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Grossman ES, Fradinho J, Chiu D, Wolfe RE, Grossman SA. The effect of increasing emergency department observation volumes on downstream admission rates. Am J Emerg Med 2024; 77:17-20. [PMID: 38096635 DOI: 10.1016/j.ajem.2023.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/23/2023] [Accepted: 11/25/2023] [Indexed: 02/16/2024] Open
Abstract
Rising length of stay and inpatient boarding in emergency departments have directly affected patient satisfaction and nearly all provider-to-patient care metrics. Prior studies suggest that ED observation has significant clinical and financial benefits including decreasing hospitalization and length of stay. ED observation is one method long employed to shorten ED length of stay and to free up inpatient beds, yet many patients continue to be admitted to the hospital with an average hospital length of stay of only one day. The objectives of this study were to evaluate whether vigorous tracking and provider reviews of one day hospital admits affected the utilization of ED observation and whether this correlated with significant change in rates of admission from observation status. Between September 2020 and May 2021, in a tertiary care hospital with an annual ED volume of 55,0000, chart reviews of 24-h inpatient discharges were initiated by two senior EM faculty to determine perceived suitability for ED observation. Non-punitive email reviews were then initiated with ED attending providers in order to encourage evaluation of whether these patients would have benefitted from being placed into observation. We then analyzed ED observation patient volumes and subsequent admission rates to the hospital from ED observation and compared these numbers to baseline ED observation volume and admission rates between September 2018 and May 2019. A total of 1448 reviews were conducted on 24-h discharges which correlated with an increase in utilization of ED observation from 11.77% (95% CI [11.62, 12.31]) of total ED volume in our control period to 14.21% (95% CI [13.84, 14.58]) during the study period. We found that the overall admission rate from ED observation increased from 20.12% (95% CI [18.97, 21.26]) baseline to 23.80% (95% CI [22.60, 25.00]) during the same time periods. Our data suggest that increasing the total number of patients placed into observation by 21% correlated with a relative increase in admission rates from ED observation by 18%. This would suggest that our efforts to potentially include more patients into our observation program led to a significant increase in subsequent admission rates. There is likely a balance that must be struck between under- and over-utilization of ED observation, and expanding ED observation may be an effective solution to hospital boarding and ED overcrowding.
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Affiliation(s)
- Elianna S Grossman
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jorge Fradinho
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David Chiu
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Richard E Wolfe
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Shamai A Grossman
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Pasquer A, Pascal L, Polazzi S, Skinner S, Poncet G, Lifante JC, Duclos A. Association of Hospital Bed Turnover With Patient Outcomes in Digestive Surgery. ANNALS OF SURGERY OPEN 2022; 3:e229. [PMID: 37600282 PMCID: PMC10406035 DOI: 10.1097/as9.0000000000000229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/10/2022] [Indexed: 03/05/2023] Open
Abstract
To determine the influence of hospital bed turnover rate (BTR) on the occurrence of complications following minor or major digestive surgery. Background Performance improvement in surgery aims at increasing productivity while preventing complications. It is unknown whether this relationship can be influenced by the complexity of surgery. Methods A nationwide retrospective cohort study was conducted, based on generalized estimating equation modeling to determine the effect of hospital BTR on surgical outcomes, adjusting for patient mix and clustering within 631 public and private French hospitals. All patients who underwent minor or major digestive surgery between January 1, 2013 and December 31, 2018 were included. Hospital BTR was defined as the annual number of stays per bed for digestive surgery and categorized into tertiles. The primary endpoint was a composite measurement of events occurring within 30 days after surgery: inpatient death, extended intensive care unit (ICU) admission, and reoperation. Results Rate of adverse events was 2.51% in low BTR hospitals versus 2.25% in high BTR hospitals for minor surgery, and 16.79% versus 16.83% for major surgery. Patients who underwent minor surgery in high BTR hospitals experienced lower complications (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.81-0.97; P = 0.009), mortality (OR, 0.87; 95% CI, 0.78-0.98, P = 0.02), ICU admission (OR, 0.83; 95% CI, 0.70-0.99; P = 0.03), and reoperation (OR, 0.91; 95% CI, 0.85-0.97; P = 0.002) compared to those in low BTR hospitals. Such differences were not consistently observed among patients admitted for major surgery. Conclusions High turnover of patients in beds is beneficial for minor procedures, but questionable for major surgeries.
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Affiliation(s)
- Arnaud Pasquer
- From the Research on Healthcare Performance RESHAPE, Inserm U1290, Université Claude Bernard Lyon 1, Lyon, France
- Department of Digestive and Colorectal Surgery, Edouard Herriot Hospital, Hospices Civils de Lyon, France
| | - Léa Pascal
- From the Research on Healthcare Performance RESHAPE, Inserm U1290, Université Claude Bernard Lyon 1, Lyon, France
- Health Data Department, Hospices Civils de Lyon, France
| | - Stephanie Polazzi
- From the Research on Healthcare Performance RESHAPE, Inserm U1290, Université Claude Bernard Lyon 1, Lyon, France
- Health Data Department, Hospices Civils de Lyon, France
| | - Sarah Skinner
- From the Research on Healthcare Performance RESHAPE, Inserm U1290, Université Claude Bernard Lyon 1, Lyon, France
- Health Data Department, Hospices Civils de Lyon, France
| | - Gilles Poncet
- Department of Digestive and Colorectal Surgery, Edouard Herriot Hospital, Hospices Civils de Lyon, France
| | - Jean-Christophe Lifante
- From the Research on Healthcare Performance RESHAPE, Inserm U1290, Université Claude Bernard Lyon 1, Lyon, France
- Department of Endocrine Surgery, Lyon Sud Hospital, Hospices Civils de Lyon, France
| | - Antoine Duclos
- From the Research on Healthcare Performance RESHAPE, Inserm U1290, Université Claude Bernard Lyon 1, Lyon, France
- Health Data Department, Hospices Civils de Lyon, France
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Chaftari P, Lipe DN, Wattana MK, Qdaisat A, Krishnamani PP, Thomas J, Elsayem AF, Sandoval M. Outcomes of Patients Placed in an Emergency Department Observation Unit of a Comprehensive Cancer Center. JCO Oncol Pract 2021; 18:e574-e585. [PMID: 34905410 PMCID: PMC9014449 DOI: 10.1200/op.21.00478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Emergency department observation units (EDOUs) have been shown to decrease length of stay and improve cost effectiveness. Yet, compared with noncancer patients, patients with cancer are placed in EDOUs less often. In this study, we aimed to describe patients who were placed in a cancer center's EDOU to discern their clinical characteristics and outcomes. Outcomes of patients placed in an emergency department observation unit of a comprehensive cancer center
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Affiliation(s)
- Patrick Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Demis N Lipe
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Monica K Wattana
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Jomol Thomas
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ahmed F Elsayem
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marcelo Sandoval
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Terry N, Franks N, Moran T, Pitts S, Osborne A, Ross MA. The Changing Role of Chest Pain in the Emergency Department Observation Unit. Crit Pathw Cardiol 2021; 20:119-125. [PMID: 33534505 DOI: 10.1097/hpc.0000000000000253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study objective was to describe changes in the utilization of a protocol-driven emergency department observation unit (EDOU) for chest pain over time. METHODS This is a retrospective serial cross-sectional study of data from a clinical data warehouse of a single integrated healthcare system. We estimated long-term trends (2009-2019) in EDOU visits at 4 system hospitals, using monthly proportions as the main outcome, and month of visit as the exposure variable, accounting for age and sex. Rate changes associated with compulsory use of the History, EKG, Age, Risk factors, Troponin (HEART) score in 2016 were analyzed. RESULTS There were 83,168 EDOU admissions among 1.3 million ED visits during the study interval, with an average admission rate of 5.9% of ED visits. The most common conditions were chest pain (41.2%), transient ischemic attack (7.8%), dehydration (6.3%), syncope (5.8%), and abdominal pain (5.2%). In each hospital, there was a temporal annual decline in the proportion of EDOU visits for chest pain protocols ranging from -7.9% to -2.8%, an average rate of -3.3% per year (95% CI, -4.6% to -2.0%) or a 54% (from 54% to 25%) relative decline in over the 11-year study interval. This decline was significantly steeper in younger middle-aged patients (ages 39-49). The HEART score intervention had a small impact on baseline decline of -3.1% at the 2 intervention hospitals, reducing it by -1.5% (95% CI, -2.2% to -0.8%). CONCLUSIONS Utilization of the EDOU for chest pain decreased over time, with corresponding increases in other conditions. This decline preceded the introduction of the HEART score.
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Affiliation(s)
- Nataisia Terry
- From the Department of Emergency Medicine, Emory, Atlanta, GA
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Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti. Afr J Emerg Med 2020; 10:145-151. [PMID: 32923326 PMCID: PMC7474244 DOI: 10.1016/j.afjem.2020.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 04/27/2020] [Accepted: 05/20/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti. METHODS We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency. RESULTS Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023). CONCLUSION Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.
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Mechanic OJ, Pascheles CY, Lopez GJ, Winans AM, Shapiro NI, Tibbles C, Wolfe RE, Grossman SA. Using the Boston Syncope Observation Management Pathway to Reduce Hospital Admission and Adverse Outcomes. West J Emerg Med 2019; 20:250-255. [PMID: 30881544 PMCID: PMC6404692 DOI: 10.5811/westjem.2018.11.39657] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/26/2018] [Accepted: 11/21/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction In an age of increasing scrutiny of each hospital admission, emergency department (ED) observation has been identified as a low-cost alternative. Prior studies have shown admission rates for syncope in the United States to be as high as 70%. However, the safety and utility of substituting ED observation unit (EDOU) syncope management has not been well studied. The objective of this study was to evaluate the safety of EDOU for the management of patients presenting to the ED with syncope and its efficacy in reducing hospital admissions. Methods This was a prospective before-and-after cohort study of consecutive patients presenting with syncope who were seen in an urban ED and were either admitted to the hospital, discharged, or placed in the EDOU. We first performed an observation study of syncope management and then implemented an ED observation-based management pathway. We identified critical interventions and 30-day outcomes. We compared proportions of admissions and adverse events rates with a chi-squared or Fisher’s exact test. Results In the “before” phase, 570 patients were enrolled, with 334 (59%) admitted and 27 (5%) placed in the EDOU; 3% of patients discharged from the ED had critical interventions within 30 days and 10% returned. After the management pathway was introduced, 489 patients were enrolled; 34% (p<0.001) of pathway patients were admitted while 20% were placed in the EDOU; 3% (p=0.99) of discharged patients had critical interventions at 30 days and 3% returned (p=0.001). Conclusion A focused syncope management pathway effectively reduces hospital admissions and adverse events following discharge and returns to the ED.
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Affiliation(s)
- Oren J Mechanic
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Celine Y Pascheles
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Gregory J Lopez
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alina M Winans
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Nathan I Shapiro
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Carrie Tibbles
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Richard E Wolfe
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Shamai A Grossman
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
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Southerland LT, Hunold KM, Carpenter CR, Caterino JM, Mion LC. A National Dataset Analysis of older adults in emergency department observation units. Am J Emerg Med 2018; 37:1686-1690. [PMID: 30563716 DOI: 10.1016/j.ajem.2018.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Emergency Department (ED) Observation Units (Obs Units) are prevalent in the US, but little is known regarding older adults in observation. Our objective was to describe the Obs Units nationally and observation patients with specific attention to differences in care with increasing age. DESIGN This is an analysis of 2010-2013 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national observational cohort study including ED patients. Weighted means are presented for continuous data and weighted percent for categorical data. Multivariable logistic regression was used to identify variables associated with placement in and admission from observation. RESULTS The number of adult ED visits varied from 100 million to 107 million per year and 2.3% of patients were placed in observation. Adults ≥65 years old made up a disproportionate number of Obs Unit patients, 30.6%, compared to only 19.7% of total ED visits (odds ratio 1.5 (95% CI 1.5-1.6), adjusting for sex, race, month, day of week, payer source, and hospital region). The overall admission rate from observation was 35.6%, ranging from 31.3% for ages 18-64 years to 47.5% for adults ≥85 years old (p < 0.001). General symptoms (e.g., nausea, dizziness) and hypertensive disease were the most common diagnoses overall. Older adults varied from younger adults in that they were frequently observed for diseases of the urinary system (ICD-9 590-599) and metabolic disorders (ICD-9 270-279). CONCLUSIONS Older adults are more likely to be cared for in Obs Units. Older adults are treated for different medical conditions than younger adults.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lorraine C Mion
- College of Nursing, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Shetty AL, Teh C, Vukasovic M, Joyce S, Vaghasiya MR, Forero R. Impact of emergency department discharge stream short stay unit performance and hospital bed occupancy rates on access and patient flowmeasures: A single site study. Emerg Med Australas 2017; 29:407-414. [DOI: 10.1111/1742-6723.12777] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/19/2017] [Accepted: 02/20/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Amith L Shetty
- Emergency Department; Westmead Hospital; Sydney New South Wales Australia
- Sydney Medical School - Westmead Campus, The University of Sydney; Sydney New South Wales Australia
| | - Caleb Teh
- The Sydney Children's Hospitals Network, The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Matthew Vukasovic
- Emergency Department; Westmead Hospital; Sydney New South Wales Australia
| | - Shannon Joyce
- Emergency Department; Westmead Hospital; Sydney New South Wales Australia
| | - Milan R Vaghasiya
- Emergency Department; Westmead Hospital; Sydney New South Wales Australia
| | - Roberto Forero
- Health Services Planning, Simpson Centre for Health Services Research, South Western Sydney Clinical School; The University of New South Wales; Sydney New South Wales Australia
- The Ingham Institute for Applied Research; Liverpool Hospital; Liverpool New South Wales Australia
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Utilization of Observation Units for the Care of Poisoned Patients: Trends from the Toxicology Investigators Consortium Case Registry. J Med Toxicol 2016; 12:111-20. [PMID: 26275996 DOI: 10.1007/s13181-015-0498-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Many poisoned patients may only require a period of observation after their exposure. There are limited data describing the use of observation units for managing poisoned adult and pediatric patients. We performed a retrospective review of all patients reported to the ToxIC Case Registry between January 1, 2012 and December 31, 2013. Eligible patients included those who received a bedside consultation by a medical toxicologist and whose care was provided in an observation unit, or those who were admitted under the care of a medical toxicologist in an observation unit. A total of 15,562 poisonings were reported to the registry during the study period, of which 340 (2.2 %) involved patients who were cared for in an observation unit. Of these patients, 22.1 % were 18 years of age or younger, and the remaining 77.9 % were greater than 18 years of age. The most common reason for exposure was the intentional ingestion of a pharmaceutical agent in both adult (30.2 %) and pediatric patients (36.0 %). Alcohols (ethanol) (24.9 %), opioids (20.0 %), and sedative-hypnotics (17.7 %) were the most common agent classes involved in adult patient exposures. The most common agent classes involved in pediatric exposures were antidepressants (12.0 %), anticonvulsants (10.7 %), and envenomations (10.7 %). In adult patients, the most common signs and symptoms involved the nervous system (52.0 %), a toxidrome (17.0 %), or a major vital sign abnormality (14.7 %). In pediatric patients, the most common signs and symptoms involved the nervous system (53.3 %), a toxidrome (21.3 %), or a major vital sign abnormality (17.3 %). The results of this study demonstrate that a wide variety of poisoned patients have been cared for in an observation unit in consultation with a board-certified medical toxicologist. Patterns for the reasons for exposure, agents responsible for the exposure, and toxicological treatments will continue to evolve. Further study is needed to identify better those poisoned patients who can be appropriately managed in an observation unit.
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Liao TF, Wang C. Permanent emergency: Inequality in access to hospitalisation among urban elderly Chinese. Glob Public Health 2016; 13:1098-1113. [DOI: 10.1080/17441692.2016.1250938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Tim F. Liao
- Department of Sociology, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Cuntong Wang
- Department of Sociology, School of Social Development, Central University of Finance and Economics, Beijing, People’s Republic of China
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Grossman AM, Volz KA, Shapiro NI, Salem R, Sanchez LD, Smulowitz P, Grossman SA. Comparison of 1-Day Emergency Department Observation and Inpatient Ward for 1-Day Admissions in Syncope Patients. J Emerg Med 2016; 50:217-22. [DOI: 10.1016/j.jemermed.2015.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 06/02/2015] [Indexed: 11/29/2022]
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Lansang EZ, Horsburgh D, Lee YN, Sng A, Moussalli R, Wai K, Anand I, Zhang S, Shimizu W, Narasimhan C, Weon Park S, Yu CM, Ngarmukos T, Omar R, Reyes EB, Siswanto BB, Richards AM, Lam CS. Physicians’ Perception of the Patient Care Pathway for Acute Heart Failure in Asian Countries: Implications for Resource Allocation, Preventive Strategies and Clinical Trial Design. ACTA ACUST UNITED AC 2014. [DOI: 10.7603/s40602-014-0015-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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