International perspectives on emergency department crowding

Prolonged stay in the emergency department is an independent risk factor for hospital-acquired pressure ulcer

It is not easy to ensure optimal prevention of hospital-acquired pressure ulcer (HAPU) in crowded emergency departments (EDs). We hypothesised that a prolonged ED length of stay (LOS) is associated with an increased risk of HAPU. This is a single-centre observational study. Prospectively collected HAPU surveillance data were analysed. Adult (aged ≥20 years) patients admitted through the ED from April 1, 2013 to December 31, 2016 were included. The primary outcome was the development of HAPU within a month. Covariates included demographics, comorbidities, conditions at triage, initial laboratory results, primary ED diagnosis, critical ED interventions, and ED dispositions. The association between ED LOS and HAPU was modelled using logistic and extended Cox regression. A total of 48 641 admissions were analysed. The crude odds ratio (OR) and hazard ratio (HR) for HAPU were increased to 1.44 (95% CI, 1.20-1.72) and 1.21 (95% CI, 1.02-1.45), respectively, in ED LOS ≥24 hours relative to ED LOS <6 hours. In multivariable logistic regression, ED LOS ≥12 and ≥24 hours were associated with higher risk of HAPU, with ORs of 1.30 (95% CI, 1.05-1.60) and 1.80 (95% CI, 1.45-2.23) relative to ED LOS <6 hours, respectively. The extended Cox regression showed that the risk lasted up to a week, with HRs of 1.42 (95% CI, 1.07-1.88) and 1.92 (95% CI, 1.44-2.57) relative to ED LOS <6 hours, respectively. In conclusion, Prolonged ED LOS is independently associated with HAPU. Shorter ED LOS should be pursued as a goal in a multifaceted solution for HAPU.

[Workload in emergency departments : A Problem for personnel and patients?]

Apart from operating theaters, intensive care units and diagnostic services, the central emergency department is one of the areas of any hospital with a high workload, which is very susceptible to risk. The following aspects of routine daily work can lead to a great strain on the personnel working in the central emergency department: the need for quick, targeted decisions, especially for patients with life-threatening disorders, a high number of patients with insufficient available resources, dissatisfaction of patients with low treatment priority and longer waiting times and delayed inpatient admissions with long stays. Interruptions in the individual work process during activities are not uncommon but represent additional disruptive factors for employees and can lead to treatment errors. Furthermore, a workload that is permanently perceived as too high leads to psychological and physical disturbances for the team members. Suitable structural, organizational and personnel prerequisites as well as solution strategies for the central emergency department are necessary to avoid corresponding treatment errors and also as a duty of care for employees.

The use of a dedicated neurological triage system improves process times and resource utilization: a prospective observational study from an interdisciplinary emergency department

Background

Patients with neurological symptoms have been contributing to the increasing rates of emergency department (ED) utilization in recent years. Existing triage systems represent neurological symptoms rather crudely, neglecting subtler but relevant aspects like temporal evolution or associated symptoms. A designated neurological triage system could positively impact patient safety by identifying patients with urgent need for medical attention and prevent inadequate utilization of ED and hospital resources.

Methods

We compared basic demographic information, chief complaint/presenting symptom, door-to-doctor time and length of stay (LOS) as well as utilization of ED resources of patients presenting with neurological symptoms or complaints during a one-month period before as well as after the introduction of the Heidelberg Neurological Triage System (HEINTS) in our interdisciplinary ED. In a second step, we compared diagnostic and treatment processes for both time periods according to assigned acuity.

Results

During the two assessment periods, 299 and 300 patients were evaluated by a neurologist, respectively. While demographic features were similar for both groups, overall LOS (p < 0.001) was significantly shorter, while CT (p = 0.023), laboratory examinations (p = 0.006), ECG (p = 0.011) and consultations (p = 0.004) were performed significantly less often when assessing with HEINTS. When considering acuity, an epileptic seizure was less frequently evaluated as acute with HEINTS than in the pre-HEINTS phase (p = 0.002), while vertigo patients were significantly more often rated as acute with HEINTS (p < 0.001). In all cases rated as acute, door-to-doctor-time (DDT) decreased from 41.0 min to 17.7 min (p < 0.001), and treatment duration decreased from 304.3 min to 149.4 min (p < 0.001) after introduction of HEINTS triage.

Conclusion

A dedicated triage system for patients with neurological complaints reduces DDT, LOS and ED resource utilization, thereby improving ED diagnostic and treatment processes.

[Routine Data from Emergency Departments: Varying Documentation Standards, Billing Modalities and Data Custodians at an Identical Unit of Care]

Hintergrund Nicht nur im Kontext der Neuordnung der Notfallversorgung in Deutschland besteht derzeit ein hoher Bedarf an Daten aus Notaufnahmen. Für die Versorgungsforschung bieten sich Daten an, welche auf gesetzlicher Grundlage generiert werden. Unterschiedliche Kostenträger und Abrechnungsmodi stellen eigene Anforderungen an die Dokumentation dieser Routinedaten.

Methodische Herausforderungen Aufgrund der sektoralen Trennung gibt es keinen Datensatz oder Datenhalter, der Auskunft über alle Notaufnahmebehandlungen geben kann. Aus administrativer Sicht gilt die gesamte Notaufnahmebehandlung als ambulant oder stationär, tatsächlich wird die Entscheidung darüber erst während der Versorgung getroffen. Für die stationäre Versorgung existiert ein administratives Notfallkennzeichen, allerdings kein direktes Merkmal für Notaufnahmebehandlungen. Bei Abrechnung ambulanter Fälle über die kassenärztlichen Vereinigungen ist mindestens eine Diagnose (ICD-10-Kode) zu erfassen, versehen mit einem Kennzeichen zur Diagnosesicherheit. Es können mehrere ICD-10-Kodes ohne Hierarchie angegeben werden. Bei stationär behandelten Patienten ist eine Aufnahmediagnose und nach Behandlungsende die Hauptdiagnose und ggf. Nebendiagose(n) an die zuständige Krankenkasse zu übermitteln. Die gesetzliche Unfallversicherung hat eigene Dokumentationsanforderungen.

Lösungsansätze Je nach Forschungsfrage und Studiendesign sind unterschiedliche Vorgehensweisen erforderlich. Stammen die Daten unmittelbar aus Notaufnahmen bzw. Kliniken ist eine Information über den Kostenträger und den Abrechnungsmodus hilfreich. Bei Nutzung von Krankenkassendaten muss die Identifikation von stationär behandelten Patienten in einer Notaufnahme aktuell indirekt erfolgen. Dazu können unter anderem die Parameter Aufnahmegrund und definierte „eindeutige“ Notfall-Diagnosen herangezogen werden. Die fallpauschalenbezogene Krankenhausstatistik hat eigene Limitationen, enthält dafür aber die stationären Fälle aller Kostenträger.

Diskussion Die divergierenden Anforderungen an die administrative Dokumentation verursachen einen hohen Aufwand in den Kliniken. Perspektivisch ist eine Vereinheitlichung der Leistungserfassung und Dokumentation von Notfallbehandlungen aller Kostenarten auch zur Generierung von validen, vergleichbaren und repräsentativen Daten für die Versorgungsforschung erstrebenswert. Die Einführung eines eigenen Fachabteilungsschlüssels würde zur Identifikation von Notaufnahmebehandlungen beitragen.

Death in the Emergency Department: A Retrospective Analysis of Mortality in a Swiss University Hospital

Acute treatment in emergency medicine revolves around the management and stabilization of sick patients, followed by a transfer to the relevant medical specialist, be it outpatient or inpatient. However, when patients are too sick to be stabilized, i.e., when the care provided in the Emergency Department (ED) may not be sufficient to enable transfer, death may occur. This aspect of emergency medicine is often overlooked, and very few public data exist regarding who dies in the ED. The following retrospective analysis of the mortality figures of a Swiss university hospital from January 1st 2013 to December 31st 2016 attests to the fact that with an incidence of 2.6/1,000, death does occur in the ED. With a broad range of aetiologies, clinical severity at presentation has a high correlation with mortality, a finding that reinforces the necessity of good triage system. Our analysis goes on to show that however (in)frequent death in the ED may be, there exists a lack of advanced directives in a majority of patients (present in only 14.8% of patients during the time of study), a worrying and often challenging situation for Emergency Medicine (EM) teams faced with premorbid patients. Furthermore, a lack of such directives may hinder access to palliative care, as witnessed in part by the fact that palliative measures were only started in 16.6% of patients during the study. The authors hope this study will serve as a stepping stone to promote further research and discussion into early identification methods for patients at risk of death in the ED, as well as motivate a discussion into the integration of palliative care within the ED and EM training curriculum.

Key occupational stressors in the ED: an international comparison

Background

The ED Stressor Scale outlines 15 stressors that are of importance for ED staff. Limited research has identified how commonly such stressors occur, or whether such factors are perceived with similar importance across different hospitals. This study sought to examine the frequency or perceived severity of these 15 stressors using a multicentre cohort of emergency clinicians (nurses and physicians) in EDs in two countries (Australia and Sweden).

Method

This was a cross-sectional survey of staff working in eight hospitals in Australia and Sweden. Data were collected between July 2016 and June 2017 (depending on local site approvals) via a printed survey incorporating the 15-item ED stressor scale. The median stress score for each item and the frequency of experiencing each event was reported.

Results

Events causing most distress include heavy workload, death or sexual abuse of a child, inability to provide optimum care and workplace violence. Stressors reported most frequently include dealing with high acuity patients, heavy workload and crowding. Violence, workload, inability to provide optimal care, poor professional relations, poor professional development and dealing with high-acuity patients were reported more commonly by Australian staff. Swedish respondents reported more frequent exposure to mass casualty incidents, crisis management and administrative concerns.

Conclusions

Workload, inability to provide optimal care, workplace violence and death or sexual abuse of a child were consistently reported as the most distressing events across sites. The frequency with which these occurred differed in Australia and Sweden, likely due to differences in the healthcare systems.

An interrupted time-series analysis of the impact of emergency department reconfiguration on regional emergency department trolley numbers in Ireland from 2005 to 2015

OBJECTIVES

To understand the impact of emergency department (ED) reconfiguration on the number of patients waiting for hospital beds on trolleys in the remaining EDs in four geographical regions in Ireland using time-series analysis.

SETTING

EDs in four Irish regions; the West, North-East, South and Mid-West from 2005 to 2015.

PARTICIPANTS

All patients counted as waiting on trolleys in an ED for a hospital bed in the study hospitals from 2005 to 2015.

INTERVENTION

The system intervention was the reconfiguration of ED services, as determined by the Department of Health and Health Service Executive. The timing of these interventions varied depending on the hospital and region in question.

RESULTS

Three of the four regions studied experienced a significant change in ED trolley numbers in the 12-month post-ED reconfiguration. The trend ratio before and after the intervention for these regions was as follows: North-East incidence rate ratio (IRR) 2.85 (95% CI 2.04 to 3.99, p<0.001), South IRR 0.68 (95% CI 0.51 to 0.89, p=0.006) and the Mid-West IRR 0.03 (95% 1.03 to 2.03, p=0.03). Two of these regions, the South and the Mid-West, displayed a convergence between the observed and expected trolley numbers in the 12-month post-reconfiguration. The North-East showed a much steeper increase, one that extended beyond the 12-month period post-ED reconfiguration.

CONCLUSIONS

Findings suggest that the impacts of ED reconfiguration on regional level ED trolley trends were either non-significant or caused a short-term shock which converged on the pre-reconfiguration trend over the following 12 months. However, the North-East is identified as an exception due to increased pressures in one regional hospital, which caused a change in trend beyond the 12-month post reconfiguration.

Triage accuracy and causes of mistriage using the Korean Triage and Acuity Scale

Purpose

To identify emergency department triage accuracy using the Korean Triage and Acuity Scale (KTAS) and evaluate the causes of mistriage.

Methods

This cross-sectional retrospective study was based on 1267 systematically selected records of adult patients admitted to two emergency departments between October 2016 and September 2017. Twenty-four variables were assessed, including chief complaints, vital signs according to the initial nursing records, and clinical outcomes. Three triage experts, a certified emergency nurse, a KTAS provider and instructor, and a nurse recommended based on excellent emergency department experience and competence determined the true KTAS. Triage accuracy was evaluated by inter-rater agreement between the expert and emergency nurse KTAS scores. The comments of the experts were analyzed to evaluate the cause of triage error. An independent sample t-test was conducted to compare the number of patient visits per hour in terms of the accuracy and inaccuracy of triage.

Results

Inter-rater reliability between the emergency nurse and the true KTAS score was weighted kappa = .83 and Pearson’s r = .88 (p < .001). Of 1267 records, 186 (14.7%) showed some disagreement (under triage = 131, over triage = 55). Causes of mistriage included: error applying the numerical rating scale (n = 64) and misjudgment of the physical symptoms associated with the chief complaint (n = 47). There was no statistically significant difference in the number of patient visits per hour for accurate and inaccurate triage (t = -0.77, p = .442).

Conclusion

There was highly agreement between the KTAS scores determined by emergency nurses and those determined by experts. The main cause of mistriage was misapplication of the pain scale to the KTAS algorithm.

Do health care professionals' perceptions help to measure the degree of overcrowding in the emergency department? A pilot study in an Italian University hospital

BACKGROUND

Overcrowding in emergency departments (EDs) is internationally recognized as one of the greatest challenges to healthcare provision. Numerous studies have highlighted the ill-effects of overcrowding, including increased length of stay, mortality and cost per admission. This study measures overcrowding in EDs through health care professionals' perceptions of it, comparing the results with the NEDOCS score, an objectively validated measurement tool and describing meaningful tools and strategies used to manage ED overcrowding.

METHODS

This single-centre prospective, observational, pilot study was conducted from February 19th to March 7th, 2018 at the ED in the University Hospital of Ferrara, Italy to measure the agreement of the NEDOCS, comparing objective scores with healthcare professionals' perception of overcrowding, using the kappa statistic assessing linear weights according to Cohen's method. The tools and strategies used to manage ED overcrowding are described.

RESULTS

Seventy-two healthcare professionals (66.1% of 109 eligible subjects) were included in the analyses. The study obtained a total of 262 surveys from 23 ED physicians (31.9%), 31 nurses (43.1%) and 18 nursing assistants (25.0%) and a total of 262 NEDOCS scores. The agreement between the NEDOCS and the subjective scales was poor (k = 0.381, 95% CI 0.313-0.450).

CONCLUSIONS

The subjective health care professionals' perceptions did not provide an adequate real-time measure of the current demands and capacity of the ED. A more objective measure is needed to make quality decisions about health care professional needs and the ability to manage patients to ensure the provision of proper care.

Prediction of emergency department patient disposition decision for proactive resource allocation for admission

We investigate the capability of information from electronic health records of an emergency department (ED) to predict patient disposition decisions for reducing "boarding" delays through the proactive initiation of admission processes (e.g., inpatient bed requests, transport, etc.). We model the process of ED disposition decision prediction as a hierarchical multiclass classification while dealing with the progressive accrual of clinical information throughout the ED caregiving process. Multinomial logistic regression as well as machine learning models are built for carrying out the predictions. Utilizing results from just the first set of ED laboratory tests along with other prior information gathered for each patient (2.5 h ahead of the actual disposition decision on average), our model predicts disposition decisions with positive predictive values of 55.4%, 45.1%, 56.9%, and 47.5%, while controlling false positive rates (1.4%, 1.0%, 4.3%, and 1.4%), with AUC values of 0.97, 0.95, 0.89, and 0.84 for the four admission (minor) classes, i.e., intensive care unit (3.6% of the testing samples), telemetry unit (2.2%), general practice unit (11.9%), and observation unit (6.6%) classes, respectively. Moreover, patients destined to intensive care unit present a more drastic increment in prediction quality at triage than others. Disposition decision classification models can provide more actionable information than a binary admission vs. discharge prediction model for the proactive initiation of admission processes for ED patients. Observing the distinct trajectories of information accrual and prediction quality evolvement for ED patients destined to different types of units, proactive coordination strategies should be tailored accordingly for each destination unit.

Substituting emergency services: primary care vs. hospital care

Overcrowding in emergency departments (EDs) is inefficient, especially if it is caused by inappropriate visits for which primary care physicians could be equally effective as a hospital ED. Our paper investigates the extent to which both ambulatory ED visits and inpatient ED admissions are substitutes for primary care emergency services (PCES) in Germany. We use extensive longitudinal data and fixed effects models. Moreover, we add interaction terms to investigate the influence of various determinants on the strength of the substitution. Our results show significant substitution between PCES and ambulatory ED visits. Regarding the determinants, we find the largest substitution for younger patients. The more accessible the hospital ED is, the significantly larger the substitution. Moreover, substitution is larger among better-educated patients. For inpatient ED admission, we find significant substitution that is eight times smaller than the substitution for ambulatory ED visits. With regard to the determinants, we find the strongest substitution for non-urgent, short-stay admission and elderly patients. Countries with no gate-keeping system (such as Germany) have difficulties redirecting the patients streaming to EDs. Our estimated elasticities can help policy makers to resolve this issue, as our findings indicate where incentivizing the utilization of PCES is particularly effective.

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.

Older adults are prioritized in terms of waiting time under the emergency triage system in Guangzhou, China

AIM

To assess whether elderly patients are prioritized under the emergency triage system in Guangzhou, China.

METHODS

This was a cross-sectional survey of clinical data from adult visitors to the emergency department of the Third Affiliated Hospital of Sun Yat-sen University between 1 August 2015 and 31 December 2017. The primary end-point was receiving the first medical service within the target waiting time, which varied according to the triage level of the patient. Multivariate logistic regression was used to determine whether age was an independent predictor of a shorter waiting time.

RESULTS

Data from 262 282 emergency patients were analyzed. The mean age of patients was 35.97 years, and 7.5% were aged ≥65 years. In total, 88.3% of patients received medical service within the target waiting time, and 87.4% of elderly patients received medical service within the target waiting time. Multivariate logistic regression analysis showed that advanced age was independently associated with receiving medical service within the target waiting time (adjusted odds ratio 1.258, 95% confidence interval 1.198-1.321; P < 0.001). The triage level, type of emergency subdivision, availability of outpatient services and time of day were also associated with receiving medical service within the target waiting time.

CONCLUSION

Under the emergency triage system of the hospital, older adults are more likely to receive medical service within the target waiting time than younger patients. Geriatr Gerontol Int 2019; 19: 786-791.

Why are people increasingly attending the emergency department? A study of the French healthcare system

Objective

It is often asserted that the crowding phenomenon in emergency departments (ED) can be explained by an increase in visits considered as non-urgent. The aim of our study was to quantify the increase in ED visit rates and to determine whether this increase was explained by non-severe visit types.

Methods

This observational study covers all ED visits between 2002 and 2015 by adult inhabitants of the Midi-Pyrénées region in France. Their characteristics were collected from the emergency visit summaries. We modelled the visit rates per year using linear regression models, and an increase was considered significant when the 95% CIs did not include zero. The severity of the patients’ condition during ED visit was determined through the ‘Clinical Classification of Emergency’ score. Non-severe visits were those where the patient was stable, and the physician deemed no intervention necessary. Intermediate-severity visits concerned patients who were stable but requiring diagnostic or therapeutic procedures.

Results

The 37 studied EDs managed >7 million visits between 2002 and 2015. There was an average increase of +4.83 (95% CI 4.33 to 5.32) visits per 1000 inhabitants each year. The increase in non-severe visit types was +0.88 (95% CI 0.42 to 1.34) per 1000 inhabitants, while the increase in intermediate-severity visit types was +3.26 (95% CI 2.62 to 3.91) per 1000 inhabitants. This increase affected all age groups and all sexes.

Discussion

It appears that the increase in ED use is not based on an increase in non-severe visit types, with a greater impact of intermediate-severity visit types requiring diagnostic or therapeutic procedures in ED.

Health Promotion Practices in Nursing for Elderly Persons in Municipal Home Care: An Integrative Literature Review

Elderly patients sometimes seek emergency services unnecessarily. Emergency clinics can be detrimental to the elderly. The purpose of this study was to find health promotion practices that enable a registered nurse in community health to reduce the need for home care clients to seek emergency care. The method of integrative literature review was used. Through health promotion work in the home, the registered nurses in community health (in conjunction with other professionals) can strengthen patients’ self-esteem and reduce their emergency care visits. Patient involvement is part of this work, and the registered nurses in community health needs to get to know patients to learn their health needs, design individual care plans, and find out whether they need education about their own health and/or health care services available to them. Registered nurses in community health experience difficulties in performing health promotion because they perceive that other tasks have higher priority.

Emergency medicine in Saudi Arabia: a century of progress and a bright vision for the future

Although emergency medical services (EMS) and pre-hospital care have existed in the Kingdom of Saudi Arabia (KSA) since 1934, emergency medicine (EM) is a relatively new medical field in the country that was not formally recognized as a medical specialty until 2001. In 2005, the Saudi Board of Emergency Medicine formed to develop, implement, and evaluate a standardized curriculum for EM residents. Since then, EM and the pre-hospital system in the KSA has evolved and grown. This article provides an overview of emergency medicine in Saudi Arabia and the progress it has made in the pre-hospital system, healthcare delivery system, and emergency medicine training. Finally, we will discuss the challenges and opportunities faced as this specialty continues to develop.

Deciding whether to consult the GP or an emergency department: A qualitative study of patient reasoning in Switzerland

Background: Non-urgent care is an important factor responsible for rising healthcare costs and general practitioners (GPs) are known to be more cost-effective than emergency departments (EDs).

Objectives: To understand the reasons why patients confronted with a medical problem perceived as urgent choose to consult either a GP or an ED.

Methods: We conducted a qualitative study in Switzerland, using data collected between 2014 and 2015 through semi-structured interviews of adults with non-vital medical problems. Half were recruited after an ambulatory consultation in an ED, and half were patients who consulted their GP. The audio-recorded interviews were transcribed, coded, and analysed according to the constant comparative method.

Results: The main reason given by patients who consulted their GP first was the quality of the relationship. The more meaningful the relationship, the more likely patients were to seek advice from their GP. One marker of a privileged relationship was GPs supplying their mobile phone number to the patient. The perceived nature of the complaint, for example, symptoms considered as life-threatening or severe pain, together with the expected waiting time in an ED were additional factors influencing the patients’ choice.

Conclusion: Our study showed that when patients are confronted with what they perceive as a medical emergency, the quality of the relationship with the GP, in particular the continuity of care provided, seem to be the major reasons why they consult their GP rather than an ED.

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.

Referral pathway of patients aged 75 years and older after a telephone triage by the French emergency medical communication center (SAMU)

OBJECTIVES

To map the referral pathways of elderly people after telephone calls to Emergency Medical Communication Centers (ECC) in France.

DESIGN

Retrospective observational study.

SETTING

ECC and Emergency Departments (ED) of the Rhone region in France in 2013.

PARTICIPANTS

Patients aged 75 years and older who called or had calls made to the ECC on 7 non-consecutive days (n = 712).

MEASUREMENTS

All calls made by/for patients aged 75 and over were analyzed. Data were collected regarding geriatric assessment and patient discharge destination after admission to an ED.

RESULTS

All 4168 calls received over the 7 days were analyzed. Of these, 692 involved the care of elderly people and were included. The median call duration was 2min59 [1min57; 4min13]. Following the call, 35% of the patients remained at home, 62% were referred to ED and 3% were directly hospitalized in intensive care units. Of the patients admitted to ED, 73% had a stable clinical condition and the main reason for admission was a fall (28%). Following ED care, 56% of patients were hospitalized and 44% returned directly home.

CONCLUSION

Over half the elderly patients included in this study were referred to an ED after a call to ECC. For half of them, their clinical condition was considered stable and they were discharged after the ED visit. A more appropriate assessment of clinical conditions among geriatric patients could help to improve patient triage during ECC calls, and therefore reduce ED referrals.

Effect of triage nurse-led application of the Ottawa Ankle Rules on number of radiographic tests and length of stay in selected emergency departments in Oman

AIM

Ankle injuries are commonly seen in the emergency department (ED) and contribute to overcrowding. In Oman, injuries are a leading cause of years of life lost, disability-adjusted life years, and pose a burden to the healthcare system. This study aimed to evaluate the effectiveness of ED triage nurse-led application of the Ottawa Ankle Rules (OARs) toward improving the healthcare outcomes of ankle injury patients.

METHODS

A quasi-experimental design was used to collect data (demographic characteristics, waiting time, length of stay, and number of radiographic tests) from 96 patients. The intervention group (n = 46) received ED triage nurse-led assessment and initiation of radiographic tests based on the OARs. The control group (n = 50) received usual care.

RESULTS

The participants' mean age was 26.4 ± 7.90 years. The main causes of ankle injuries were football (36%), falls (31%) and twisting while walking (24%). There was a significant difference in number of ankle X-rays (t = 6.19; p < .001); length of stay (U = 549; p < .001); and waiting time (U = 167; p < .001) between the control and intervention group. The intervention reduced the mean waiting time and length of stay by 25.09 and 41.01 min, respectively.

CONCLUSION

Application of the OARs by the ED triage nurse can decrease the number of unnecessary radiographic tests, waiting time and length of stay in the ED. Nurses' utilization of evidence-based clinical decision-making tools can improve ED care outcomes of common acute conditions such as ankle injuries.

The disease spectrum of adult patients at a tertiary care center emergency department in Lebanon

OBJECTIVE

There is an increase in Emergency Department (ED) utilization globally. Understanding what patients present to EDs with is important for resource allocation, training and staffing purposes. There is paucity of data pertaining to ED visit presentations in Lebanon. This study aims at describing the spectrum of diseases among adult patients who present to a tertiary care center in Lebanon, an upper-middle income country (UMIC).

METHODS

A retrospective chart review of adult patients (age ≥ 19) presenting to a tertiary care hospital ED during 2010-2011 was completed. Common diagnoses in three categories (all adult visits, treat and release, admitted visits) were assessed. Diagnoses were classified according to the Clinical Classifications Software. Descriptive statistics were presented in tables as frequencies and percentages.

RESULTS

During the study period, 32787 adults presented to the ED with 18.7% resulting in hospital admission. The most common diagnoses in ED patients were injuries and conditions due to external causes, abdominal pain, non-specific chest pain and intestinal infections. In the treat and release group, intestinal infections emerged in the common list for ages 19-44. Coronary atherosclerosis was common in admitted patients aged ≥45 years. Summer was the busiest season, with abdominal pain and intestinal infection being prominent diagnoses during that season.

CONCLUSIONS

This study is the first to assess adult ED visits in a Lebanese setting. Our study suggests that patients in our population suffer from the double burden of both communicable and non-communicable disease, with coronary atherosclerosis common in admitted patients (≥ 45 years) and intestinal infections common in treat and release adult patients (19-44years), the latter condition peaking in summer and driving seasonal surges in ED visits.

Repeat Emergency Department Visits for Individuals With Intellectual and Developmental Disabilities and Psychiatric Disorders

Although individuals with intellectual and developmental disabilities (IDD) and psychiatric concerns are more likely than others to visit hospital emergency departments (EDs), the frequency of their returns to the ED within a short time is unknown. In this population-based study we examined the likelihood of this group returning to the ED within 30 days of discharge and described these visits for individuals with IDD + psychiatric disorders (n = 3,275), and persons with IDD only (n = 1,944) compared to persons with psychiatric disorders only (n = 41,532). Individuals with IDD + psychiatric disorders, and individuals with IDD alone were more likely to make 30-day repeat ED visits. Improving hospital care and postdischarge community linkages may reduce 30-day returns to the ED among adults with IDD.

Association entre mortalité et attente aux urgences chez les adultes à hospitaliser pour étiologies médicales

Introduction : Notre objectif principal est de comparer, dans un centre hospitalier universitaire (CHU) français et chez les patients hospitalisés pour étiologies médicales à partir de la structure des urgences (SU), le taux de mortalité intrahospitalière entre ceux qui n’attendent pas faute de place en service et ceux en attente (boarding).

Méthode : Il s’agit d’une étude quasi expérimentale, monocentrique, observationnelle, rétrospective, par recueil d’informations à partir des dossiers patients informatisés. Nous avons appliqué un score de propension pour ajuster les critères de jugement aux variables mesurées dans les deux groupes, c’est-à-dire les données : 1) démographiques (âge et sexe) ; 2) médicales (niveau de triage) ; 3) biologiques (numération leucocytaire, hémoglobinémie, natrémie, kaliémie, taux sérique de CRP, créatininémie) ; 4) d’imageries (réalisation ou non de radiographie, d’échographie, d’imagerie par résonance magnétique, de tomodensitométrie).

Résultats : En 2017, la SU du CHU a admis 60 062 patients adultes. Sur les 15 496 patients hospitalisés après admission en SU, 6 997 l’ont été pour une étiologie médicale, dont 2 546 (36 %) sans attente et 4 451 (64 %) après une attente. Après pondération, le taux de mortalité intrahospitalière était plus important dans le groupe en attente : 7,8 vs 6,3 % ; p < 0,05. De même, la durée médiane d’hospitalisation était plus importante dans le groupe en attente : 7,6 [4,7– 12,0] vs 7,1 j [4,3–11,5] ; p < 0,01.

Discussion : Les taux de mortalité et de la durée de séjour intrahospitaliers sont plus importants chez les patients étudiés qui attendent en SU faute de place en service. Nos résultats sont concordants avec la littérature internationale. Il est nécessaire de trouver des solutions pour réduire cette surmortalité.

Interventions to improve emergency department use for mental health reasons: protocol for a mixed-methods systematic review

BACKGROUND

Healthcare resources are limited and unnecessary, and inappropriate emergency department use is now a highly visible healthcare priority. Individuals visiting the emergency department for mental health-related reasons are often amongst the most frequent presenters. In response, researchers and clinicians have created interventions to streamline emergency department use and several primary studies describe the effects of these interventions. Yet, no consensus exists on the optimal approach, and information on the quality of development, effectiveness, acceptability, and economic considerations is hard to find. The purpose of this study is to systematically review interventions designed to improve appropriate use of the emergency department for mental health reasons.

METHOD

A mixed-method systematic review using Joanna Briggs Methodology. Search combining electronic databases (EMBASE, MEDLINE, PsycINFO, CINAHL, HealthSTAR, PROQUEST, Cumulative Index to Nursing and Allied Health) and secondary searches (grey literature and hand search with consultation). Two independent reviewers will screen titles and abstracts using predetermined eligibility criteria and a third reviewer will resolve conflicts. Full texts will also be screened by two independent reviews and conflicts resolved in a consensus meeting with a third reviewer. A pilot-tested data extraction form will be used to retrieve data relevant to the study objectives. We will assess the quality and of all included studies. Data describing interventions will be summarized using logic models and reported narratively. Quality of development will be assessed using the Oxford Implementation Index. For data on intervention effectiveness, we will assess statistical heterogeneity and conduct a meta-analysis using a random effects method, if appropriate. For interventions that cannot be pooled, we will report outcomes narratively and descriptively. Qualitative data on acceptability will be synthesized using meta-aggregation and an economic evaluation of interventions will be done. The reporting of this protocol follows the PRISMA-P statement.

DISCUSSION

Using a combined systematic review methodology and integrated knowledge translation plan, the project will provide decision makers with concrete evidence to support the implementation and evaluation of interventions to improve emergency department use for mental health reasons. These interventions reflect widespread priorities in the area of mental health care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018087430.

How to decide adequately? Qualitative study of GPs' view on decision-making in self-referred and physician-referred emergency department consultations in Berlin, Germany

OBJECTIVES

Patients with acute symptoms present not only to general practitioners (GPs), but also frequently to emergency departments (EDs). Patients' decision processes leading up to an ED self-referral are complex and supposed to result from a multitude of determinants. While they are key providers in primary care, little is known about GPs' perception of such patients. This qualitative study explores the GPs' view regarding motives and competences of patients self-referring to EDs, and also GPs' rationale for or against physician-initiated ED referrals.

DESIGN

Qualitative study with semi-structured, face-to-face interviews; qualitative content analysis.

SETTING

GP practices in Berlin, Germany.

PARTICIPANTS

15 GPs (female/male: 9/6; mean age 53.6 years).

RESULTS

The interviewed GPs related a wide spectrum of factors potentially influencing their patients' decision to visit an ED, and also their own decision-making in potential referrals. Considerations go beyond medical urgency. Statements concerning patients' surmised rationale corresponded to GPs' reasoning in a variety of important areas. For one thing, the timely availability of an extended spectrum of diagnostic and therapeutic options may make ED services attractive to both. Access difficulties in the ambulatory setting were mentioned as additional triggers for an ED visit initiated by a patient or a GP. Key patient factors like severity of symptoms and anxiety also play a major role; a desire for reassurance may lead to both self-referred and physician-initiated ED visits. Patients' health competence was prevailingly depicted as limited, with the internet as an important influencing factor. Counselling efforts by GP were described as crucial for improving health literacy.

CONCLUSIONS

Health education could hold promise when aiming to reduce non-urgent ED consultations. Primary care providers are in a key position here. Amelioration of organisational shortages in ambulatory care, for example, limited consultation hours, might also make an important impact, as these trigger both self-referrals and GP-initiated ED referrals.

TRIAL REGISTRATION NUMBER

DRKS00011930.

Global, regional and national burden of emergency medical diseases using specific emergency disease indicators: analysis of the 2015 Global Burden of Disease Study

Objective

There are currently no metrics for measuring population-level burden of emergency medical diseases (EMDs). This study presents an analysis of the burden of EMDs using two metrics: the emergency disease mortality rate (EDMR) and the emergency disease burden (EDB) per 1000 population at the national, regional and global levels.

Methods

We used the 1990 and 2015 Global Burden of Disease Study for morbidity and mortality data on 249 medical conditions in 195 countries. Thirty-one diseases were classified as 'emergency medical diseases' based on earlier published work. We developed two indicators, one focused on mortality (EDMR) and the other on burden (EDB). We compared the EDMR and EDB across countries, regions and income groups and compared these metrics from 1990 to 2015.

Results

In 2015, globally, there were 28.3 million deaths due to EMDs. EMDs contributed to 50.7% of mortality and 41.5% of all burden of diseases. The EDB in low-income countries is 4.4 times that of high-income countries. The EDB in the African region is 273 disability-adjusted life years (DALYs) per 1000 compared with 100 DALYs per 1000 in the European region. There has been a 6% increase in overall mortality due to EMDs from 1990 to 2015. Globally, injuries (22%), ischaemic heart disease (17%), lower respiratory infections (11%) and haemorrhagic strokes (7%) made up about 60% of EMDs in 2015.

Conclusion

Globally, EMDs contributed to more than half of all years of life lost. There is a significant disparity between the EDMR and EDB between regions and socioeconomic groups at the global level.

Uncompleted Emergency Department Care (UEDC): a 5-year population-based study in the Veneto Region, Italy

Introduction

Uncompleted visits to emergency departments (UEDC) are a patient safety concern. The purpose of this study was to investigate risk factors for UEDC, describing not only the sociodemographic characteristics of patients who left against medical advice (AMA) and those who left without being seen (LWBS), but also the characteristics of their access to the emergency department (ED) and of the hospital structure.

Methods

This was a cross sectional study on anonymized administrative data in a population-based ED database.

Results

A total of 9,147,415 patients attended EDs in the Veneto Region from 2011 to 2015. The UEDC rate was 28.7‰, with a slightly higher rate of AMA than of LWBS (15.3‰ vs 13.4‰). Age, sex, citizenship, and residence were sociodemographic factors associated with UEDC, and so were certain characteristics of access, such as mode of admission, type of referral, emergency level, waiting time before being seen, and type of medical issue (trauma or other). Some characteristics of the hospital structure, such as the type of hospital and the volume of patients managed, could also be associated with UEDC.

Conclusion

Cases of UEDC, which may involve patients who leave AMA and those who LWBS, differ considerably from other cases managed at the ED. The present findings are important for the purpose of planning and staffing health services. Decision-makers should identify and target the factors associated with UEDC to minimize walkouts from public hospital EDs.

Association of sudden in-hospital cardiac arrest with emergency department crowding

BACKGROUND

In Taiwan, emergency department (ED) crowding is inevitable; many studies have investigated the various negative effects of ER crowding on patients. In general, ED crowding reduces patient satisfaction, delays treatment, and increases mortality. However, most studies have focused on the relationship between ED crowding and delay mortality rather than sudden mortality. This study investigates the association of ED crowding with sudden unexpected in-hospital cardiac arrest (IHCA).

METHODS

The retrospective observational study recruited patients with sudden IHCA in an ED from February 2016 to September 2017. Exclusion criteria included (1) out-of-hospital cardiac arrest, (2) patient with signed do-not-resuscitate consent, (3) pediatric patient, and (4) trauma patient. ED crowding parameters, including ED bed occupancy rates (EDBORs), number of boarding patients, and patients with boarding time to general ward or intensive care unit of >24 and >48 h, all were recorded every 2 h.

RESULTS

Significant increments were noted in IHCA incidence when EDBOR was >260%, with a rate ratio of 1.50 (95% confidence interval [CI], 1.03-2.17). However, the number of boarding patients was not associated with IHCA incidence (P > 0.05). Prolonged boarding time to general ward and ICU of >24 and >48 h both increased the IHCA incidence.

CONCLUSION

This first study investigating the relationship between ED crowding and sudden IHCA found EDBORs and prolonged boarding to general wards or ICUs were associated with increased sudden IHCA incidence.

Cross-sectional study in an out-of-hours primary care centre in northwestern Germany - patient characteristics and the urgency of their treatment

Background

Due to the increasing number of non-urgent visits to emergency departments, it is becoming increasingly important to also investigate emergency care in out-of-hours (OOH) primary care. The aim of this study was to provide an insight into the care structures of an OOH primary care centre, to evaluate the reasons for encounter (RFE) and to assess the urgency of the treatment from the physicians´ point of view.

Methods

In the summer of 2017, we conducted a cross-sectional study over four weeks in the OOH primary care centre of Oldenburg, a city in Lower Saxony with about 160,000 inhabitants. We collected socio-demographic data, RFE and the duration of the complaints. The International Classification for Primary Care 2nd Edition (ICPC-2) was used to categorize symptoms. The attending physicians supplemented information on further treatment (including hospitalization) and the urgency of consultation in the OOH primary care centre.

Results

A total of 892 of the 1098 OOH patients which were visiting the OOH primary care centre took part in the study (participation: 81.2%). More than half of the patients were between 18 and 39 years old. A quarter of all RFE named by study participants were in the ICPC-2 category “skin”. More than 60% of patients had the symptoms for more than two days before visiting the OOH primary care centre. In 34.5% of all cases no medication was prescribed and one in six patients received further diagnostic tests such as urinalysis and blood tests (15.8%). From the physicians’ point of view, 26.3% of all study participants could have been treated by the family doctor during the regular consultation hours.

Conclusion

The study shows that in the OOH primary care centre about a quarter of all patients could have waited until regular consultation hours. Mostly young patients used the easily accessible and free care in the OOH primary care centre. Further studies are necessary to better understand the individual reasons of patients to use the OOH primary care centre.

Real-time estimation of inpatient beds required in emergency departments

BACKGROUND

Long boarding time in emergency department (ED) leads to increased morbidity and mortality. Prediction of admissions upon triage could improve ED care efficiency and decrease boarding time.

OBJECTIVE

To develop a real-time automated model (MA) to predict admissions upon triage and compare this model with triage nurse prediction (TNP).

PATIENTS AND METHODS

A cross-sectional study was conducted in four EDs during 1 month. MA used only variables available upon triage and included in the national French Electronic Emergency Department Abstract. For each patient, the triage nurse assessed the hospitalization risk on a 10-point Likert scale. Performances of MA and TNP were compared using the area under the receiver operating characteristic curves, the accuracy, and the daily and hourly mean difference between predicted and observed number of admission.

RESULTS

A total of 11 653 patients visited the EDs, and 19.5-24.7% were admitted according to the emergency. The area under the curves (AUCs) of TNP [0.815 (0.805-0.826)] and MA [0.815 (0.805-0.825)] were similar. Across EDs, the AUCs of TNP were significantly different (P < 0.001) in all EDs, whereas AUCs of MA were all similar (P>0.2). Originally, using daily and hourly aggregated data, the percentage of errors concerning the number of predicted admission were 8.7 and 34.4%, respectively, for MA and 9.9 and 35.4%, respectively, for TNP.

CONCLUSION

A simple model using variables available in all EDs in France performed well to predict admission upon triage. However, when analyzed at an hourly level, it overestimated the number of inpatient beds needed by a third. More research is needed to define adequate use of these models.

International migrants' use of emergency departments in Europe compared with non-migrants' use: a systematic review

Background

International migration across Europe is increasing. High rates of net migration may be expected to increase pressure on healthcare services, including emergency services. However, the extent to which immigration creates additional pressure on emergency departments (EDs) is widely debated. This review synthesizes the evidence relating to international migrants' use of EDs in European Economic Area (EEA) countries as compared with that of non-migrants.

Methods

MEDLINE, EMBASE, CINAHL, The Cochrane Library and The Web of Science were searched for the years 2000-16. Studies reporting on ED service utilization by international immigrants, as compared with non-migrants, were eligible for inclusion. Included studies were restricted to those conducted in EEA countries and English language publications only.

Results

Twenty-two articles (from six host countries) were included. Thirteen of 18 articles reported higher volume of ED service use by immigrants, or some immigrant sub-groups. Migrants were seen to be significantly more likely to present to the ED during unsocial hours and more likely than non-migrants to use the ED for low-acuity presentations. Differences in presenting conditions were seen in 4/7 articles; notably a higher rate of obstetric and gynaecology presentations among migrant women.

Conclusions

The principal finding of this review is that migrants utilize the ED more, and differently, to the native populations in EEA countries. The higher use of the ED for low-acuity presentations and the use of the ED during unsocial hours suggest that barriers to primary healthcare may be driving the higher use of these emergency services although further research is needed.

Mortality Associated With Emergency Department Boarding Exposure: Are There Differences Between Patients Admitted to ICU and Non-ICU Settings?

BACKGROUND

Emergency Department (ED) boarding threatens patient safety. It is unclear whether boarding differentially affects patients admitted to intensive care units (ICUs) versus non-ICU settings.

RESEARCH DESIGN AND SUBJECTS

We performed a 2-hospital, 18-month, cross-sectional, observational, descriptive study of adult patients admitted from the ED. We used Kaplan-Meier estimation and Cox Proportional Hazards regression to describe differences in boarding time among patients who died during hospitalization versus those who survived, controlling for covariates that could affect mortality risk or boarding exposure, and separately evaluating patients admitted to ICUs versus non-ICU settings.

MEASURES

We extracted age, race, sex, time variables, admission unit, hospital disposition, and Elixhauser comorbidity measures and calculated boarding time for each admitted patient.

RESULTS

Among 39,781 admissions from the EDs (21.3% to ICUs), non-ICU patients who died in-hospital had a 1.2-fold risk (95% confidence interval, 1.03-1.36; P=0.016) of having experienced longer boarding times than survivors, accounting for covariates. We did not observe a difference among patients admitted to ICUs.

CONCLUSIONS

Among non-ICU patients, those who died during hospitalization were more likely to have had incrementally longer boarding exposure than those who survived. This difference was not observed for ICU patients. Boarding risk mitigation strategies focused on ICU patients may have accounted for this difference, but we caution against interpreting that boarding can be safe. Segmentation by patients admitted to ICU versus non-ICU settings in boarding research may be valuable in ensuring that the safety of both groups is considered in hospital flow and boarding care improvements.

Assessing quality indicators related to mental health emergency room utilization

Background

This descriptive study compared 2014–15 to 2005–06 data on the quality of mental health services (MHS) in relation to emergency room (ER) use to assess the impact of the 2005 Quebec MH reform regarding access, continuity and appropriateness of care for patients with mental illnesses (PMI).

Methods

Data emanated from the Quebec Integrated Chronic Disease Surveillance System (Quebec/Canada). Participants (865,255 for 2014–15; 817,395 for 2005–06) were age 12 or over, with at least one MI, including substance use disorders (SUD), diagnosed during an ER visit, outpatient treatment or hospitalization. Variables included: access (ER use/frequency, hospitalization rates, outpatient consultations preceding an ER visit), care continuity (outpatient consultations following an ER visit/hospitalization, consecutive returns to the ERs), and care appropriateness (high ER use, recurrence of yearly ER visits, length of hospitalization). Frequency distributions were calculated on sex, age and geographic area for ER visits/hospitalizations in 2014–15, and between 2014 and 15 and 2005–06.

Results

PMI accounted for 12 % of the Quebec population in 2014–15 (n = 865,255), of whom 39% visited an ER for any reason. Amount and frequency of ER use and number/length of hospitalizations were almost twice as high for PMI versus patients without MI; 17% of PMI were also high/very high ER users and were frequently hospitalized. Among PMI, ER users were also frequent users of outpatient services despite a lack of follow-up appointments after ER visits or hospitalizations. Findings revealed some positive changes over time, such as decreased ER and hospitalization rates; yet overall access, continuity and appropriateness of care, as measured in this study, remained low.

Conclusions

This study demonstrated that the Quebec reform did not produce a substantial impact on ER use or substantially improved care, as hypothesized. Better access and continuity of care should be promoted to reduce the high prevalence of ER use among PMI. Quality improvement in MHS may be realized if ERs are supported by substantial and well-integrated community MH networks.

Procedural sedation and analgesia in the emergency department in Japan: interim analysis of multicenter prospective observational study

PURPOSE

Procedural sedation and analgesia (PSA) is widely performed outside of the operating theater, often in emergency departments (EDs). The practice and safety of PSA in the ED in an aging society such as in Japan have not been well described. We aimed to characterize the practice pattern of PSA including indications, pharmacology and incidence of adverse events (AEs) in Japan.

METHODS

We formed the Japanese Procedural Sedation and Analgesia Registry, a multicenter prospective observation registry of ED patients undergoing PSA. We included all patients who received PSA in the ED. PSA was defined as any systemic pharmacological intervention intended to facilitate a painful or uncomfortable procedure. The main variables in this study were patients' demographics, American Society of Anesthesiologists (ASA) physical status, indication of PSA, medication choices, and AEs. The primary outcome measure was overall AEs from PSA.

RESULTS

We enrolled 332 patients in four EDs during the 12-month period. The median age was 67 years (IQR, 46-78). In terms of ASA physical status, 79 (23.8%), 172 (51.8%), and 81 (24.4%) patients were class 1, 2, 3 or higher, respectively. The most common indication was cardioversion (44.0%). The most common sedative used was thiopental (38.9%), followed by midazolam (34.0%) and propofol (19.6%). Among all patients, 72 (21.7%, 95% confidence interval, 17-26) patients experienced one or more AEs. The most common AE was hypoxia (9.9%), followed by apnea (7.2%) and hypotension (3.5%). All of the AEs were transient and no patient had a serious AE.

CONCLUSION

In a multicenter prospective registry in Japan, PSA in the ED appears safe particularly since the patients who underwent PSA were older and had a higher risk profile compared to patients in previous studies in different countries.

Determinants of antibiotic prescribing for upper respiratory tract infections in an emergency department with good primary care access: a qualitative analysis

Upper respiratory tract infections (URTIs) account for substantial attendances at emergency departments (EDs). There is a need to elucidate determinants of antibiotic prescribing in time-strapped EDs - popular choices for primary care despite highly accessible primary care clinics. Semi-structured in-depth interviews were conducted with purposively sampled physicians (n = 9) in an adult ED in Singapore. All interviews were analysed using thematic analysis and further interpreted using the Social Ecological Model to explain prescribing determinants. Themes included: (1) reliance on clinical knowledge and judgement, (2) patient-related factors, (3) patient-physician relationship factors, (4) perceived practice norms, (5) policies and treatment guidelines and (6) patient education and awareness. The physicians relied strongly on their clinical knowledge and judgement in managing URTI cases and seldom interfered with their peers' clinical decisions. Despite departmental norms of not prescribing antibiotics for URTIs, physicians would prescribe antibiotics when faced with uncertainty in patients' diagnoses, treating immunocompromised or older patients with comorbidities, and for patients demanding antibiotics, especially under time constraints. Participants had a preference for antibiotic prescribing guidelines based on local epidemiology, but viewed hospital policies on prescribing as a hindrance to clinical judgement. Participants highlighted the need for more public education and awareness on the appropriate use of antibiotics and management of URTIs. Organisational practice norms strongly influenced antibiotic prescribing decisions by physicians, who can be swayed by time pressures and patient demands. Clinical decision support tools, hospital guidelines and patient education targeting at individual, interpersonal and community levels could reduce unnecessary antibiotic use.

Characteristics of ED crowding in the Lazio Region (Italy) and short-term health outcomes

The effect of emergency department (ED) crowding on patient care has been studied for several years in the scientific literature. We evaluate the association between ED crowding and short-term mortality and hospitalization in the Lazio region (Italy) using two different measures. A cohort of visits in the Lazio region ED during 2012-2014 was enrolled. Only discharged patients were selected. ED crowding was estimated using two measures, length of stay (LOS), and Emergency Department volume (EDV). LOS was defined as the interval of time from entrance to discharge; EDV was defined at the time of each new entrance in ED. The outcomes under study were mortality and hospitalization within 7 days from ED discharge. A multivariate logistic model was performed (Odds Ratios, ORs, 95% CI). The cohort includes 2,344,572 visits. ED crowding is associated with an increased risk of short-term hospitalization using both LOS and EDV as exposures (LOS 1-2 h: OR = 1.71, 95% CI 1.66-1.76, LOS 2-5 h: OR = 1.38, 95% CI 1.34-1.43, LOS > 5 h OR = 1.45 95% CI 1.40-1.50 compared to patients with 1 h of LOS; EDV 75°-95° percentile: OR = 1.02, 95% CI 0.99-1.05 and EDV > 95° percentile: OR = 1.06, 95% CI 1.01-1.11 compared to patients with a EDV < 75° percentile upon arrival). Increased risk of short-term mortality is found with increasing level of LOS. High levels of EDV at the time of patients' arrival and longer LOS in ED are associated with greater risks of hospitalization for patients discharged 7 days before. LOS in ED is also associated with an increased risk of mortality.

Factors and outcomes associated with paediatric emergency department arrival patterns through the day

Introduction

Steadily increasing emergency department (ED) utilization has prompted efforts to increase resource allocation to meet demand. Little is known about the distribution and characteristics of patient arrivals by time of day. This study describes the variability and patterns of ED resource utilization related to patient, acuity, clinical, and disposition characteristics over a 24-hour period.

Methods

Retrospective cross-sectional study of all visits to a tertiary children's hospital over a 1-year period. We use descriptive statistics to present ED visit details stratified by shift of arrival, and multivariable regression to explore the association between shift of presentation and hospital admission at index and 7-day return ED visits.

Results

Of 46,942 visits during the study period, 12% arrived overnight, 42% during the day, and 45% during the evening with variability in pattern of shift arrival by day of week. Overnight arrivals had a higher acuity (Canadian Triage and Acuity Scale [CTAS]) and different presenting complaints (more viral infection, less minor trauma) than day and evening arrivals, but similar ED length of stay. Shift of arrival was not associated with admission to hospital, but age, gender, socioeconomic status (SES), and day of week were.

Discussion

ED utilization patterns vary by shift of arrival. Though overnight arrivals represent a smaller proportion of total daily arrivals, their acuity is higher, and the spectrum of disease differs from day or evening arrivals.

Conclusions

Understanding variations and patterns of ED utilization by shift of arrival and day of week may be helpful in tailoring resource allocation to more accurately and specifically meet demands.

Influence of social characteristics on use of paediatric emergency care in Sweden - a questionnaire based study

Background

Parental social characteristics influence the use of emergency departments (ED) in the USA, but less is known about paediatric ED care-seeking in countries with national health insurance. This prospective study was designed to evaluate associations between parental care-seeking and social characteristics, with emphasis on impact of non-native origin, at a paediatric ED in Sweden, a European country providing paediatric healthcare free of charge.

Methods

Parents attending a paediatric ED at a large urban university hospital filled out a questionnaire on social characteristics and reasons for care-seeking. Information on patient characteristics and initial management was obtained from ED registers and patient records. Paediatric ED physicians assessed the medical appropriateness of each patient visit triaged for ED care.

Results

In total, 962 patient visits were included. Telephone healthline service before the paediatric ED visit was less often used by non-native parents (63/345 vs. 249/544, p < 0.001). Low-aquity visits, triaged away from the ED, were more common among non-native parents (80/368 vs. 67/555, OR = 1.66; p = 0.018), and among those reporting lower abilities in the Swedish language (23/82 vs. 120/837, OR = 2.66; p = 0.003). Children of non-native parents were more often assessed by physicians not to require ED care (122/335 vs. 261/512, OR = 0.70; p = 0.028).

Conclusions

This study confirms more direct and less urgent use of paediatric ED care by parents of non-native origin or with limited abilities in the Swedish language, proposing that parental social characteristics influence paediatric ED care-seeking, also in a country with healthcare free of charge, and that specific needs of these groups should be better met by prehospital medical services.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0210-5) contains supplementary material, which is available to authorized users.

Another Look at the Persistent Moral Problem of Emergency Department Crowding

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.

Admission rates in emergency departments in Geneva during tennis broadcasting: a retrospective study

Background

Literature provides mixed results regarding the influence of large-scale sporting events on emergency department attendance. To contribute to the research on the subject, we sought to evaluate whether the broadcasting of major tennis tournaments, one of the most popular sports in Switzerland, has an impact on patient admission rates in emergency units in Geneva including 1) type of match 2) the role of a Swiss player, 3) degree of triage, 4) reason of attendance and 5) age of patients.

Methods

Admission rates between periods with tennis matches regarding the semi-finals and finals of 3 major tennis tournaments were compared to equivalent periods without matches from May 2013 to August 2017. Patient admission data was retrieved retrospectively from administrative databases of two Outpatient Emergency Units in Geneva. Patients’ admission rates in periods with and without a tennis match were investigated using a negative binomial regression model with mixed effects.

Results

We observed a statistically significant decrease (− 10%, 95% CI -17 to − 2, p = 0.015) in admission rates in periods with a tennis match compared to periods without a tennis match, more pronounced during finals (− 15%, 95% CI -26 to − 3, p = 0.017) than during semi-finals (− 7%, − 16 to 2, p = 0.13). In addition, this effect was more pronounced in patients aged between 26 to 64 years of age, a category representing professionnally active people. No modification in the admission rates was detected in the hours preceding and following the matches, nor in type of consultations (traumatology vs non traumatology related admissions).

Conclusion

Although modest, the results support the hypothesis that the broadcasting of large-scale sporting events such as tennis matches decreases admission rates in emergency units. Further research is required to explore for a potential causal relationship.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0209-y) contains supplementary material, which is available to authorized users.

The impact of Australian healthcare reforms on emergency department time-based process outcomes: An interrupted time series study

Background

In 2011, the Australian government introduced national healthcare reforms aimed at increasing the timeliness and quality of hospital care. The healthcare reforms included, but were not limited to, emergency department (ED) time-based targets, financial incentives, and public performance reporting of hospital data. We sought to evaluate the impact of the national healthcare reforms on ED time-based process outcomes.

Methods

A quasi-experimental study of ED presentations from 2006 to 2016 in the state of Victoria, Australia. Uncontrolled, interrupted time-series analyses were used to evaluate, by hospital peer groups, the effect of national healthcare reforms on: patient wait times for treatment; treatment within recommended time; and patient departure within four hours of arrival in ED.

Results

There were small improvements in ED time-based process outcomes following the introduction of the national healthcare reforms. These occurred in most hospital peer groups immediately and over the longer term, across the various triage categories. The largest improvements occurred in small hospitals and smallest improvements in medium sized hospitals. ED time-based targets, now abolished by the Australian government, were not achieved in any hospital peer groups.

Conclusions

Our findings suggest that national healthcare reforms had the potential to prompt fundamental changes in ED processes leading to significant improvements in ED performances across most hospital peer groups but were generally unable to reach the ED targets imposed nationally. ED performances also varied by hospital peer groups. Attention to ED time-based process outcomes within hospital peer groups may provide insights into hospital practices that could improve the quality and efficiency of ED care.

The proportion, conditions, and predictors of emergency department visits that can be potentially managed by pharmacists with expanded scope of practice

BACKGROUND

Pharmacists have been shown to be beneficial for inclusion in emergency department (ED) services; however, little has been done to assess these benefits with pharmacists having even wider scopes of practice, including limited prescribing authority.

OBJECTIVES

The aims of this study were to determine the proportion of ED visits that can potentially be managed by pharmacists, the most prevalent conditions within these cases, and the factors associated with patients presenting with such cases to the ED.

METHODS

This was a retrospective quantitative cohort study using administrative databases from 2010 to 2017. Among all unscheduled ED visits in Ontario, all visits with a Family Practice Sensitive Condition and Canadian Triage and Acuity Scale score of IV or V were identified, in addition to conditions that can be managed by pharmacists with expanded scope. Logistic regression was performed to identify determinants of having a potentially pharmacist-manageable condition.

RESULTS

Of 34,550,020 ED visits identified, 12.4% (n = 4,293,807) were considered FPSC with CTAS IV or V. Of these, 1,494,887 (34.8%) were for conditions considered to be potentially manageable by pharmacists, representing 4.3% of all ED visits. The most frequent diagnoses observed were: acute pharyngitis, conjunctivitis, rash and other nonspecific skin eruption, otitis externa, cough, acute sinusitis, and dermatitis. Female gender, having a family physician or presenting with a CTAS of IV were associated with higher odds of presenting to the ED, while increased age and income were associated with lower odds.

CONCLUSIONS

Under an expanded scope, pharmacists could potentially have managed nearly 1.5 million cases presenting to the ED over the study period. The introduction of ED-based or community pharmacists practicing under an expanded scope may have a positive impact on overcrowding in EDs.

La prise en charge de la douleur aux urgences : indicateur de qualité et de performance aux urgences

La qualité et la performance des services d'urgences sont des objectifs nationaux. La mise en place d'une stratégie d'amélioration continue de la qualité et de la performance nécessite de fédérer l'ensemble des équipes de soins autour d'un projet innovant. Les visites de certification sont un des outils que nous pouvons utiliser comme un levier pour mettre en place et améliorer la qualité. Un projet fédérateur nécessite de définir des valeurs partagées entre les équipes de soins. La lutte contre la douleur est une des valeurs fortes pour les équipes de soins, notamment aux urgences. Nous devons utiliser le projet de prise en charge de la douleur comme un moyen de revoir nos organisations, d'évaluer nos processus et de les simplifier, afin d'atteindre les objectifs définis par une cartographie des risques spécifiques. Nous présentons ici l'expérience de nos services d'urgences pour la prise en charge de la douleur d'origine traumatique, les méthodes suivies et les outils d'amélioration mis en place.

Patients Attending Emergency Departments

BACKGROUND

The number of patients in emergency departments has risen steadily in recent years, with a particular increase in patients not requiring urgent treatment. The aim of this study is to characterize this group of patients with respect to their sociodemographic features, health status, and reasons for attending an emergency department.

METHODS

PiNo Nord is a cross-sectional observational study representing two full working weeks in five different hospitals. Patients were questioned in personal interviews, and medical diagnoses were documented. The data were analyzed with multivariate logistic regressions in mixed multilevel models. Predictors for the subjectively perceived treatment urgency were identified by stepwise backward selection.

RESULTS

The 1175 patients questioned had an average age of 41.8 years and 52.9% were male. 54.7% said the degree of their treatment urgency was low. 41.3% had visited the emergency department on their own initiative, 17.0% on the advice or referral of their primary care physician, and 8.0% on the advice or referral of a specialist. The strongest predictors for low subjective treatment urgency were musculoskeletal trauma (odds ratio [OR] 2.18), skin conditions (OR 2.15), and the momentary unavailability of a primary care physician (OR 1.70).

CONCLUSION

More than half of the patients do not think their condition requires urgent treatment and thus do not meet the definition of a medical emergency. Patients' reasons for visiting the emergency department are varied; aside from the treatment urgency of the health condition itself, the reason may lie in perceived structural circumstances and individual preferences.