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Baugh CW, Freund Y, Steg PG, Body R, Maron DJ, Yiadom MYAB. Strategies to mitigate emergency department crowding and its impact on cardiovascular patients. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:633-643. [PMID: 37163667 DOI: 10.1093/ehjacc/zuad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
Emergency department (ED) crowding is a worsening global problem caused by hospital capacity and other health system challenges. While patients across a broad spectrum of illnesses may be affected by crowding in the ED, patients with cardiovascular emergencies-such as acute coronary syndrome, malignant arrhythmias, pulmonary embolism, acute aortic syndrome, and cardiac tamponade-are particularly vulnerable. Because of crowding, patients with dangerous and time-sensitive conditions may either avoid the ED due to anticipation of extended waits, leave before their treatment is completed, or experience delays in receiving care. In this educational paper, we present the underlying causes of crowding and its impact on common cardiovascular emergencies using the input-throughput-output process framework for patient flow. In addition, we review current solutions and potential innovations to mitigate the negative effect of ED crowding on patient outcomes.
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Affiliation(s)
- Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Neville House 2nd Floor, Boston, MA 02115, USA
| | - Yonathan Freund
- Emergency Department Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Philippe Gabriel Steg
- Department of Cardiology, Université Paris-Cité, Institut Universitaire de France, FACT, French Alliance for Cardiovascular Trials, INSERM-1148, and Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
- Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Imhoff B, Marshall K, Nazir N, Pal A, Parkhurst M. Reducing time to admission in emergency department patients: a cross-functional quality improvement project. BMJ Open Qual 2022; 11:bmjoq-2022-001987. [PMID: 36122996 PMCID: PMC9486293 DOI: 10.1136/bmjoq-2022-001987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/25/2022] [Indexed: 11/15/2022] Open
Abstract
Crowding and boarding are common issues facing emergency departments (EDs) in the USA. These issues have negative effects on efficiency, patient care, satisfaction and healthcare team well-being. Data from an audit of the admissions process at a large, urban, academic US ED demonstrated a lengthy process, exceeding national benchmarks in both length of stay and boarding of admitted patients. We performed a pre–post study between July 2019 and July 2021 focused on the first step of the admission process at our institution, the time to bed request. All patients admitted to an internal medicine (IM) floor team from the ED were included in the study. The primary outcome was the time from decision to admit by the emergency medicine physician to placement of the bed request order by the IM physician. Quality improvement (QI) occurred in three phases: an initial preintervention process and electronic health record change to better capture admission times, a primary intervention focused on process change and provider education and a second intervention focused on improvements to provider communication. During the study period, 25 183 patients were admitted to IM floor teams and met inclusion criteria. Prior to the primary intervention, the mean time from ED decision to admit to IM placement of the bed request order was 75.1 min. Postintervention, the mean time decreased to 39.7 min, a statistically significant improvement of 35.4 min (p value <0.0001). This QI project demonstrates the ability of interventions to reduce the time to admission bed request order, a key step in the overall admission process and a contributor to boarding at our institution. In making process changes, the team also reduced provider handoffs and improved provider communication.
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Affiliation(s)
- Bryan Imhoff
- Department of Emergency Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Kenneth Marshall
- Department of Emergency Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Niaman Nazir
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - Aroop Pal
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Melissa Parkhurst
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
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Badr S, Nyce A, Awan T, Cortes D, Mowdawalla C, Rachoin JS. Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:5-14. [PMID: 35018125 PMCID: PMC8742612 DOI: 10.2147/oaem.s338079] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.
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Affiliation(s)
- Samer Badr
- Division of Hospital Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Andrew Nyce
- Department of Emergency Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Taha Awan
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Dennise Cortes
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Cyrus Mowdawalla
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jean-Sebastien Rachoin
- Division of Hospital Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA.,Division of Critical Care, Cooper University Health Care, Camden, NJ, USA
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Bogler O, Liu J, Cadesky B, Bell CM. Quality of care and outcomes in internal medicine patients bedspaced to noninternal medicine units. Medicine (Baltimore) 2021; 100:e25737. [PMID: 33950957 PMCID: PMC8104304 DOI: 10.1097/md.0000000000025737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/25/2021] [Indexed: 01/04/2023] Open
Abstract
Hospital overcrowding has led to a practice known as bedspacing (in which admitted patients are placed on a different specialty's inpatient ward), yet little is known about the impact of this practice on healthcare quality.We investigated whether hospital outcome measures differ between bedspaced general internal medicine (GIM) patients vs nonbedspaced patients.Our retrospective study included patients admitted to GIM wards at 2 academic hospitals (2012-2014), comparing bedspaced to nonbedspaced patients, and identifying adverse events from the hospital's Electronic Patient Record.We compared these groups with respect to actual length of stay vs the expected length of stay (% ELOS), which is defined as length of stay (LOS) divided by expected length of stay (ELOS), 30-day readmission, adverse events (falls, medication-related incidents, equipment-related incidents, first treatment related incidents, laboratory-related incidents, and operative/invasive events), and in-hospital mortality.There were 22,519 patients analyzed with 15,985 (71%) discharged from a medical ward and 6534 (29%) discharged from a non-medical ward. Bedspaced patients had shorter lengths of stay (4.1 vs 6.2 days, P < .001) and expected lengths of stay (ELOS) (6.1 vs 6.4 days, P < .001). Bedspaced patients had a lower percentage of ELOS (% ELOS) than nonbedspaced patients (70% vs 91%, P < .001), similar readmission rates (9.8 vs 10.3 events per 100 patients, P = .24), lower in-hospital mortality rates (2.6 vs 3.3 events per 100 patients, P = .003) and fewer adverse events (0.20 vs 0.60 events per 100 patient days, P < .01).Bedspacing of patients is common. Patients who are bedspaced to off-service wards have better outcomes. This may relate to preferential allocation practices.
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Affiliation(s)
- Orly Bogler
- Department of Medicine, University of Toronto
| | - Jessica Liu
- Department of Medicine, University of Toronto
- Toronto General Hospital, Division of Internal Medicine, Sinai Health Systems and University Health Network, Toronto
| | - Ben Cadesky
- Department of Medicine, Lakeridge Health, Oshawa
- Department of Medicine, Queen's University, Kingston, Ontario
| | - Chaim M. Bell
- Toronto General Hospital, Division of Internal Medicine, Sinai Health Systems and University Health Network, Toronto
- Institute for Clinical Evaluative Sciences
- Institute for Health Policy, Management, and Evaluation, University of Toronto
- Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
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Abstract
Emergency department crowding is a multifactorial issue with causes intrinsic to the emergency department and to the health care system. Understanding that the causes of emergency department crowding span this continuum allows for a more accurate analysis of its effects and a more global consideration of potential solutions. Within the emergency department, boarding of inpatients is the most appreciable effect of hospital-wide crowding, and leads to further emergency department crowding. We explore the concept of emergency department crowding, and its causes, effects, and potential strategies to overcome this problem.
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Affiliation(s)
- James F Kenny
- Milstein Adult Emergency Department, NewYork-Presbyterian Hospital, Department of Emergency Medicine, Columbia University Irving Medical Center, 622 West 168th Street, Suite VC2-260, New York, NY 10032, USA.
| | - Betty C Chang
- Milstein Adult Emergency Department, NewYork-Presbyterian Hospital, Department of Emergency Medicine, Columbia University Irving Medical Center, 622 West 168th Street, Suite VC2-260, New York, NY 10032, USA
| | - Keith C Hemmert
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Ground Floor Ravdin, Philadelphia PA 19104, USA
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Rasouli HR, Aliakbar Esfahani A, Abbasi Farajzadeh M. Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study. BMC Emerg Med 2019; 19:62. [PMID: 31666023 PMCID: PMC6822347 DOI: 10.1186/s12873-019-0275-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background Emergency Department (ED) overcrowding adversely affects patients’ health, accessibility, and quality of healthcare systems for communities. Several studies have addressed this issue. This study aimed to conduct a systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals. Methods Original research articles on crowding of emergencies at hospitals published from 1st January 2007, and 1st August 2018 were utilized. Relevant studies from the PubMed and EMBASE databases were assessed using suitable keywords. Two reviewers independently screened the titles, abstracts and the methodological validity of the records using data extraction format before their inclusion in the final review. Discussions with the senior faculty member were used to resolve any disagreements among the reviewers during the assessment phase. Results Out of the total 117 articles in the final record, we excluded 11 of them because of poor quality. Thus, this systematic review synthesized the reports of 106 original articles. Overall 14, 55 and 29 of the reviewed refer to causes, effects, and solutions of ED crowding, respectively. The review also included four articles on both causes and effects and another four on causes and solutions. Multiple individual patients and healthcare system related challenges, experiences and responses to crowding and its consequences are comprehensively synthesized. Conclusion ED overcrowding is a multi-facet issue which affects by patient-related factors and emergency service delivery. Crowding of the EDs adversely affected individual patients, healthcare delivery systems and communities. The identified issues concern organizational managers, leadership, and operational level actions to reduce crowding and improve emergency healthcare outcomes efficiently.
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Affiliation(s)
- Hamid Reza Rasouli
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
| | - Ali Aliakbar Esfahani
- Marine Medicine Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Rasouli HR, Esfahani AA, Nobakht M, Eskandari M, Mahmoodi S, Goodarzi H, Abbasi Farajzadeh M. Outcomes of Crowding in Emergency Departments; a Systematic Review. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2019; 7:e52. [PMID: 31602435 PMCID: PMC6785211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Emergency Department (ED) crowding is a global public health phenomenon affecting access and quality of care. In this study, we seek to conduct a systematic review concerning the challenges and outcomes of ED crowding. METHODS This systematic review utilized original research articles published from 1st January 2007, to 1st January 2019. Relevant articles from the PubMed (MEDLINE), EMBASE, and Google scholar databases were extracted using predesigned keywords. Following the PRISMA guidelines, two reviewers independently evaluated the quality of the studies using Critical Appraisal Skills Programme for cohort studies and qualitative studies, and Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument for studies. RESULTS Out of the total of 73 articles in the final record, we excluded 15 of them because of poor quality. This systematic review synthesized the reports of 58 original articles. The outcomes of multiple individual patients and healthcare-related challenges are comprehensively assessed. CONCLUSIONS ED crowding affects individual patients, healthcare systems and communities at large. The negative influences of crowding on healthcare service delivery result in delayed service delivery, poor quality care, and inefficiency; all negatively affecting the emergency patients' healthcare outcomes, in turn.
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Affiliation(s)
- Hamid Reza Rasouli
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Ali Aliakbar Esfahani
- Marine Medicine Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohammad Nobakht
- Marine Medicine Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohsen Eskandari
- Marine Medicine Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Sardollah Mahmoodi
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hassan Goodarzi
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohsen Abbasi Farajzadeh
- Marine Medicine Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.,Corresponding author: Mohsen Abbasi Farajzadeh; Marine Medicine Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran. E-mail: , Tel: +9888053766, Mobile: +989368507054
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Moskop JC, Geiderman JM, Marshall KD, McGreevy J, Derse AR, Bookman K, McGrath N, Iserson KV. Another Look at the Persistent Moral Problem of Emergency Department Crowding. Ann Emerg Med 2018; 74:357-364. [PMID: 30579619 DOI: 10.1016/j.annemergmed.2018.11.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/23/2018] [Accepted: 11/19/2018] [Indexed: 11/16/2022]
Abstract
This article revisits the persistent problem of crowding in US hospital emergency departments (EDs). It begins with a brief review of origins of this problem, terms used to refer to ED crowding, proposed definitions and measures of crowding, and causal factors. The article then summarizes recent studies that document adverse moral consequences of ED crowding, including poorer patient outcomes; increased medical errors; compromises in patient physical privacy, confidentiality, and communication; and provider moral distress. It describes several organizational strategies implemented to relieve crowding and implications of ED crowding for individual practitioners. The article concludes that ED crowding remains a morally significant problem and calls on emergency physicians, ED and hospital leaders, emergency medicine professional associations, and policymakers to collaborate on solutions.
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Affiliation(s)
- John C Moskop
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Joel M Geiderman
- Ruth and Harry Roman Emergency Department, Department of Emergency Medicine, and Center for Healthcare Ethics, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kenneth D Marshall
- Department of Emergency Medicine and Department of History and Philosophy of Medicine, University of Kansas Health System, Kansas City, KS
| | - Jolion McGreevy
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, and Center for Bioethics, Harvard Medical School, Boston, MA
| | - Arthur R Derse
- Center for Bioethics and Medical Humanities, Institute for Health and Society, and Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Kelly Bookman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Norine McGrath
- Department of Emergency Medicine and John J. Lynch, MD, Center for Ethics, Medstar Washington Medical Center, Washington, DC
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Tsai MH, Xirasagar S, Carroll S, Bryan CS, Gallagher PJ, Davis K, Jauch EC. Reducing High-Users' Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2018; 55:46958018763917. [PMID: 29591539 PMCID: PMC5888802 DOI: 10.1177/0046958018763917] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use-based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users' mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P < .001). Postintervention, the visit rates of new high-users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users' rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention.
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Affiliation(s)
| | | | | | | | | | - Kim Davis
- Providence Health, Columbia, SC, USA
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Wickman L, Svensson P, Djärv T. Effect of crowding on length of stay for common chief complaints in the emergency department: A STROBE cohort study. Medicine (Baltimore) 2017; 96:e8457. [PMID: 29095294 PMCID: PMC5682813 DOI: 10.1097/md.0000000000008457] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Crowding in emergency departments (EDs) is associated with long lengths of stay (LOS); however, it is not known whether the effect is equal across different chief complaints.The aim of the study was to compare the effect of crowding on LOS in the 10 most common medical or surgical chief complaints in the ED.All adult visits to a university hospital ED on weekdays between 8 AM and 9 PM in 2012 (n = 19,200) were stratified based on chief complaint and triage priority. The ED bed occupancy rate was measured and crowding was defined as an occupancy rate over one. The impact of crowding on LOS was calculated for the different groups.During crowding, LOS was longer among all chief complaints (P ≤.01) (except for high-acuity patients with wounds, where the study group was very small). During crowding, LOS increased the most among patients with extremity pain/swelling (145% among high-acuity patients, 125% among low-acuity patients) and flank pain (87% among high-acuity patients, 117% among low-acuity patients) and the least among patients with chest pain (32% among high-acuity patients, 45% among low-acuity patients) or arrhythmia (37% among high-acuity patients, 52% among low-acuity patients).The effect of ED crowding on LOS is unequal across different chief complaints. These findings could be used to improve the processing of specific chief complaints in the ED.
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Affiliation(s)
- Linnéa Wickman
- Functional Area of Emergency Medicine, Karolinska University Hospital Solna
| | - Per Svensson
- Functional Area of Emergency Medicine, Karolinska University Hospital Solna
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Therese Djärv
- Functional Area of Emergency Medicine, Karolinska University Hospital Solna
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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