMCC between June 2019 and April 2020 were included in the study. We excluded calls notifying the death of a resident, for completing data from a previous call, and for nursing home staff.

METHODS

The primary outcome was the proportion of residents dispatched to an ED after their first call to the EMCC. The secondary outcomes were the proportion of second calls, proportion of residents dispatched to an ED after a second call, and proportion of death within 30 days.

RESULTS

We included 3103 calls in the final analysis (355 from equipped nursing homes and 2748 from unequipped nursing homes). The proportion of patients dispatched to an ED after the first call was lower among telemedicine-equipped than among telemedicine-unequipped nursing homes (41% vs 50%; odds ratio, 0.71; 95% CI, 0.56-0.90). The proportion of a second call for the same purpose within 72 hours, proportion of dispatching to an ED at the second call, and proportion of deaths within 30 days were similar between the groups.

CONCLUSION AND IMPLICATIONS

The use of telemedicine by nursing home residents requiring a call to the EMCC is associated with a reduction in the number of dispatches to an ED without any increase in the number of 72-hour callbacks or 30-day mortality rates.

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.

Impact on all-cause mortality of a case prediction and prevention intervention designed to reduce secondary care utilisation: findings from a randomised controlled trial

BACKGROUND

Health coaching services could help to reduce emergency healthcare utilisation for patients targeted proactively by a clinical prediction model (CPM) predicting patient likelihood of future hospitalisations. Such interventions are designed to empower patients to confidently manage their own health and effectively utilise wider resources. Using CPMs to identify patients, rather than prespecified criteria, accommodates for the dynamic hospital user population and for sufficient time to provide preventative support. However, it is unclear how this care model would negatively impact survival.

METHODS

Emergency Department (ED) attenders and hospital inpatients between 2015 and 2019 were automatically screened for their risk of hospitalisation within 6 months of discharge using a locally trained CPM on routine data. Those considered at risk and screened as suitable for the intervention were contacted for consent and randomised to one-to-one telephone health coaching for 4-6 months, led by registered health professionals, or routine care with no contact after randomisation. The intervention involved motivational guidance, support for self-care, health education, and coordination of social and medical services. Co-primary outcomes were emergency hospitalisation and ED attendances, which will be reported separately. Mortality at 24 months was a safety endpoint.

RESULTS

Analysis among 1688 consented participants (35% invitation rate from the CPM, median age 75 years, 52% female, 1139 intervention, 549 control) suggested no significant difference in overall mortality between treatment groups (HR (95% CI): 0.82 (0.62, 1.08), pr(HR<1=0.92), but did suggest a significantly lower mortality in men aged >75 years (HR (95% CI): 0.57 (0.37, 0.84), number needed to treat=8). Excluding one site unable to adopt a CPM indicated stronger impact for this patient subgroup (HR (95% CI): 0.45 (0.26, 0.76)).

CONCLUSIONS

Early mortality in men aged >75 years may be reduced by supporting individuals at risk of unplanned hospitalisation with a clear outreach, out-of-hospital nurse-led, telephone-based coaching care model.

Emergency Department Time Targets for Interhospital Transfer of Patients with Acute Ischemic Stroke

Background and objectives: Although the intravenous tissue plasminogen activator (rt-PA) has been shown to be effective in the treatment of acute ischemic stroke (AIS), only a small proportion of stroke patients receive this drug. The low administration rate is mainly due to the delayed presentation of patients to the emergency department (ED) or the lack of a stroke team/unit in most of the hospitals. Thus, the aim of this study is to analyze ED time targets and the rate of rt-PA intravenous administration after the initial admission of patients with AIS in an ED from a traditional healthcare center (without a neurologist or stroke team/unit). Methods: To analyze which factors influence the administration of rt-PA, we split the general sample (n = 202) into two groups: group No rt-PA (n = 137) and group rt-PA (n = 65). This is based on the performing or no intravenous thrombolysis. Results: Analyzing ED time targets for all samples, we found that the median onset-to-ED door time was 180 min (IQR, 120-217.5 min), door-to-physician time was 4 min (IQR, 3-7 min), door-to-CT time was 52 min (IQR, 48-55 min), and door-in-door-out time was 61 min (IQR, 59-65 min). ED time targets such as door-to-physician time (p = 0.245), door-to-CT time (p = 0.219), door-in-door-out time (p = 0.24), NIHSS at admission to the Neurology department (p = 0.405), or NIHSS after 24 h (p = 0.9) did not have a statistically significant effect on the administration or no rt-PA treatment in patients included in our study. Only the highest door-to-CT time was statistically significantly correlated with the death outcome. Conclusion: In our study, the iv rt-PA administration rate was 32.18%. A statistically significant correlation between the highest door-to-CT time and death outcome was found.

Addressing the Knowledge Deficit in Hospital Bed Planning and Defining an Optimum Region for the Number of Different Types of Hospital Beds in an Effective Health Care System

Based upon 30-years of research by the author, a new approach to hospital bed planning and international benchmarking is proposed. The number of hospital beds per 1000 people is commonly used to compare international bed numbers. This method is flawed because it does not consider population age structure or the effect of nearness-to-death on hospital utilization. Deaths are also serving as a proxy for wider bed demand arising from undetected outbreaks of 3000 species of human pathogens. To remedy this problem, a new approach to bed modeling has been developed that plots beds per 1000 deaths against deaths per 1000 population. Lines of equivalence can be drawn on the plot to delineate countries with a higher or lower bed supply. This method is extended to attempt to define the optimum region for bed supply in an effective health care system. England is used as an example of a health system descending into operational chaos due to too few beds and manpower. The former Soviet bloc countries represent a health system overly dependent on hospital beds. Several countries also show evidence of overutilization of hospital beds. The new method is used to define a potential range for bed supply and manpower where the most effective health systems currently reside. The method is applied to total curative beds, medical beds, psychiatric beds, critical care, geriatric care, etc., and can also be used to compare different types of healthcare staff, i.e., nurses, physicians, and surgeons. Issues surrounding the optimum hospital size and the optimum average occupancy will also be discussed. The role of poor policy in the English NHS is used to show how the NHS has been led into a bed crisis. The method is also extended beyond international benchmarking to illustrate how it can be applied at a local or regional level in the process of long-term bed planning. Issues regarding the volatility in hospital admissions are also addressed to explain the need for surge capacity and why an adequate average bed occupancy margin is required for an optimally functioning hospital.

Head-to-head comparison of 19 prediction models for short-term outcome in medical patients in the emergency department: a retrospective study

INTRODUCTION

Prediction models for identifying emergency department (ED) patients at high risk of poor outcome are often not externally validated. We aimed to perform a head-to-head comparison of the discriminatory performance of several prediction models in a large cohort of ED patients.

METHODS

In this retrospective study, we selected prediction models that aim to predict poor outcome and we included adult medical ED patients. Primary outcome was 31-day mortality, secondary outcomes were 1-day mortality, 7-day mortality, and a composite endpoint of 31-day mortality and admission to intensive care unit (ICU).The discriminatory performance of the prediction models was assessed using an area under the receiver operating characteristic curve (AUC). Finally, the prediction models with the highest performance to predict 31-day mortality were selected to further examine calibration and appropriate clinical cut-off points.

RESULTS

We included 19 prediction models and applied these to 2185 ED patients. Thirty-one-day mortality was 10.6% (231 patients), 1-day mortality was 1.4%, 7-day mortality was 4.4%, and 331 patients (15.1%) met the composite endpoint. The RISE UP and COPE score showed similar and very good discriminatory performance for 31-day mortality (AUC 0.86), 1-day mortality (AUC 0.87), 7-day mortality (AUC 0.86) and for the composite endpoint (AUC 0.81). Both scores were well calibrated. Almost no patients with RISE UP and COPE scores below 5% had an adverse outcome, while those with scores above 20% were at high risk of adverse outcome. Some of the other prediction models (i.e. APACHE II, NEWS, WPSS, MEWS, EWS and SOFA) showed significantly higher discriminatory performance for 1-day and 7-day mortality than for 31-day mortality.

CONCLUSIONS

Head-to-head validation of 19 prediction models in medical ED patients showed that the RISE UP and COPE score outperformed other models regarding 31-day mortality.

Aiming toWards Evidence baSed inTerpretation of Cardiac biOmarkers in patients pResenting with chest pain using Point of Care Testing (WESTCOR-POC): study design

OBJECTIVES

Patients presenting with symptoms suggestive of acute coronary syndrome (ACS) contribute to a high workload and overcrowding in the Emergency Department (ED). Accelerated diagnostic protocols for non-ST-elevation myocardial infarction have proved challenging to implement. One obstacle is the turnaround time for analyzing high-sensitivity cardiac troponin (hs-cTn). In the WESTCOR-POC study (Clinical Trials number NCT05354804) we aim to evaluate safety and efficiency of a 0/1 h hs-cTn algorithm utilizing a hs-cTnI point of care (POC) instrument in comparison to central laboratory hs-cTnT measurements.

DESIGN

This is a prospective single-center randomized clinical trial aiming to include 1500 patients admitted to the ED with symptoms suggestive of ACS. Patients will receive standard investigations following the European Society of Cardiology 0/1h protocols for centralized hs-cTnT measurements or the intervention using a 0/1h POC hs-cTnI algorithm. Primary end-points are 1) Safety; death, myocardial infarction or acute revascularization within 30 days 2) Efficiency; length of stay in the ED, 3) Cost- effectiveness; total episode cost, 4) Patient satisfaction, 5) Patient symptom burden and 6) Patients quality of life. Secondary outcomes are 12-months death, myocardial infarction or acute revascularization, percentage discharged after 3 and 6 h, total length of hospital stay and all costs related to hospital contact within 12 months.

CONCLUSION

Results from this study may facilitate implementation of POC hs-cTn testing assays and accelerated diagnostic protocols in EDs, and may serve as a valuable resource for guiding future investigations for the use of POC high sensitivity troponin assays in outpatient clinics and prehospital settings.

Overnight Stay in the Emergency Department and Mortality in Older Patients

Importance

Patients in the emergency department (ED) who are waiting for hospital admission on a wheeled cot may be subject to harm. However, mortality and morbidity among older patients who spend the night in the ED while waiting for a bed in a medical ward are unknown.

Objective

To assess whether older adults who spend a night in the ED waiting for admission to a hospital ward are at increased risk of in-hospital mortality.

Design, Settings, and Participants

This was a prospective cohort study of older patients (≥75 years) who visited the ED and were admitted to the hospital on December 12 to 14, 2022, at 97 EDs across France. Two groups were defined and compared: those who stayed in the ED from midnight until 8:00 am (ED group) and those who were admitted to a ward before midnight (ward group).

Main Outcomes and Measures

The primary end point was in-hospital mortality, truncated at 30 days. Secondary outcomes included in-hospital adverse events (ie, falls, infection, bleeding, myocardial infarction, stroke, thrombosis, bedsores, and dysnatremia) and hospital length of stay. A generalized linear-regression mixed model was used to compare end points between groups.

Results

The total sample comprised 1598 patients (median [IQR] age, 86 [80-90] years; 880 [55%] female and 718 [45%] male), with 707 (44%) in the ED group and 891 (56%) in the ward group. Patients who spent the night in the ED had a higher in-hospital mortality rate of 15.7% vs 11.1% (adjusted risk ratio [aRR], 1.39; 95% CI, 1.07-1.81). They also had a higher risk of adverse events compared with the ward group (aRR, 1.24; 95% CI, 1.04-1.49) and increased median length of stay (9 vs 8 days; rate ratio, 1.20; 95% CI, 1.11-1.31). In a prespecified subgroup analysis of patients who required assistance with the activities of daily living, spending the night in the ED was associated with a higher in-hospital mortality rate (aRR, 1.81; 95% CI, 1.25-2.61).

Conclusions and Relevance

The findings of this prospective cohort study indicate that for older patients, waiting overnight in the ED for admission to a ward was associated with increased in-hospital mortality and morbidity, particularly in patients with limited autonomy. Older adults should be prioritized for admission to a ward.

Resuscitate, not palliate, emergency care

Emergency care in the UK is in crisis, and stories of long waits, poor care and harm have become commonplace. This situation can no longer be ignored. This article looks at some of the ways in which emergency care can be resuscitated.

Improving the safety and effectiveness of urgent and emergency care

Delays and waiting in urgent and emergency care (UEC) services are causing avoidable harm to patients and affecting staff morale. Patients are often having a poor experience of using UEC services, increasing stress and anxiety for both their families and themselves, delaying their recovery. Despite the constraints of available permanent staffing, funding and competing NHS priorities, changes along the whole UEC pathway in and out of hospital, admitted and non-admitted pathways need to be made safe, timely and accessible, to provide clinically appropriate care for patients. Changes in clinician behaviour, culture, and training toward the management and sharing of clinical risk differently along the whole UEC pathway are also required. Modifying operational processes with a focus on patients in different UEC settings will improve productivity, flow and the patient experience. There is a need to do things differently rather than continuing as we are and expecting a different result to unlock the perennial UEC crisis.

Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change?

Older patients are more vulnerable to acute illness or injury because of reduced physiologic reserve associated with aging. Therefore, their assessment in the emergency department (ED) should include not only vital signs and their baseline values but also changes that reflect physiologic reserve, such as mobility, mental status, and frailty. Combining aggregated vitals sign scores and frailty might improve risk stratification in the ED. Implementing these changes in ED assessment may require the introduction of senior-friendly processes to ensure ED treatment is appropriate to the older patients' immediate discomfort, personal goals, and likely prognosis.

The need for ambulatory emergency oncology: exemplified by the management of immune checkpoint inhibitor toxicity

Cancer patients seeking emergency care can be vulnerable in increasingly overcrowded Emergency Departments and timely delivery of care is often aspirational rather than reality in many acute care systems. Ambulatory emergency care and its various international models are recognized as contributing to the safety and sustainability of emergency care services. This schema can logically be extended to the emergency oncology setting. The recent proliferation of immune checkpoint inhibitors (ICIs) has led to another opportunity for the management of oncologic complications in the ambulatory emergency care setting. More nuanced risk stratification of currently perceived high-risk toxicities may also afford the opportunity to personalize acute management. Virtual wards, which predominantly provide virtual monitoring only, and hospital at home services, which provide more comprehensive in-person assessment and interventions, may be well suited to supporting care for ICI toxicity alongside hospital-based assessment. Emergency management guidelines for immune-mediated toxicities will increasingly need to be both pragmatic and deliverable, especially as larger numbers of patients will present outside cancer centers. Identifying and modelling those suitable for emergency ambulatory care is integral to achieving this.

Establishing the core elements of a frailty at the front door model of care using a modified real-time Delphi technique

BACKGROUND

Innovations in models of care for older adults living with frailty presenting to the emergency department (ED) have become a key priority for clinicians, researchers and policymakers due to the deleterious outcomes older adults experience due to prolonged exposure to such an environment. This study aimed to develop a set of expert consensus-based statements underpinning operational design, outcome measurement and evaluation of a Frailty at the Front Door (FFD) model of care for older adults within an Irish context.

METHODS

A modified real-time Delphi method was used. Facilitation of World Café focus groups with an expert panel of 86 members and seperate advisory groups with a Public and Patient Involvement panel of older adults and members of the Irish Association of Emergency Medicine generated a series of statements on the core elements of the FFD model of care. Statements were analysed thematically and incorporated into a real-time Delphi survey, which was emailed to members of the expert panel. Members were asked to rank 70 statements across nine domains using a 9-point Likert scale. Consensus criteria were defined a priori and guided by previous research using 9-point rating scales.

RESULTS

Fifty members responded to the survey representing an overall response rate of 58%. Following analyses of the survey responses, the research team reviewed statements for content overlap and refined a final list of statements across the following domains: aims and objectives of the FFD model of care; target population; screening and assessment; interventions; technology; integration of care; evaluation and metrics; and research.

CONCLUSION

Development of a consensus derived FFD model of care represents an important step in generating national standards, implementation of a service model as intended and enhances opportunities for scientific impact. Future research should focus on the development of a core outcome set for studies involving older adults in the ED.