International perspectives on emergency department crowding

Predictors of emergency department use by adolescents and adults with autism spectrum disorder: a prospective cohort study

OBJECTIVES

To determine predictors of emergency department (ED) visits in a cohort of adolescents and adults with autism spectrum disorder (ASD).

DESIGN

Prospective cohort study.

SETTING

Community-based study from Ontario, Canada.

PARTICIPANTS

Parents reported on their adult sons and daughters with ASD living in the community (n=284).

MAIN OUTCOME MEASURES

ED visits for any reason, ED visits for medical reasons and ED visits for psychiatric reasons over 1 year.

RESULTS

Among individuals with ASD, those with ED visits for any reason were reported to have greater family distress at baseline (p<0.01), a history of visiting the ED during the year prior (p<0.01) and experienced two or more negative life events at baseline (p<0.05) as compared with those who did not visit the ED. Unique predictors of medical versus psychiatric ED visits emerged. Low neighbourhood income (p<0.01) and living in a rural neighbourhood (p<0.05) were associated with medical but not psychiatric ED visits, whereas a history of aggression (p<0.05) as well as being from an immigrant family (p<0.05) predicted psychiatric but not medical emergencies.

CONCLUSIONS

A combination of individual and contextual variables may be important for targeting preventative community-based supports for individuals with ASD and their families. In particular, attention should be paid to how caregiver supports, integrative crisis planning and community-based services may assist in preventing or minimising ED use for this vulnerable population.

The three paradoxes of patient flow: an explanatory case study

BACKGROUND

Health systems in many jurisdictions struggle to reduce Emergency Department congestion and improve patient flow across the continuum of care. Flow is often described as a systemic issue requiring a "system approach"; however, the implications of this idea remain poorly understood. Focusing on a Canadian regional health system whose flow problems have been particularly intractable, this study sought to determine what system-level flaws impede healthcare organizations from improving flow.

METHODS

This study drew primarily on qualitative data from in-depth interviews with 62 senior, middle and departmental managers representing the Region, its programs and sites; quantitative analysis of key flow indicators (1999-2012) and review of ~700 documents furnished important context. Examination of the interview data revealed that the most striking feature of the dataset was contradiction; accordingly, a technique of dialectical analysis was developed to examine observed contradictions at successively deeper levels.

RESULTS

Analysis uncovered three paradoxes: "Many Small Successes and One Big Failure" (initiatives improve parts of the system but fail to fix underlying system constraints); "Your Innovation Is My Aggravation" (local innovation clashes with regional integration); and most critically, "Your Order Is My Chaos" (rules that improve service organization for my patients create obstacles for yours). This last emerges when some entities (sites/hospitals) define their patients in terms of their location in the system, while others (regional programs) define them in terms of their needs/characteristics. As accountability for improving flow was distributed among groups that thus variously defined their patients, local efforts achieved little for the overall system, and often clashed with each other. These paradoxes are indicative of a fundamental antagonism between the system's parts and the whole.

CONCLUSION

An accretion of flow initiatives in all parts of the system will never add up to a system approach, and may indeed perpetuate the paradoxes. What is needed is a coherent strategy of defining patient populations by needs, analyzing their entire trajectories of care, and developing consistent processes to better meet those needs.

Two emergency departments, 6000km apart: Differences in patient flow and staff perceptions about crowding

INTRODUCTION

Emergency department (ED) crowding is a worldwide public health issue. In this study, patient flow and staff perceptions of crowding were assessed in Pakistan (Aga Khan University Hospital (AKUH)) and in the Netherlands (Haaglanden Medical Centre Westeinde (HMCW)). Bottlenecks affecting ED patient flow were identified.

METHODS

First, a one-year review of patient visits was performed. Second, staff perceptions about ED crowding were collected using face-to-face interviews. Non-participant observation and document review were used to interpret the findings.

RESULTS

At AKUH 58,839 (160visits/day) and at HMCW 50,802 visits (140visits/day) were registered. Length of stay (LOS) at AKUH was significantly longer than at HMCW (279min (IQR 357) vs. 100min (IQR 152)). There were major differences in patient acuities, admission and mortality rates, indicating a sicker population at AKUH. Respondents from both departments experienced hampered patient flow on a daily basis, and perceived similar causes for crowding: increased patients' complexity, long treatment times, and poor availability of inpatient beds.

CONCLUSION

Despite differences in environment, demographics, and ED patient flow, respondents perceived similar bottlenecks in patient flow. Interventions should be tailored to specific ED and hospital needs. For both EDs, improving the outflow of boarded patients is essential.

Patients' and providers' perceptions of the preventability of hospital readmission: a prospective, observational study in four European countries

OBJECTIVES

Because of fundamental differences in healthcare systems, US readmission data cannot be extrapolated to the European setting: To investigate the opinions of readmitted patients, their carers, nurses and physicians on predictability and preventability of readmissions and using majority consensus to determine contributing factors that could potentially foresee (preventable) readmissions.

DESIGN

Prospective observational study. Readmitted patients, their carers, and treating professionals were surveyed during readmission to assess the discharge process and the predictability and preventability of the readmission. Cohen's Kappa measured pairwise agreement of considering readmission as predictable/preventable by patients, carers and professionals. Subsequently, multivariable logistic regressionidentified factors associated with predictability/preventability.

SETTING

15 hospitals in four European countries PARTICIPANTS: 1398 medical patients readmitted unscheduled within 30 days MAIN OUTCOMES AND MEASURES: (1) Agreement between the interviewed groups on considering readmissions likely predictable or preventable;(2) Factors distinguishing predictable from non-predictable and preventable from non-preventable readmissions.

RESULTS

The majority deemed 27.8% readmissions potentially predictable and 14.4% potentially preventable. The consensus on predictability and preventability was poor, especially between patients and professionals (kappas ranged from 0.105 to 0.173). The interviewed selected different factors as potentially associated with predictability and preventability. When a patient reported that he was ready for discharge during index admission, the readmission was deemed less likely by the majority (predictability: OR 0.55; 95% CI 0.40 to 0.75; preventability: OR 0.35; 95% CI 0.24 to 0.49).

CONCLUSIONS

There is no consensus between readmitted patients, their carers and treating professionals about predictability and preventability of readmissions, nor associated risk factors. A readmitted patient reporting not feeling ready for discharge at index admission was strongly associated with preventability/predictability. Therefore, healthcare workers should question patients' readiness to go home timely before discharge.

The organisational value of diagnostic strategies using high-sensitivity troponin for patients with possible acute coronary syndromes: a trial-based cost-effectiveness analysis

OBJECTIVES

To evaluate hospital-specific health economic implications of different protocols using high-sensitivity troponin I for the assessment of patients with chest pain.

DESIGN

A cost prediction model and an economic microsimulation were developed using a cohort from a single centre recruited as part of the (ADAPT) trial, a prospective observational trial conducted from 2008 to 2011. The model was populated with 40 000 bootstrapped samples in five high-sensitivity troponin I-enabled algorithms versus standard care.

SETTING

Adult emergency department (ED) of a tertiary referral hospital.

PARTICIPANTS

Data were available for 938 patients who presented to the ED with at least 5 min of symptoms suggestive of acute coronary syndrome. The analyses included 719 patients with complete data.

MAIN OUTCOMES/MEASURES

This study examined direct hospital costs, number of false-negative and false-positive cases in the assessment of acute coronary syndrome.

RESULTS

High-sensitivity troponin I-supported algorithms increased diagnostic accuracy from 90.0% to 94.0% with an average cost reduction per patient compared with standard care of $490. The inclusion of additional criteria for accelerated rule-out (limit of detection and the modified 2-hour ADAPT trial rules) avoided 7.5% of short-stay unit admissions or 25% of admissions to a cardiac ward. Protocols using high-sensitivity troponin I alone or high-sensitivity troponin I within accelerated diagnostic algorithms reduced length of stay by 6.2 and 13.6 hours, respectively. Overnight stays decreased up to 43%. Results were seen for patients with non-acute coronary syndrome; no difference was found for patients with acute coronary syndrome.

CONCLUSIONS

High-sensitivity troponin I algorithms are likely to be cost-effective on a hospital level compared with sensitive troponin protocols. The positive effect is conferred by patients not diagnosed with acute coronary syndrome. Implementation could improve referral accuracy or facilitate safe discharge. It would decrease costs and provide significant hospital benefits.

TRIAL REGISTRATION

The original ADAPT trial was registered with the Australia-New Zealand Clinical trials Registry, ACTRN12611001069943.

European Society of Cardiology - Acute Cardiovascular Care Association position paper on safe discharge of acute heart failure patients from the emergency department

Heart failure is a global public health challenge frequently presenting to the emergency department. After initial stabilization and management, one of the most important decisions is to determine which patients can be safely discharged and which require hospitalization. This is a complex decision that depends on numerous subjective factors, including both the severity of the patient's underlying condition and an estimate of the acuity of the presentation. An emergency department observation period may help select the correct option. Ideally, during an observation period, risk stratification should be carried out using parameters specifically designed for use in the emergency department. Unfortunately, there is little objective literature to guide this disposition decision. An objective and reliable definition of low-risk characteristics to identify early discharge candidates is needed. Benchmarking outcomes in patients discharged from the emergency department without hospitalization could aid this process. Biomarker determinations, although undoubtedly useful in establishing diagnosis and predicting longer-term prognosis, require prospective validation for emergency department disposition guidance. The challenge of identifying emergency department acute heart failure discharge candidates will only be overcome by future multidisciplinary research defining the current knowledge gaps and identifying potential solutions.

Factors associated with failure of emergency wait-time targets for high acuity discharges and intensive care unit admissions

Objective

Ontario established emergency department length-of-stay (EDLOS) targets but has difficulty achieving them. We sought to determine predictors of target time failure for discharged high acuity patients and intensive care unit (ICU) admissions.

Methods

This was a retrospective, observational study of 2012 Sunnybrook Hospital emergency department data. The main outcome measure was failing to meet government EDLOS targets for high acuity discharges and ICU emergency admissions. The secondary outcome measures examined factors for low acuity discharges and all admissions, as well as a run chart for 2015 – 2016 ICU admissions. Multiple logistic regression models were created for admissions, ICU admissions, and low and high acuity discharges. Predictor variables were at the patient level from emergency department registries.

Results

For discharged high acuity patients, factors predicting EDLOS target failure were having physician initial assessment duration (PIAD)>2 hours (OR 5.63 [5.22-6.06]), consultation request (OR 10.23 [9.38-11.14]), magnetic resonance imaging (MRI) (OR 19.33 [12.94-28.87]), computed tomography (CT) (OR 4.24 [3.92-4.59]), and ultrasound (US) (OR 3.47 [3.13-3.83]). For ICU admissions, factors predicting EDLOS target failure were bed request duration (BRD)>6 hours (OR 364.27 [43.20-3071.30]) and access block (AB)>1 hour (OR 217.27 [30.62-1541.63]). For discharged low acuity patients, factors predicting failure for the 4-hour target were PIAD>2 hours (OR 15.80 [13.35-18.71]), consultation (OR 20.98 [14.10-31.22]), MRI (OR 31.68 [6.03-166.54]), CT (OR 16.48 [10.07-26.98]), and troponin I (OR 13.37 [6.30-28.37]).

Conclusion

Sunnybrook factors predicting failure of targets for high acuity discharges and ICU admissions were hospital-controlled. Hospitals should individualize their approach to shortening EDLOS by analysing its patient population and resource demands.

Parameters affecting length of stay in a pediatric emergency department: a retrospective observational study

Prolonged emergency department (ED) length of stay (LOS) is used as a proxy for ED overcrowding and is associated with adverse outcomes of patients requiring therapy and reduced patient satisfaction. Our aim was to identify and quantify variables which affect ED-LOS. Patients admitted to the pediatric ED of a large regional Swiss hospital during a 1-year period were analyzed for LOS (in minutes). Predictor variables included patient-associated parameters (time of admission and discharge, ED occupancy, triage score, diagnosis, and demographic data) and external factors (weekday, time, and season). A total of 4885 visits were included in a multivariable logistic regression analysis. Median LOS was 124 min. The most important factors associated with prolonged LOS were physician referral (adjusted odds ratio [OR], 1.97; 95% confidence interval [CI], 1.47-2.62); morning admissions, especially before noon (OR, 1.92; 95% CI, 1.23-3.07); and gastrointestinal infections (OR, 1.38; 95% CI, 1.08-1.76). Upper airway infections (OR, 0.37; 95% CI, 0.27-0.49) and triage level 5 (OR, 0.18; 95% CI, 0.06-0.61) were inversely associated with ED-LOS. Together with ED occupancy, these factors did significantly contribute to log LOS in a stepwise backward multiple regression model (p < 0.001).

CONCLUSION

Several parameters are associated with prolonged ED-LOS. Notably, morning arrivals represent possible targets for strategies to reduce LOS. What is Known: • Prolonged length of stay (LOS) may affect care delivered to admitted patients in the emergency department (ED) and is well studied in the setting of adult patients with high acuity conditions. • Little is known about parameters which impact LOS in European pediatric EDs. What is New: • Several predictors of prolonged LOS could be identified in a European pediatric setting. • Our results indicate that prolonged LOS is associated with modifiable factors like morning and summer admission, which have the potential to be addressed by modification in staffing, infrastructure, and higher attention to faster processing.

One hundred injured patients a day: multicenter emergency room surveillance of trauma in Pakistan

OBJECTIVES

Injuries increasingly contribute to the global burden of disease in low- and middle-income countries. This study presents results from a large-scale surveillance study on injury from several urban emergency departments (EDs) in Pakistan. The objective is to document the burden of injuries that present to the healthcare system in Pakistan and to test the feasibility of an ED-based injury and trauma surveillance system.

STUDY DESIGN

Cross-sectional study conducted using active surveillance approach.

METHODS

This study included EDs of seven tertiary care hospitals in Pakistan. The data were collected between November 2010 and March 2011. All patients presenting with injuries to the participating EDs were enrolled. The study was approved by the Institutional Review Boards of the Johns Hopkins School of Public Health, Aga Khan University, and all participating sites.

RESULTS

The study recorded 68,390 patients; 93.8% were from the public hospitals. There were seven male for every three female patients, and 50% were 20-39 years of age. About 69.3% were unintentional injuries. Among injuries with a known mechanism (19,102), 51.1% were road traffic injuries (RTIs) and 17.5% were falls. Female, patients aged 60 years or older, patients transferred by ambulance, patients who had RTIs, and patients with intentional injuries were more likely to be hospitalized.

CONCLUSION

The study is the first to use standardized methods for regular collection of multiple ED data in Pakistan. It explored the pattern of injuries and the feasibility to develop and implement facility-based systems for injury and acute illness in countries like Pakistan.

[Not Available]

Zusammenfassung. Es lässt sich in den westlichen Industrienationen eine deutliche Zunahme der Inanspruchnahme von Zentralen Notaufnahmen (ZNA) der Krankenhäuser beobachten. Aufgrund der Flüchtlingswelle erhält dieses Thema zusätzliche Brisanz. In Städten machen Migranten einen relevanten Teil des Patientengutes der ZNAs aus, trotzdem sind sie in der Versorgungsforschung bisher nicht angemessen repräsentiert. Die retrospektive Studie beleuchtet die Entwicklung der Inanspruchnahme einer Universitären Notaufnahme durch Migranten bezüglich Patientenzahlen differenziert nach Soziodemografie, Wochentag und Zuweisungsart über zehn Jahre. Bei der jährlich steigenden Behandlungszahl in Notaufnahmen kommt es zu einem überproportionalen Anstieg von ausländischen Patientenkontakten. Der aufgezeigte Trend wird zunehmen und es sollte bei der Planung von notfallmedizinischen Vorhalteleistungen die soziodemografische Struktur berücksichtigt werden, insbesondere sollte sich die Notfallmedizin auf zusätzlich migrationsspezifisch veränderte Anforderungen einstellen.

Emergency medicine: what keeps me, what might lose me? A narrative study of consultant views in Wales

EDs are currently under intense pressure due to increased patient demand. There are major issues with retention of senior personnel, making the specialty a less attractive choice for junior doctors. This study aims to explore what attracted EM consultants to their career and keeps them there. It is hoped this can inform recruitment strategies to increase the popularity of EM to medical students and junior doctors, many of whom have very limited EM exposure.

Methods

Semistructured interviews were conducted with 10 consultants from Welsh EDs using a narrative approach.

Results

Three main themes emerged that influenced the career choice of the consultants interviewed: (1) early exposure to positive EM role models; (2) non-hierarchical team structure; (3) suitability of EM for flexible working. The main reason for consultants leaving was the pressure of work impacting on patient care.

Conclusion

The study findings suggest that EM consultants in post are positive about their careers despite the high volume of consultant attrition. This study reinforces the need for dedicated undergraduate EM placements to stimulate interest and encourage medical student EM aspirations. Consultants identified that improving the physical working environment, including organisation, would increase their effectiveness and the attractiveness of EM as a long-term career.

Retrospective comparison of the Low Risk Ankle Rules and the Ottawa Ankle Rules in a pediatric population

BACKGROUND

A recent multicenter prospective Canadian study presented prospective evidence supporting the Low Risk Ankle Rules (LRAR) as a means of reducing the number of ankle radiographs ordered for children presenting with an ankle injury while maintaining nearly 100% sensitivity. This is in contrast to a previous prospective study which showed that this rule yielded only 87% sensitivity.

OBJECTIVE

It is important to further investigate the LRAR and compare them with the already validated Ottawa Ankle Rules (OAR) to potentially curb healthcare costs and decrease unnecessary radiation exposure without compromising diagnostic accuracy.

METHODS

We conducted a retrospective chart review of 980 qualifying patients ages 12months to 18years presenting with ankle injury to a commonly staffed 310 bed children's hospital and auxiliary site pediatric emergency department.

RESULTS

There were 28 high-risk fractures identified. The Ottawa Ankle Rules had a sensitivity of 100% (95% CI 87.7-100), specificity of 33.1% (95% CI 30.1-36.2), and would have reduced the number of ankle radiographs ordered by 32.1%. The Low Risk Ankle Rules had a sensitivity of 85.7% (95% CI 85.7-96), specificity of 64.9% (95% CI 61.8-68), and would have reduced the number of ankle radiographs ordered by 63.1%. The latter rule missed 4 high-risk fractures.

CONCLUSION

The Low Risk Ankle Rules may not be sensitive enough for use in Pediatric Emergency Departments, while the Ottawa Ankle Rules again demonstrated 100% sensitivity. Further research on ways to implement the Ottawa Ankle Rules and maximize its ability to decrease wait times, healthcare costs, and improve patient satisfaction are needed.

Applicability of the modified Emergency Department Work Index (mEDWIN) at a Dutch emergency department

Background

Emergency department (ED) crowding leads to prolonged emergency department length of stay (ED-LOS) and adverse patient outcomes. No uniform definition of ED crowding exists. Several scores have been developed to quantify ED crowding; the best known is the Emergency Department Work Index (EDWIN). Research on the EDWIN is often applied to limited settings and conducted over a short period of time.

Objectives

To explore whether the EDWIN as a measure can track occupancy at a Dutch ED over the course of one year and to identify fluctuations in ED occupancy per hour, day, and month. Secondary objective is to investigate the discriminatory value of the EDWIN in detecting crowding, as compared with the occupancy rate and prolonged ED-LOS.

Methods

A retrospective cohort study of all ED visits during the period from September 2010 to August 2011 was performed in one hospital in the Netherlands. The EDWIN incorporates the number of patients per triage level, physicians, treatment beds and admitted patients to quantify ED crowding. The EDWIN was adjusted to emergency care in the Netherlands: modified EDWIN (mEDWIN). ED crowding was defined as the 75^th percentile of mEDWIN per hour, which was ≥0.28.

Results

In total, 28,220 ED visits were included in the analysis. The median mEDWIN per hour was 0.15 (Interquartile range (IQR) 0.05–0.28); median mEDWIN per patient was 0.25 (IQR 0.15–0.39). The EDWIN was higher on Wednesday (0.16) than on other days (0.14–0.16, p<0.001), and a peak in both mEDWIN (0.30–0.33) and ED crowding (52.9–63.4%) was found between 13:00–18:00 h. A comparison of the mEDWIN with the occupancy rate revealed an area under the curve (AUC) of 0.86 (95%CI 0.85–0.87). The AUC of mEDWIN compared with a prolonged ED-LOS (≥4 hours) was 0.50 (95%CI 0.40–0.60).

Conclusion

The mEDWIN was applicable at a Dutch ED. The mEDWIN was able to identify fluctuations in ED occupancy. In addition, the mEDWIN had high discriminatory power for identification of a busy ED, when compared with the occupancy rate.

The Most Crowded US Hospital Emergency Departments Did Not Adopt Effective Interventions To Improve Flow, 2007-10

Emergency department (ED) crowding adversely affects patient care and outcomes. Despite national recommendations to address crowding, it persists in most US EDs today. Using nationally representative data, we evaluated the use of interventions to address crowding in US hospitals in the period 2007-10. We examined the relationship between crowding within an ED itself, measured as longer ED lengths-of-stay, and the number of interventions adopted. In our study period the average number of interventions adopted increased from 5.2 to 6.6, and seven of the seventeen studied interventions saw a significant increase in adoption. In general, more crowded EDs adopted greater numbers of interventions than less crowded EDs. However, in the most crowded quartile of EDs, a large proportion had not adopted effective interventions: 19 percent did not use bedside registration, and 94 percent did not use surgical schedule smoothing. Thus, while adoption of strategies to reduce ED crowding is increasing, many of the nation's most crowded EDs have not adopted proven interventions.

[Position paper for a reform of medical emergency care in German emergency departments]

The hospital emergency departments play a central role for the in- and outpatient care of patients with medical emergencies in Germany. In this position paper we point out some general financial and organizational problems of German emergency departments and urge for a higher significance of emergency care in the German health system as an element of public services. The corresponding reform proposals include a change in hospital financing towards a more budget-based system for the emergency departments, an improved structural planning for regional and transregional emergency care, an intensified cooperation with the emergency services of the ambulatory care physicians, a better organizational representation of emergency care within the hospitals and an advancement of emergency medicine in postgraduate medical education.

Frequent Use of Emergency Departments by the Elderly Population When Continuing Care Is Not Well Established

Introduction

The elderly, who suffer from multiple chronic diseases, represent a substantial proportion of Emergency Department (ED) frequent users, thus contributing to ED overcrowding, although they could benefit from other health care facilities, if those were available. The aim of this study was to evaluate and characterize hospital visits of older patients (age 65 or greater) to the ED of a university teaching hospital in Rome from the 1st of January to the 31st of December 2014, in order to identify clinical and social characteristics potentially associated with “elderly frequent users”.

Material and Methods

A retrospective study was performed during the calendar year 2014 (1^st January 2014 – 31^st December 2014) analyzing all ED admissions to the University Hospital of Rome Tor Vergata. Variables collected included age, triage code, arrival data, discharge diagnosis, and visit outcome. We performed a risk analysis using univariate binary logistic regression models.

Results

A total number of 38,016 patients accessed the ED, generating 46,820 accesses during the study period, with an average of 1.23 accesses for patient. The elderly population represented a quarter of the total ED population and had an increased risk of frequent use (OR 1.5: CI 1.4–1.7) and hospitalization (OR 3.8: CI 3.7–4). Moreover, they showed a greater diagnostic complexity, as demonstrated by the higher incidence of yellow and red priority codes compared to other ED populations (OR 3.1: CI 2.9–3.2).

Discussion

Older patients presented clinical and social characteristics related to the definition of “elderly frail frequent users”. The fact that a larger number of hospitalizations occurred in such patients is indirect evidence of frailty in this specific population, suggesting that hospital admissions may be an inappropriate response to frailty, especially when continued care is not established.

Conclusion

Enhancement of continuity of care, establishment of a tracking system for those who are at greater risk of visiting the ED and evaluating fragile individuals should be the highest priority in addressing ED frequent usage by the elderly.

Does the extension of primary care practice opening hours reduce the use of emergency services?

Overcrowding in emergency departments generates potential inefficiencies. Using regional administrative data, we investigate the impact that an increase in the accessibility of primary care has on emergency visits in Italy. We consider two measures of avoidable emergency visits recorded at list level for each General Practitioner. We test whether extending practices' opening hours to up to 12 hours/day reduces the inappropriate utilization of emergency services. Since subscribing to the extension program is voluntary, we account for the potential endogeneity of participation in a count model for emergency admissions in two ways: first, we use a two-stage residual inclusion approach. Then we exploit panel methods on data covering a three-year period, thus accounting directly for individual heterogeneity. Our results show that increasing primary care accessibility acts as a restraint on the inappropriate use of emergency departments. The estimated effect is in the range of a 10-15% reduction in inappropriate admissions.

Patient motives behind low-acuity visits to the emergency department in Germany: a qualitative study comparing urban and rural sites

OBJECTIVES

The increasing number of low-acuity visits to emergency departments (ED) is an important issue in Germany, despite the fact that all costs of inpatient and outpatient treatment are covered by mandatory health insurance. We aimed to explore the motives of patients categorised with low-acuity conditions for visiting an ED.

METHODS

We conducted a qualitative study in two urban and one rural ED. We recruited a purposive sample of adults, who were assigned to the lowest two categories in the Manchester triage system. One-to-one interviews took place in the ED during patients' waiting time for treatment. Interview transcripts were analysed using the qualitative data management software MAXQDA. A qualitative content analysis approach was taken to identify motives and to compare the rural with the urban sites.

RESULTS

A total of 86 patients were asked to participate; of these, n=15 declined participation and n=7 were excluded because they were admitted as inpatients, leaving a final sample of 40 female and 24 male patients. We identified three pathways leading to an ED visit: (1) without primary care contact, (2) after unsuccessful attempts to see a resident specialist or general practitioner (GP) and (3) recommendation to visit the ED by an outpatient provider. The two essential motives were (1) convenience and (2) health anxiety, triggered by time constraints and focused usage of multidisciplinary medical care in a highly equipped setting. All participants from the rural region were connected to a GP, whom they saw more or less regularly, while more interviewees from the urban site did not have a permanent GP. Still, motives to visit the ED were in general the same.

CONCLUSIONS

We conclude that the ED plays a pivotal role in ambulatory acute care which needs to be recognised for adequate resource allocation.

TRIAL REGISTRATION NUMBER

DRK S00006053.

Characteristic substance misuse profiles among youth entering an urban emergency department: neighborhood correlates and behavioral comorbidities

BACKGROUND

Little is known about characteristic profiles of substance use - and their individual- and neighborhood-level correlates - among high-risk youth.

OBJECTIVES

To identify characteristic substance misuse profiles among youth entering an urban emergency department (ED) and explore how those profiles relate to individual- and community-level factors.

METHODS

Individual-level measures came from screening surveys administered to youth aged 14-24 at an ED in Flint, Michigan (n = 878); alcohol outlet and crime data came from public sources. Binary misuse indicators were generated by using previously established cut-points on scores of alcohol and drug use severity. Latent class analysis (LCA) identified classes of substance use; univariate tests and multinomial models identified correlates of class membership.

RESULTS

Excluding non-misusers (51.5%), LCA identified three classes: marijuana-only (27.9%), alcohol/marijuana (16.1%), and multiple substances (polysubstance) (4.6%). Moving from non-misusers to polysubstance misusers, there was an increasing trend in rates of: unprotected sex, motor vehicle crash, serious violence, weapon aggression, and victimization (all p < .001). Controlling for individual-level variables, polysubstance misusers lived near more on-premises alcohol outlets than non-misusers (RRR = 1.42, p = .01) and marijuana-only misusers (RRR = 1.31, p = .03). Alcohol/marijuana misusers were more likely to live near high violent crime density areas than non-misusers (RRR = 1.83, p = .01), and were also more likely than marijuana-only misusers to live in areas of high drug crime density (RRR = 1.98, p = .03). No other relationships were significant.

CONCLUSION

Substance-misusing youth seeking ED care have higher risk for other problem behaviors and neighborhood-level features display potential for distinguishing between use classes. Additional research to elucidate at-risk sub-populations/locales has potential to improve interventions for substance misuse by incorporating geographic information.

Burden of emergency conditions and emergency care usage: new estimates from 40 countries

OBJECTIVE

To estimate the global and national burden of emergency conditions, and compare them to emergency care usage rates.

METHODS

We coded all 291 Global Burden of Disease 2010 conditions into three categories to estimate emergency burden: conditions that, if not addressed within hours to days of onset, commonly lead to serious disability or death; conditions with common acute decompensations that lead to serious disability or death; and non-emergencies. Emergency care usage rates were obtained from a systematic literature review on emergency care facilities in low-income and middle-income countries (LMICs), supplemented by national health system reports.

FINDINGS

All 15 leading causes of death and disability-adjusted life years (DALYs) globally were conditions with potential emergent manifestations. We identified 41 facility-based reports in 23 countries, 12 of which were in LMICs; data for 17 additional countries were obtained from national or regional reports on emergency usage. Burden of emergency conditions was the highest in low-income countries, with median DALYs of 47 728 per 100 000 population (IQR 45 253-50 085) in low-income, 25 186 (IQR 21 982-40 480) in middle-income and 15 691 (IQR 14 649-16 382) in high-income countries. Patterns were similar using deaths to measure burden and excluding acute decompensations from the definition of emergency conditions. Conversely, emergency usage rates were the lowest in low-income countries, with median 8 visits per 1000 population (IQR 6-10), 78 (IQR 25-197) in middle-income and 264 (IQR 177-341) in high-income countries.

CONCLUSIONS

Despite higher burden of emergency conditions, emergency usage rates are substantially lower in LMICs, likely due to limited access to emergency care.

Interventions to reduce emergency department utilisation: A review of reviews

OBJECTIVE

To describe policy interventions that have the objective to reduce ED use and to estimate their effectiveness.

METHODS

Narrative review by searching three electronic databases for scientific literature review papers published between 2010 and October 2015. The quality of the included studies was assessed with AMSTAR, and a narrative synthesis of the retrieved papers was applied.

RESULTS

Twenty-three included publications described six types of interventions: (1) cost sharing; (2) strengthening primary care; (3) pre-hospital diversion (including telephone triage); (4) coordination; (5) education and self-management support; (6) barriers to access emergency departments. The high number of interventions, the divergent methods used to measure outcomes and the different populations complicate their evaluation. Although approximately two-thirds of the primary studies showed reductions in ED use for most interventions the evidence showed contradictory results.

CONCLUSION

Despite numerous publications, evidence about the effectiveness of interventions that aim to reduce ED use remains insufficient. Studies on more homogeneous patient groups with a clearly described intervention and control group are needed to determine for which specific target group what type of intervention is most successful and how the intervention should be designed. The effective use of ED services in general is a complex and multi-factorial problem that requires integrated interventions that will have to be adapted to the specific context of a country with a feedback system to monitor its (un-)intended consequences. Yet, the co-location of GP posts and emergency departments seems together with the introduction of telephone triage systems the preferred interventions to reduce inappropriate ED visits while case-management might reduce the number of ED attendances by frequent ED users.

Emergency physicians as human billboards for injury prevention: a randomized controlled trial

OBJECTIVES

The objective of this study was to evaluate the impact of a novel injury prevention intervention designed to prompt patients to initiate an injury prevention discussion with the ED physician, thus enabling injury prevention counselling and increasing bicycle helmet use among patients.

METHODS

A repeated measures 2 x 3 randomized controlled trial design was used. Fourteen emergency physicians were observed for two shifts each between June and August 2013. Each pair of shifts was randomized to either an injury prevention shift, during which the emergency physician would wear a customized scrub top, or a control shift. The outcomes of interest were physician time spent discussing injury prevention, current helmet use, and self-reported change in helmet use rates at one year. Logistic regression analyses were used to examine the impact of the intervention.

RESULTS

The average time spent on injury prevention for all patients was 3.3 seconds. For those patients who actually received counselling, the average time spent was 17.0 seconds. The scrub top intervention did not significantly change helmet use rates at one year. The intervention also had no significant impact on patient decisions to change or reinforcement of helmet use.

CONCLUSIONS

Our study showed that the intervention did not increase physician injury prevention counselling or self-reported bicycle helmet use rates among patients. Given the study limitations, replication and extension of the intervention is warranted.

Family involvement in emergency department discharge education for older people

AIMS AND OBJECTIVES

To report findings concerning family involvement in emergency department discharge education for older people.

BACKGROUND

The current trend of population ageing in Western countries has caused an increase in emergency department visits. Due to the continuing improvement in the mental and physical status of older people, they are frequently discharged home. Proper discharge education enables older people and their families to better understand how they can cope with the medical issue at home. Given the lack of research, we know relatively little about the significance of family involvement in older people's emergency department discharge education.

DESIGN

A descriptive qualitative design was used.

METHODS

Qualitative thematic interviews of seven older patients, five family members and fifteen nurses were conducted. Data were analysed using content analysis.

RESULTS

Family involvement in discharge education was seen as turbulent. The experiences were twofold: family involvement was acknowledged, but there was also a feeling that family members were ostracised. Families were seen as a resource for nurses, but as obliged initiators of their own involvement.

CONCLUSIONS

Our findings suggest that family members are not considered participants in emergency department care. For a family-friendly approach, actions should be taken on both individual and organisational levels.

RELEVANCE TO CLINICAL PRACTICE

The findings support healthcare providers and organisation leaders in promoting family involvement in discharge education for older people. Families can be encouraged to be involved without feeling responsible for the interaction.

Agents endowed with uncertainty management behaviors to solve a multiskill healthcare task scheduling

Health organizations are complex to manage due to their dynamic processes and distributed hospital organization. It is therefore necessary for healthcare institutions to focus on this issue to deal with patients' requirements. We aim in this paper to develop and implement a management decision support system (DSS) that can help physicians to better manage their organization and anticipate the feature of overcrowding. Our objective is to optimize the Pediatric Emergency Department (PED) functioning characterized by stochastic arrivals of patients leading to its services overload. Human resources allocation presents additional complexity related to their different levels of skills and uncertain availability dates. So, we propose a new approach for multi-healthcare task scheduling based on a dynamic multi-agent system. Decisions about assignment and scheduling are the result of a cooperation and negotiation between agents with different behaviors. We therefore define the actors involved in the agents' coalition to manage uncertainties related to the scheduling problem and we detail their behaviors. Agents have the same goal, which is to enhance care quality and minimize long waiting times while respecting degrees of emergency. Different visits to the PED services and regular meetings with the medical staff allowed us to model the PED architecture and identify the characteristics and different roles of the healthcare providers and the diverse aspects of the PED activities. Our approach is integrated in a DSS for the management of the Regional University Hospital Center (RUHC) of Lille (France). Our survey is included in the French National Research Agency (ANR) project HOST (Hôpital: Optimisation, Simulation et évitement des Tensions (ANR-11-TecSan-010: http://host.ec-lille.fr/wp-content/themes/twentyeleven/docsANR/R0/HOST-WP0.pdf)).

Determinants of out-of-hours service users' potentially inappropriate referral or non-referral to an emergency department: a retrospective cohort study in a local health authority, Veneto Region, Italy

BACKGROUND

A growing presence of inappropriate patients has been recognised as one of the main factors influencing emergency department (ED) overcrowding, which is a very widespread problem all over the world. On the other hand, out-of-hours (OOH) physicians must avoid delaying the diagnostic and therapeutic course of patients with urgent medical conditions. The aim of this study was to analyse the appropriateness of patient management by OOH services, in terms of their potentially inappropriate referral or non-referral of non-emergency cases to the ED.

METHODS

This was an observational retrospective cohort study based on data collected in 2011 by the local health authority No. 4 in the Veneto Region (Italy). After distinguishing between patients contacting the OOH service who were or were not referred to the ED, and checking for patients actually presenting to the ED within 24 hours thereafter, these patients' medical management was judged as potentially appropriate or inappropriate.

RESULTS

The analysis considered 22 662 OOH service contacts recorded in 2011. The cases of potentially inappropriate non-referral to the ED were 392 (1.7% of all contacts), as opposed to 1207 potentially inappropriate referrals (5.3% of all contacts). Age, nationality, type of disease and type of intervention by the OOH service were the main variables associated with the appropriateness of patient management.

CONCLUSIONS

These findings may be useful for pinpointing the factors associated with a potentially inappropriate patient management by OOH services and thus contribute to improving the deployment of healthcare and the quality of care delivered by OOH services.

Six ways not to improve patient flow: a qualitative study

Background

Although well-established principles exist for improving the timeliness and efficiency of care, many organisations struggle to achieve more than small-scale, localised gains. Where care processes are complex and include segments under different groups' control, the elegant solutions promised by improvement methodologies remain elusive. This study sought to identify common design flaws that limit the impact of flow initiatives.

Methods

This qualitative study was conducted within an explanatory case study of a Canadian regional health system in which multitudinous flow initiatives had yielded no overall improvement in system performance. Interviews with 62 senior, middle and departmental managers, supplemented by ∼700 documents on flow initiatives, were analysed using the constant comparative method.

Results

Findings suggested that smooth flow depends on linking a defined population to appropriate capacity by means of an efficient process; flawed initiatives reflected failure to consider one or more of these essential elements. Many initiatives focused narrowly on process, failing to consider that the intended population was poorly defined or the needed capacity inaccessible; some introduced capacity for an intended population, but offered no process to link the two. Moreover, interveners were unable to respond effectively when a bottleneck moved to another part of the system. Errors of population, capacity and process, in different combinations, generated six ‘formulae for failure’.

Conclusions

Typically, flawed initiatives focused on too small a segment of the patient journey to properly address the impediments to flow. The proliferation of narrowly focused initiatives, in turn, reflected a decentralised system in which responsibility for flow improvement was fragmented. Thus, initiatives' specific design flaws may have their roots in a deeper problem: the lack of a coherent system-level strategy.

Engaging the public in healthcare decision-making: results from a Citizens' Jury on emergency care services

BACKGROUND

Policies addressing ED crowding have failed to incorporate the public's perspectives; engaging the public in such policies is needed.

OBJECTIVE

This study aimed at determining the public's recommendations related to alternative models of care intended to reduce crowding, optimising access to and provision of emergency care.

METHODS

A Citizens' Jury was convened in Queensland, Australia, to consider priority setting and resource allocation to address ED crowding. Twenty-two jurors were recruited from the electoral roll, who were interested and available to attend the jury from 15 to 17 June 2012. Juror feedback was collected via a survey immediately following the end of the jury.

RESULTS

The jury considered that all patients attending the ED should be assessed with a minority of cases diverted for assistance elsewhere. Jurors strongly supported enabling ambulance staff to treat patients in their homes without transporting them to the ED, and allowing non-medical staff to treat some patients without seeing a doctor. Jurors supported (in principle) patient choice over aspects of their treatment (when, where and type of health professional) with some support for patients paying towards treatment but unanimous opposition for patients paying to be prioritised. Most of the jurors were satisfied with their experience of the Citizens' Jury process, but some jurors perceived the time allocated for deliberations as insufficient.

CONCLUSIONS

These findings suggest that the general public may be open to flexible models of emergency care. The jury provided clear recommendations for direct public input to guide health policy to tackle ED crowding.

A generic method for evaluating crowding in the emergency department

Background

Crowding in the emergency department (ED) has been studied intensively using complicated non-generic methods that may prove difficult to implement in a clinical setting. This study sought to develop a generic method to describe and analyse crowding from measurements readily available in the ED and to test the developed method empirically in a clinical setting.

Methods

We conceptualised a model with ED patient flow divided into separate queues identified by timestamps for predetermined events. With temporal resolution of 30 min, queue lengths were computed as Q(t + 1) = Q(t) + A(t) – D(t), with A(t) = number of arrivals, D(t) = number of departures and t = time interval. Maximum queue lengths for each shift of each day were found and risks of crowding computed. All tests were performed using non-parametric methods. The method was applied in the ED of Aarhus University Hospital, Denmark utilising an open cohort design with prospectively collected data from a one-year observation period.

Results

By employing the timestamps already assigned to the patients while in the ED, a generic queuing model can be computed from which crowding can be described and analysed in detail. Depending on availability of data, the model can be extended to include several queues increasing the level of information. When applying the method empirically, 41,693 patients were included. The studied ED had a high risk of bed occupancy rising above 100 % during day and evening shift, especially on weekdays. Further, a ‘carry over’ effect was shown between shifts and days.

Conclusions

The presented method offers an easy and generic way to get detailed insight into the dynamics of crowding in an ED.

Predictors for Delayed Emergency Department Care in Medical Patients with Acute Infections - An International Prospective Observational Study

Introduction

In overcrowded emergency department (ED) care, short time to start effective antibiotic treatment has been evidenced to improve infection-related clinical outcomes. Our objective was to study factors associated with delays in initial ED care within an international prospective medical ED patient population presenting with acute infections.

Methods

We report data from an international prospective observational cohort study including patients with a main diagnosis of infection from three tertiary care hospitals in Switzerland, France and the United States (US). We studied predictors for delays in starting antibiotic treatment by using multivariate regression analyses.

Results

Overall, 544 medical ED patients with a main diagnosis of acute infection and antibiotic treatment were included, mainly pneumonia (n = 218; 40.1%), urinary tract (n = 141; 25.9%), and gastrointestinal infections (n = 58; 10.7%). The overall median time to start antibiotic therapy was 214 minutes (95% CI: 199, 228), with a median length of ED stay (ED LOS) of 322 minutes (95% CI: 308, 335). We found large variations of time to start antibiotic treatment depending on hospital centre and type of infection. The diagnosis of a gastrointestinal infection was the most significant predictor for delay in antibiotic treatment (+119 minutes compared to patients with pneumonia; 95% CI: 58, 181; p<0.001).

Conclusions

We found high variations in hospital ED performance in regard to start antibiotic treatment. The implementation of measures to reduce treatment times has the potential to improve patient care.

High prevalence of frequent attendance in the over 65s

INTRODUCTION

Characteristics of older frequent users of Emergency Departments (EDs) are poorly understood. Our aim was to examine the characteristics of the ED frequent attenders (FAs) by age (under 65 and over 65 years).

METHODS

We examined the prevalence of FA attending the ED of an Urban Teaching Hospital in a cross-sectional study between 2009 and 2011. FA was defined as an individual who presented to the ED four or more times over a 12-month period. Randomly selected groups of FA and non-FA from two age groups (under 65 and over 65 years) were then examined to compare the characteristics between older FAs and non-FAs and older FAs and younger FAs. Logistic regression was used to calculate the odds ratio and 95% confidence intervals for 12-month mortality in FA compared with non-FA aged at least 65 years.

RESULTS

Overall, 137 150 ED attendances were recorded between 2009 and 2011. A total of 21.6% were aged at least 65 years, 4.4% of whom were FAs, accounting for 18.4% of attendances by patients older than 65 years. There was a bimodal age distribution of FA (mean±SD; under 65 years 40±12.7; and over 65 years 76.9±7.4). Older FAs were five times more likely to present outside normal working hours and 5.5 times more likely to require admission. Cardiovascular emergencies were the most common complaint, in contrast with the younger FA group, where injury and psychosocial conditions dominated. The odds ratio for death at 12 months was 2.07 (95% confidence interval 0.93-4.63; P=0.07), adjusting for age and sex.

CONCLUSION

One-in-five ED patients older than 65 years of age are FAs. Older FAs largely present with complex medical conditions. Enhanced access to expert gerontology assessment should be considered as part of effective intervention strategies for older ED users.

Influence of CT utilisation on patient flow in the emergency department: a retrospective 1-year cohort study

OBJECTIVE

CT, an important diagnostic tool in the emergency department (ED), might increase the ED length of stay (LOS). Considering the issue of ED overcrowding, it is important to evaluate whether CT use delays or facilitates patient disposition in the ED.

DESIGN

A retrospective 1-year cohort study.

SETTING

5 EDs within the same healthcare system dispersed nationwide in Taiwan.

PARTICIPANTS

All adult non-trauma patients who visited the 5 EDs from 1 July 2011 to 30 June 2012.

INTERVENTIONS

Patients were grouped by whether or not they underwent a CT scan (CT and non-CT groups, respectively).

PRIMARY AND SECONDARY OUTCOME MEASURES

The ED LOS and hospital LOS between patients who had and had not undergone CT scans were compared by stratifying different dispositions and diagnoses.

RESULTS

CT use prolonged patient ED LOS among those who were directly discharged from the ED. Among patients admitted to the observation unit and then discharged, patients diagnosed with nervous system disease had shorter ED LOS if they underwent a CT scan. CT use facilitated patient admission to the general ward. CT use also accelerated patients' admission to the intensive care unit (ICU) for patients with nervous system disease, neoplasm and digestive disease. Finally, patients admitted to the general wards had shorter hospital LOS if they underwent CT scans in the ED.

CONCLUSIONS

CT use did not seem to have delayed patient disposition in ED. While CT use facilitated patient disposition if they were finally hospitalised, it mildly prolonged ED LOS in cases of patients discharged from the ED.

New Intervention Model of Regional Transfer Network System to Alleviate Crowding of Regional Emergency Medical Center

Emergency department (ED) crowding is a serious problem in most tertiary hospitals in Korea. Although several intervention models have been established to alleviate ED crowding, they are limited to a single hospital-based approach. This study was conducted to determine whether the new regional intervention model could alleviate ED crowding in a regional emergency medical center. This study was designed as a "before and after study" and included patients who visited the tertiary hospital ED from November 2011 to October 2013. One tertiary hospital and 32 secondary hospitals were included in the study. A transfer coordinator conducted inter-hospital transfers from a tertiary hospital to a secondary hospital for suitable patients. A total of 1,607 and 2,591 patients transferred from a tertiary hospital before and after the study, respectively (P < 0.001). We found that the median ED length of stay (LOS) decreased significantly from 3.68 hours (interquartile range [IQR], 1.85 to 9.73) to 3.20 hours (IQR, 1.62 to 8.33) in the patient group after implementation of the Regional Transfer Network System (RTNS) (P < 0.001). The results of multivariate analysis showed a negative association between implementation of the RTNS and ED LOS (beta coefficient -0.743; 95% confidence interval -0.914 to -0.572; P < 0.001). In conclusion, the ED LOS in the tertiary hospital decreased after implementation of the RTNS.

Medical Team Evaluation: Effect on Emergency Department Waiting Time and Length of Stay

Emergency Departments (ED) are trying to alleviate crowding using various interventions. We assessed the effect of an alternative model of care, the Medical Team Evaluation (MTE) concept, encompassing team triage, quick registration, redesign of triage rooms and electronic medical records (EMR) on door-to-doctor (waiting) time and ED length of stay (LOS). We conducted an observational, before-and-after study at an urban academic tertiary care centre. On July 17^th 2014, MTE was initiated from 9:00 a.m. to 10 p.m., 7 days a week. A registered triage nurse was teamed with an additional senior ED physician. Data of the 5-month pre-MTE and the 5-month MTE period were analysed. A matched comparison of waiting times and ED LOS of discharged and admitted patients pertaining to various Emergency Severity Index (ESI) triage categories was performed based on propensity scores. With MTE, the median waiting times improved from 41.2 (24.8–66.6) to 10.2 (5.7–18.1) minutes (min; P < 0.01). Though being beneficial for all strata, the improvement was somewhat greater for discharged, than for admitted patients. With a reduction from 54.3 (34.2–84.7) to 10.5 (5.9–18.4) min (P < 0.01), in terms of waiting times, MTE was most advantageous for ESI4 patients. The overall median ED LOS increased for about 15 min (P < 0.01), increasing from 3.4 (2.1–5.3) to 3.7 (2.3–5.6) hours. A significant increase was observed for all the strata, except for ESI5 patients. Their median ED LOS dropped by 73% from 1.2 (0.8–1.8) to 0.3 (0.2–0.5) hours (P < 0.01). In the same period the total orders for diagnostic radiology increased by 1,178 (11%) from 10,924 to 12,102 orders, with more imaging tests being ordered for ESI 2, 3 and 4 patients. Despite improved waiting times a decrease of ED LOS was only seen in ESI level 5 patients, whereas in all the other strata ED LOS increased. We speculate that this was brought about by the tendency of triage physicians to order more diagnostic radiology, anticipating that it may be better for the downstream physician to have more information rather than less.

A systematic review of health service interventions to reduce use of unplanned health care in rural areas

RATIONALE, AIMS AND OBJECTIVES

Use of unplanned health care has long been increasing, and not enough is known about which interventions may reduce use. We aimed to review the effectiveness of interventions to reduce the use of unplanned health care by rural populations.

METHODS

The method used was systematic review. Scientific databases (Medline, Embase and Central), grey literature and selected references were searched. Study quality and bias was assessed using Cochrane Risk of Bias and modified Newcastle Ottawa Scales. Results were summarized narratively.

RESULTS

A total of 2708 scientific articles, reports and other documents were found. After screening, 33 studies met the eligibility criteria, of which eight were randomized controlled trials, 13 were observational studies of unplanned care use before and after new practices were implemented and 12 compared intervention patients with non-randomized control patients. Eight of the 33 studies reported modest statistically significant reductions in unplanned emergency care use while two reported statistically significant increases in unplanned care. Reductions were associated with preventative medicine, telemedicine and targeting chronic illnesses. Cost savings were also reported for some interventions.

CONCLUSION

Relatively few studies report on unscheduled medical care by specifically rural populations, and interventions were associated with modest reductions in unplanned care use. Future research should evaluate interventions more robustly and more clearly report the results.

Distribution and predictors of emergency department charges: the case of a tertiary hospital in Lebanon

Background

As health care costs continue to increase worldwide, health care systems, and more specifically hospitals are facing continuous pressure to operate more efficiently. One service within the hospital sector whose cost structure has been modestly investigated is the Emergency Department (ED). The study aims to report on the distribution of ED resource use, as expressed in charges, and to determine predictors of/contributors to total ED charges at a major tertiary hospital in Lebanon.

Methods

The study used data extracted from the ED discharge database for visits between July 31, 2012 and July 31, 2014. Patient visit bills were reported under six major categories: solutions, pharmacy, laboratory, physicians, facility, and radiology. Characteristics of ED visits were summarized according to patient gender, age, acuity score, and disposition. Univariate and multivariate analyses were conducted with total charges as the dependent variable.

Results

Findings revealed that the professional fee (40.9 %) followed by facility fee (26.1 %) accounted for the majority of the ED charges. While greater than 80 % of visit charges went to physician and facility fee for low acuity cases, these contributed to only 52 and 54 % of the high acuity presentations where ancillary services and solutions’ contribution to the total charges increased. The total charges for males were $14 higher than females; age was a predictor of higher charges with total charges of patients greater than 60 years of age being around $113 higher than ages 0–18 after controlling for all other variables.

Conclusion

Understanding the components and determinants of ED charges is essential to developing cost-containment interventions. Institutional modeling of charging patterns can be used to offer price estimates to ED patients who request this information and ultimately help create market competition to drive down costs.

A review of inpatient ward location and the relationship to Medical Emergency Team calls

OBJECTIVE

To identify the relationship between in-hospital location and patient outcomes as measured by Medical Emergency Team calls.

STUDY DESIGN

A narrative systematic review of the literature.

DATA SOURCES

A systematic search of the literature was conducted in October 2014 using the electronic databases: Embase, Cochrane, Medline, CINAHL, Science Direct and Google Scholar for the most recent literature from 1997 to 2014.

INCLUSION CRITERIA

Non-randomised study designs such as case control or cohort studies were eligible. Articles were selected independently by two researchers using a predetermined selection criterion.

DATA SYNTHESIS

The screening process removed manuscripts that did not meet the inclusion criteria resulting in an empty review with one manuscript meeting most of the criteria for inclusion. The protocol was revised to a narrative synthesis including a broader scope of studies. The search strategy was expanded and modified to include manuscripts of any study design that comprise both inlier and outlier patients. Two manuscripts were selected for the narrative synthesis.

CONCLUSION

Two recently published studies investigated the incidence of MET calls for outlier patients, and whilst MET calls were increased in outlier hospital patients, definitive conclusions associated with patient outcomes cannot be made at this time due to paucity of studies.

The impacts of prolonged emergency department length of stay on clinical outcomes of patients with ST-segment elevation myocardial infarction after reperfusion

Emergency department and hospital crowding have become an increasing problem. The clinical outcomes of prolonged emergency department (ED) length of stay in acute ST-segment elevation myocardial infarction (STEMI) patients after reperfusion are still unknown. Between January 2008 and December 2011, 432 consecutive patients with STEMI undergoing primary PCI were recruited. Patients were divided into two groups: the immediate admission group (length of ED stay <8 h; IA group) and the prolonged ED stay group (length of ED stay ≧8 h; PS group). The median lengths of ED stay of the patients in both groups were 29.97 h in the PS group (n = 145, 33.6%) and 1.78 h in the IA group (n = 287, 66.4%), respectively. The age, gender, risk factors of coronary artery disease, characteristic of coronary angiography, and TIMI risk score did not differ between the two groups. During nearly 4-year clinical follow-up, the short-term and long-term clinical outcomes were similar between the two groups. B-blocker and statins were used infrequently in the ED. In addition, patients with high TIMI risk score in the PS group had higher incidence of 1-year re-MI (6.8 vs. 1.8%; p = 0.045). In the era of primary PCI for STEMI patients after reperfusion, prolonged ED length of stay may not influence clinical outcomes. Patients with high TIMI risk score in the PS group still had a trend toward worse clinical outcome after long ED stays.

Quality in paediatric emergency medicine: Measurement and reporting

There is a clear demand for quality in the delivery of health care around the world; paediatric emergency medicine is no exception to this movement. It has been identified that gaps exist in the quality of acute care provided to children. Regulatory bodies in Australia and New Zealand are moving to mandate the implementation of quality targets and measures. Within the paediatric emergency department (ED), there is a lack of research into paediatric specific indicators. The existing literature regarding paediatric acute care quality measures has been recently summarised, and expert consensus has now been reported. It is clear that there is much work to be performed to generalise this work to ED. We review suggestions from the current literature relating to feasible indicators within the paediatric acute care setting. We propose options to develop a quality 'scorecard' that could be used to assist Australian and New Zealand EDs with quality measurement and benchmarking for their paediatric patients.

Effects of a general practitioner cooperative co-located with an emergency department on patient throughput

BACKGROUND

In 2013 a General Practitioner Cooperative (GPC) was introduced at the Emergency Department (ED) of our hospital. One of the aims of this co-located GPC was to improve throughput of the remaining patients at the ED. To determine the change in patient flow, we assessed the number of self-referrals, redirection of self-referrals to the GPC and back to the ED, as well as ward and ICU admission rates and length of stay of the remaining ED population.

METHODS

We conducted a four months' pre-post comparison before and after the implementation of a co-located GPC with an urban ED in the Netherlands.

RESULTS

More than half of our ED patients were self-referrals. At triage, 54.5% of these self-referrals were redirected to the GPC. After assessment at the GPC, 8.5% of them were referred back to the ED. The number of patients treated at the ED declined with 20.3% after the introduction of the GPC. In the remaining ED population, there was a significant increase of highly urgent patients (P<0.001), regular admissions (P<0.001), and ICU admissions (P<0.001). Despite the decline of the number of patients at the ED, the total length of stay of patients treated at the ED increased from 14 682 hours in the two months' control period to 14 962 hours in the two months' intervention period, a total increase of 270 hours in two months (P<0.001).

CONCLUSION

Introduction of a GPC led to efficient redirection of self-referrals but failed to improve throughput of the remaining patients at the ED.

How vital are the vital signs? A multi-center observational study from emergency departments of Pakistan

BACKGROUND

Vital signs play a critical role in prioritizing patients in emergency departments (EDs), and are the foundation of most triage methods and disposition decisions. This study was conducted to determine the frequency of vital signs documentation anytime during emergency department treatment and to explore if abnormal vital signs were associated with the likelihood of admission for a set of common presenting complaints.

METHODS

Data were collected over a four-month period from the EDs of seven urban tertiary care hospitals in Pakistan. The variables included age, sex, hospital type (government run vs. private), presenting complaint, ED vital signs, and final disposition. Patients who were >12 years of age were included in the analysis. The data were analyzed to describe the proportion of patients with documented vitals signs, which was then crossed-tabulated with top the ten presenting complaints to identify high-acuity patients and correlation with their admission status.

RESULTS

A total of 274,436 patients were captured in the Pakistan National Emergency Department Surveillance (Pak-NEDS), out of which 259,288 patients were included in our study. Vital signs information was available for 90,569 (34.9%) patients and the most commonly recorded vitals sign was pulse (25.7%). Important information such as level of consciousness was missing in the majority of patients with head injuries. Based on available information, only 13.3% with chest pain, 12.8% with fever and 12.8% patients with diarrhea could be classified as high-acuity. In addition, hospital admission rates were two- to four-times higher among patients with abnormal vital signs, compared with those with normal vital signs.

CONCLUSION

Most patients seen in the EDs in Pakistan did not have any documented vital signs during their visit. Where available, the presence of abnormal vital signs were associated with higher chances of admission to the hospital for the most common presenting symptoms.

Solving the worldwide emergency department crowding problem - what can we learn from an Israeli ED?

ED crowding is a prevalent and important issue facing hospitals in Israel and around the world, including North and South America, Europe, Australia, Asia and Africa. ED crowding is associated with poorer quality of care and poorer health outcomes, along with extended waits for care. Crowding is caused by a periodic mismatch between the supply of ED and hospital resources and the demand for patient care. In a recent article in the Israel Journal of Health Policy Research, Bashkin et al. present an Ishikawa diagram describing several factors related to longer length of stay (LOS), and higher levels of ED crowding, including management, process, environmental, human factors, and resource issues. Several solutions exist to reduce ED crowding, which involve addressing several of the issues identified by Bashkin et al. This includes reducing the demand for and variation in care, and better matching the supply of resources to demands in care in real time. However, what is needed to reduce crowding is an institutional imperative from senior leadership, implemented by engaged ED and hospital leadership with multi-disciplinary cross-unit collaboration, sufficient resources to implement effective interventions, access to data, and a sustained commitment over time. This may move the culture of a hospital to facilitate improved flow within and across units and ultimately improve quality and safety over the long-term.

An Interrupted Time-Series Analysis to Assess Impact of Introduction of Co-Payment on Emergency Room Visits in Cyprus

INTRODUCTION

A co-payment fee of EUR10 was introduced in Cyprus, in order to cope with overcrowding of emergency room services. The scope of this paper is the assessment of the short-term impact of this measure.

METHODS

We used an interrupted time-series autoregressive integrated moving average model, and we analyzed official data from Cyprus' largest emergency room facility for three years.

RESULTS

Co-payment is associated with a 16% statistically significant reduction of emergency room visits. No impact was observed in categories of teenagers, children, infants, and people over 70 years old.

CONCLUSIONS

Co-payment was proven to be effective in Cyprus' emergency room setting and is expected to lessen congestion in the emergency room. The price insensitivity of people aged over 70 years, teenagers, children and infants, merits additional research for the identification of the underlying reasons.

The Robustness and Effectiveness of the Triage System at Times of Overcrowding and the Extra Costs due to Inappropriate Use of Emergency Departments

BACKGROUND

Overcrowding is one of the most harmful problems for Emergency Department (ED) management and the correct estimation of time resource absorption by each type of patient plays a strategic role in dealing with overcrowding and correctly programming ED activity.

OBJECTIVE

We aimed to investigate how overcrowding may affect urgent patients' waiting times (i.e., the robustness of the triage patient priority system) and to evaluate the extra costs due to inappropriate use of EDs.

METHODS

Data referring to 54,254 patients who accessed the ED of a major Italian hospital in 2011 were analyzed to study patient flows and overcrowding. To define an average per-patient cost, according to the severity of his or her health condition, the 2010 profit and loss account of the aforementioned hospital was studied and the time devoted by physicians to each type of patient was estimated by means of a self-reported survey.

RESULTS

Empirical findings confirm a positive correlation between overcrowding and the time a patient has to wait before receiving treatment. This effect is relevant only for non-urgent patients who are responsible for the overcrowding itself. However, urgent patients' waiting times do not increase in the presence of overcrowding, confirming that the triage priority system is robust against the overcrowding situation. The analysis estimates, using 2010 data, that the actual per patient cost incurred by the hospital when treating white-coded patients is, on average, 36.54 euros; a green code costs 93.17, yellow 170.62, and red 227.62. It emerges that 4% of all the personnel costs are attributable to white color-code assistance, 67% to green codes, 23% to yellow codes, and the remaining 6% to red codes.

CONCLUSION

The implementation of effective policies intended to improve both efficiency and quality in providing emergency health services has to deal with the systemic problem of inappropriate use of EDs. Policy-makers should be aware of the fact that there is a considerable portion of ED demand for assistance that is inappropriate and that oversizing EDs with respect to the true, appropriate, urgent patients' demands, could bring about a further and undesirable rise in inappropriate assistance demands and, therefore, an increase in ED costs that are not consistent with their objectives.