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

Emergency department crowding: An assessment of the potential impact of the See-and-Treat protocol for patient flow management at an Italian hospital

BACKGROUND

Crowding and patient flow management are among the most relevant issues for emergency departments (EDs). This results in delayed treatment, adverse outcomes and increased costs. For these reasons, nurse-independent treatment protocols were developed aimed at managing non-emergency patients outside EDs thus improving patient flow. Our objective was to assess the potential impact of the implementation of the "See-and-Treat" protocol on eligible patients and related healthcare costs at an Italian ED.

METHODS

We selected all minor access codes from 2022 at the ED of Sassuolo Hospital in Northern Italy. We only included subjects discharged to home, while we excluded those who required specialized medical care or had received "Fast-Track" treatment. We identify a list of medical conditions to identify subjects eligible for inclusion in the See-and-Treat protocol and calculate the related healthcare costs.

RESULTS

Of 40,906 individual ED admissions, 2,607 (6.4%) qualified for See-and-Treat management. Limb injuries and pain were the leading conditions at presentation. Through cost analysis, we found that implementation of the See-and-Treat protocol may result in savings over €100,000/year at Sassuolo Hospital, and over €7 million if projected to the entire Emilia-Romagna Region.

CONCLUSIONS

Despite some limitations affecting protocol implementation, especially availability of highly-specialized and specifically-trained nurses, the study provided a foundation for a more comprehensive understanding of the implementation of the See-and-Treat protocol as a possible valid model with a view to both human and economic healthcare resources.

Leveraging graph neural networks for supporting automatic triage of patients

Patient triage is crucial in emergency departments, ensuring timely and appropriate care based on correctly evaluating the emergency grade of patient conditions. Triage methods are generally performed by human operator based on her own experience and information that are gathered from the patient management process. Thus, it is a process that can generate errors in emergency-level associations. Recently, Traditional triage methods heavily rely on human decisions, which can be subjective and prone to errors. A growing interest has recently been focused on leveraging artificial intelligence (AI) to develop algorithms to maximize information gathering and minimize errors in patient triage processing. We define and implement an AI-based module to manage patients' emergency code assignments in emergency departments. It uses historical data from the emergency department to train the medical decision-making process. Data containing relevant patient information, such as vital signs, symptoms, and medical history, accurately classify patients into triage categories. Experimental results demonstrate that the proposed algorithm achieved high accuracy outperforming traditional triage methods. By using the proposed method, we claim that healthcare professionals can predict severity index to guide patient management processing and resource allocation.

An explainable machine learning approach for hospital emergency department visits forecasting using continuous training and multi-model regression

BACKGROUND AND OBJECTIVE

In the last years, the Emergency Department (ED) has become an important source of admissions for hospitals. Since late 90s, the number of ED visits has been steadily increasing, and since Covid19 pandemic this trend has been much stronger. Accurate prediction of ED visits, even for moderate forecasting time-horizons, can definitively improve operational efficiency, quality of care, and patient outcomes in hospitals.

METHODS

In this paper we propose two different interpretable approaches, based on Machine Learning algorithms, to accurately forecast hospital emergency visits. The proposed approaches involve a first step of data segmentation based on two different criteria, depending on the approach considered: first, a threshold-based strategy is adopted, where data is divided depending on the value of specific predictor variables. In a second approach, a cluster-based ensemble learning is proposed, in such a way that a clustering algorithm is applied to the training dataset, and ML models are then trained for each cluster.

RESULTS

The two proposed methodologies have been evaluated in real data from two hospital ED visits datasets in Spain. We have shown that the proposed approaches are able to obtain accurate ED visits forecasting, in short-term and also long-term prediction time-horizons up to one week, improving the efficiency of alternative prediction methods for this problem.

CONCLUSIONS

The proposed forecasting approaches have a strong emphasis on providing explainability to the problem. An analysis on which variables govern the problem and are pivotal for obtaining accurate predictions is finally carried out and included in the discussion of the paper.

Emergency department performance assessment using administrative data: A managerial framework

Administrative data play an important role in performance monitoring of healthcare providers. Nonetheless, little attention has been given so far to the emergency department (ED) evaluation. In addition, most of existing research focuses on a single core ED function, such as treatment or triage, thus providing a limited picture of performance. The goal of this study is to harness the value of routinely produced records proposing a framework for multidimensional performance evaluation of EDs able to support internal decision stakeholders in managing operations. Starting with the overview of administrative data, and the definition of the desired framework's characteristics from the perspective of decision stakeholders, a review of the academic literature on ED performance measures and indicators is conducted. A performance measurement framework is designed using 224 ED performance metrics (measures and indicators) satisfying established selection criteria. Real-world feedback on the framework is obtained through expert interviews. Metrics in the proposed ED performance measurement framework are arranged along three dimensions: performance (quality of care, time-efficiency, throughput), analysis unit (physician, disease etc.), and time-period (quarter, year, etc.). The framework has been judged as "clear and intuitive", "useful for planning", able to "reveal inefficiencies in care process" and "transform existing data into decision support information" by the key ED decision stakeholders of a teaching hospital. Administrative data can be a new cornerstone for health care operation management. A framework of ED-specific indicators based on administrative data enables multi-dimensional performance assessment in a timely and cost-effective manner, an essential requirement for nowadays resource-constrained hospitals. Moreover, such a framework can support different stakeholders' decision making as it allows the creation of a customized metrics sets for performance analysis with the desired granularity.

Validity of the Korean triage and acuity scale in older patients compared to the adult group

INTRODUCTION

While many patients visit the emergency department (ED) for various reasons, medical resources are limited. Therefore, various triage scale systems have been used to predict patient urgency and severity. South Korea has developed and used the Korean Triage and Accuracy Scale (KTAS) based on the Canadian classification tool. As the elderly population increases, the number of elderly patients visiting the ED also increases. However, in KTAS, there is no consideration for the elderly, and the same classification system as adults. The aim of this study is to verify the ability of KTAS to predict severity levels in the elderly group, compared to the adult group.

METHODS

This is a retrospective study for patients who visited the ED at two centers between February 1, 2018 and January 31, 2021. The initial KTAS level, changed level at ED discharge, general patient character, ED treatment results, in-hospital mortality, and lengths of hospital and ED stays were acquired. Area under the receiver operating characteristics (AUROC) was used to verify the severity prediction ability of the elderly group to KTAS, and logistic regression analysis was used for the prediction up-triage of KTAS.

RESULTS

The enrolled patients in the study were 87,220 in the adult group and 37,627 in the elderly group. The proportion of KTAS up-triage was higher in the elderly group (1.9 % vs. 1.2 %, p < 0.001). The AUROC for the overall admission rate was 0.686, 0.667 in the adult and elderly group, the AUROC for ICU admission was 0.842, 0.767, and the AUROC for in-hospital mortality prediction was 0.809, 0.711, indicating a decrease in the AUROC value in the elderly group. The independent factors of the up-triage predictors were old age, male gender, pulse, and ED length of stay, and old age was the most influential variable.

CONCLUSION

KTAS was poorly associated with severity in the elderly than in adults, and it was found that up-triaging was more likely to occur in the elderly. The severity and urgency of patients over 65 years of age should not be underestimated when initially determining the triage scale.

Drug-Related Hypersensitivity Reactions Leading to Emergency Department: Original Data and Systematic Review

The aim of the present study is to describe pharmacological characteristics of drug-related allergies and anaphylaxis leading to the emergency department (ED). An 8-year post hoc analysis on the MEREAFaPS Study database was performed (2012−2019). Subjects who experienced drug-related hypersensitivity leading to an ED visit were selected. Logistic regression analyses were used to estimate the reporting odds ratios (RORs) of drug-related allergies and anaphylaxis adjusting for sex, age classes, and ethnicity. In addition, a systematic review of observational studies evaluating drug-related hypersensitivity reactions leading to ED visits in outpatients was performed. Out of 94,073 ED visits, 14.4% cases were drug-related allergies and 0.6% were anaphylaxis. Females accounted for 56%. Multivariate logistic regression showed a higher risk of drug-related allergy among males and all age classes < 65 years, while a higher risk of anaphylaxis was observed for females (ROR 1.20 [1.01−1.42]) and adults (ROR 2.63 [2.21−3.14]). The systematic review included 37 studies. ED visits related to allergy and anaphylaxis ranged from 0.004% to 88%, and drug-related allergies and anaphylaxis ranged from 0.007% to 88%. Both in our analysis and in primary studies, antibacterials, analgesics, and radiocontrast agents were identified as the most common triggers of hypersensitivity.

Psychiatric patients at the emergency department: factors associated with length of stay and likelihood of hospitalization

Emergency department (ED) care for psychiatric patients is currently understudied despite being highly utilized. Therefore, we aimed to analyze psychiatric patients' length of stay (LOS) and LOS-related factors at the ED and to investigate and quantify the likelihood of being hospitalized after an emergency psychiatric evaluation. Charts of 408 individuals who sought help at the ED were retrospectively assessed to identify patients' sociodemographic and clinical data upon ED admission and discharge. All interventions performed at the ED (e.g., medications, hospitalization, clinical advice at discharge) were collected as well. The LOS for psychiatric patients was relatively short (6.5 h), and substance/alcohol intoxication was the main factor impacting LOS. Upon ED arrival, hospitalized patients were mostly men, most often had a yellow/severe triage code, and most often had a positive history of psychiatric illness, psychotic symptoms, euphoric mood, or suicidal ideation. Manic symptoms and suicidal ideation were the conditions most frequently leading to hospitalization. Given the paucity of real-world data on psychiatric patients' LOS and outcomes in the ED context, our findings show that psychiatric patients are evaluated in a reasonable amount of time. Their hospitalization is mostly influenced by clinical conditions rather than predisposing (e.g., age) or system-related factors (e.g., mode of arrival).

Development and Validation of Simple Age-Adjusted Objectified Korean Triage and Acuity Scale for Adult Patients Visiting the Emergency Department

PURPOSE

The study aimed to develop an objectified Korean Triage and Acuity Scale (OTAS) that can objectively and quickly classify severity, as well as a simple age-adjusted OTAS (S-OTAS) that reflects age and evaluate its usefulness.

MATERIALS AND METHODS

A retrospective analysis was performed of all adult patients who had visited the emergency department at three teaching hospitals. Sex, systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, body temperature, O₂ saturation, and consciousness level were collected from medical records. The OTAS was developed with objective criterion and minimal OTAS level, and S-OTAS was developed by adding the age variable. For usefulness evaluation, the 30-day mortality, the rates of computed tomography scan and emergency procedures were compared between Korean Triage and Acuity Scale (KTAS) and OTAS.

RESULTS

A total of 44402 patients were analyzed. For 30-day mortality, S-OTAS showed a higher area under the curve (AUC) compared to KTAS (0.751 vs. 0.812 for KTAS and S-OTAS, respectively, p<0.001). Regarding the rates of emergency procedures, AUC was significantly higher in S-OTAS, compared to KTAS (0.807 vs. 0.830, for KTAS and S-OTAS, respectively, p=0.013).

CONCLUSION

S-OTAS showed comparative usefulness for adult patients visiting the emergency department as a triage tool compared to KTAS.

Nonurgent Visits to the Pediatric Emergency Department before and during the First Peak of the COVID-19 Pandemic

Background

Nonurgent visits in pediatric Emergency Departments are a growing burden. In order to find predictors for those nonurgent visits, we performed a retrospective analysis of unscheduled visits at the Pediatric Emergency Department of the University Hospital of Bonn, Germany, in the year 2017. Additionally, we compared these findings to unscheduled visits during the first peak of the worldwide pandemic of the Coronavirus disease 2019, to see if there would be an effect on nonurgent pediatric Emergency Department attendances.

Methods

For our retrospective cohort study, we analyzed more than 5.000 visits at the pediatric Emergency Department of the University Hospital of Bonn, Germany, before and during the first peak of the ongoing worldwide pandemic of the Coronavirus disease 2019, particularly with regard to their urgency. Data included gender, age, zip code, urgency, and preexisting conditions.

Results

Our study shows that more than half of unscheduled pediatric Emergency Department visits (69%) at the University Hospital in Bonn are for nonurgent reasons, with short living distance being a factor to present children to a pediatric Emergency Department, even with minor complaints. During the first peak of the pandemic of the Coronavirus disease 2019, nonurgent visits decreased significantly, potentially due to hesitation to attend a pediatric Emergency Department with minor issues, fearing an infection with SARS-CoV-2 at the hospital.

Conclusion

Many people use pediatric Emergency Departments for nonemergency complaints. In order to address the reasons for nonurgent visits to pediatric Emergency Departments and to prevent parents from doing so, further studies and targeted education concepts for parents are needed.

Machine learning methods applied to triage in emergency services: A systematic review

BACKGROUND

In emergency services is important to accurately assess and classify symptoms, which may be improved with the help of technology. One mechanism that could help and improve predictions from health records or patient flow is machine learning (ML).

AIM

To analyse the effectiveness of ML systems in triage for making predictions at the emergency department in comparison with other triage scales/scores.

METHODS

Following the PRISMA recommendations, a systematic review was conducted using CINAHL, Cochrane, Cuiden, Medline and Scopus databases with the search equation "Machine learning AND triage AND emergency".

RESULTS

Eleven studies were identified. The studies show that the use of ML methods consistently predict important outcomes like mortality, critical care outcomes and admission, and the need for hospitalization in comparison with scales like Emergency Severity Index or others. Among the ML models considered, XGBoost and Deep Neural Networks obtained the highest levels of prediction accuracy, while Logistic Regression performed obtained the worst values.

CONCLUSIONS

Machine learning methods can be a good instrument for helping triage process with the prediction of important emergency variables like mortality or the need for critical care or hospitalization.

Development and validity of the Korea psychiatric triage algorithm

Background

Psychiatric emergencies require timely intervention because of the risk of harm to individuals and society, including others. The aim of the present study was to test the content validity of a psychiatric triage algorithm developed for use in South Korea.

Methods

The initial algorithm was developed through systematic literature review. Its validity was then verified by 10 experts. Based on results of expert validity, the algorithm was modified and the final algorithm was developed.

Results

Its clinical validity was then verified by 37 emergency room nurses who had used triage. Four questions of expert validity results with a CVI of 0.8 or less were revised to reflect expert opinion. The usefulness, adequacy, and convenience of the final modified algorithm was 2.98 ~ 3.53.

Conclusion

After sufficiently validated by follow-up studies, it is expected that the use of psychiatric classification algorithms in emergency room nurses will not only improve the quality of care, but also can improve patient outcomes and experience.

Factors associated to inappropriate use of emergency services

The increase in the demand for Emergency Services is a worldwide phenomenon, and its inappropriate use is one of the main problems. Factors related to the inappropriate use must be investigated to guide improvement in the quality of services. This article aims at analyzing factors associated with the inappropriate use of emergency services. This is a cross-sectional study with secondary data from 384 medical records from two emergency services in a city in central-southern region of the state of Paraná, Brazil, in 2013. A descriptive, bivariate using Pearson's chi-squared test was performed to verify associations between inappropriate use and independent variables. Multiple Logistic Regression was also performed. The proportion of inappropriate use of Emergency Services was 73.4% and was associated with people with some primary health care sensitive conditions, residents in areas without primary care coverage, people between 0 and 11 years old, and 12 to 17 years old, care in the first trimester of the year, respiratory diseases, lesions and poisonings and diseases of the musculoskeletal system. Primary care must be strengthened to reduce the inappropriate use of care, especially in the attention to primary health care sensitive conditions and to increase the socio-organizational accessibility.

The new emergency department "Tuscan triage System". Validation study

INTRODUCTION

A new organizational framework was recently implemented in Tuscan Emergency Departments (EDs), including specific low-priority streaming. A new ED triage system, named "Tuscan Triage System" (TTS), was devised with the purpose of applying this reorganization.

METHODS

A validation study was designed with the primary aims of assessing the content, face, and criterion validities, and the inter-rater reliability of the TTS. The secondary aim was to estimate the differences in triage level assignation between the previous "Regional Triage System" (RTS) and the TTS. Twenty-four nurses trained for the TTS were enrolled to assign TTS priority levels to 100 triage clinical case vignettes drawn up by the developers of the TTS (reference standard).

RESULTS

The Content Validity Index - Scale/Average (S-CVI/Ave) of TTS was 0.98. Concerning to face validity, the S-CVI/Ave was 1. The highest adherence of triage level assignation to the reference standard was for levels 1 and 2. The Krippendorff α value was 0.808. Undertriage and overtriage were 10.45% and 14.29%, respectively. Overall, the comparation between RTS and TTS showed a marked shift of level assignation towards TTS low priority levels.

CONCLUSIONS

The TTS seems to be safe. These results should be confirmed through studies in the real clinical settings.

How the COVID-19 Wave Changed Emergency Urology: Results From an Academic Tertiary Referral Hospital in the Epicentre of the Italian Red Zone

OBJECTIVE

To quantify and characterize the burden of urological patients admitted to emergency department (ED) in Lombardy during Italian COVID-19 outbreak, comparing it to a reference population from 2019.

METHODS

We retrospectively analysed all consecutive admissions to ED from 1 January to 9 April in both 2019 and 2020. According to the ED discharge ICD-9-CM code, patients were grouped in urological and respiratory patients. We evaluated the type of access (self-presented/ambulance), discharge priority code, ED discharge (hospitalization, home), need for urological consultation or urgent surgery.

RESULTS

The number of urological diagnoses in ED was inversely associated to COVID-19 diagnoses (95% confidence interval -0.41/-0.19; Beta = -0.8; P < .0001). The average access per day was significantly lower after 10 March 2020 (1.5 ± 1.1 vs 6.5 ± 2.6; P < .0001), compared to reference period. From 11 March 2020, the inappropriate admissions to ED were reduced (10/45 vs 96/195; P = .001). Consequently, the patients admitted were generally more demanding, requiring a higher rate of urgent surgeries (4/45 vs 4/195; P = .02). This reflected in an increase of the hospitalization rate from 12.7% to 17.8% (Beta = 0.88; P < .0001) during 2020.

CONCLUSION

Urological admissions to ED during lockdown differed from the same period of 2019 both qualitatively and quantitatively. The spectrum of patients seems to be relatively more critical, often requiring an urgent management. These patients may represent a challenge due to the difficult circumstances caused by the pandemic.

When fear backfires: Emergency department accesses during the Covid-19 pandemic

INTRODUCTION

The increase in access to Emergency Departments (ED) worldwide causes inefficiencies, but also signals its importance. The Coronavirus (Covid-19) outbreak allows to study the reactions of patients to the news about the spreading of the infection, which may have generated the fear that ED was no longer safe.

METHODS

We study access to ED of a large teaching hospital in Brescia - one of the most hit provinces in Italy by Covid-19 - during the pandemic (from the announcement of the first cases to the explosion of the pandemic, to months after end of the acute phase) to study how patients reacted to the news that ED could no longer be a safe place. We analyse triage code, mode of arrival to ED, and accesses related to chest and abdominal pain, to evaluate who was discouraged most.

RESULTS

Accesses have drastically reduced immediately after the news of the first contagion. During the lockdown accesses and admissions to hospital ward have decreased; this may mean that some patients may have suffered reduced health or increased mortality risks because of this decision. At the end of June accesses to ED and admissions to hospital ward are still lower than usual.

DISCUSSION

Fear of contagion and appeals not to use ED directly by Covid-19 patients may have discouraged access also for pressing health need.

Frequent use of emergency departments and chronic conditions in ageing societies: a retrospective analysis based in Italy

BACKGROUND

Most western countries are facing relevant demographic changes, and the percentage of older people is destined to rise in the next decades. This fact is likely to affect the sustainability of healthcare systems significantly, mainly due to the connected issue of chronicity.

METHODS

In this paper, using an extensive and comprehensive administrative dataset, we analyse the phenomenon of frequent use of emergency departments (ED) in the oldest region in Europe (i.e. Liguria) over 4 years (2013-2016). Two alternative approaches are used to define categories of ED users based on the intensity and frequency of accesses and splitting patients into different age groups.

RESULTS

Results allow identifying clinical and socio-demographic risk-factors connected to different levels of ED utilisation and highlight the influential role played by chronic conditions (particularly mental disorders, respiratory diseases) and by multiple chronic conditions.

CONCLUSIONS

The study aims at representing an informative tool to support policy-makers in setting proper policies addressed, on the one side, towards the potentially preventable frequent users and, on the other, towards those accessing due to complex medical conditions. The results can help in building a warning system to help general practitioners in the identification of potential frequent users and to develop preventive policies.

Emergency Department Overcrowding: A Retrospective Spatial Analysis and the Geocoding of Accesses. A Pilot Study in Rome

The overcrowding of first aid facilities creates considerable hardship and problems which have repercussions on patients’ wellbeing, the time needed for a diagnosis, and on the quality of the assistance. The basic objective of this contribution, based on the data collected by the Hospital Policlinico Umberto I in Rome (Lazio region, Italy), is to carry out a territorial screening of the municipality using GIS applications and spatial analyses aimed at reducing—in terms of triage—code white (inappropriate) attendances, after having identified the areas of greatest provenance of improperly used emergency room access. Working in a GIS environment and using functions for geocoding, we have tested an experimental model aimed at giving a close-up geographical-sanitary look at the situation: recognizing the territorial sectors in Rome which contribute to amplifying the Policlinico Umberto I emergency room overcrowding; leading up to an improvement of the situation; promoting greater awareness and knowledge of the services available on the territory, a closer relationship between patient and regular doctor (general practitioner, GP) or Local Healthcare Unit and a more efficient functioning of the emergency room. In particular, we have elaborated a “source” map from which derive all the others and it is a dot map on which all the codes white have been geolocalized on a satellite image through geocoding. We have produced three sets made up of three digital cartographic elaborations each, constructed on the census sections, the census areas and the sub-municipal areas, according to data aggregation, for absolute and relative values, and using different templates. Finally, following the same methodology and steps, we elaborated another dot map about all the codes red to provide another kind of information and input for social utility. In the near future, this system could be tested on a platform that spatially analyzes the emergency department (ED) accesses in near-real-time in order to facilitate the identification of critical territorial issues and intervene in a shorter time to regulate the influx of patients to the ED.

Speeding up the clinical pathways by accessing emergency departments

Inappropriate emergency admissions create overcrowding and may reduce the quality of emergency care. In Italy, overcrowding is further exacerbated by patients who use emergency admissions as a shortcut to avoid the general practitioner (GP) gateway. In this paper, we investigate access to emergency departments (EDs) by patients with non-severe medical conditions and their willingness to wait. Population data for ED accesses in Liguria (an Italian administrative region) in 2016 were used to estimate the number of strategic accesses and waiting time elasticities of low-severity patients. Our results show that the practice of using EDs to skip gatekeeping is a serious problem. The percentage of patients who engage in such practice vary from 8.7 to 9.9% of non-urgent patients; they generally prefer to access more specialized hospitals, especially during weekdays, when GPs are available, but hospitals run at full capacity. Strategic patients are usually much younger than average. From a policy point of view, our results show that long waits may discourage "genuine" patients rather than strategic ones. It is necessary to develop a system to improve access to patients mainly requiring specialist care, along with enhancing the management of diagnostic examinations through primary care.

Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study

Background

Emergency Department (ED) overcrowding adversely affects patients’ health, accessibility, and quality of healthcare systems for communities. Several studies have addressed this issue. This study aimed to conduct a systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals.

Methods

Original research articles on crowding of emergencies at hospitals published from 1st January 2007, and 1st August 2018 were utilized. Relevant studies from the PubMed and EMBASE databases were assessed using suitable keywords. Two reviewers independently screened the titles, abstracts and the methodological validity of the records using data extraction format before their inclusion in the final review. Discussions with the senior faculty member were used to resolve any disagreements among the reviewers during the assessment phase.

Results

Out of the total 117 articles in the final record, we excluded 11 of them because of poor quality. Thus, this systematic review synthesized the reports of 106 original articles. Overall 14, 55 and 29 of the reviewed refer to causes, effects, and solutions of ED crowding, respectively. The review also included four articles on both causes and effects and another four on causes and solutions. Multiple individual patients and healthcare system related challenges, experiences and responses to crowding and its consequences are comprehensively synthesized.

Conclusion

ED overcrowding is a multi-facet issue which affects by patient-related factors and emergency service delivery. Crowding of the EDs adversely affected individual patients, healthcare delivery systems and communities. The identified issues concern organizational managers, leadership, and operational level actions to reduce crowding and improve emergency healthcare outcomes efficiently.

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

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

Robustness and Effectiveness of the Triage System in the Pediatric Context

BACKGROUND

The increasing use of emergency departments (EDs) potentially compromises their effectiveness and quality. The evaluation of the performance of the triage code system in a pediatric context is important because waiting time affects the quality of care for acutely ill patients.

OBJECTIVE

In this study, we aimed to assess the effectiveness and robustness of the triage code system in a pediatric context and identify the determinants of waiting times for urgent and non-urgent patients.

METHODS

Data regarding 37,767 pediatric patients who accessed the ED of a major Italian pediatric hospital in 2015 were investigated in order to study patient numbers and waiting times. The determinants of waiting times for urgent and non-urgent patients, as well as variables referring to the "supply side," such as periods of staff shortage, were analyzed using a survival analysis framework.

RESULTS

For urgent patients, the waiting time between triage and the first physician assessment is generally below the standard threshold of 15 min and this is not affected by the number of non-urgent patients waiting for care. Conversely, the waiting time for non-urgent patients is affected by ED flow, periods of staff shortage, and non-clinical variables (age and nationality).

CONCLUSION

Our results suggest that the triage level assignation system is effective in terms of safety for urgent patients. The current ED organization adequately fulfills its primary goal of providing healthcare for acutely ill patients.

Validation of an emergency triage scale for obstetrics and gynaecology: a prospective study

OBJECTIVE

To evaluate the reliability of a four-level triage scale for obstetrics and gynaecology emergencies and to explore the factors associated with an optimal triage.

DESIGN

Thirty clinical vignettes presenting the most frequent indications for obstetrics and gynaecology emergency consultations were evaluated twice using a computerised simulator.

SETTING

The study was performed at the emergency unit of obstetrics and gynaecology at the Geneva University Hospitals.

SAMPLE

The vignettes were submitted to nurses and midwives.

METHODS

We assessed inter- and intra-rater reliability and agreement using a two-way mixed-effects intra-class correlation (ICC). We also performed a generalised linear mixed model to evaluate factors associated triage correctness.

MAIN OUTCOME MEASURES

Triage acuity.

RESULTS

We obtained a total of 1191 evaluations. Inter-rater reliability was good (ICC 0.748; 95% CI 0.633-0.858) and intra-rater reliability was almost perfect (ICC 0.812; 95% CI 0.726-0.889). We observed a wide variability: the mean number of questions varied from 6.9 to 18.9 across individuals and from 8.4 to 16.9 across vignettes. Triage acuity was underestimated in 12.4% of cases and overestimated in 9.3%. Undertriage occurred less frequently for gynaecology compared with obstetric vignettes [odds ratio (OR) 0.45; 95% CI 0.23-0.91; P = 0.035] and decreased with the number of questions asked (OR 0.94; 95% CI 0.88-0.99; P = 0.047). Certification in obstetrics and gynaecology emergencies was an independent factor for the avoidance of undertriage (OR 0.35; 95% CI 0.17-0.70; P = 0.003).

CONCLUSION

The four-level triage scale is a valid and reliable tool for the integrated emergency management of obstetrics and gynaecology patients.

TWEETABLE ABSTRACT

The Swiss Emergency Triage Scale is a valid and reliable tool for obstetrics and gynaecology emergency triage.

Where did civil servants go? the effect of an increase in public co-payments on double insured patients

In Portugal, Civil Servants may have a differential utilization of health services due to their supplementary Health Subsystem (ADSE), which grants them access to health services in the private sector at lower price. We exploit the impact of this double coverage on the demand for Portuguese Public Emergency Departments (ED), following the recent increase in co-payments for public health care services in Portugal.Using detailed ED level data from three different EDs, one for each level of the Portuguese ED care, we rely on a difference-in-differences strategy, under the assumption that both civil servants and National Health Service (NHS) users were targeted by the public co-payment increase, but just the former have a low-cost alternative in the private sector that they can use when prices increase in the NHS.We found that the existence of a low-price alternative in the private sector caused ED demand to decrease among ADSE beneficiaries following a policy that increased co-payments in public NHS hospitals. Specifically, we show that this decrease was only significant for conditions which have arguably the closest substitutes in the private sector - the low and intermediate-severity conditions - and to patients who lived closer to the ED and to whom the co-payment was the largest share of the ED visit cost.These findings cast some concerns over the equity of the Portuguese Health System, since civil servants increasingly opt out from public health services but must co-fund both the ADSE and the NHS.

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.

Targeting frequent users of emergency departments: Prominent risk factors and policy implications

This study investigates the characteristics of frequent users of accident and emergency departments (AEDs) and recommends alternative medical services for such patients. Prominent demographic and clinical risk factors for individuals accessing seven AEDs located in the metropolitan area of Genoa, Italy are identified and analysed. A truncated count data model is implemented to establish the determinants of access, while a multinomial logistic regression is used to highlight potential differences among different user categories. According to previous studies, empirical findings suggest that despite the relevance of demographic drivers, vulnerability conditions (e.g. abuse of alcohol and drugs, chronic conditions, and psychological distress) are the main reasons behind frequent AED use; the analysis seems to confirm an association between AED frequent use and lower level of urgency. Since frequent and highly frequent users are found responsible for disproportionate resource absorption with respect to total amount of AED costs (they represent roughly 10% of the total number of patients, but contribute to more than 19% of the total annual AED cost), policies aiming to reduce frequent use of AEDs could bring significant savings in economic resources. Thus, efficient actions could be oriented toward extending primary care services outside AED and toward instituting local aid services specifically addressed to people under the influence of substances or in conditions of mental distress.