Impact of a well-developed primary care system on the length of stay in emergency departments in the Netherlands: a multicenter study

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The prevalence of prescription opioid use and misuse among emergency department patients in The Netherlands

RATIONALE

Prescription opioid use and misuse have increased rapidly in many Western countries in the past decade. Patients (mis)using opioids are at risk of presenting to the emergency department (ED) with opioid-related problems. European data concerning prescription opioid (mis)use among the ED population is lacking.

AIMS AND OBJECTIVES

This study aims to determine prevalence of prescription opioid use, misuse, and opioid use disorder (OUD) among Dutch ED patients. Secondary objectives were to explore factors associated with prescription opioid misuse and the number of patients discharged with a new opioid prescription.

METHODS

In a cross-sectional multicenter study at three hospitals in the Netherlands, adult ED patients were screened for current prescription opioid use. Opioid users filled out questionnaires regarding opioid (mis)use, and underwent a structured interview to assess OUD criteria. The primary outcomes were prevalence rates of (1) current prescription opioid use, (2) prescription opioid misuse (based on a Current Opioid Misuse Measure [COMM] score > 8), (3) OUD, based on DSM-5 criteria. Independent T-tests, Pearson χ2 and Fisher's Exact tests were used to analyse differences in characteristics between groups.

RESULTS

A total of 997 patients were screened, of which 15% (n = 150) used prescription opioids. Out of 93 patients assessed, 22.6% (n = 21) showed signs of prescription opioid misuse, and 9.8% (n = 9, 95% CI: 4.5-17.8) fulfilled criteria for OUD. A medical history of psychiatric disorder was significantly more common in patients with prescription opioid misuse and OUD.

CONCLUSION

This study shows that prescription opioid use is relatively common in ED patients in the Netherlands, compared to the overall population. Over one fifth of these patients shows signs of opioid misuse or OUD. Awareness among ED personnel about the high prevalence of prescription opioid (mis)use in their population is critical for signalling opioid-related problems.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prevalence and risk factors of burden among caregivers of older emergency department patients

The number of older individuals that live independently at home is rising. These older individuals often rely on caregivers who have a similar age and health status. Therefore, caregivers may experience a high burden. We determined the prevalence and associating factors of burden among caregivers of older patients in the emergency department (ED). A cross-sectional study of primary caregivers of patients aged ≥ 70 years visiting the ED of a Dutch teaching hospital was performed. Structured interviews were conducted with patients and their caregivers. Caregiver burden was measured using the caregiver strain index (CSI). Additionally, data from questionnaires and medical records were extracted to determine potential associating factors. Univariate and multivariate regression analyses were conducted to identify independent determinants for burden. Seventy-eight caregivers (39%) experienced a high burden. Multivariate analysis showed a significant association between high caregiver burden and patients with cognitive impairment or dependency for instrumental activities of daily living (IADL) and more self-reported hours of care per day. Almost 40% of older patients in the ED have a caregiver who experiences a high burden. Formal assessment in the ED may help provide adequate care to the patients and their caregivers.

Primary care access to radiology: Characteristics of trauma patients referred to the emergency department

RATIONALE, AIMS AND OBJECTIVES

Low-urgent Emergency Department (ED) attendances are a known contributing factor to ED crowding. In the Netherlands, general practitioners (GPs) have direct access to radiology facilities during office hours. Patients with radiographically confirmed traumatic injuries are subsequently referred to the ED. We analysed these ED trauma patients' characteristics, provided treatments and ED discharge diagnoses to identify the possibility of alternative care pathways.

METHODS

Single-centre retrospective observational study of trauma patients referred to the ED by the radiology department during office hours (January 2017-December 2017). Data were obtained from patient records. Descriptive statistics were used to analyse the extracted data.

RESULTS

A total of 662 patients were included. The median age was 42 years (range: 1-100, interquartile range (IQR): 15-63) and patients presented to the ED with a median delay of 1 day (range: 0-112 days, IQR: 0-5). Most patients were referred for injuries involving the upper extremities (61.5%) and lower extremities (30%). A total of 48 additional diagnoses were made in the ED. The majority of injuries was classified as 'minor' (29.5%) or 'moderate' (68.3%) on the Abbreviated Injury Scale (AIS). The median length of stay in the ED was 65 min (range: 7-297 min, IQR: 43-102).

CONCLUSION

Most patients presented with low acuity injuries and often with a notable delay to the ED. This suggests that the majority of these patients do not necessarily need ED treatment, which may provide an opportunity to counter ED crowding.

Minor traumatic injuries in the emergency department pre- and post-implementation of an emergency care access point

OBJECTIVE

In the Netherlands, out-of-hours General Practice Cooperatives (GPCs) increasingly collaborate with Emergency Departments (EDs) to form an Emergency Care Access Point (ECAP). ECAPs aim to decrease the number of low-urgent ED attendances, of which many compromise minor traumatic injuries. In this study, we evaluated the impact of ECAP implementation on the incidence of minor traumatic injuries in the ED.

METHODS

We evaluated a total of 2772 ED patients who presented with a minor traumatic injury (categorized into traumatic wounds and isolated extremity injuries) 1 year before and 1 year after ECAP implementation. We compared patient characteristics, throughput, diagnosis, treatment and follow-up before and after ECAP implementation.

RESULTS

ECAP implementation was associated with a reduction in ED volume for minor traumatic injuries: -12.4% for isolated extremity injuries (1249 vs. 1094) and -74.6% for traumatic wounds (342 vs. 87). Multivariable logistic regression analysis controlling for patient characteristics showed that ECAP implementation was associated with higher rates of substantial injuries in the ED (OR 1.20, 95% CI = 1.01-1.43), and more patients requiring outpatient follow-up.

CONCLUSION

Implementation of an ECAP was associated with a reduction of ED utilization by patients with minor traumatic injuries, traumatic wounds in particular. This healthcare intervention may therefore help to reduce ED utilization for low-urgent complaints.

Portrait of the Emergency Department at Orotta National Referral and Teaching Hospital in Asmara, Eritrea: A Prospective Observational Study

Background

Provision of high-quality emergency care for acute, life-threatening illnesses can significantly reduce DALY and mortality in sub-Saharan Africa. Here, we present data on the profile of an Emergency Department (ED) in the largest referral hospital in Eritrea and potential gaps for intervention.

Patients and Methods

This was a prospective single-center observational study of 1093 patients who presented to the ED between September and October of 2020. Data were collected using a questionnaire from the patients’ interview, observation and medical record review. The data were summarized using descriptive statistics and where applicable logistic regressions were performed.

Results

The median age was 45.0 years among the patients. In terms of acuity, 741 (68.5%), 283 (26.2%), 48 (4.4%), 10 (0.9%) patients were triaged as green, yellow, red, and black, respectively. In addition, the number of self-referred patients was 857 (79.1%) and among all the visitors, 376 (34.9%) used Ambulance service. The median ± IQR for ED length of stay (LOS) was 2.7 (1.4–10.0) Hours. Further, 154 (14.4%) patients stayed in the ED for >24 hours. The hospitalization rate was 146 (14.7%). In the multivariate analysis, higher likelihood of prolonged ED LOS was observed in: medical department patients (aOR = 3.53, 95% CI = 2.03–6.14); patients referred from primary health-care centers (aOR = 2.63, 95% CI = 1.10–6.30) and hospital (aOR = 3.70, 95% CI = 2.15–6.37). Prolonged ED LOS was also associated with prior emergency visit (aOR = 1.96, 95% CI = 1.13–3.40); consultation (aOR = 12.27, 95% CI = 6.98–21.56); the need for inpatient admission (aOR = 2.34, 95% CI = 1.38–3.96); and the need for investigation and treatment (aOR = 2.03, 95% CI = 1.07–3.85).

Conclusion

Improvements regarding ED specialist personnel, inpatient ward capacity, availability of investigations throughout the day and night shifts, amendments in referral system, strengthening ED and critical care capacity in zonal referral hospitals, and access to quality care among the non-communicable disease patients may ameliorate most of the bottlenecks observed in this set-up.

Reduced Emergency Department Utilization During the Early Phase of the COVID-19 Pandemic: Viral Fear or Lockdown Effect?

OBJECTIVE

Since the beginning of the coronavirus disease (COVID-19) pandemic, several frontline workers have expressed their concerns about reduced emergency department (ED) utilization. We aimed to examine the changes in ED utilization during the early phase of the COVID-19 pandemic, in a country with a well-developed primary care system.

METHODS

A retrospective analysis of ED utilization was performed in 3 Dutch hospitals during a 60-day period, starting on February 15, 2020. The identical period in 2019 was used as a reference. ED visits were labeled as COVID-related (defined as COVID-19 suspected) or non-COVID-related. Admission rates were compared using chi-square tests, and the reduction in ED visits was assessed descriptively.

RESULTS

During the study period, daily ED volume was 18% lower compared to that of 2019. ED utilization further declined (-29%) during lockdown. Combined admission rates were higher in 2020 compared to those in 2019 (P < 0.001), and they were higher for COVID-19 versus non-COVID-19 ED visits (P < 0.001).

CONCLUSIONS

ED utilization was markedly reduced during the local rise of COVID-19 in a region with a well-developed primary care system and relatively low ED self-referral rates. Although it cannot directly be concluded from the findings of our study, this observation likely reflects a complex interaction between pure lockdown effects and viral fear, which warrants further research.

Effects of access to radiology in out-of-hours primary care on patient satisfaction and length of stay

BACKGROUND

Direct access to hospital radiology facilities by general practitioner (GP) cooperatives is known to decrease the number of emergency department referrals, but the effects on length of stay (LOS; time from patient arrival at GP cooperative till departure to home) and patient experiences are unclear.

OBJECTIVES

To provide insight into the LOS and experiences of trauma patients with an indication for radiology at GP cooperatives with and without access to radiology.

METHODS

A multi-methods observational study in April 2014-October 2015 at six GP cooperatives in The Netherlands, covering three organisational models for access to radiology: no direct access, limited access and unlimited access. Patient experiences were measured with a questionnaire. Patient records were analysed for background characteristics, radiology outcomes, referral and LOS.

RESULTS

In total 657 patients were included, 232 no direct access model, 307 limited access model and 118 unlimited access model. The mean LOS was 99 minutes, with a significant difference between GP cooperatives without access to radiology (121 minutes), with limited access (86 minutes), and with unlimited access (90 minutes). The differences were larger for patients without radiological abnormalities. On a ten-point scale, patients rated GP cooperatives with unlimited access to radiology higher (8.62) than those without access (8.36) or with limited access (8.39).

CONCLUSION

Access to radiology by GP cooperatives seems to reduce the length of stay and is slightly more appreciated by patients. GP cooperatives with unlimited access seem to provide the most efficient and best-valued care, contributing to more patient-centred care.

Factors associated with emergency department length of stay of internal medicine patients

Emergency Department (ED) Length Of Stay (ED-LOS) is associated with quality of care, patient safety and treatment outcome. The aim of this study is to identify factors associated with ED-LOS of internal medicine patients and provide recommendations to shorten ED-LOS. A retrospective cohort study was conducted in a single center in the Netherlands. Anonymised data of 7,380 ED attendances from January 2016 to January 2018 were analyzed. Data included time of ED arrival and departure, sex, age, source of referral, triage category, first or consecutive visit and number of radiological examinations. Univariate analyses were used. Mean ED-LOS was 220 minutes. Factors which significantly prolonged ED-LOS were older age, source of referral, triage category, need for admission, first visit, number of radiological examinations, presentation in winter or spring and time of arrival (day and evening). Several patient and circumstantial factors are associated with ED-LOS. To shorten ED-LOS, we recommend to anticipate need for admission for older patients who arrive by ambulance and to create time slots in the radiology program and to restructure the morning report.

Differences between recorded diagnoses of patients of an emergency department and office-hours primary care doctors: a register-based study in a Finnish town

To determine the extent to which it is possible to provide continuity of primary care for those who visit Emergency Departments (EDs) we studied how recorded diagnoses in primary care differ, depending on whether the patient is met in an ED or a primary care office-hours practice. In the present, 12-year follow-up study a report generator of the Electronic Health Record-system provided monthly figures for the number of different recorded diagnoses using the International Classification of Diagnoses (10^thedition, ICD-10) and the total number of ED doctors and office-hour visits to General Practitioners (GPs). The 20 most common diagnoses covered 48.1% of the visits with recorded diagnoses to the office hour GPs and 45.9% of the visits to the doctors of the ED. Of these 20 diagnoses, 10 were common in both systems. These 10 diagnoses constituted about 30% of the diagnoses given by ED doctors. Furthermore, five out of the six most common diagnoses were the same in the ED and office-hours practices. The doctors in EDs and office-hour GPs treat quite similar patient material. This may provide organisational ways to reorganise the work of primary care and to guarantee continuity of care for those who may benefit from it.

Effect of Delayed Admission to Intensive Care Units from the Emergency Department on the Mortality of Critically Ill Patients

Background: Increasing in emergency department need to critical care, the number of intensive care unit bed worldwide is inadequate to meet these applies. Objectives: The aim of this study was to investigate the effect of waiting for admission to the Intensive Care Unit (ICU) in the Emergency Department (ED) on the length of stay in the ICU and the mortality of critically ill patients. Methods: This retrospective cohort study carried out between January 2012 - 2019 patients admitted to the ICU of a training and research hospital. The data of 1297 adult patients were obtained by searching the Clinical Decision Support System. Results: The data of the patients were evaluated in two groups as those considered to be delayed and non-delayed. It was determined that the delay of two hours increased the risk of mortality 1.5 times. Hazard Ratios (HR) was 1.548 (1.077 - 2.224). Patients whose ICU admission was delayed by 5 - 6 hours were found to have the highest risk in terms of mortality (HR = 2.291 [1.503 - 3.493]). A statistically significant difference was found in the ICU mortality, 28-day and, 90-day mortality between the two groups. ICU mortality for all patients’ general was 25.2% (327/1297). This rate was 11.4% (55/481) in the non-delayed group and 33.3% (272/816) in the delayed group (P < 0.001). The 28-day mortality rate for all patients’ general was 26.9% (349/1297). This rate was found to be 13.5% (65/481) in the non-delayed group and 34.8% (284/816) in the delayed group (P < 0.001). The 90-day mortality for all patients’ general was 28.4% (368/1297). This rate was 14.1% (68/481) in the non-delayed group and 36.8% (300/816) in the delayed group (P < 0.001). Conclusions: Prolonged stay in the ED before admission to the ICU is associated with worse consequences, and increased mortality.

Emergency Department to ICU Time Is Associated With Hospital Mortality: A Registry Analysis of 14,788 Patients From Six University Hospitals in The Netherlands

Supplemental Digital Content is available in the text.

Prolonged emergency department to ICU waiting time may delay intensive care treatment, which could negatively affect patient outcomes. The aim of this study was to investigate whether emergency department to ICU time is associated with hospital mortality.

Factors affecting medical file documentation during telephone triage at an emergency call centre: a cross-sectional study of out-of-hours home visits by general practitioners in France

Background

In France, general practitioners (GPs) perform out-of-hours home visits (OOH-HVs) after physician-led telephone triage at the emergency call centre. The quality of a systematic physician-led triage has not been determined in France and may affect the efficiency of the OOH-HV process. The objectives of this study were first, to evaluate the quality of reporting in the electronic patient’s file after such triage and second, to analyse the factors associated with altered reporting.

Methods

Cross-sectional study in a French urban emergency call centre (district of Paris area) from January to December 2015. For a random selection of 30 days, data were collected from electronic medical files that ended with an OOH-HV decision. Missing key quality criteria (medical interrogation, diagnostic hypothesis or ruled-out severity criteria) were analysed by univariate then multivariate logistic regression, adjusted on patient, temporal and organizational data.

Results

Among 10,284 OOH-HVs performed in 2015, 748 medical files were selected. Reasons for the encounter were digestive tract symptoms (22%), fever (19%), ear nose and throat symptoms, and cardiovascular and respiratory problems (6% each). Medical interrogation was not reported in 2% of files (n = 16/748) and a diagnostic hypothesis in 58% (n = 432/748); ruled-out severity criteria were not reported in 60% (n = 449/748). On multivariate analysis, altered reporting was related to the work overload of triage assistants (number of incoming calls, call duration, telephone occupation rate; p < 0.03).

Conclusion

In the electronic files of patients requiring an OOH-HV by a GP in a French urban area, quality in medical reporting appeared to depend on organizational factors only, especially the triage assistants-related work factors. Corrective measures are needed to ensure good quality of triage and care.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4350-4) contains supplementary material, which is available to authorized users.

The impact of an emergency care access point on pediatric attendances at the emergency department: An observational study

OBJECTIVE

Crowding is a growing concern in general and pediatric Emergency Departments (EDs). The Emergency Care Access Point (ECAP) - a collaboration between general practitioners and the ED - has been established to reduce the number of self-referrals and non-urgent ED visits. The aim of this study was to determine the impact of an ECAP on pediatric attendances in the ED.

METHODS

Retrospective analysis of 3997 pediatric patients who visited the ED of a regional teaching hospital in the Netherlands, one year before and one year after the implementation of an ECAP. Patient characteristics, presented complaints and diagnoses, throughput times, and follow-up between the study groups were compared, both during office hours and after-hours.

RESULTS

After ECAP implementation, a 16.3% reduction in pediatric ED visits was observed. ECAP implementation was associated with a decline in self-referrals by 97.2%. Presented complaints, ED diagnoses and acuity were similar pre- and post-ECAP. However, consultations and follow-up were required more frequently. The admission rate during nights increased (49.3% versus 64.0%). Overall admission rates were similar.

CONCLUSIONS

The implementation of an ECAP was associated with a reduction of pediatric ED use, including a considerable but expected decline in pediatric self-referrals. Patient acuity pre- and post-ECAP was similar. Our results suggest that this primary care intervention might help reduce the workload in a pediatric ED. Future studies are warranted to further investigate this hypothesis and to evaluate the impact of an ECAP in other healthcare settings. These future efforts need to include patient oriented outcomes.

Effects of access to radiology in out-of-hours primary care in the Netherlands: a prospective observational study

BACKGROUND

In the Netherlands, out-of-hours primary care is provided in general-practitioner-cooperatives (GPCs). These are increasingly located on site with emergency departments (ED), forming Emergency-Care-Access-Points (ECAP). A more efficient and economical organization of out-of-hours primary emergency care could be realized by increased collaboration at an ECAP. In this study, we compared the effects of different models with respect to access to (hospital) radiology by the GPC. We investigated patient and care characteristics, indication for diagnostics and outcomes at GPCs with and without access to radiology.

METHODS

A prospective observational record review study of patients referred for conventional radiology for trauma by one of five GPCs in the period April 2014-October 2015, covering three organizational models.

RESULTS

The mean age was 31 years and 56% was female. Extremities were predominately involved (91%). There was a medical indication for radiology in 85% and the assessed risk by requesting GPs on abnormalities was high in 66%. There was a significant difference in outcomes between models. Radiological abnormalities (fractures/luxations) were present in 51% without direct access and in 35% with partial and unlimited access. Overall, 61% of the included patients were referred to the ED; 100% in the models without access and 38% in the models with (partial) access.

CONCLUSIONS

GPC access to radiology is beneficial for patients and professionals. The diagnostics were adequately used. With access to radiology, unnecessary referrals and specialist care are prevented. This may lead to a decrease in ED attendance and overcrowding.

Emergency department boarding: a descriptive analysis and measurement of impact on outcomes

OBJECTIVES

Delays in transfer of admitted patients boarded in the emergency department (ED) to an inpatient bed is a major driver of ED overcrowding. We sought to identify explanatory factors behind ED boarding as well as the impact of boarding on total inpatient length of stay (IP LOS) and inpatient mortality.

METHODS

We conducted a retrospective single-centre observational study during the period between January 1 and December 31, 2015 at a very high volume community hospital. All patients admitted from the ED to Medicine, Pediatrics, Surgery, and Critical Care were identified. The mean ED LOS and boarding time as well as patient-specific and institutional factors that were independently associated with prolonged ED LOS (≥24 hours) and prolonged boarding time (≥12 hours) were identified. Mean inpatient length of stay (IP LOS) and the odds of inpatient mortality were calculated for those patients with prolonged ED wait times.

RESULTS

There were 13,872 unique admissions during the study period. Patients admitted to the Medicine service exhibited significantly higher ED wait times than other services. Within Medicine patients, there was a statistically significant greater odds of prolonged ED wait times for patients who were older, had a greater comorbidity burden, and required more specialized inpatient care. Medicine patients with prolonged boarding times also experienced a mean of 0.9 days longer IP LOS even after adjusting for confounders.

CONCLUSION

Within our cohort, older, sicker patients and those patients requiring more resource-intensive inpatient care had the longest ED wait times. These prolonged wait times are associated with significantly increased IP LOS.

The YEARS algorithm for suspected pulmonary embolism: shorter visit time and reduced costs at the emergency department

Essentials The YEARS algorithm was designed to simplify the diagnostic workup of suspected pulmonary embolism. We compared emergency ward turnaround time of YEARS and the conventional algorithm. YEARS was associated with a significantly shorter emergency department visit time of ˜60 minutes. Treatment of pulmonary embolism was initiated 53 minutes earlier with the YEARS algorithm SUMMARY: Background Recently, the safety of the YEARS algorithm, designed to simplify the diagnostic work-up of pulmonary embolism (PE), was demonstrated. We hypothesize that by design, YEARS would be associated with a shorter diagnostic emergency department (ED) visit time due to simultaneous assessment of pre-test probability and D-dimer level and reduction in number of CT scans. Aim To investigate whether implementation of the YEARS diagnostic algorithm is associated with a shorter ED visit time compared with the conventional algorithm and to evaluate the associated cost savings. Methods We selected consecutive outpatients with suspected PE from our hospital included in the YEARS study and ADJUST-PE study. Different time-points of the diagnostic process were extracted from the to-the-minute accurate electronic patients' chart system of the ED. Further, the costs of the ED visits were estimated for both algorithms. Results All predefined diagnostic turnaround times were significantly shorter after implementation of YEARS: patients were discharged earlier from the ED; 54 min (95% CI, 37-70) for patients managed without computed tomography pulmonary angiography (CTPA) and 60 min (95% CI, 44-76) for the complete study population. Importantly, patients diagnosed with PE by CTPA received the first dose of anticoagulants 53 min (95% CI, 22-82) faster than those managed according to the conventional algorithm. Total costs were reduced by on average €123 per visit. Conclusion YEARS was shown to be associated with a shorter ED visit time compared with the conventional diagnostic algorithm, leading to faster start of treatment in the case of confirmed PE and savings on ED resources.

Does X-ray imaging by GPC at emergency care access points in the Netherlands change patient flow and reduce ED crowding? A cohort study

OBJECTIVE

Organizing out-of-hours emergency care is a challenge in many countries. In the Netherlands, general practitioner cooperatives (GPCs) and emergency departments (EDs) are increasingly working together, creating one emergency care access point (ECAP). This has redirected the majority of patients with musculoskeletal problems from the ED to the GPC in out-of-hours care, due to the treatment of self-referrals by the general practitioner (GP). Only a minority of the GPs at ECAPs have the possibility to request X-rays, and expanding these facilities could reduce patient presentations to the ED even more. The aim of our study was to explore patient flow and possible reductions in ED referrals at an ECAP with X-ray facilities for GPs.

METHODS

This retrospective cohort study examines all patients that visited an ECAP at a general city hospital in the Netherlands and had an X-ray imaging requested by the GPC between January 1, 2014 and December 31, 2014. General practitioner cooperatives could request X-rays between 5 pm and 10 pm on weekdays and between 8 am and 10 pm during weekends. Recorded data included sex, age, number and type of X-ray, X-ray abnormalities, referral to the ED, and treatment. The annual number of patients presenting to the GPC and ED in 2014 were gathered. Patient outcome was stated negative when the X-ray revealed no abnormality.

RESULTS

A total of 2243 patients received 2663 X-ray examinations. The mean age was 31 years and 48% was male. A total of 1517 (68%) patients were treated at the GPC without an ED referral, a reduction of 4.5% of the annual ED patients.

CONCLUSIONS

With a majority (68%) of the patients examined and treated at the GPC, X-ray facilities at ECAPs will substantially reduce ED population, change patient flow, and have a positive effect on ED crowding. Implementing 24/7 X-ray facilities at all ECAPs will further enhance these effects.

Patient and care characteristics of self-referrals treated by the general practitioner cooperative at emergency-care-access-points in the Netherlands

Background

In the Netherlands, out-of-hours primary care is provided in general practitioner-cooperatives (GPCs). These are increasingly located on site and in collaboration with emergency departments of hospitals (ED). At such sites, also called emergency-care-access-points (ECAP), the GPC is generally responsible for the triage and treatment of self-referrals who used to attend the ED. To evaluate the effects and safety of this novel organisation, we studied the characteristics and the quality of care given by GPCs to self-referrals at ECAPs.

Methods

Retrospective analysis (August 2011–January 2012) of 783 records of self-referred patients at three Dutch GPCs in an ECAP. This was supplemented with a retrospective analysis of patient records during a follow-up period of three-months to asses safety.

Results

Patient-characteristics: 59% was male, 46% aged between 16–45 years and 59% trauma-related. Most cases (95%) were triaged low-urgent. None received the highest urgency-category. Quality: The triage outcome was correct in 79%, underestimated in 12% and overestimated in 9%. After GP consultation 20% were referred to the ED, mostly for radio-diagnostics. Of the referrals to secondary care, 98% were according to common medical practice. Thirty percent had a follow-up contact, mostly with their own general practitioner, seldom with the ED. Complications, all non-severe, were registered in 3.2%; 0.4% were possibly preventable.

Conclusions

Self-referred patients at an ECAP are mostly trauma related, low-urgent and male patients. The majority could be treated by the GPC without subsequent referral to the ED. Care given at the GPC is reasonably efficient and safe. Triage and treatment of self-referrals by the GPC at ECAPs might offer opportunities for other countries facing problems with inappropriate emergency department visits.