Access block and emergency department overcrowding

A New Perspective on Missed Nursing Care in the Emergency Department: A Descriptive Cross-Sectional Study

INTRODUCTION

This descriptive cross-sectional study describes missed nursing care, quality of care, and patient safety rated by nursing staff in emergency departments. Required patient care that is omitted or delayed (missed nursing care) is associated with poorer quality of care and increased risk for adverse events, but studies are scarce in the emergency setting.

METHODS

Emergency registered nurses and nursing assistants (N=126) at 2 Swedish emergency departments participated in the study. The MISSCARE survey-Swedish version was used for data collection.

RESULTS

Emergency nursing staff assessed that nursing care is frequently missed in the emergency department. More than half of the 24 nursing care items were reported as missed by over 50% of the participants, and registered nurses rated most items significantly higher compared to nursing assistants. Half of the nursing staff perceived quality of care to be good, but nearly the same proportion perceived patient safety as poor. Registered nurses viewed both quality and safety worse than nursing assistants.

DISCUSSION

The present study found very high levels of missed nursing care in most nursing items. Results indicate that nursing staff in emergency departments need to prioritize between the tasks and that some tasks may not be relevant in the context. The emergency setting focuses primarily on identifying signs of urgency, assessing patients, performing interventions, and diagnostics. However, even items that seemed to be prioritized, such as reassessment of vital signs, had a surprisingly high level of missed nursing care in comparison to in-hospital wards.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Emergency short stay area improves access and flow in a rural hospital

OBJECTIVES

Shoalhaven District Memorial Hospital is a rural (MM3) 150-bed hospital in Nowra, New South Wales, whose ED has evolved to a FACEM-led model of care (MOC). It has never had an emergency short stay area (ESSA). The objective of the present study was to pilot an ESSA and determine whether this MOC would increase the operational performance of the ED.

METHODS

An ESSA was designed and delivered by emergency medicine medical, nursing and allied health practitioners. The study period was July-December 2021, with a seasonally matched retrospective cohort of records extracted for comparison (July-December 2020). Both took place within the context of the ongoing COVID-19 pandemic. The primary outcome measured was percentage of admitted patients meeting Emergency Treatment Performance (ETP). Secondary outcomes included discharge ETP, overall ED and inpatient length of stay (LOS), mortality and representation rates.

RESULTS

The admission ETP for patients after the implementation of the ESSA significantly increased, from 13.9% to 31.6% (χ2  = 288, P < 0.001). Discharge ETP significantly declined. There was no effect improvement on overall ETP. There was no change to mortality or representation rates. Average admission LOS decreased.

CONCLUSIONS

The introduction of the ESSA significantly improved the ETP of admitted patients. Ongoing refinement of the ESSA admission processes, as well as the lifting of certain COVID-19 restrictions, could show even greater improvements in this and other areas. Ongoing research in this field is necessary, as well as a more detailed cost-benefit analysis.

Cost-effectiveness analysis of direct admission to acute geriatric unit versus admission after an emergency department visit for elderly patients

BACKGROUND

Elderly individuals represent an increasing proportion of emergency department (ED) users. In the Greater Paris University Hospitals (APHP) direct-admission study, direct admission (DA) to an acute geriatric unit (AGU) was associated with a shorter hospital length of stay (LOS), lower post-acute care transfers, and lower risk of an ED return visit in the month following the AGU hospitalization compared with admission after an ED visit. Until now, no economic evaluation of DA has been available.

METHODS

We aimed to evaluate the cost-effectiveness of DA to an AGU versus admission after an ED visit in elderly patients. This was conducted alongside the APHP direct-admission study which used electronic medical records and administrative claims data from the Greater Paris University Hospitals (APHP) Health Data Warehouse and involved 19 different AGUs. We included all patients ≥ 75 years old who were admitted to an AGU for more than 24 h between January 1, 2013 and December 31, 2018. The effectiveness criterion was the occurrence of ED return visit in the month following AGU hospitalization. We compared the costs of an AGU stay in the DA versus the ED visit group. The perspective was that of the payer. To characterise and summarize uncertainty, we used a non-parametric bootstrap resampling and constructed cost-effectiveness accessibility curves.

RESULTS

At baseline, mean costs per patient were €5113 and €5131 in the DA and ED visit groups, respectively. ED return visit rates were 3.3% (n = 81) in the DA group and 3.9% (n = 160) in the ED group (p = 0.21). After bootstrap, the incremental cost-effectiveness ratio was €-4249 (95%CI= -66,001; +45,547) per ED return visit averted. Acceptability curves showed that DA could be considered a cost-effective intervention at a threshold of €-2405 per ED return visit avoided.

CONCLUSION

The results of this cost-effectiveness analysis of DA to an AGU versus admission after an ED visit for elderly patients argues in favor of DA, which could help provide support for public decision making.

The Association Between Age and Admission to an Inappropriate Ward: A Cross-Sectional Survey in France

Half of elderly patient hospitalizations are preceded by an emergency department (ED) visit. Hospitalization in inappropriate wards (IWs), which is more frequent in case of ED overcrowding and high hospital occupancy, leads to increased morbidity. Elderly individuals are the most exposed to these negative health care outcomes. Based on a nationwide cross-sectional survey involving all EDs in France, the aim of this study was to explore whether age was associated with admission to an IW after visiting an ED. Among the 4384 patients admitted in a medical ward, 4065 were admitted in the same hospital where the ED was located, among which 17.7% were admitted to an IW. Older age was associated with an increased likelihood of being admitted to an IW (OR = 1.39; 95% CI = 1.02-1.90 for patients aged 85 years and older and OR = 1.40; 95% CI = 1.02-1.91 for patients aged 75-84 years, compared with those under 45 years). ED visits during peak periods and cardio-pulmonary presenting complaint were also associated with an increased likelihood of admission to an IW. Despite their higher vulnerability, elderly patients are more likely to be admitted to an IW than younger patients. This result reinforces the need for special attention to be given to the hospitalization of this fragile population.

Predicting Adult Hospital Admission from Emergency Department Using Machine Learning: An Inclusive Gradient Boosting Model

BACKGROUND AND AIM

We analyzed an inclusive gradient boosting model to predict hospital admission from the emergency department (ED) at different time points. We compared its results to multiple models built exclusively at each time point.

METHODS

This retrospective multisite study utilized ED data from the Mount Sinai Health System, NY, during 2015-2019. Data included tabular clinical features and free-text triage notes represented using bag-of-words. A full gradient boosting model, trained on data available at different time points (30, 60, 90, 120, and 150 min), was compared to single models trained exclusively at data available at each time point. This was conducted by concatenating the rows of data available at each time point to one data matrix for the full model, where each row is considered a separate case.

RESULTS

The cohort included 1,043,345 ED visits. The full model showed comparable results to the single models at all time points (AUCs 0.84-0.88 for different time points for both the full and single models).

CONCLUSION

A full model trained on data concatenated from different time points showed similar results to single models trained at each time point. An ML-based prediction model can use used for identifying hospital admission.

Rapid access clinics: Improving the efficiency of referral after discharge from the Emergency Department

Background:

Rapid access clinics are an increasingly common model of care in tertiary hospitals. Early streaming of suitable patients to appropriate clinic services could reduce Emergency Department overcrowding. This study set out to investigate the current utilisation of rapid access clinic dispositions in a tertiary centre. The findings have led to useful mapping of local services and early nurse led identification of patients suitable for streaming to clinic locations.

Methods:

A cross-sectional observational study in a tertiary centre. Complete lists of consecutive discharged Emergency Department patients were generated by a trained data manger. Individual electronic medical records were reviewed for evidence of clinic disposition, patient demographics and compared with concurrent Emergency Department patients who were not referred.

Results:

1367 patients included from 144 h of consecutive weekday presentations. Referral to clinic locations occurred in 179/1357 (13.2%) with rapid access clinics utilised in 129/179 (70.4%). No difference in median length of stay was observed for patients referred to clinics (3.9 h) versus patients not referred (3.8 h) (p = 0.29).

Conclusion:

In a tertiary Emergency Department setting, discharged patients were frequently referred to rapid access clinics. Early streaming to suitable outpatient locations may be an additional strategy to consider for mitigating Emergency Department overcrowding.

Wait times in an Australian emergency department: A comparison of mental health and non-mental health patients in a regional emergency department

Worldwide, emergency departments in regional and remote areas have a higher per capita mental health presentation rate than their metropolitan counterparts. Evidence suggests that mental health presentations to metropolitan or city emergency departments are exposed to longer waiting times, extended length of stays, and higher rates of access block than non-mental health presentations. However, there is little research investigating the experiences for mental health and non-mental health presentations in the emergency department in regional and remote areas. The aim of the current study was to explore wait time and length of stay for mental and non-mental health patients at a regional emergency department. Audit data from 38,782 presentations to a regional emergency department in NSW over a 12-month period in 2019 were reviewed. The STROBE cross-sectional research checklist was adhered to for reporting of results. Time to be seen, length of stay, and access block (length of stay longer than 8 hours) were described and compared for mental and non-mental health patients. It was found that mental health patients in this study disproportionately experience longer wait times and length of stay in a regional emergency department. Future research is needed to identify whether this issue is present across other Australian regional emergency departments and review funding models to address the discrepancy. These findings make a unique contribution to the literature as previous research focussed on metropolitan emergency departments and only identified time to be seen and length of stay, largely ignoring differences in access block between mental health and non-mental health patients.

Effect of a Boarding Restriction Protocol on Emergency Department Crowding

PURPOSE

Access block due to the lack of hospital beds causes crowding of emergency departments (ED). We initiated the "boarding restriction protocol" that limits the time of stay in the ED for patients awaiting hospitalization to 24 hours from arrival. The purpose of this study was to determine the effect of the boarding restriction protocol on ED crowding.

MATERIALS AND METHODS

The primary outcome was ED occupancy rate, which was calculated as the ratio of the number of occupying patients to the total number of ED beds. Time factors, such as length of stay (LOS), treatment time, and boarding time, were investigated.

RESULTS

The mean of the ED occupancy rate decreased from 1.532±0.432 prior to implementation of the protocol to 1.273±0.353 after (p<0.001). According to time series analysis, the absolute effect caused by the protocol was -0.189 (-0.277 to -0.110) (p=0.001). The proportion of patients with LOS exceeding 24 hours decreased from 7.6% to 4.0% (p<0.001). Among admitted patients, ED LOS decreased from 770.7 (421.4-1587.1) minutes to 630.2 (398.0-1156.8) minutes (p<0.001); treatment time increased from 319.6 (198.5-482.8) minutes to 344.7 (213.4-519.5) minutes (p<0.001); and boarding time decreased from 298.9 (109.5-1149.0) minutes to 204.1 (98.7-545.7) minutes (p<0.001). In pre-protocol period, boarding patients accumulated in the ED during the weekdays and resolved on Friday, but this pattern was alleviated in post-period.

CONCLUSION

The boarding restriction protocol was effective in alleviating ED crowding by reducing the accumulation of boarding patients in the ED during the weekdays.

Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions

It is certain and established that overcrowding represents one of the main problems that has been affecting global health and the functioning of the healthcare system in the last decades, and this is especially true for the emergency department (ED). Since 1980, overcrowding has been identified as one of the main factors limiting correct, timely, and efficient hospital care. The more recent COVID-19 pandemic contributed to the accentuation of this phenomenon, which was already well known and of international interest. Considering what would appear to be a trivial definition of overcrowding, it may seem simple for the reader to hypothesize solutions for what seems to be one of the most avoidable problems affecting the hospital system. However, proposing solutions to overcrowding, as well as their implementation, cannot be separated from a correct and precise definition of the issue, which must consider the main causes and aggravating factors. In light of the need of finding solutions that can put an end to hospital overcrowding, this review aims, through a review of the literature, to summarize the triggering factors, as well as the possible solutions that can be proposed.

Areas of delay related to prolonged length of stay in an emergency department of an academic hospital in South Africa

Introduction

Globally, length of stay of patients in emergency departments remains a challenge. Remaining in the emergency department for >12 h increases health care costs, morbidity and mortality rates and leads to crowding and lower patient satisfaction.The aim of this research was to describe the areas of delay related to prolonged length of stay in the emergency department of an academic hospital.

Methods

A quantitative retrospective study was done. The Input-Throughput-Output model was used to identify the areas of patients' journey through the emergency department. The possible areas of delay where then described. Using systematic sampling, a total of 100 patient files managed in an emergency department of an academic hospital in South Africa were audited over a period of 3 months. Descriptive statistics and regression analysis was used to analyse data.

Results

The mean length of stay of patients in the emergency department was 73 h 49 min. The length of stay per phase was: input (3 h 17 min), throughput (16 h 25 min) and output (54 h 7 min). A strong significant relationship found between the length of stay and the time taken between disposition decision (throughput phase) disposition decision to admission or discharge of patients from the ED (output phase) (p < 0.05).

Conclusion

The output phase was identified as the longest area of delay in this study, with the time taken between disposition decision to admission or discharge of patients from the ED (patients waiting for inpatient beds) as the main significant area of delay.

Predicting adult neuroscience intensive care unit admission from emergency department triage using a retrospective, tabular-free text machine learning approach

Early admission to the neurosciences intensive care unit (NSICU) is associated with improved patient outcomes. Natural language processing offers new possibilities for mining free text in electronic health record data. We sought to develop a machine learning model using both tabular and free text data to identify patients requiring NSICU admission shortly after arrival to the emergency department (ED). We conducted a single-center, retrospective cohort study of adult patients at the Mount Sinai Hospital, an academic medical center in New York City. All patients presenting to our institutional ED between January 2014 and December 2018 were included. Structured (tabular) demographic, clinical, bed movement record data, and free text data from triage notes were extracted from our institutional data warehouse. A machine learning model was trained to predict likelihood of NSICU admission at 30 min from arrival to the ED. We identified 412,858 patients presenting to the ED over the study period, of whom 1900 (0.5%) were admitted to the NSICU. The daily median number of ED presentations was 231 (IQR 200–256) and the median time from ED presentation to the decision for NSICU admission was 169 min (IQR 80–324). A model trained only with text data had an area under the receiver-operating curve (AUC) of 0.90 (95% confidence interval (CI) 0.87–0.91). A structured data-only model had an AUC of 0.92 (95% CI 0.91–0.94). A combined model trained on structured and text data had an AUC of 0.93 (95% CI 0.92–0.95). At a false positive rate of 1:100 (99% specificity), the combined model was 58% sensitive for identifying NSICU admission. A machine learning model using structured and free text data can predict NSICU admission soon after ED arrival. This may potentially improve ED and NSICU resource allocation. Further studies should validate our findings.

Prediction of emergency department resource requirements during triage: An application of current natural language processing techniques

OBJECTIVE

Accurate triage in the emergency department (ED) is critical for medical safety and operational efficiency. We aimed to predict the number of future required ED resources, as defined by the Emergency Severity Index (ESI) triage protocol, using natural language processing of nursing triage notes.

METHODS

We constructed a retrospective cohort of all 265,572 consecutive ED encounters from 2015 to 2016 from 3 separate clinically heterogeneous academically affiliated EDs. We excluded encounters missing relevant information, leaving 226,317 encounters. We calculated the number of resources used by patients in the ED retrospectively and based outcome categories on criteria defined in the ESI algorithm: 0 (30,604 encounters), 1 (49,315 encounters), and 2 or more (146,398 encounters). A neural network model was trained on a training subset to predict the number of resources using triage notes and clinical variables at triage. Model performance was evaluated using the test subset and was compared with human ratings.

RESULTS

Overall model accuracy and macro F1 score for number of resources were 66.5% and 0.601, respectively. The model had similar macro F1 (0.589 vs 0.592) and overall accuracy (65.9% vs 69.0%) compared to human raters. Model predictions had slightly higher F1 scores and accuracy for 0 resources and were less accurate for 2 or more resources.

CONCLUSIONS

Machine learning of nursing triage notes, combined with clinical data available at ED presentation, can be used to predict the number of required future ED resources. These findings suggest that machine learning may be a valuable adjunct tool in the initial triage of ED patients.

The utility of serial chest X-rays for detection of delayed pneumothorax, haemothorax or haemopneumothorax following penetrating thoracic injury

Introduction

Penetrating thoracic injuries are a common presentation in Emergency Departments in South Africa with pneumothorax, haemothorax and haemopneumothorax (PTX/HTX/HPTX) a cause of morbidity and mortality. Serial chest X-rays (CXRs) are used to assess patients with penetrating thoracic injury without PTX/HTX/HPTX on initial CXR in order to increase sensitivity and thus detection of PTX/HTX/HPTX. This study aimed to assess the utility of serial CXRs to detect a delayed presentation of PTX/HTX/HPTX following penetrating thoracic injury.

Methods

This retrospective observational study analysed data from Helen Joseph Hospital Emergency Department, Johannesburg, South Africa for patients presenting with penetrating thoracic injury over a 2-year period for whom the initial CXR was negative for a PTX/HTX/HPTX to determine the utility of serial CXRs for detection of a delayed presentation of PTX/HTX/HPTX.

Results

118 patients, the majority of which had penetrating trauma secondary to a stab wound, were included in the study. Eight (7%) had a PTX/HTX/HPTX detected on subsequent investigation. Three (3%) patients with normal initial CXRs and three (3%) patients with abnormal initial CXRs had a PTX/HPX/HPTX detected on serial CXRs. Two (2%) delayed presentations of PTX/HTX/HPTX were noted on computerised tomography (CT) scan only. Six patients had an intercostal drain (ICD) inserted and were admitted; 2 patients (those with PTX/HTX/HPTX noted on CT only) were managed conservatively. Three patients (3%) had an ICD inserted to manage a delayed presentation of PTX/HTX/HPTX with a normal initial CXR.

Discussion

Only 3% of patients with normal initial CXRs required intervention.

Conclusions

It is recommended that patients for whom the presentation CXR shows an abnormality undergo serial CXRs. Given the low incidence of PTX/HTX/HPTX in patients with a normal presentation CXR, along with the resource implications of serial CXRs, it may be prudent to discharge patients with thorough counselling and advice to return for review if warranted.

Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care

Background: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients’ characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient’s clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients’ management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusions: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.

The impact of emergency department triage on the treatment outcomes of cancer patients with febrile neutropenia: A retrospective review

INTRODUCTION

The emergency department (ED) is an important entry point for patients with cancer requiring acute care due to oncological emergencies. Febrile neutropenia (FN) is one of the most common oncological emergencies and carries a significant risk of morbidity and mortality. There is evidence from previous studies that FN patients wait far longer in the ED than recommended by international guidelines.

PURPOSE

The aim was to examine whether individuals with cancer presenting at the ED with FN were triaged appropriately, and to explore if, and how, triage affected their treatment outcomes.

METHODS

A retrospective cohort design was employed to collect data over five years from all available ED records of adult cancer patients who presented with fever.

RESULTS

Of the 431 eligible patients, 63% (n = 272) were assigned triage scores that were detrimental to their immediate health. Findings from the multiple linear regression analyses showed that inaccurate or under triage was significantly associated with delayed times for the initial physician assessment, administration of antibiotics, and decision on admission. The absence of fever at the time of triage assessment contributed significantly to the prediction of under triage.

CONCLUSION

The allocation of patients with FN to a lower, inaccurate priority was partly responsible for the inability of those patients to meet the standard benchmarks for the initial physician assessment and the administration of antibiotics identified by the triage and febrile neutropenia guidelines. Ongoing strategies are needed to both enhance the application of the triage guidelines and institute organizational and system changes that promote timeliness and effectiveness throughout the entire ED episode of care.

Beyond Access Block: Understanding the Role of Health Literacy and Self-Efficacy in Low-Acuity Emergency Department Patients

Background: Health literacy, self-efficacy, and patient satisfaction are factors associated with healthcare utilization. The relationships among these factors and their combined impact on patients’ self-rated health have historically been studied in chronic disease populations. This study assessed low-acuity emergency department (ED) patients’ ratings of these factors, the relationships among these factors, and their effect on re-presentation rates to the ED.

Methods: In this single-arm cohort survey, patients provided demographic data, completed health literacy and self-efficacy assessments prior to being seen by a physician, and completed a discharge perceptions questionnaire that included a global satisfaction question at the time of departure. Three months later, patients answered a telephone survey to measure post-ED visit health outcomes.

Results: Health literacy (r=0.114, P=0.023) and self-efficacy (r=0.469, P<0.001) were both independently and positively associated with self-rated health. Neither factor was associated with patient satisfaction. Self-rated health was negatively associated with return ED visits (r=–0.137, P=0.011).

Conclusion: Existing research shows that health literacy has a linear association with self-efficacy and self-rated health. The results of this study suggest that in the context of low-acuity ED patients, health literacy and self-efficacy affect patients’ understanding of their health status (self-rated health) but do not lead to better utilization of healthcare resources. Improvement of health literacy and self-efficacy, specifically to increase self-rated health, may provide a future avenue of intervention to reduce low-acuity ED patient re-presentation.

Rates of Intracranial Hemorrhage in Mild Head Trauma Patients Presenting to Emergency Department and Their Management: A Comparison of Direct Oral Anticoagulant Drugs with Vitamin K Antagonists

Background and objectives: Anticoagulants are thought to increase the risks of traumatic intracranial injury and poor clinical outcomes after blunt head trauma. The safety of using direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) after intracranial hemorrhage (ICH) is unclear. This study aims to compare the incidence of post-traumatic ICH following mild head injury (MHI) and to assess the need for surgery, mortality rates, emergency department (ED) revisit rates, and the volume of ICH. Materials and Methods: This is a retrospective, single-center observational study on all patients admitted to our emergency department for mild head trauma from 1 January 2016, to 31 December 2018. We enrolled 234 anticoagulated patients, of which 156 were on VKAs and 78 on DOACs. Patients underwent computed tomography (CT) scans on arrival (T0) and after 24 h (T24). The control group consisted of patients not taking anticoagulants, had no clotting disorders, and who reported an MHI in the same period. About 54% in the control group had CTs performed. Results: The anticoagulated groups were comparable in baseline parameters. Patients on VKA developed ICH more frequently than patients on DOACs and the control group at 17%, 5.13%, and 7.5%, respectively. No significant difference between the two groups was noted in terms of surgery, intrahospital mortality rates, ED revisit rates, and the volume of ICH. Conclusions: Patients with mild head trauma on DOAC therapy had a similar prevalence of ICH to that of the control group. Meanwhile, patients on VKA therapy had about twice the ICH prevalence than that on the control group or patients on DOAC, which remained after correcting for age. No significant difference in the need for surgery was determined; however, this result must take into account the very small number of patients needing surgery.

Role of a Brief Intensive Observation Area with a Dedicated Team of Doctors in the Management of Acute Heart Failure Patients: A Retrospective Observational Study

Background and objectives: Acute heart failure (AHF) is one of the main causes of hospitalization in Western countries. Usually, patients cannot be admitted directly to the wards (access block) and stay in the emergency room. Holding units are clinical decision units, or observation units, within the ED that are able to alleviate access block and to contribute to a reduction in hospitalization. Observation units have also been shown to play a role in specific clinical conditions, like the acute exacerbation of heart failure. This study aimed to analyze the impact of a brief intensive observation (OBI) area on the management of acute heart failure (AHF) patients. The OBI is a holding unit dedicated to the stabilization of unstable patients with a team of dedicated physicians. Materials and Methods: We conducted a retrospective and single-centered observational study with retrospective collection of the data of all patients who presented to our emergency department with AHF during 2017. We evaluated and compared two cohorts of patients, those treated in the OBI and those who were not, in terms of the reduction in color codes at discharge, mortality rate within the emergency room (ER), hospitalization rate, rate of transfer to less intensive facilities, and readmission rate at 7, 14, and 30 days after discharge. Results: We enrolled 920 patients from 1^st January to 31^st December. Of these, 61% were transferred to the OBI for stabilization. No statistically significant difference between the OBI and non-OBI populations in terms of age and gender was observed. OBI patients had worse clinical conditions on arrival. The patients treated in the OBI had longer process times, which would be expected, to allow patient stabilization. The stabilization rate in the OBI was higher, since presumably OBI admission protected patients from “worse condition” at discharge. Conclusions: Data from our study show that a dedicated area of the ER, such as the OBI, has progressively allowed a change in the treatment path of the patient, where the aim is no longer to admit the patient for processing but to treat the patient first and then, if necessary, admit or refer. This has resulted in very good feedback on patient stabilization and has resulted in a better management of beds, reduced admission rates, and reduced use of high intensity care beds.

Adverse outcomes of delayed intensive care unit

OBJECTIVE

To examine the impact of delayed transfer from the emergency room into the intensive care unit on the length of intensive care unit stay and death.

METHODS

This prospective, cohort study performed in a tertiary academic hospital obtained data from 1913 patients admitted to the emergency room with a documented request for admission into the intensive care unit. The patients admitted directly into the medical-surgical intensive care unit (n = 209) were categorized into tertiles according to their waiting time for intensive care unit admission (Group 1: < 637 min, Group 2: 637 to 1602 min, and Group 3: > 1602 min). Patients who stayed in the intensive care unit for longer than 3.2 days (median time of intensive care unit length of stay of all patients) were considered as having a prolonged intensive care unit stay.

RESULTS

A total of 6,176 patients were treated in the emergency room during the study period, among whom 1,913 (31%) required a bed in the intensive care unit. The median length of stay in the emergency room was 17 hours [9 to 33 hours]. Hospitalization for infection/sepsis was an independent predictor of prolonged intensive care unit stay (OR 2.75 95%CI 1.38 - 5.48, p = 0.004), but waiting time for intensive care unit admission was not. The mortality rate was higher in Group 3 (38%) than in Group 1 (31%) but the difference was not statistically significant.

CONCLUSION

Delayed admission into the intensive care unit from the emergency room did not result in an increased intensive care unit stay or mortality.

Adjusting Daily Inpatient Bed Allocation to Smooth Emergency Department Occupancy Variation

Study Objective: Overcrowding in emergency departments (ED) is an increasingly common problem in Taiwanese hospitals, and strategies to improve efficiency are in demand. We propose a bed resource allocation strategy to overcome the overcrowding problem. Method: We investigated ED occupancy using discrete-event simulation and evaluated the effects of suppressing day-to-day variations in ED occupancy by adjusting the number of empty beds per day. Administrative data recorded at the ED of Taichung Veterans General Hospital (TCVGH) in Taiwan with 1500 beds and an annual ED volume of 66,000 visits were analyzed. Key indices of ED quality in the analysis were the length of stay and the time in waiting for outward transfers to in-patient beds. The model is able to analyze and compare several scenarios for finding a feasible allocation strategy. Results: We compared several scenarios, and the results showed that by reducing the allocated beds for the ED by 20% on weekdays, the variance of daily ED occupancy was reduced by 36.25% (i.e., the percentage of reduction in standard deviation). Conclusions: This new allocation strategy was able to both reduce the average ED occupancy and maintain the ED quality indices.

Factors associated with inappropriate attendances at the emergency department of a tertiary hospital in Singapore

INTRODUCTION

Inappropriate attendances (IAs) at emergency departments (ED) are contributed by patients with mild or moderate medical conditions that can be effectively managed by primary care physicians. IAs strain limited ED resources and have an adverse impact on efficiency. This study aimed to identify factors associated with IA at the ED of a tertiary hospital in Singapore.

METHODS

We conducted a retrospective cohort study of all eligible visits to the aforementioned ED between 1 January 2015 and 31 December 2015. The appropriateness of each attendance was estimated using criteria based on investigations or procedures that were performed on the attendee and the discharge type of that attendance. IAs were then compared against appropriate attendances in these areas: attendee demographics; referral source; time of ED visit; proximity to ED and 24-hour general practitioner clinics; and history of ED visits in 2014. Multivariate analysis was performed on significant variables associated with IAs.

RESULTS

Among 120,606 attendances, 11,631 (9.6%) were IAs. Multivariate analysis showed that gender, ethnicity, referral source, time of ED visit, nationality and history of frequent visits to the ED were factors associated with IAs. Moreover, the odds of IA were found to be higher among attendees who were younger, were self-referred, or had at least one IA in 2014.

CONCLUSION

This study identified subgroups in the population who were more likely to contribute to IAs at the ED. These findings offer relevant insights into future research directions and strategies that might potentially reduce avoidable IAs.

Development and evaluation of a code frame to identify potential primary care presentations in the hospital emergency department

OBJECTIVE

A major challenge in evaluating the appropriateness of ED presentations is the lack of a universal and workable definition of patients who could have received primary care instead. Our objective was to develop a standardised code frame to identify potential primary care patients in the ED.

METHODS

A standardised code frame to identify which patients could potentially be treated in a primary care setting was developed and tested on all patient episodes of care who presented to the ED of the St George Hospital, Sydney, between December 2016 and February 2017. Sensitivity and specificity of the code frame were performed. The code frame was then tested on all presentations from 2011 to 2016 in the St George Hospital and The Sutherland Hospital in Sydney.

RESULTS

Of 19 916 ED presentations, 5810 (29%) were potential primary care presentations. The code frame had a sensitivity of 99.9% and a specificity of 49.0%. Results were consistent (28%) when applied to 5 years of presentations (601 168 presentations).

CONCLUSION

This standardised code frame enables accurate retrospective local and national data estimations. The code frame could be used prospectively to evaluate interventions such as diverting patients to primary care settings, and to identify populations for specifically targeted interventions. The conservative nature of the code frame ensures that only those that can safely receive care in a primary care setting are identified as potential primary care.

Management of patients brought in by ambulance to the emergency department: role of the Advanced Musculoskeletal Physiotherapist

Objective The aim of the present study was to evaluate the role of the Advanced Musculoskeletal Physiotherapist (AMP) in managing patients brought in by ambulance to the emergency department (ED). Methods This study was a dual-centre observational study. Patients brought in by ambulance to two Melbourne hospitals over a 12-month period and seen by an AMP were compared with a matched group seen by other ED staff. Primary outcome measures were wait time and length of stay (LOS) in the ED. Results Data from 1441 patients within the Australasian Triage Scale (ATS) Categories 3-5 with musculoskeletal complaints were included in the analysis. Subgroup analysis of 825 patients aged ≤65 years demonstrated that for Category 4 (semi-urgent) patients, the median wait time to see the AMP was 9.5min (interquartile range (IQR) 3.25-18.00min) compared with 25min (IQR 10.00-56.00min) to see other ED staff (P ≤ 0.05). LOS analysis was undertaken on patients discharged home and demonstrated that there was a 1.20 greater probability (95% confidence interval 1.07-1.35) that ATS Category 4 patients managed by the AMP were discharged within the 4-hour public hospital target compared with patients managed by other ED staff: 87.04% (94/108) of patients managed by the AMPs met this standard compared with 72.35% (123/170) of patients managed by other ED staff (P=0.002). Conclusions Patients aged ≤65 years with musculoskeletal complaints brought in by ambulance to the ED and triaged to ATS Category 4 are likely to wait less time to be seen and are discharged home more quickly when managed by an AMP. This study has added to the evidence that AMPs improve patient flow in the ED, freeing up time for other ED staff to see higher-acuity, more complex patients. What is known about the topic? There is a growing body of evidence establishing that AMPs improve the flow of patients presenting with musculoskeletal conditions to the ED through reduced wait times and LOS and, at the same time, providing good-quality care and enhanced patient satisfaction. What does this paper add? Within their primary contact capacity, AMPs also manage patients who are brought in by ambulance presenting with musculoskeletal conditions. To the authors' knowledge, there is currently no available literature documenting the performance of AMPs in the management of this cohort of patients. What are the implications for practitioners? This study has added to the body of evidence that AMPs improve patient flow in the ED and illustrates that AMPs, by seeing patients brought in by ambulance, are able to have a positive impact on the pressures increasingly facing the Victorian Ambulance Service and emergency hospital care.

Timing of respiratory virus molecular testing in emergency departments and its association with patient care outcomes: a retrospective observational study across six Australian hospitals

OBJECTIVE

A rapid molecular diagnostic test (RMDT) offers a fast and accurate detection of respiratory viruses, but its impact on the timeliness of care in the emergency department (ED) may depend on the timing of the test. The aim of the study was to determine if the timing of respiratory virus testing using a RMDT in the ED had an association with patient care outcomes.

DESIGN

Retrospective observational study.

SETTING

Linked ED and laboratory data from six EDs in New South Wales, Australia.

PARTICIPANTS

Adult patients presenting to EDs during the 2017 influenza season and tested for respiratory viruses using a RMDT. The timing of respiratory virus testing was defined as the time from a patient's ED arrival to time of sample receipt at the hospital laboratory.

OUTCOME MEASURES

ED length of stay (LOS), >4 hour ED LOS and having a pending RMDT result at ED disposition.

RESULTS

A total of 2168 patients were included. The median timing of respiratory virus testing was 224 min (IQR, 133-349). Every 30 min increase in the timing of respiratory virus testing was associated with a 24.0 min increase in the median ED LOS (95% CI, 21.8-26.1; p<0.001), a 51% increase in the likelihood of staying >4 hours in ED (OR, 1.51; 95% CI, 1.41 to 1.63; p<0.001) and a 4% increase in the likelihood of having a pending RMDT result at ED disposition (OR, 1.04; 95% CI, 1.02 to 1.05; p<0.001) after adjustment for confounders.

CONCLUSION

The timing of respiratory virus molecular testing in EDs was significantly associated with a range of outcome indicators. Results suggest the potential to maximise the benefits of RMDT by introducing an early diagnostic protocol such as triage-initiated testing.

Are service and patient indicators different in the presence or absence of nurse practitioners? The EDPRAC cohort study of Australian emergency departments

OBJECTIVES

To evaluate the impact of nurse practitioner (NP) service in Australian public hospital emergency departments (EDs) on service and patient safety and quality indicators.

DESIGN AND SETTING

Cohort study comprising ED presentations (July 2013-June 2014) for a random sample of hospitals, stratified by state/territory and metropolitan versus non-metropolitan location; and a retrospective medical record audit of ED re-presentations.

METHODS

Service indicator data (patient waiting times for Australasian Triage Scale categories 2, 3, 4 and 5; number of patients who did not-wait; length of ED stay for non-admitted patients) were compared between EDs with and without NPs using logistic regression and Cox proportional hazards regression, adjusting for hospital and patient characteristics and correlation of outcomes within hospitals. Safety and quality indicator data (rates of ED unplanned re-presentations) for a random subset of re-presentations were compared using Poisson regression.

RESULTS

Of 66 EDs, 55 (83%) provided service indicator data on 2 463 543 ED patient episodes while 58 (88%) provided safety and quality indicator data on 2853 ED re-presentations. EDs with NPs had significantly (p<0.001) higher rates of waiting times compared with EDs without NPs. Patients presenting to EDs with NPs spent 13 min (8%) longer in ED compared with EDs without NPs (median, (first quartile-third quartile): 156 (93-233) and 143 (84-217) for EDs with and without NPs, respectively). EDs with NPs had 1.8% more patients who did not wait, but similar re-presentations rates as EDs with NPs.

CONCLUSIONS

EDs with NPs had statistically significantly lower performance for service indicators. However, these findings should be treated with caution. NPs are relatively new in the ED workforce and low NP numbers, staffing patterns and still-evolving roles may limit their impact on service indicators. Further research is needed to explain the dichotomy between the benefits of NPs demonstrated in individual clinical outcomes research and these macro system-wide observations.

Identifying Potentially Avoidable Emergency Department Visits of Long-Term Care Hospital Residents in Korea: A Multicenter Retrospective Cohort Study

The aims of this study were to investigate the reasons of transfers from long-term care hospitals (LTCHs) to emergency departments (EDs) of university hospitals in geriatric patients and to categorize the avoidable causes of these transfers. This retrospective multicenter study involved patients aged 65 years and older who were transferred from LTCHs to 5 EDs of university hospitals located in the metropolitan area of South Korea between January 2017 and December 2017. The expert panel reviewed and categorized the reason of transfers as avoidable or not. Moreover, we also investigated the number of patients with do-not-resuscitate (DNR) documents and the date these DNR documents were written. A total of 255,543 patients visited 5 EDs during the study period. Of these, 1,131 patients were from LTCHs. The number of potentially avoidable transfers was 168/1,131 (14.9%). The most common reason of avoidable transfers was noncritical diagnoses that could be assessed and managed in LTCHs (57.1%). There were 162 patients with DNR orders; of these, 12 had approved the DNR order before transfer. In conclusion, in Korea, potentially avoidable transfers could be reduced by managing noncritical diseases in LTCH and preparing advance care directives, including DNR orders, during admission to LTCH.

Impact of the implementation of a fast-track on emergency department length of stay and quality of care indicators in the Champagne-Ardenne region: a before-after study

OBJECTIVES

We aimed to evaluate the effect of the implementation of a fast-track on emergency department (ED) length of stay (LOS) and quality of care indicators.

DESIGN

Adjusted before-after analysis.

SETTING

A large hospital in the Champagne-Ardenne region, France.

PARTICIPANTS

Patients admitted to the ED between 13 January 2015 and 13 January 2017.

INTERVENTION

Implementation of a fast-track for patients with small injuries or benign medical conditions (13 January 2016).

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of patients with LOS ≥4 hours and proportion of access block situations (when patients cannot access an appropriate hospital bed within 8 hours). 7-day readmissions and 30-day readmissions.

RESULTS

The ED of the intervention hospital registered 53 768 stays in 2016 and 57 965 in 2017 (+7.8%). In the intervention hospital, the median LOS was 215 min before the intervention and 186 min after the intervention. The exponentiated before-after estimator for ED LOS ≥4 hours was 0.79; 95% CI 0.77 to 0.81. The exponentiated before-after estimator for access block was 1.19; 95% CI 1.13 to 1.25. There was an increase in the proportion of 30 day readmissions in the intervention hospital (from 11.4% to 12.3%). After the intervention, the proportion of patients leaving without being seen by a physician decreased from 10.0% to 5.4%.

CONCLUSIONS

The implementation of a fast-track was associated with a decrease in stays lasting ≥4 hours without a decrease in access block. Further studies are needed to evaluate the causes of variability in ED LOS and their connections to quality of care indicators.

Prediction of emergency department patient disposition based on natural language processing of triage notes

BACKGROUND

Nursing triage documentation is the first free-form text data created at the start of an emergency department (ED) visit. These 1-3 unstructured sentences reflect the clinical impression of an experienced nurse and are key in gauging a patient's illness. We aimed to predict final ED disposition using three commonly-employed natural language processing (NLP) techniques of nursing triage notes in isolation from other data.

METHODS

We constructed a retrospective cohort of all 260,842 consecutive ED encounters in 2015-16, from three clinically heterogeneous academically-affiliated EDs. After exclusion of 3964 encounters based on completeness of triage, and disposition data, we included 256,878 encounters. We defined the outcome as: 1) admission, transfer, or in-ED death [68,092 encounters] vs. 2) discharge, "left without being seen," and "left against medical advice" [188,786 encounters]. The dataset was divided into training and testing subsets. Neural network regression models were trained using bag-of-words, paragraph vectors, and topic distributions to predict disposition and were evaluated using the testing dataset.

RESULTS

Area under the curve for disposition using triage notes as bag-of-words, paragraph vectors, and topic distributions were 0.737 (95% CI: 0.734 - 0.740), 0.785 (95% CI: 0.782 - 0.788), and 0.687 (95% CI: 0.684 - 0.690), respectively.

CONCLUSIONS

Nursing triage notes can be used to predict final ED patient disposition, even when used separately from other clinical information. These findings have substantial implications for future studies, suggesting that free text from medical records may be considered as a critical predictor in research of patient outcomes.

Advanced diagnostic imaging utilization during emergency department visits in the United States: A predictive modeling study for emergency department triage

Background

Emergency department (ED) crowding is associated with negative health outcomes, patient dissatisfaction, and longer length of stay (LOS). The addition of advanced diagnostic imaging (ADI), namely CT, ultrasound (U/S), and MRI to ED encounter work up is a predictor of longer length of stay. Earlier and improved prediction of patients’ need for advanced imaging may improve overall ED efficiency. The aim of the study was to detect the association between ADI utilization and the structured and unstructured information immediately available during ED triage, and to develop and validate models to predict utilization of ADI during an ED encounter.

Methods

We used the United States National Hospital Ambulatory Medical Care Survey data from 2009 to 2014 to examine which sociodemographic and clinical factors immediately available at ED triage were associated with the utilization of CT, U/S, MRI, and multiple ADI during a patient’s ED stay. We used natural language processing (NLP) topic modeling to incorporate free-text reason for visit data available at time of ED triage in addition to other structured patient data to predict the use of ADI using multivariable logistic regression models.

Results

Among the 139,150 adult ED visits from a national probability sample of hospitals across the U.S, 21.9% resulted in ADI use, including 16.8% who had a CT, 3.6% who had an ultrasound, 0.4% who had an MRI, and 1.2% of the population who had multiple types of ADI. The c-statistic of the predictive models was greater than or equal to 0.78 for all imaging outcomes, and the addition of text-based reason for visit information improved the accuracy of all predictive models.

Conclusions

Patient information immediately available during ED triage can accurately predict the eventual use of advanced diagnostic imaging during an ED visit. Such models have the potential to be incorporated into the ED triage workflow in order to more rapidly identify patients who may require advanced imaging during their ED stay and assist with medical decision-making.

Emergency psychiatric services in Roozbeh Hospital: A qualitative study of the staff's experiences

PURPOSE

This study aims to explore how psychiatric residents and nurses experience the conditions of psychiatric emergency services.

DESIGN AND METHODS

This qualitative study was carried out using content analysis. Data were collected through unstructured interviews conducted during three focus groups.

FINDINGS

The results of the focus groups were classified into the following five categories of issues influencing the staff's experiences: repetitive problems, long wait times, ambiguity, insecurity, and stability.

PRACTICE IMPLICATIONS

Improving the staff's communication skills and educating them on how to manage violence, establishing a well-functional system of triage, and optimizing bed management and discharge planning are among several potential strategies that might be considered to improve the quality of care in psychiatric emergency services.

Comparison of emergency department time performance between a Canadian and an Australian academic tertiary hospital

OBJECTIVE

To compare performance and factors predicting failure to reach Ontario and Australian government time targets between a Canadian (Sunnybrook Hospital) and an Australian (Austin Health) academic tertiary-level hospitals in 2012, and to assess for change of factors and performance in 2016 between the same hospitals.

METHODS

This was a retrospective, observational study of patient administrative data in two calendar years. The main outcome measure was reaching Ontario and Australian ED time targets for admissions, high and low urgency discharges. Secondary outcomes were factors predicting failure to reach these targets.

RESULTS

Between 2012 and 2016, Sunnybrook and Austin experienced increased patient volume of 10.2% and 19.2%, respectively. Bed capacity decreased at Sunnybrook (-10.8%) but increased at the Austin (+30.3%). For both years, Austin failed to achieve the Australian time target, but succeeded for all Ontario targets except for low urgency discharges. Sunnybrook failed all targets irrespective of year. The top factors for failing Ontario ED length-of-stay targets for both hospitals in 2012 and 2016 were bed request greater than 6 h, access block greater than 1 h, use of cross-sectional imaging, consultation and waiting for the emergency physician greater than 2 h.

CONCLUSION

Austin outperformed Sunnybrook for Ontario and Australian government time targets. Both hospitals failed the Australian targets. Factors predicting failure to achieve targets were different between hospitals, but were mainly clinical resources. Sunnybrook focussed on increasing human resources. Austin focussed on increasing human resources, observation unit and hospital beds. Intrinsic hospital characteristics and infrastructure influenced target success.

Health Care Provision During a Sporting Mass Gathering: A Structure and Process Description of On-Site Care Delivery

INTRODUCTION

Mass gatherings such as marathons are increasingly frequent. During mass gatherings, the provision of timely access to health care services is required for the mass-gathering population, as well as for the local community. However, the nature and impact of health care provision during sporting mass gatherings is not well-understood.

PURPOSE

The aim of this study was to describe the structures and processes developed for an emergency health team to operate an in-event, acute health care facility during one of the largest mass-sporting participation events in the southern hemisphere, the Gold Coast Marathon (Queensland, Australia).

METHODS

A pragmatic, qualitative methodology was used to describe the structures and processes required to operate an in-event, acute health care facility providing services for marathon runners and spectators. Content analysis from 12 semi-structured interviews with emergency department (ED) clinical staff working during the two-day event was undertaken in 2016.

FINDINGS

Important structural elements of the in-event health care facility included: physical spaces, such as the clinical zones in the marathon health tent and surrounding area, and access and egress points; and resources such as bilingual staff, senior medical staff, and equipment such as electrocardiograms (ECGs) and intravenous fluids. Process elements of the in-event health care facility included clear communication pathways, as well as inter-professional care coordination and engagement involving shared knowledge of and access to resources, and distinct but overlapping clinical scope between nurses and doctors. This was seen to be critical for timely care provision and appropriate case management. Staff reported many perceived benefits and opportunities of in-event health care delivery, including ED avoidance and disaster training.

CONCLUSIONS

This in-event model of emergency care delivery, established in an out-of-hospital location, enabled the delivery of acute health care that could be clearly described and defined. Staff reported satisfaction with their ability to provide a meaningful contribution to hospital avoidance and to the local community. With the number of sporting mass gatherings increasing, this temporary, in-event model of health care provision is one option for event and health care planners to consider.JohnstonANB, WadhamJ, Polong-BrownJ, AitkenM, RanseJ, HuttonA, RichardsB, CrillyJ.Health care provision during a sporting mass gathering: a structure and process description of on-site care delivery. Prehosp Disaster Med. 2019;34(1):62-71.

Violence and aggression in the intensive care unit: What is the impact of Australian National Emergency Access Target?

INTRODUCTION

Violence in healthcare settings is a concern for healthcare professionals and patients. Media reports, and debate within the healthcare profession, and the academic literature infer that workplaces such as intensive care units are becoming exposed to increasing violence. Increases in the incidence of violent behaviour are sometimes attributed to the increased pressure on emergency departments to accelerate the throughput of patients to meet targets. To ensure the wellbeing of patients and staff, there is a need to evaluate the impact of such targets. The aim in this study was to evaluate the incidence and to describe the context in which patients' aggressive and violent behaviours occurred since the introduction of the National Emergency Access Target in a local tertiary Australian intensive care unit.

METHODS

A retrospective examination of events triggering violence-related emergency codes from 12 months before the introduction of the National Emergency Access Target up until 12 months after its implementation (2011-2013).

RESULTS

A small increase in the number of Code Grey/Code Black activation was identified after the introduction of the target (before = 18, after = 29). Admissions following drug overdoses, isolated head trauma, and cardiac arrest were the presentations most likely to have been associated with a violence-related emergency call. Female registered nurses, male critical care registered nurses, and clinical nurse specialists were the most at risk of occupational violence. Male nursing staff members were found to be more likely to be involved in incidences of verbal violence (p < 0.003).

CONCLUSION

Although there was a minimal increase in the overall number of emergencies triggered by violent behaviour, valuable information on the type of occupational violence occurring towards healthcare professionals and patients in this setting was found. We suggest that these findings add further important detail to the existing understanding of the problem of occupational violence. These detailed insights can further inform policy development, professional education, and practice.

Burden, Characteristics and Process of Care Among the Pediatric and Adult Trauma Patients in Botswana's Main Hospitals

BACKGROUND

Botswana is notable among countries with high rates of Road Traffic Collisions (RTC); like many other lower-middle-income countries (LMICs), it lacks trauma systems. The World Health Organization recommends 'Essential Trauma Care' in countries with no formal trauma systems. The proportion of injuries in Emergency Departments and the care process were investigated to gain an overview for enabling the design of a relevant LMICs trauma system.

METHOD

Blunt and penetrating trauma patients were included from three major hospitals, examining the proportion of injuries, patient characteristics, the care process and comparing these between pediatrics and adults. Data are presented using descriptive statistics.

RESULTS

The proportion of trauma ranged between 6 and 10% of Emergency Department cases. Pediatrics constituted 19%, and 59% of all patients were male. The median age was 28 years [IQR 17-39] and 8 years [IQR 4-11] for adults and pediatrics, respectively. The leading causes of injuries were: falls in pediatrics (55%) and interpersonal violence in the adults (34%), followed by RTC in both children (20%) and adults (30%). The public inter-hospital vehicles transported 77% of pediatrics and 69% of adults, while formal ambulance transported only 9% of pediatrics and 22% of adults. The median Emergency Department waiting time for pediatrics was 187 min [IQR 102-397] and for adults was 208 min [IQR 100-378]: Most were triaged as non-urgent (70% pediatrics and 72% adults), and the majority were discharged (84% pediatrics and 76% adults).

CONCLUSION

The Emergency Department workload of injuries is notably high, with differing mechanisms of injury and transport modes between pediatrics and adults: Waiting time is severely prolonged for urgent and critical patients. Diagnoses, triage categories and patients disposition were similar.

Hospital's instability wedges

In this study, we define a hospital congestion episode as a situation where the number of new patients needing admission is greater than the number of available beds in the hospital, and investigate the likelihood that the current day's midnight occupancy will exceed any specified threshold level. We demonstrate that this measure of risk exhibits a characteristic sensitivity phenomenon that we have named as hospital's instability wedge. In particular, it is seen that frequently even small changes in the numbers of patients admitted or discharged can dramatically change the risk of exceeding the threshold, thereby changing the risk of subsequent congestion episodes. While this finding captures a salient difficulty of operating a modern public hospital, it also opens up an opportunity for monitoring and alleviating the above defined risk with only small changes in admission, discharge, and cancellation rates. A case study with recent patient journey data from Flinders Medical Centre in South Australia is presented.

Feasibility of predictive model by clinical and laboratory parameters for risk stratification of geriatric abdominal pain

Background:

Assessment of geriatric patients presented with abdominal pain had been challenge for emergency physicians with the ageing population. A rapid, reproducible risk stratification model for the assessment of the need for admission for geriatric abdominal pain would be required to identify low-risk patients to be managed as out-patient basis.

Objective:

Assess the feasibility of risk stratification model to predict the need of hospital admission based on readily available bedside parameters in emergency departments.

Methods:

This is a multicenter retrospective cohort study in four emergency departments. Patients aged at least 65 who presented with chief complaint of abdominal pain within the previous 7 days of attendance as the chief complaint were included. Chart review was performed for the included patients. The primary outcome was defined as a composite of mortality, abdominal surgery or endoscopic treatment, and other inpatient treatments for abdominal diseases within 14 days, surrogating the need of hospital admission. Logistic regression was modeled to identify independent predictors. The diagnostic accuracy of the risk model was evaluated with the receiver operating characteristic curve and compared with the clinical gestalt of decision for hospital admission by the attending physician.

Results:

In total, 553 patients were included. Symptoms of upper gastrointestinal bleeding, non-ambulatory presenting status, pain duration, focal abdominal tenderness, hyperglycemia, leukocytosis, and elevated creatinine were independent predictors of the outcome. The area under the receiver operating characteristic curve of the predicted probabilities of the logistic model was 0.741. In keeping for a low-risk criterion to achieve more than 90% sensitivity, the predictive model would only achieve 18.2% specificity which was inferior to clinical gestalt for hospital admission (sensitivity 99.3%, specificity 44.3%).

Conclusion:

Risk stratification model by clinical assessment and laboratory markers alone were inadequate and inferior to clinical gestalt for identification of the group of patients requiring inpatient treatment.