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Wu Y, Wang DY, Zhao S, Wang MH, Wong ELY, Yeoh EK. Emergency Department Use Across Income Groups Following an Increase in Cost-Sharing. JAMA Netw Open 2023; 6:e2329577. [PMID: 37589972 PMCID: PMC10436128 DOI: 10.1001/jamanetworkopen.2023.29577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/11/2023] [Indexed: 08/18/2023] Open
Abstract
Importance To encourage the appropriate utilization of emergency care, cost-sharing for emergency care was increased from HK$100 (US $12.8) to HK$180 (US $23.1) per visit in June 2017 in all public hospitals in Hong Kong. However, there are concerns that this increase could deter appropriate emergency department (ED) visits and be associated with income-related disparities. Objective To examine changes in ED visits after the fee increase. Design, Setting, and Participants This retrospective cohort study used administrative data from June 2015 to May 2019 from all public hospitals in Hong Kong. Participants included all Hong Kong residents aged 64 years and younger, categorized into low-income, middle-income, and high-income groups according to the median household income in their district of residence. Data analysis was performed from May to June 2023. Main Outcomes and Measures The primary outcome was the ED visit rate per 100 000 people per month, categorized into 3 severity levels (emergency, urgent, and nonurgent). Secondary outcomes include general outpatient (GOP) visit rate, emergency admission rate, and in-hospital mortality rate per month at public hospitals. Segmented regression analyses were used to estimate changes in the level and slope of outcome variables before and after the fee increase. Results This study included a total of 5 441 679 ED patients (2 606 332 male patients [47.9%]; 2 108 933 patients [38.5%] aged 45-64 years), with 2 930 662 patients (1 407 885 male patients [48.0%]; 1 111 804 patients [37.9%] aged 45-64 years) from the period before the fee increase. The fee increase was associated with an 8.0% (95% CI, 7.1%-9.0%) immediate reduction in ED visits after June 2017, including a 5.9% (95% CI, 3.3%-8.5%) reduction in urgent visits and an 8.9% (95% CI, 8.0%-9.8%) reduction in nonurgent visits. In addition, a 5.7% (95% CI, 4.7%-6.8%) reduction of emergency admissions was found, whereas no significant changes were observed in in-hospital mortality. Specifically, a statistically significant increase in GOP visits (4.1%; 95% CI, 0.9%-7.2%) was found within the low-income group, but this association became insignificant after controlling for the social security group, who were exempted from payment, as a control. Conclusions and Relevance In this cohort study, the fee increase was not associated with changes in ED visits for emergency conditions, but there was a negative and significant association with both urgent and nonurgent conditions across all income groups. Considering the marginal increase in public GOP services, further study is warranted to examine strategies to protect low-income people from avoiding necessary care.
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Affiliation(s)
- Yushan Wu
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems and Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Dorothy Yingxuan Wang
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Shi Zhao
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems and Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
| | - Maggie Haitian Wang
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
| | - Eliza Lai-yi Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems and Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Eng-kiong Yeoh
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems and Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
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Pérez-Milena A, Ramos-Ruiz JA, Zafra-Ramirez N, Noguera-Cuenca C, Rodríguez-Bayón A, Ruiz-Díaz B. Qualitative study on the use of emergency services by people with serious mental disorder in Spain. BMC PRIMARY CARE 2023; 24:125. [PMID: 37340353 PMCID: PMC10280892 DOI: 10.1186/s12875-023-02078-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/08/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The population with severe mental disorders (SMD) is a frequent user of emergency services. Situations of psychiatric decompensation can have devastating consequence and can cause problems in getting urgent medical care. The objective was to study the experiences and needs of these patients and their caregivers regarding the demand for emergency care in Spain. METHODS Qualitative methodology involving patients with SMD and their informal caregivers. Purposive sampling by key informants in urban and rural areas. Paired interviews were carried out until data saturation. A discourse analysis was conducted, obtaining a codification in categories by means of triangulation. RESULTS Forty-two participants in twenty-one paired interviews (19 ± 7.2 min as mean duration). Three categories were identified. 1º Reasons for urgent care: poor self-care and lack of social support, as well as difficulties in accessibility and continuity of care in other healthcare settings. 2º Urgent care provision: trust in the healthcare professional and the information patients receive from the healthcare system is crucial, telephone assistance can be a very useful resource. 3º Satisfaction with the urgent care received: they request priority care without delays and in areas separated from the other patients, as well as the genuine interest of the professional who attends them. CONCLUSIONS The request for urgent care in patients with SMD depends on different psychosocial determinants and not only on the severity of the symptoms. There is a demand for care that is differentiated from the other patients in the emergency department. The increase in social networks and alternative systems of care would avoid overuse of the emergency departments.
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Affiliation(s)
- Alejandro Pérez-Milena
- "El Valle" Primary Care Center, Andalusian Public Health System, 4 Human Rights Street, 23009, Jaén, Spain.
| | - Juan Andrés Ramos-Ruiz
- Multiprofessional Teaching Unit of Family and Community Care Jaén North - Northeast, Andalusian Public Health System, Linares, Spain
| | - Natalia Zafra-Ramirez
- Multiprofessional Teaching Unit of Family and Community Care Jaén - South Jaén, Andalusian Public Health System, Jaén, Spain
| | | | - Antonina Rodríguez-Bayón
- Multiprofessional Teaching Unit of Family and Community Care North - Northeast Jaén, Andalusian Public Health System, Jaén, Spain
| | - Beatriz Ruiz-Díaz
- "El Valle" Primary Care Center, Andalusian Public Health System, 4 Human Rights Street, 23009, Jaén, Spain
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Graham CA, Leung LY, Lo RSL, Yeung CY, Chan SY, Hung KKC. NEWS and qSIRS superior to qSOFA in the prediction of 30-day mortality in emergency department patients in Hong Kong. Ann Med 2020; 52:403-412. [PMID: 32530356 PMCID: PMC7877938 DOI: 10.1080/07853890.2020.1782462] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND We aim to compare the prognostic value of Quick Sepsis-Related Organ Failure Assessment (qSOFA) and the previous Systemic Inflammatory Response Syndrome (SIRS) criteria, the National Early Warning Score (NEWS) and along with their combinations in the emergency department (ED). METHODS This single-centre prospective study recruited a convenience sample of unselected ED patients triaged as category 2 (Emergency) and 3 (Urgent). Receiver Operating Characteristic analyses were performed to determine the Area Under the Curve (AUC), along with sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios for the various scores. RESULTS Of 1253 patients recruited, overall 30-day mortality was 5.7%. The prognostic value for prediction of 30-day mortality, with AUCs for qSOFA ≥2, SIRS ≥2, NEWS ≥5, qSIRS (qSOFA + SIRS) ≥2 and NSIRS (NEWS + SIRS) ≥5 of 0.56 (95%CI 0.53-0.58), 0.61 (95%CI 0.58-0.64), 0.61 (95%CI 0.58-0.64), 0.64 (95%CI 0.62-0.67) and 0.61 (95%CI 0.58-0.63), respectively. Using pairwise comparisons of ROC curves, NEWS ≥5 and qSIRS ≥2 were better than qSOFA ≥2 at predicting 30-day mortality. CONCLUSIONS Among unselected emergency and urgent ED patients, the prognostic value for NEWS and qSIRS were greater than qSOFA, Combinations of qSOFA and SIRS could improve the predictive value for 30-day mortality for ED patients. Key messages NEWS ≥5 and qSIRS ≥2 were better than qSOFA ≥2 at predicting 30-day mortality in ED patients. Combinations of qSOFA and SIRS could improve the predictive value for 30-day mortality for ED patients.
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Affiliation(s)
- Colin A Graham
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ling Yan Leung
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ronson Sze Long Lo
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chun Yu Yeung
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Suet Yi Chan
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kevin Kei Ching Hung
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong SAR, China
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A Study of the Pattern of Admissions to the Accident and Emergency (A&E) Department of a Tertiary Care Hospital in Sri Lanka. Emerg Med Int 2020; 2020:6327293. [PMID: 32855825 PMCID: PMC7443021 DOI: 10.1155/2020/6327293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 07/20/2020] [Accepted: 07/27/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction The latest national healthcare reform policies of Sri Lanka include the development of accident and emergency (A&E) departments in all major hospitals. Provincial General Hospital Kurunegala (PGHK) is a home to the first established A&E department in Sri Lanka. PGHK provides services to a population of 2.4 million spread out in the North Western Province and part of the Sabaragamuwa Province. This study was carried out to identify the pattern of all admissions to the A&E department of PGHK. Methods The prospective observational study was carried out from July 1, 2016, to June 30, 2017 (one year) to identify the pattern of admissions to the A&E department. Results There were 49,213 admissions to PGHK's A&E department during the study period. The average number of admissions was 135 (±17.9) per day. The percentage of deaths in the A&E department was 0.21%. The mean age of admitted patients was 46.7 (±21.7) years. A further 62% of admitted patients were males. The number of medical, surgical, paediatric, and gynaecological and obstetrical admissions was 55%, 42%, 3.5%, and 0.22%, respectively. Among the common emergency medical presentations, 34% were chest pain, 11% patients presented with unilateral weakness and/or slurring of speech, 10% covered dyspnoea, and 9% complained of dizziness/giddiness. Among emergency surgical presentations, 83% were trauma due to accidents, of which 27% were road-traffic-related accidents (RTAs). Discussion. The A&E department of PGHK provides services to a significantly high number of health emergencies every day. The majority of these admissions was due to chest pain and trauma related to accidents. The lower recorded number of paediatric and gynaecological and obstetrical emergencies presented to the A&E department is a result of a government policy mandating the admission of these types of patients directly to their respective wards. Further infrastructure development, staff recruitment, and training have to be planned and implemented to address the significantly high number of admissions to the A&E Department of PGHK.
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Graham CA, Leung LY, Lo RS, Lee KH, Yeung CY, Chan SY, Cattermole GN, Hung KK. Agreement between capillary and venous lactate in emergency department patients: prospective observational study. BMJ Open 2019; 9:e026109. [PMID: 30948594 PMCID: PMC6500234 DOI: 10.1136/bmjopen-2018-026109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Capillary blood lactate testing with handheld analysers has great advantages to reduce the time needed for clinical decisions, and for extended use in the prehospital setting. We investigated the agreement of capillary lactate measured using handheld analysers (CL-Nova and CL-Scout+ measured by Nova and Lactate Scout+ analyzers) and the reference venous level assessed using a point-of-care testing (POCT) blood gas analyser (VL-Ref). DESIGN A prospective observational study. SETTING A university teaching hospital emergency department in Hong Kong. PARTICIPANTS Patients triaged as 'urgent' (Category 3 of a 5-point scale), aged ≥18 years during 2016 were eligible. 240 patients (mean age 69.9 years) were recruited. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was the agreement of the capillary blood lactate level measured by handheld lactate analyser when compared with the reference standard technique, namely venous blood samples obtained by venepuncture and analysed using the blood gas analyser. The secondary outcome measure was the difference in values of venous lactate using blood gas analysers and handheld lactate analysers. RESULTS The results of VL-Ref ranged from 0.70 to 5.38 mmol/L (mean of 1.96 mmol/L). Regarding capillary lactate measurements, the bias (mean difference) between VL-Ref and CL-Scout+ was -0.22 with 95% limits of agreement (LOA) of -2.17 to 1.73 mmol/L and the bias between VL-Ref and CL-Nova was 0.46, with LOA of -1.08 to 2.00 mmol/L. For venous lactate, results showed the bias between VL-Ref and VL-Scout+ was 0.22 with LOA being -0.46 to 0.90 mmol/L, and the bias between VL-Ref and VL-Nova was 0.83 mmol/L with LOA -0.01 to 1.66 mmol/L. CONCLUSION Our study shows poor agreement between capillary lactate and reference values. The study does not support the clinical utility of capillary lactate POCT. However, venous lactate measured by Scout+ handheld analyser may have potential for screening patients who may need further testing. TRIAL REGISTRATION NUMBER NCT02694887.
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Affiliation(s)
- Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, Hong Kong
- Emergency Department, Prince of Wales Hospital, Shatin, Hong Kong SAR
| | - Ling Yan Leung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ronson Sl Lo
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kwok Hung Lee
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, Hong Kong
- Emergency Department, Prince of Wales Hospital, Shatin, Hong Kong SAR
| | - Chun Yu Yeung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Suet Yi Chan
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Giles N Cattermole
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kevin Kc Hung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, Hong Kong
- Emergency Department, Prince of Wales Hospital, Shatin, Hong Kong SAR
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Lowthian JA, Brand C, Barker AL, Andrianopoulos N, Smith C, Batey C, Smit PD, Newnham HH, Hunter P, Cameron PA. Managing Older Patients Safely in the Time Critical Environment of an Emergency Department. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791201900405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Demand for emergency department (ED) services is increasing worldwide. The fastest growth in ED presentations is by patients aged ≥65 years, currently representing 18% of all attendances. Older patients present with more complex clinical conditions and multiple co-morbidities. This means they are likely to spend more time in ED, are more likely to be admitted to hospital, and are more likely to re-attend. The Safe Elderly Emergency Discharge (SEED) project aims to determine whether current models of emergency care ensure safe discharge and facilitate optimal health outcomes for older patients; and develop a tailored evidence-based care framework applicable to Australian and international settings. Risk screening for unsafe discharge will be conducted on patients aged ≥65 years discharged home from ED. Patients will be followed for 6 months post-ED presentation to monitor health outcomes and map their care journey. Demographic, clinical, and functional characteristics will be collected. The primary outcome is unsafe discharge, defined as unplanned re-presentation/admission within 30 days of the index presentation. Secondary outcomes include unplanned ED re-presentation/hospital admission within 6 months; patient experience; change in functional status; functional decline; health service utilisation; and death within 6 months. The effectiveness of the ED discharge risk screening tools for predicting unsafe discharge will be evaluated at 30 days and 6 months. SEED will determine the risk factors for unplanned ED re-presentation/hospital admission at 30 days for patients aged ≥65 years presenting to ED; which will inform the development of an evidence-based older patient care framework for EDs.
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Affiliation(s)
| | | | | | | | - C Smith
- Alfred Health, Alfred Emergency & Trauma Centre, Melbourne, Australia
| | - C Batey
- Alfred Health, Alfred Emergency & Trauma Centre, Melbourne, Australia
| | - PDeV Smit
- Alfred Health, Alfred Emergency & Trauma Centre, Melbourne, Australia
| | - HH Newnham
- Alfred Health, General Medicine, Melbourne, Australia
| | - P Hunter
- Alfred Health, Alfred Emergency & Trauma Centre, Melbourne, Australia
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Lam HC, Lee HKH, Ting SM, Li KM. The Impact of Enhanced Triage on the Emergency Service with Special Track Streams. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791201900601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Over sixty percent of emergency department (ED) attendances belonged to the semi-urgent or non-urgent categories. The existing triage system failed to detect those patients in need of emergency service within these groups. It increased the risk to patients and affected the quality of care especially with overcrowding and long waiting time. Objective To assess the impact of a special track program in providing medical services to targeted groups and on the overall emergency service. Method Four special groups of patients triaged as semi- or non-urgent and required procedural interventions or possible in-hospital treatment were identified. The impact on waiting time, length of stay, rate of left without being seen and re-attendances rate were measured and studied prospectively. Results A total of 438 cases were analysed. Special track groups had a shorter mean waiting time and mean disposal time (36.6 minutes and one hour) when compared with all category 4 patients. Special track group had no disappeared case and a smaller re-attendance rate. Conclusions Special track program improves the safety and quality of care in patients of fast track streams without compromising care to other semi-urgent or non-urgent categories patients.
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Lee JCY, Tung KTS, Li TMH, Ho FKW, Ip P, Wong WHS, Chow CB. Fall-related attendance and associated hospitalisation of children and adolescents in Hong Kong: a 12-year retrospective study. BMJ Open 2017; 7:e013724. [PMID: 28174223 PMCID: PMC5306530 DOI: 10.1136/bmjopen-2016-013724] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The present study aimed to examine the trends and characteristics of fall-related attendance in accident and emergency department (AED) by injury type and the trend in associated average length of stay (LOS) among children and adolescents in Hong Kong. DESIGN A retrospective approach was adopted. SETTING AED, involving all local public emergency departments from 2001 to 2012. PARTICIPANTS 63 557 subjects aged 0-19 years with fall injury record were included in the analysis. PRIMARY OUTCOME MEASURES Fall-related injury number and rates were calculated and reported. Poisson and negative binomial regression models were used to study the trends of injury incidence rate at different body regions. RESULTS AED fall-related attendance rate increased significantly with an annual percentage change of 4.45 (95% CI 3.43 to 5.47%, p<0.0001). The attendance number of male subjects was persistently higher than female subjects. The standardised rate of fracture injury increased by 1.31% (95% CI 0.56 to 2.05%, p<0.0001) and that of non-fracture injury increased by 9.23% (95% CI 7.07 to 11.43%, p<0.0001) annually. Upper limb was the most frequently fractured location. It included forearm/elbow, shoulder/upper arm and wrist/hand with descending order of frequency. On the contrary, head was the most frequent non-fracture location, followed by forearm/elbow. CONCLUSIONS The rates of fall-related attendance have been increasing and still remain high. There were significant increases in non-fracture injuries. Fractures were most frequently found in the upper extremity of a child while the most common non-fracture location was head. It appears that more efforts should be made and preventive measures should be implemented for children and adolescents in Hong Kong.
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Affiliation(s)
- James Chun-Yin Lee
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Keith Tsz-Suen Tung
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Tim M H Li
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Frederick Ka-Wing Ho
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Patrick Ip
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Wilfred Hing-Sang Wong
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chun-Bong Chow
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Madavan Nambiar KT, Nedungalaparambil NM, Aslesh OP. Studying the Variability in Patient Inflow and Staffing Trends on Sundays versus Other Days in the Academic Emergency Department. J Emerg Trauma Shock 2017; 10:121-127. [PMID: 28855774 PMCID: PMC5566018 DOI: 10.4103/jets.jets_139_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Resource limitation, staff deficiency, and variability in patient inflow contribute to emergency department (ED) overcrowding, associated with delayed care, poor care, and poor patient outcomes. This study seeks to describe and analyze patient inflow variability and staffing trends on Sundays versus other days in a tertiary academic ED from South India. Methods: Patient inflow and staffing data for 2 years were collected from hospital records, cross-checked, and statistically analyzed using Epi Info 7.0. Results: Significant increase in patient inflow (45.6%) was noted on Sundays compared to other days (155.9 [95% confidence interval (CI): 152.75–159.05] vs. 107.1 [95% CI: 105.98–108.22]; P < 0.001), with higher inflow in the morning shifts (67.4 [95% CI: 65.41–69.45] vs. 32.1 [95% CI: 31.45–32.70]; P < 0.001). All categories of ED staff were deficient across all shifts (2.1 [95% CI: 2.05–2.15] tier-2 physicians, 4.9 [95% CI: 4.86–4.94] nurses, and 1.9 [95% CI: 1.88–1.92] nurse assistants on an average), especially tier-1 physicians (0.3 [95% CI: 0.24–0.36] on Sundays and 0.5 [95% CI: 0.48–0.52] on other days; P < 0.001). Patient-per-hour (PPH)-per-provider based on patient arrival rate was generally high. PPH per tier-1 physician was the highest, being 10.6 (95% CI: 9.95–11.14) versus 5.4 (95% CI: 5.26–5.59; P < 0.001) in the morning and 7.2 (95% CI: 6.95–7.45) versus 6.6 (95% CI: 6.43–6.74; P = 0.08) in the evening shifts on Sundays and other days, respectively. Conclusions: There were deficiencies in all categories of ED staff on all days, and this was pronounced on Sundays due to significantly higher patient inflow. Inadequate ED staffing, especially due to a significant dearth of tier-1 physicians is a pointer toward quality compromise in developing EDs. Authors recommend adequate staff deployment in developing EDs for optimum quality care. This should be implemented such that staffing is based on expected patient inflow so that a PPH-per-provider goal of 2.5 is targeted across all shifts.
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Affiliation(s)
- K T Madavan Nambiar
- Department of Emergency Medicine, Academy of Medical Sciences, Kannur, Kerala, India
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Pun JKH, Matthiessen CMIM, Murray KA, Slade D. Factors affecting communication in emergency departments: doctors and nurses' perceptions of communication in a trilingual ED in Hong Kong. Int J Emerg Med 2015; 8:48. [PMID: 26667242 PMCID: PMC4678128 DOI: 10.1186/s12245-015-0095-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 12/02/2015] [Indexed: 11/10/2022] Open
Abstract
Background This study investigates clinicians’ views of clinician-patient and clinician-clinician communication, including key factors that prevent clinicians from achieving successful communication in a large, high-pressured trilingual Emergency Department (ED) in Hong Kong. Methods Researchers interviewed 28 doctors and nurses in the ED. The research employed a qualitative ethnographic approach. The interviews were audio-recorded, transcribed, translated into English and coded using the Nvivo software. The researchers examined issues in both clinician-patient and clinician-clinician communication. Through thematic analyses, they identified the factors that impede communication most significantly, as well as the relationship between these factors. This research highlights the significant communication issues and patterns in Hong Kong EDs. Results The clinician interviews revealed that communication in EDs is complex, nuanced and fragile. The data revealed three types of communication issues: (1) the experiential parameter (i.e. processes and procedures), (2) the interpersonal parameter (i.e. clinicians’ engagements with patients and other clinicians) and (3) contextual factors (i.e. time pressures, etc.). Within each of these areas, the specific problems were the following: compromises in knowledge transfer at key points of transition (e.g. triage, handover), inconsistencies in medical record keeping, serious pressures on clinicians (e.g. poor clinician-patient ratio and long working hours for clinicians) and a lack of focus on interpersonal skills. Conclusions These communication problems (experiential, interpersonal and contextual) are intertwined, creating a complex yet weak communication structure that compromises patient safety, as well as patient and clinician satisfaction. The researchers argue that hospitals should develop and implement best-practice policies and educational programmes for clinicians that focus on the following: (1) understanding the primary causes of communication problems in EDs, (2) accepting the tenets and practices of patient-centred care, (3) establishing clear and consistent knowledge transfer procedures and (4) lowering the patient-to-clinician ratio in order to create the conditions that foster successful communication. The research provides a model for future research on the relationship between communication and the quality and safety of the patient safety.
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Affiliation(s)
- Jack K H Pun
- Department of English, The Hong Kong Polytechnic University, Hong Kong SAR, China. .,The International Research Centre for Communication in Healthcare (IRCCH), The Hong Kong Polytechnic University, Hong Kong; & The University of Technology Sydney, Sydney, Australia. .,Department of Education, St Antony's College, University of Oxford, Oxford, UK.
| | - Christian M I M Matthiessen
- Department of English, The Hong Kong Polytechnic University, Hong Kong SAR, China.,The International Research Centre for Communication in Healthcare (IRCCH), The Hong Kong Polytechnic University, Hong Kong; & The University of Technology Sydney, Sydney, Australia
| | - Kristen A Murray
- Department of English, The Hong Kong Polytechnic University, Hong Kong SAR, China.,The International Research Centre for Communication in Healthcare (IRCCH), The Hong Kong Polytechnic University, Hong Kong; & The University of Technology Sydney, Sydney, Australia
| | - Diana Slade
- Department of English, The Hong Kong Polytechnic University, Hong Kong SAR, China.,The International Research Centre for Communication in Healthcare (IRCCH), The Hong Kong Polytechnic University, Hong Kong; & The University of Technology Sydney, Sydney, Australia.,Faculty of Arts and Social Science, The University of Technology Sydney, Sydney, Australia
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Brabrand M, Lassen AT, Knudsen T, Hallas J. Seven-day mortality can be predicted in medical patients by blood pressure, age, respiratory rate, loss of independence, and peripheral oxygen saturation (the PARIS score): a prospective cohort study with external validation. PLoS One 2015; 10:e0122480. [PMID: 25867881 PMCID: PMC4395094 DOI: 10.1371/journal.pone.0122480] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 02/22/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Most existing risk stratification systems predicting mortality in emergency departments or admission units are complex in clinical use or have not been validated to a level where use is considered appropriate. We aimed to develop and validate a simple system that predicts seven-day mortality of acutely admitted medical patients using routinely collected variables obtained within the first minutes after arrival. METHODS AND FINDINGS This observational prospective cohort study used three independent cohorts at the medical admission units at a regional teaching hospital and a tertiary university hospital and included all adult (≥ 15 years) patients. Multivariable logistic regression analysis was used to identify the clinical variables that best predicted the endpoint. From this, we developed a simplified model that can be calculated without specialized tools or loss of predictive ability. The outcome was defined as seven-day all-cause mortality. 76 patients (2.5%) met the endpoint in the development cohort, 57 (2.0%) in the first validation cohort, and 111 (4.3%) in the second. Systolic blood Pressure, Age, Respiratory rate, loss of Independence, and peripheral oxygen Saturation were associated with the endpoint (full model). Based on this, we developed a simple score (range 0-5), ie, the PARIS score, by dichotomizing the variables. The ability to identify patients at increased risk (discriminatory power and calibration) was excellent for all three cohorts using both models. For patients with a PARIS score ≥ 3, sensitivity was 62.5-74.0%, specificity 85.9-91.1%, positive predictive value 11.2-17.5%, and negative predictive value 98.3-99.3%. Patients with a score ≤ 1 had a low mortality (≤ 1%); with 2, intermediate mortality (2-5%); and ≥ 3, high mortality (≥ 10%). CONCLUSIONS Seven-day mortality can be predicted upon admission with high sensitivity and specificity and excellent negative predictive values.
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Affiliation(s)
- Mikkel Brabrand
- Department of Medicine, Sydvestjysk Sygehus, Esbjerg, Denmark
- Centre South Western Denmark, Institute of Regional Health Research—University of Southern Denmark, Esbjerg, Denmark
- * E-mail:
| | | | - Torben Knudsen
- Department of Medicine, Sydvestjysk Sygehus, Esbjerg, Denmark
- Centre South Western Denmark, Institute of Regional Health Research—University of Southern Denmark, Esbjerg, Denmark
| | - Jesper Hallas
- Reseach Unit of Clinical Pharmacology, University of Southern Denmark, Odense, Denmark
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Integrating simulation with simulated annealing for scheduling physicians in an understaffed emergency department. ACTA ACUST UNITED AC 2014. [DOI: 10.1080/1023697x.2014.970748] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Jung H, Do YK, Kim Y, Ro J. The impact of an emergency fee increase on the composition of patients visiting emergency departments. J Prev Med Public Health 2014; 47:309-16. [PMID: 25475198 PMCID: PMC4263005 DOI: 10.3961/jpmph.14.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 10/27/2014] [Indexed: 12/22/2022] Open
Abstract
Objectives: This study aimed to test our hypothesis that a raise in the emergency fee implemented on March 1, 2013 has increased the proportion of patients with emergent symptoms by discouraging non-urgent emergency department visits. Methods: We conducted an analysis of 728 736 patients registered in the National Emergency Department Information System who visited level 1 and level 2 emergency medical institutes in the two-month time period from February 1, 2013, one month before the raise in the emergency fee, to March 31, 2013, one month after the raise. A difference-in-difference method was used to estimate the net effects of a raise in the emergency fee on the probability that an emergency visit is for urgent conditions. Results: The percentage of emergency department visits in urgent or equivalent patients increased by 2.4% points, from 74.2% before to 76.6% after the policy implementation. In a group of patients transferred using public transport or ambulance, who were assumed to be least conscious of cost, the change in the proportion of urgent patients was not statistically significant. On the other hand, the probability that a group of patients directly presenting to the emergency department by private transport, assumed to be most conscious of cost, showed a 2.4% point increase in urgent conditions (p<0.001). This trend appeared to be consistent across the level 1 and level 2 emergency medical institutes. Conclusions: A raise in the emergency fee implemented on March 1, 2013 increased the proportion of urgent patients in the total emergency visits by reducing emergency department visits by non-urgent patients.
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Affiliation(s)
- Hyemin Jung
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
| | - Young Kyung Do
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea ; Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, Korea
| | - Yoon Kim
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea ; Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, Korea
| | - Junsoo Ro
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
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Claret PG, Bobbia X, Richard P, Poher F, de La Coussaye JE. Surcharge du service des urgences : causes, conséquences et ébauches de solutions. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0415-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Xu M, Wong T, Chin K. A medical procedure-based patient grouping method for an emergency department. Appl Soft Comput 2014. [DOI: 10.1016/j.asoc.2013.09.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Williams G, Crilly J, Souter J, Veach K, Good N. A state wide validation and utilisation study of the Queensland emergency nursing workforce tool. J Nurs Manag 2013; 22:1076-88. [DOI: 10.1111/jonm.12063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Ged Williams
- Gold Coast Health Service District; Gold Coast Queensland Australia
- Health Practice Innovation; Griffith Health Institute; Griffith University; Gold Coast Queensland Australia
| | - Julia Crilly
- Health Practice Innovation; Griffith Health Institute; Griffith University; Gold Coast Queensland Australia
- State Wide Emergency Department Clinical Network; Gold Coast Hospital; Southport Queensland Australia
| | - Jeffrey Souter
- Nursing Clinical Support Unit; Townsville Hospital; Townsville Queensland Australia
| | - Kate Veach
- Business Planning Framework Project; Nursing and Midwifery Office; Brisbane Queensland Australia
| | - Norm Good
- Division of Mathematics; Informatics & Statistics; CSIRO; Royal Brisbane and Women's Hospital; Herston Queensland Australia
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Delays in service for non-emergent patients due to arrival of emergent patients in the emergency department: a case study in Hong Kong. J Emerg Med 2013; 45:271-80. [PMID: 23759699 PMCID: PMC7126712 DOI: 10.1016/j.jemermed.2012.11.102] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 09/20/2012] [Accepted: 11/02/2012] [Indexed: 11/20/2022]
Abstract
Background In Hong Kong Emergency Departments (EDs), the timeliness of providing high-quality services has been compromised by the increasing attendance of non-emergent patients in addition to the unpredictable arrival of emergency patients. Objectives We sought to quantify the impact of the presence of emergent patients and other related factors on the delay in service for non-emergent patients. Methods We conducted a retrospective study in patients who visited the ED of a large hospital in Hong Kong from July 1, 2009 to June 30, 2010. We estimated waiting and length of stay (LOS) for individual non-emergent patients registered during day and evening shifts. Using multiple linear regression, we estimated waiting time and LOS as a function of the presence of emergent patients and other related factors such as patient demographics and clinical factors. In particular, we evaluated the influence of the arrival or presence of emergent patients on the odds of violating the 120-min waiting time target for semi-urgent patients. Results The arrival of a new emergent patient prolonged the waiting time and LOS of a non-emergent patient by 14.9% (95% confidence interval [CI] 14.2–15.5) and 10.8% (95% CI 10.6–11.0), respectively. An additional patient-hour needed for an emergent patient increased the probability of violating the waiting time target for non-emergent patients (odds ratio 2.3, 95% CI 2.2–2.4). Conclusions The arrival of an emergent patient significantly prolonged the waiting time and LOS for non-emergent patients. Discouraging non-urgent ED utilization and building a real-time decision-support system are critical methods needed to relieve staff pressure and guide contingent resource reallocation when emergent patients arrive.
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Analysis of current situation of Chinese health care reform by studying emergency overcrowding in a typical Shanghai hospital. Am J Emerg Med 2012; 30:1313-8. [PMID: 22818562 DOI: 10.1016/j.ajem.2012.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 05/04/2012] [Accepted: 05/04/2012] [Indexed: 11/22/2022] Open
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Sun Y, Heng BH, Tay SY, Seow E. Predicting hospital admissions at emergency department triage using routine administrative data. Acad Emerg Med 2011; 18:844-50. [PMID: 21843220 DOI: 10.1111/j.1553-2712.2011.01125.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To be able to predict, at the time of triage, whether a need for hospital admission exists for emergency department (ED) patients may constitute useful information that could contribute to systemwide hospital changes designed to improve ED throughput. The objective of this study was to develop and validate a predictive model to assess whether a patient is likely to require inpatient admission at the time of ED triage, using routine hospital administrative data. METHODS Data collected at the time of triage by nurses from patients who visited the ED in 2007 and 2008 were extracted from hospital administrative databases. Variables included were demographics (age, sex, and ethnic group), ED visit or hospital admission in the preceding 3 months, arrival mode, patient acuity category (PAC) of the ED visit, and coexisting chronic diseases (diabetes, hypertension, and dyslipidemia). Chi-square tests were used to study the association between the selected possible risk factors and the need for hospital admission. Logistic regression was applied to develop the prediction model. Data were split for derivation (60%) and validation (40%). Receiver operating characteristic curves and goodness-of-fit tests were applied to the validation data set to evaluate the model. RESULTS Of 317,581 ED patient visits, 30.2% resulted in immediate hospital admission. In the developed predictive model, age, PAC status, and arrival mode were most predictive of the need for immediate hospital inpatient admission. The c-statistic of the receiver operating characteristic (ROC) curve was 0.849 (95% confidence interval [CI] = 0.847 to 0.851). The goodness-of-fit test showed that the predicted patients' admission risks fit the patients' actual admission status well. CONCLUSIONS A model for predicting the risk of immediate hospital admission at triage for all-cause ED patients was developed and validated using routinely collected hospital data. Early prediction of the need for hospital admission at the time of triage may help identify patients deserving of early admission planning and resource allocation and thus potentially reduce ED overcrowding.
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Affiliation(s)
- Yan Sun
- Health Services & Outcomes Research, National Healthcare Group, Singapore, Singapore.
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Holliman CJ, Mulligan TM, Suter RE, Cameron P, Wallis L, Anderson PD, Clem K. The efficacy and value of emergency medicine: a supportive literature review. Int J Emerg Med 2011; 4:44. [PMID: 21781295 PMCID: PMC3158547 DOI: 10.1186/1865-1380-4-44] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 07/22/2011] [Indexed: 11/10/2022] Open
Abstract
Study objectives The goal of this study was to identify publications in the medical literature that support the efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. In this study we use the term "value" to refer both to the "efficacy of clinical care" in terms of achieving desired patient outcomes, as well as "efficiency" in terms of effective and/or cost-effective utilization of healthcare resources in delivering emergency care. A comprehensive listing of publications describing the efficacy or value of EM has not been previously published. It is anticipated that the accumulated reference list generated by this study will serve to help promote awareness of the value of EM as a medical specialty, and acceptance and development of the specialty of EM in countries where EM is new or not yet fully established. Methods The January 1995 to October 2010 issues of selected journals, including the EM journals with the highest article impact factors, were reviewed to identify articles of studies or commentaries that evaluated efficacy, effectiveness, and/or value related to EM as a specialty or to clinical care delivered by EM practitioners. Articles were included if they found a positive or beneficial effect of EM or of EM physician-provided medical care. Additional articles that had been published prior to 1995 or in other non-EM journals already known to the authors were also included. Results A total of 282 articles were identified, and each was categorized into one of the following topics: efficacy of EM for critical care and procedures (31 articles), efficacy of EM for efficiency or cost of care (30 articles), efficacy of EM for public health or preventive medicine (34 articles), efficacy of EM for radiology (11 articles), efficacy of EM for trauma or airway management (27 articles), efficacy of EM for using ultrasound (56 articles), efficacy of EM faculty (34 articles), efficacy of EM residencies (24 articles), and overviews and editorials of EM efficacy and value (35 articles). Conclusion There is extensive medical literature that supports the efficacy and value for both EM as a medical specialty and for emergency patient care delivered by trained EM physicians.
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Affiliation(s)
- C James Holliman
- The Center for Disaster and Humanitarian Assistance Medicine, Uniformed Services University of the Health Sciences, and George Washington University School of Medicine and Health Sciences, Bethesda, MD, USA.
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