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Parnass G, Levtzion-Korach O, Peres R, Assaf M. Estimating emergency department crowding with stochastic population models. PLoS One 2023; 18:e0295130. [PMID: 38039309 PMCID: PMC10691698 DOI: 10.1371/journal.pone.0295130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/15/2023] [Indexed: 12/03/2023] Open
Abstract
Environments such as shopping malls, airports, or hospital emergency-departments often experience crowding, with many people simultaneously requesting service. Crowding highly fluctuates, with sudden overcrowding "spikes". Past research has either focused on average behavior, used context-specific models with a large number of parameters, or machine-learning models that are hard to interpret. Here we show that a stochastic population model, previously applied to a broad range of natural phenomena, can aptly describe hospital emergency-department crowding. We test the model using data from five-year minute-by-minute emergency-department records. The model provides reliable forecasting of the crowding distribution. Overcrowding is highly sensitive to the patient arrival-flux and length-of-stay: a 10% increase in arrivals triples the probability of overcrowding events. Expediting patient exit-rate to shorten the typical length-of-stay by just 20 minutes (8.5%) cuts the probability of severe overcrowding events by 50%. Such forecasting is critical in prevention and mitigation of breakdown events. Our results demonstrate that despite its high volatility, crowding follows a dynamic behavior common to many systems in nature.
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Affiliation(s)
- Gil Parnass
- Racah Institute of Physics, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Renana Peres
- The Hebrew University Business school, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michael Assaf
- Racah Institute of Physics, Hebrew University of Jerusalem, Jerusalem, Israel
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Savioli G, Ceresa IF, Bressan MA, Piccini GB, Varesi A, Novelli V, Muzzi A, Cutti S, Ricevuti G, Esposito C, Voza A, Desai A, Longhitano Y, Saviano A, Piccioni A, Piccolella F, Bellou A, Zanza C, Oddone E. Five Level Triage vs. Four Level Triage in a Quaternary Emergency Department: National Analysis on Waiting Time, Validity, and Crowding-The CREONTE (Crowding and RE-Organization National TriagE) Study Group. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040781. [PMID: 37109739 PMCID: PMC10143416 DOI: 10.3390/medicina59040781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Triage systems help provide the right care at the right time for patients presenting to emergency departments (EDs). Triage systems are generally used to subdivide patients into three to five categories according to the system used, and their performance must be carefully monitored to ensure the best care for patients. Materials and Methods: We examined ED accesses in the context of 4-level (4LT) and 5-level triage systems (5LT), implemented from 1 January 2014 to 31 December 2020. This study assessed the effects of a 5LT on wait times and under-triage (UT) and over-triage (OT). We also examined how 5LT and 4LT systems reflected actual patient acuity by correlating triage codes with severity codes at discharge. Other outcomes included the impact of crowding indices and 5LT system function during the COVID-19 pandemic in the study populations. Results: We evaluated 423,257 ED presentations. Visits to the ED by more fragile and seriously ill individuals increased, with a progressive increase in crowding. The length of stay (LOS), exit block, boarding, and processing times increased, reflecting a net raise in throughput and output factors, with a consequent lengthening of wait times. The decreased UT trend was observed after implementing the 5LT system. Conversely, a slight rise in OT was reported, although this did not affect the medium-high-intensity care area. Conclusions: Introducing a 5LT improved ED performance and patient care.
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Affiliation(s)
- Gabriele Savioli
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Maria Antonietta Bressan
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Angelica Varesi
- Faculty of Medicine, University of Pavia, 27100 Pavia, Italy
| | - Viola Novelli
- Health Department, University of Pavia, 27100 Pavia, Italy
| | - Alba Muzzi
- Health Department, University of Pavia, 27100 Pavia, Italy
| | - Sara Cutti
- Health Department, University of Pavia, 27100 Pavia, Italy
| | | | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy
| | - Antonio Voza
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Desai
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Department of Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Angela Saviano
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Fabio Piccolella
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Abdel Bellou
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Christian Zanza
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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Comparison of the Level of Disaster Preparedness Between Private and Government Hospitals in Saudi Arabia: A Cross-Sectional Study. Disaster Med Public Health Prep 2023; 17:e335. [PMID: 36847257 DOI: 10.1017/dmp.2023.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
OBJECTIVE The objective of this study was to describe and compare almost all the components of disaster preparedness between private and government hospitals in the Eastern Province of the Kingdom of Saudi Arabia, using the World Health Organization's (WHO) checklist. METHODS We assessed and compared the disaster preparedness between government and private hospitals in Province, using the 10-key component WHO checklist in a descriptive cross-sectional study. Of 72 hospitals in the region, 63 responded to the survey. RESULTS All 63 hospitals had an HDP plan and reported having a multidisciplinary HDP committee. In all responding hospitals, HDP was acceptable in most indicators of preparedness; however, some hospitals to some extent fell short of preparedness in surge capacity, equipment and logistic services, and post-disaster recovery. Government and private hospitals were generally comparable in disaster preparedness. However, government hospitals were more likely to have HDP plans that cover WHO's "all-hazard" approach, both internal and external disasters, compared to private hospitals. CONCLUSION HDP was acceptable, however, preparedness in surge capacity, equipment and logistic services, and post-disaster recovery fell short. Government and private hospitals were comparable in preparedness with regards to all indicators except surge capacity, post-disaster recovery, and availability of some equipment.
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Alruwaili AS, Islam MS, Usher K. Factors Influencing Hospitals' Disaster Preparedness in the Eastern Province of Saudi Arabia. Disaster Med Public Health Prep 2023; 17:e301. [PMID: 36785527 DOI: 10.1017/dmp.2022.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
OBJECTIVE The study aimed to identify the factors that influence the disaster preparedness of hospitals and validate an evaluation framework to assess hospital disaster preparedness (HDP) capability in the Eastern Province of Saudi Arabia. METHODS A cross-sectional survey of all hospitals (n = 72) in the Eastern Region of Saudi Arabia was conducted. A factor analysis method was used to identify common factors and validate the evaluation framework to assess HDP capacity. RESULTS Sixty-three (63) hospitals responded to the survey. A 3-factor structure was identified as key predicators of HDP capacity. The first factor was the most highly weighted factor, which included education and training (0.849), monitoring and assessing HDP (0.723), disaster planning (0.721), and command and control (0.713). The second factor included surge capacity (0.708), triage system (0.844), post-disaster recovery (0.809), and communication (0.678). The third factor represented safety and security (0.638) as well as logistics, equipment, and supplies (0.766). CONCLUSION The identified 3-factor structure provides an innovative approach to assist the operationalization of the concept of HDP capacity building and service improvement, as well as serve as a groundwork to further develop instrument for assessing HDP in future studies.
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Affiliation(s)
- Abdullah Saleh Alruwaili
- Emergency Medical Services Program, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa, Saudi Arabia
- King Abdullah International Medical Research Center, Al Ahsa, Saudi Arabia
| | - Md Shahidul Islam
- School of Health, University of New England, Armidale, 2350, Australia
| | - Kim Usher
- School of Health, University of New England, Armidale, 2350, Australia
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Pehlivanturk-Kizilkan M, Ozsezen B, Batu ED. Factors Affecting Nonurgent Pediatric Emergency Department Visits and Parental Emergency Overestimation. Pediatr Emerg Care 2022; 38:264-268. [PMID: 35507379 DOI: 10.1097/pec.0000000000002723] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Understanding the factors causing nonurgent visits to the pediatric emergency departments (PED) is essential for developing effective interventions. Sociodemographic factors might have a direct effect, or they might be associated with other potential causal factors such as access, perceived severity, and convenience. Therefore, we aimed to evaluate the factors that might have an effect on nonurgent PED visits and parental overestimation of emergency severity. METHODS Data of a total of 974 patients who have been administered to the PED of a district state hospital were collected with a cross-sectional, self-administered survey. Level 5 was accepted as nonurgent cases according to the Pediatric Canadian Triage and Acuity Scale. Parents' assessment of their child's emergency status was assessed along with the age and sex of the child, the number of children, presence of a chronic illness, presence of fever, admission time, parental age, education status and occupation, transportation method, and living distance to emergency department. RESULTS Sixty-eight percent of visits were nonurgent. Among these visits, 51.6% were perceived as urgent, and 11.5% as extremely urgent by the parents. We identified that infancy age group (P = 0.001), father's unemployment status (P = 0.038), presence of a chronic disease (P = 0.020), and a previous visit to the PED in the last week (P = 0.008) are associated with urgent visits. Having a fever (P = 0.002), younger mother (P = 0.046) and father age (P = 0.007), mother not having an income (P = 0.034), and father's lower level of education (P = 0.036) increased the likelihood of overestimating the emergency severity. CONCLUSIONS Nonurgent visits constitute most of the PED admissions. Several factors were found to be associated with nonurgent visits either by causing a direct effect or by indirectly impacting the perceived severity. Health literacy-based interventions targeting common symptoms like fever and especially younger parent groups might be beneficial in lowering the patient burden of PEDs.
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Affiliation(s)
| | | | - Ezgi Deniz Batu
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
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Scorza A, Porazzi E, Strozzi F, Garagiola E, Gimigliano A, De Filippis G. A new approach for emergency department performance positioning: The quality-efficiency matrix. Int J Health Plann Manage 2022; 37:1636-1649. [PMID: 35132675 DOI: 10.1002/hpm.3428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/09/2021] [Accepted: 01/15/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The crowding of emergency departments (EDs) is one of the major poor-quality factors for patients. Because of this, measuring ED performance in Healthcare Systems is a difficult but an important task needed to enhance quality and efficiency. PURPOSE (i) Development of a tool to observe and evaluate performance measurement, analysing two critical variables (quality and efficiency), verifying the change in performance due to the implementation of a new organizational model; (ii) the implementation of the tool in two EDs with comparable annual volumes of activity in the Italian context. METHODS A literature review on ED performance was conducted in order to identify acknowledged performance measurements used in this context that can be used in the development of a tool for the evaluation of EDs' performance. The goal is to have a matrix that is easily understood and that shows a simple relationship between quality and efficiency. This was possible by setting up a method that translates the ED annual performance data (in this case the data related to year 2018) into a graph with benchmarking purposes, also including an actual situation (AS-IS) view as compared to a TO-BE situation (i.e., before and after an organizational change occurred). RESULTS Two real EDs were compared and their results depicted; they can be easily related with each other to benchmark healthcare organisations. More precisely, a comparison can be used for two main tasks: - identifying different strategic areas and observing the positioning of a health organization at any given moment in time, seeing where it stands among its competitors in a matrix; - knowing how to best allocate available resources and where to divert investment. Results show that the tool depicts the situation of EDs, with a clear indication of how performance increases or decreases in the case of AS-IS and TO-BE evaluation, and also offers a quick understanding of the benchmarked EDs' situations. PRACTICE IMPLICATIONS The results can be shown on a graph that summarises the performance change for the AS-IS versus TO-BE conditions. This can be a useful tool for the ED and for the hospital decision makers, as it allows for an observation of performance by analysing two critical variables: the quality and the efficiency of the service provided. The former represents customer satisfaction, which in this work is the combination of two factors (i.e., appropriateness of assigning the triage code and patient satisfaction), and the latter represents the ED's efficiency in providing emergency care. The tool also helps the organizational changes to be easily evaluated.
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Affiliation(s)
| | - Emanuele Porazzi
- Healthcare Datascience LAB, Centre for Research on Health Economics, Social and Health Care Management, LIUC-Università Cattaneo, Castellanza, Italy
| | - Fernanda Strozzi
- School of Industrial Engineering, LIUC-Università Cattaneo, Castellanza, Italy
| | - Elisabetta Garagiola
- Healthcare Datascience LAB, Centre for Research on Health Economics, Social and Health Care Management, LIUC-Università Cattaneo, Castellanza, Italy
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Mohr NM, Wu C, Ward MJ, McNaughton CD, Faine B, Pomeranz K, Richardson K, Kaboli PJ. Transfer boarding delays care more in low-volume rural emergency departments: A cohort study. J Rural Health 2022; 38:282-292. [PMID: 33644911 PMCID: PMC8715860 DOI: 10.1111/jrh.12559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Emergency department (ED) crowding is increasing and is associated with adverse patient outcomes. The objective of this study was to measure the relative impact of ED boarding on timeliness of early ED care for new patient arrivals, with a focus on the differential impact in low-volume rural hospitals. METHODS A retrospective cohort of all patients presenting to a Veterans Health Administration (VHA) ED between 2011 and 2014. The primary exposure was the number of patients in the ED at the time of ED registration, stratified by disposition (admit, discharge, or transfer) and mental health diagnosis. The primary outcome was time-to-provider evaluation, and secondary outcomes included time-to-EKG, time-to-laboratory testing, time-to-radiography, and total ED length-of-stay. Rurality was measured using the Rural-Urban Commuting Areas. FINDINGS A total of 5,912,368 patients were included from all 123 VHA EDs. Adjusting for acuity, new patients had longer time-to-provider when more patients were in the ED, and patients awaiting transfer for nonmental health conditions impacted time-to-provider for new patients (16.6 min delays, 95% CI: 12.3-20.7 min) more than other patient types. Rural patients saw a greater impact of crowding on care timeliness than nonrural patients (additional 5.3 min in time-to-provider per additional patient in ED, 95% CI: 4.3-6.4), and the impact of additional patients in all categories was most pronounced in the lowest-volume EDs. CONCLUSIONS Patients seen in EDs with more crowding have small, but additive, delays in early elements of ED care, and transferring patients with nonmental health diagnoses from rural facilities were associated with the greatest impact.
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Affiliation(s)
- Nicholas M. Mohr
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA;,Department of Emergency Medicine, University of Iowa Carver College of Medicine;,Department of Anesthesia, University of Iowa Carver College of Medicine
| | - Chaorong Wu
- Institute for Clinical and Translational Sciences, University of Iowa, Iowa City, Iowa
| | - Michael J. Ward
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee;,Department of Emergency Medicine, Vanderbilt University Medical Center
| | - Candace D. McNaughton
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee;,Department of Emergency Medicine, Vanderbilt University Medical Center
| | - Brett Faine
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA;,Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Kaila Pomeranz
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Kelly Richardson
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA
| | - Peter J. Kaboli
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA;,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Rocha HMDN, do Nascimento EB, dos Santos LC, Alves GV, Farre AGMDC, de Santana-Filho VJ. Usability in the admission monitoring system of an emergency room. Rev Saude Publica 2021; 55:113. [PMID: 34932702 PMCID: PMC8664066 DOI: 10.11606/s1518-8787.2021055003475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To develop and evaluate the usability of the admission monitoring system in an emergency room. METHODS This applied research intends to develop a software product and evaluate its usability. The development followed four stages: systematic review, structuring of the system framework, construction of system forms, and evaluation of the information generated. In the evaluation, the experts simulated the use of the system by inserting data from a fictitious medical record. We measured usability using the System Usability Scale (SUS). Scores and scores were calculated individually and globally. We propose these evaluation standards: worst case scenario, poor, average, good, excellent, and best-case scenario. RESULTS The Sistema de Informação e Monitoramento das Internações em Pronto-Socorro (SIMIPS - Information and Monitoring System for Emergency Room Admissions) monitors the epidemiological profile of admissions to the emergency room, time management, clinical deterioration, incidence of adverse events, and human resource management. The usability of SIMIPS, evaluated by 17 experts, reached the SUS Score 86.5 (best case scenario), and some suggestions for modifications were accepted. CONCLUSIONS We consider SIMIPS an easy-to-use tool, with real importance in the management of emergencies in view of overcrowding and congestion problems faced in Brazil.
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Affiliation(s)
- Hertaline Menezes do Nascimento Rocha
- Universidade Federal de SergipePrograma de Pós-Graduação em Ciências da SaúdeAracajuSEBrasilUniversidade Federal de Sergipe. Programa de Pós-Graduação em Ciências da Saúde. Aracaju, SE, Brasil
- Universidade Federal de SergipeDepartamento de EnfermagemLagartoSEBrasilUniversidade Federal de Sergipe. Departamento de Enfermagem. Lagarto, SE, Brasil
| | - Ester Batista do Nascimento
- Universidade Federal de SergipeDepartamento de EnfermagemLagartoSEBrasilUniversidade Federal de Sergipe. Departamento de Enfermagem. Lagarto, SE, Brasil
| | - Laryssa Carvalho dos Santos
- Universidade Federal de SergipeDepartamento de EnfermagemLagartoSEBrasilUniversidade Federal de Sergipe. Departamento de Enfermagem. Lagarto, SE, Brasil
| | - Guilherme Viturino Alves
- Universidade Federal de SergipePrograma de Pós-Graduação em Ciência da ComputaçãoSão CristóvãoSEBrasilUniversidade Federal de Sergipe. Programa de Pós-Graduação em Ciência da Computação. São Cristóvão, SE, Brasil
| | - Anny Giselly Milhome da Costa Farre
- Universidade Federal de SergipeDepartamento de EnfermagemLagartoSEBrasilUniversidade Federal de Sergipe. Departamento de Enfermagem. Lagarto, SE, Brasil
| | - Valter Joviniano de Santana-Filho
- Universidade Federal de SergipePrograma de Pós-Graduação em Ciências da SaúdeAracajuSEBrasilUniversidade Federal de Sergipe. Programa de Pós-Graduação em Ciências da Saúde. Aracaju, SE, Brasil
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Verma A, Shishodia S, Jaiswal S, Sheikh WR, Haldar M, Vishen A, Ahuja R, Khatai AA, Khanna P. Increased Length of Stay of Critically Ill Patients in the Emergency Department Associated with Higher In-hospital Mortality. Indian J Crit Care Med 2021; 25:1221-1225. [PMID: 34866817 PMCID: PMC8608642 DOI: 10.5005/jp-journals-10071-24018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives Emergency department (ED) length of stay (LOS) is defined as the time a patient is registered to the time the patient is shifted to a hospital bed or discharged. Increasing demand for quality emergency care has resulted in increased wait times due to demand and supply mismatch. It is perceived that longer LOS in the ED of critical patients leads to poor outcomes. Our goal was to study the impact of LOS in the ED on the patients who required critical care admissions. Methods This was a retrospective study conducted in the ED of a tertiary center. Data were collected using electronic health records (EHR) for patients admitted to the intensive care units (ICUs). Patient's LOS in ED was divided into 0–4, 4–8, 8–12, 12–24, and >24 hours. ED LOS was calculated from the registration time to the time patient was handed over in the ICU. Patients were divided into four categories (1–4) based on their criticality. LOS in ED, mortality, and total hospital LOS were analyzed in the study. Results Three thousand four hundred and twenty-nine patients were enrolled in the study. Mean age was 62.69 years (95% CI 62.11–63.26). A total of 42.09% (95% CI 40.5–43.8) were Category 1 patients. Overall mortality rate was 52.46% (95% CI 50.79–54.13). LOS of 48.15% (95% CI 46.54–49.88) patients in the ED was between 0 and 4 hours, 19.90% (95% CI 18.62–21.29) between 4 and 8 hours, 8.21% (95% CI 7.35–9.19) between 8 and 12 hours, 15.50% (95% CI 14.34–16.77) between 12 and 24 hours, and 8.13% (95% CI 7.27–9.10) >24 hours. Mortality for LOS of 0–4 hours was 51.30% (95% CI 48.89–53.70), 54.03% (95% CI 50.28–57.73) for 4–8 hours, 48.94% (95% CI 43.16–54.75) for 8–12 hours, 51.50% (95% CI 47.26–55.72) for 12–24 hours, and 60.57% (95% CI 54.73–66.13) for >24 hours. Conclusion We concluded that the longer the critically ill patients are boarded in the ED, the higher is the chance for mortality. Processes should be implemented to ease the throughput from the ED. How to cite this article Verma A, Shishodia S, Jaiswal S, Sheikh WR, Haldar M, Vishen A, et al. Increased Length of Stay of Critically Ill Patients in the Emergency Department Associated with Higher In-hospital Mortality. Indian J Crit Care Med 2021;25(11):1221–1225.
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Affiliation(s)
- Ankur Verma
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Shakti Shishodia
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Sanjay Jaiswal
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Wasil R Sheikh
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Meghna Haldar
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Amit Vishen
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Rinkey Ahuja
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Abbas A Khatai
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Palak Khanna
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
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Bacelar-Silva GM, Cox JF, Baptista HR, Rodrigues PP. Identifying and Addressing the Underlying Core Problems in Healthcare Environments: An Illustration Using an Emergency Department Game. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10083. [PMID: 34639391 PMCID: PMC8507676 DOI: 10.3390/ijerph181910083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 11/20/2022]
Abstract
The emergency department (ED) crowding is a critical healthcare issue worldwide that leads to long waits and poorer healthcare outcomes. Goldratt's theory of constraints (TOC) has been used effectively to improve such problematic environments for more than three decades. While most TOC solutions are simple, with many viewing them as purely common sense, they represent paradigm shifts in how to manage complex, uncertain, and silo environments. Goldratt used a simple dice game with a straight flow (I-shape) to illustrate the impact of dependent resources and statistical fluctuations in managing resources. Additionally, games help to overcome resistance to change and gain ownership by having participants develop their solutions. This new cooperative game illustrates an ED environment where patients may follow different care pathways according to their clinical needs, timeliness of care is measured in minutes, the demand is highly uncertain, and treatment must frequently start almost immediately. A Monte Carlo simulation validated the TOC solution to this ED game, achieving results similar to the real TOC's implementations. Moreover, this article provides a thorough process to Socratically introduce TOC to healthcare professionals and others to recognize that the EDs' (like other healthcare systems') core problem is the traditional approach to managing them.
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Affiliation(s)
- Gustavo M. Bacelar-Silva
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine (MEDCIDS-FMUP), University of Porto, 4200-450 Porto, Portugal;
- Center for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
- Department of Distance Learning, Bahiana School of Medicine and Public Health, Salvador 40285-001, Brazil
| | - James F. Cox
- Management Department, Terry College of Business, University of Georgia, Athens, GA 30602, USA;
| | | | - Pedro Pereira Rodrigues
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine (MEDCIDS-FMUP), University of Porto, 4200-450 Porto, Portugal;
- Center for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
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Sudarshan VK, Brabrand M, Range TM, Wiil UK. Performance evaluation of Emergency Department patient arrivals forecasting models by including meteorological and calendar information: A comparative study. Comput Biol Med 2021; 135:104541. [PMID: 34166880 DOI: 10.1016/j.compbiomed.2021.104541] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/30/2021] [Accepted: 05/30/2021] [Indexed: 11/30/2022]
Abstract
The volume of daily patient arrivals at Emergency Departments (EDs) is unpredictable and is a significant reason of ED crowding in hospitals worldwide. Timely forecast of patients arriving at ED can help the hospital management in early planning and avoiding of overcrowding. Many different ED patient arrivals forecasting models have previously been proposed by using time series analysis methods. Even though the time series methods such as Linear and Logistic Regression, Autoregressive Integrated Moving Average (ARIMA), Seasonal ARIMA (SARIMA), Exponential Smoothing (ES), and Artificial Neural Network (ANN) have been explored extensively for the ED forecasting model development, the few significant limitations of these methods associated in the analysis of time series data make the models inadequate in many practical situations. Therefore, in this paper, Machine Learning (ML)-based Random Forest (RF) regressor, and Deep Neural Network (DNN)-based Long Short-Term Memory (LSTM) and Convolutional Neural network (CNN) methods, which have not been explored to the same extent as the other time series techniques, are implemented by incorporating meteorological and calendar parameters for the development of forecasting models. The performances of the developed three models in forecasting ED patient arrivals are evaluated. Among the three models, CNN outperformed for short-term (3 days in advance) patient arrivals prediction with Mean Absolute Percentage Error (MAPE) of 9.24% and LSTM performed better for moderate-term (7 days in advance) patient arrivals prediction with MAPE of 8.91% using weather forecast information. Whereas, LSTM model outperformed with MAPE of 8.04% compared to 9.53% by CNN and 10.10% by RF model for current day prediction of patient arrivals using 3 days past weather information. Thus, for short-term ED patient arrivals forecasting, DNN-based model performed better compared to RF regressor ML-based model.
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Affiliation(s)
- Vidya K Sudarshan
- Maersk Mc-Kinney Moller Institute, University of Southern Denmark, Denmark; Biomedical Engineering, School of Science and Technology, SUSS, Singapore; College of Engineering, Science and Environment, University of Newcastle, Singapore.
| | - Mikkel Brabrand
- Department of Regional Health Research, University of Southern Denmark, Denmark; Hospital of South West Jutland, Esbjerg, Denmark
| | - Troels Martin Range
- Department of Regional Health Research, University of Southern Denmark, Denmark; Hospital of South West Jutland, Esbjerg, Denmark
| | - Uffe Kock Wiil
- Maersk Mc-Kinney Moller Institute, University of Southern Denmark, Denmark
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12
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Hoot NR, Banuelos RC, Chathampally Y, Robinson DJ, Voronin BW, Chambers KA. Does crowding influence emergency department treatment time and disposition? J Am Coll Emerg Physicians Open 2021; 2:e12324. [PMID: 33521777 PMCID: PMC7819268 DOI: 10.1002/emp2.12324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/21/2020] [Accepted: 10/28/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The objective of this study was to determine whether crowding influences treatment times and disposition decisions for emergency department (ED) patients. METHODS We conducted a retrospective cohort study at 2 hospitals from January 1, 2014, to July 1, 2014. Adult ED visits with dispositions of discharge, admission, or transfer were included. Treatment times were modeled by linear regression with log-transformation; disposition decisions (admission or transfer vs discharge) were modeled by logistic regression. Both models adjusted for chief complaint, Emergency Severity Index (ESI), and 4 crowding metrics in quartiles: waiting count, treatment count, boarding count, and National Emergency Department Overcrowding Scale. RESULTS We included 21,382 visits at site A (12.9% excluded) and 29,193 at site B (15.0% excluded). Respective quartiles of treatment count increased treatment times by 7.1%, 10.5%, and 13.3% at site A (P < 0.001) and by 4.0%, 6.5%, and 10.2% at site B (P < 0.001). The fourth quartile of treatment count increased estimates of treatment time for patients with chest pain and ESI level 2 from 2.5 to 2.9 hours at site A (20 minutes) and from 3.0 to 3.3 hours at site B (18 minutes). Treatment times decreased with quartiles of waiting count by 5.6%, 7.2%, and 7.3% at site B (P < 0.001). Odds of admission or transfer increased with quartiles of waiting count by 8.7%, 9.6%, and 20.3% at site A (P = 0.011) and for the third (11.7%) and fourth quartiles (27.3%) at site B (P < 0.001). CONCLUSIONS Local crowding influenced ED treatment times and disposition decisions at 2 hospitals after adjusting for chief complaint and ESI.
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Affiliation(s)
- Nathan R. Hoot
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Rosa C. Banuelos
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Yashwant Chathampally
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - David J. Robinson
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Benjamin W. Voronin
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Kimberly A. Chambers
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
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13
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Albarrak AI, Almansour AS, Alzahrani AA, Almalki AH, Alshehri AA, Mohammed R. Assessment of patient safety challenges and electronic occurrence variance reporting (e-OVR) barriers facing physicians and nurses in the emergency department: a cross sectional study. BMC Emerg Med 2020; 20:98. [PMID: 33317468 PMCID: PMC7737304 DOI: 10.1186/s12873-020-00391-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of patient safety is to prevent harm occurring in the healthcare system. Patient safety is improved by the use of a reporting system in which healthcare workers can document and learn from incidents, and thus prevent potential medical errors. The present study aimed to determine patient safety challenges facing clinicians (physicians and nurses) in emergency medicine and to assess barriers to using e-OVR (electronic occurrence variance reporting). METHODS This cross-sectional study involved physicians and nurses in the emergency department (ED) at King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia. Using convenience sampling, a self-administered questionnaire was distributed to 294 clinicians working in the ED. The questionnaire consisted of items pertaining to patient safety and e-OVR usability. Data were analyzed using frequencies, means, and percentages, and the chi-square test was used for comparison. RESULTS A total of 197 participants completed the questionnaire (67% response rate) of which 48 were physicians (24%) and 149 nurses (76%). Only 39% of participants thought that there was enough staff to handle work in the ED. Roughly half (48%) of participants spoke up when something negatively affected patient safety, and 61% admitted that they sometimes missed important patient care information during shift changes. Two-thirds (66%) of the participants reported experiencing violence. Regarding e-OVR, 31% of participants found reporting to be time consuming. Most (85%) participants agreed that e-OVR training regarding knowledge and skills was sufficient. Physicians reported lower knowledge levels regarding how to access (46%) and how to use (44%) e-OVR compared to nurses (98 and 95%, respectively; p < 0.01). Less than a quarter of the staff did not receive timely feedback after reporting. Regarding overall satisfaction with e-OVR, only 25% of physicians were generally satisfied compared to nearly half (52%) of nurses. CONCLUSION Although patient safety is well emphasized in clinical practice, especially in the ED, many factors hinder patient safety. More awareness is needed to eliminate violence and to emphasize the needs of additional staff in the ED. Electronic reporting and documentation of incidents should be well supported by continuous staff training, help, and feedback.
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Affiliation(s)
- Ahmed I Albarrak
- Medical Informatics Unit, Medical Education Department, Research Chair for Health Informatics and Promotion, College of Medicine, King Saud University, P O Box 63709, Riyadh, 11526, Saudi Arabia.
| | | | - Ali A Alzahrani
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | | | - Rafiuddin Mohammed
- Department of Health Informatics, College of Health Sciences, Saudi Electronic University, Riyadh, Saudi Arabia
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14
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Sarkar S, Vance A, Ramesh B, Demestihas M, Wu DT. The Influence of Professional Subculture on Information Security Policy Violations: A Field Study in a Healthcare Context. INFORMATION SYSTEMS RESEARCH 2020. [DOI: 10.1287/isre.2020.0941] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The Influence of Professional Subculture on Information Security Policy Violations: A Field Study in a Healthcare Context
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Affiliation(s)
- Sumantra Sarkar
- School of Management, Binghamton University, State University of New York, Binghamton, New York 13902
| | - Anthony Vance
- Fox School of Business, Temple University, Philadelphia, Pennsylvania 19122
| | | | | | - Daniel Thomas Wu
- Emergency Medicine, Emory University Hospital, Emory University School of Medicine, Atlanta, Georgia 30303
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15
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Short- and intermediate-term effects of a hospital-integrated walk-in clinic on emergency department-visits and case mix. Am J Emerg Med 2020; 46:410-415. [PMID: 34348436 DOI: 10.1016/j.ajem.2020.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Emergency department (ED) admissions have been rising over the last decades, especially in countries without any effective gate-keeping functions. Integration of walk-in clinics into the hospital might reduce ED-visits. Over a longer period, however, the additional service of a walk-in clinic might attract even more patients, nullifying an initial decrease in patients for the ED. OBJECTIVES, DESIGN, SETTINGS AND PARTICIPANTS This study aimed to determine short- and intermediate-term changes after the implementation of a hospital-integrated walk-in clinic. This is an observational study using routinely-collected health data. Study setting was the ED of a large tertiary care hospital in Austria, a country with universal health care and no regulations regarding level of care. OUTCOMES MEASURE AND ANALYSIS ED-visits were compared between before (2015) and after (2017 and 2018) establishment of a hospital-integrated walk-in clinic. MAIN RESULTS Total ED-visits decreased from 87,624 in 2015 to 67,479 in 2017, and 67,871 in 2018 (p < 0.001), mainly due to a decrease in non-urgent (ESI 4 & 5) cases (45,715 (54.1%) in 2015; 33,142 (51.3%) in 2017; 30,846 (47.5%) in 2018; short term OR non-urgent vs. urgent: 0.89 (95% CI 0.88-0.91); intermediate term OR urgent vs. non-urgent: 0.76 (95% CI 0.78-0.75)). A total of 2611 (13%) (2017) and 1714 (8.5%) (2018) patients were referred back to the ED. CONCLUSIONS After the introduction of the walk-in clinic, ED-visits declined significantly. This remained stable over a two-year period. Reduction in ED-visits was mainly due to low-acuity patients not requiring admission to the hospital.
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16
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Wretborn J, Henricson J, Ekelund U, Wilhelms DB. Prevalence of crowding, boarding and staffing levels in Swedish emergency departments - a National Cross Sectional Study. BMC Emerg Med 2020; 20:50. [PMID: 32552701 PMCID: PMC7301476 DOI: 10.1186/s12873-020-00342-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/28/2020] [Indexed: 01/10/2023] Open
Abstract
Background Emergency Department (ED) crowding occurs when demand for care exceeds the available resources. Crowding has been associated with decreased quality of care and increased mortality, but the prevalence on a national level is unknown in most countries. Method We performed a national, cross-sectional study on staffing levels, staff workload, occupancy rate and patients waiting for an in-hospital bed (boarding) at five time points during 24 h in Swedish EDs. Results Complete data were collected from 37 (51% of all) EDs in Sweden. High occupancy rate indicated crowding at 12 hospitals (37.5%) at 31 out of 170 (18.2%) time points. Mean workload (measured on a scale from 1, no workload to 6, very high workload) was moderate at 2.65 (±1.25). Boarding was more prevalent in academic EDs than rural EDs (median 3 vs 0). There were an average of 2.6, 4.6 and 3.2 patients per registered nurse, enrolled nurse and physician, respectively. Conclusion ED crowding based on occupancy rate was prevalent on a national level in Sweden and comparable with international data. Staff workload, boarding and patient to staff ratios were generally lower than previously described.
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Affiliation(s)
- Jens Wretborn
- Department of Emergency Medicine, Local Health Care Services in Central Östergötland, Linköping, Sweden.,Department of Clinical Sciences Lund, Emergency Medicine, Faculty of Medicine, Lund University, Lund, Sweden
| | - Joakim Henricson
- Department of Emergency Medicine, Local Health Care Services in Central Östergötland, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, S58185, Linköping, Sweden
| | - Ulf Ekelund
- Department of Clinical Sciences Lund, Emergency Medicine, Faculty of Medicine, Lund University, Lund, Sweden
| | - Daniel B Wilhelms
- Department of Emergency Medicine, Local Health Care Services in Central Östergötland, Linköping, Sweden. .,Department of Biomedical and Clinical Sciences, Linköping University, S58185, Linköping, Sweden.
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17
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Vainieri M, Panero C, Coletta L. Waiting times in emergency departments: a resource allocation or an efficiency issue? BMC Health Serv Res 2020; 20:549. [PMID: 32552829 PMCID: PMC7298831 DOI: 10.1186/s12913-020-05417-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/09/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In recent years, the flow of patients to the Emergency Departments (ED) of Western countries has steadily increased, thus generating overcrowding and extended waiting times. Scholars have identified four main causes for this phenomenon, related to: continuity of primary care services; availability of specific clinical pathways for chronic patients; ED's personnel endowment; organization of the ED. This study aims at providing a logical diagnostic framework to support managers in investigating specific solutions to be applied to their EDs to cope with high ED waiting times. The framework is based on the ED waiting times and ED admission rate matrix. It was applied to the Tuscan EDs as illustrative example. METHODS To provide the factors to be analyzed once the EDs are positioned into the matrix, a list of issues has been identified. The matrix was applied to Tuscan EDs. Data were collected from the Tuscan performance evaluation system, integrated with specific data on Tuscan EDs' personnel. The Tuscan EDs matrix, the descriptive statistics for each quadrant and the Spearman's rank correlation analysis among waiting times, admission rates and a set of performance indicators were conducted to help managers to read the phenomena that they need to investigate. RESULTS The combined reading of the correlations and waiting times-admission rates matrix shows that there are no optimal rules for all the EDs in managing admission rates and waiting times, but solutions have to be found considering mixed and personalized strategies. CONCLUSIONS The waiting times-admission rates matrix provides a tool able to support managers in detecting the problems related to the management of ED services. In particular, using this matrix, healthcare managers could be facilitated in the identification of possible solutions for their specific situation.
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Affiliation(s)
- Milena Vainieri
- Associate Professor at Management and Health Laboratory, Institute of Management, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Cinzia Panero
- Post-doctoral researcher at Università degli studi di Genova, Genoa, Italy
| | - Lucrezia Coletta
- PhD candidate, Management and Health Laboratory, Institute of Management, Scuola Superiore Sant’Anna, Pisa, Italy
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18
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Chiu WC, Powers DB, Hirshon JM, Shackelford SA, Hu PF, Chen SY, Chen HH, Mackenzie CF, Miller CH, DuBose JJ, Carroll C, Fang R, Scalea TM. Impact of trauma centre capacity and volume on the mortality risk of incoming new admissions. BMJ Mil Health 2020; 168:212-217. [PMID: 32474436 DOI: 10.1136/bmjmilitary-2020-001483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Trauma centre capacity and surge volume may affect decisions on where to transport a critically injured patient and whether to bypass the closest facility. Our hypothesis was that overcrowding and high patient acuity would contribute to increase the mortality risk for incoming admissions. METHODS For a 6-year period, we merged and cross-correlated our institutional trauma registry with a database on Trauma Resuscitation Unit (TRU) patient admissions, movement and discharges, with average capacity of 12 trauma bays. The outcomes of overall hospital and 24 hours mortality for new trauma admissions (NEW) were assessed by multivariate logistic regression. RESULTS There were 42 003 (mean=7000/year) admissions having complete data sets, with 36 354 (87%) patients who were primary trauma admissions, age ≥18 and survival ≥15 min. In the logistic regression model for the entire cohort, NEW admission hospital mortality was only associated with NEW admission age and prehospital Glasgow Coma Scale (GCS) and Shock Index (SI) (all p<0.05). When TRU occupancy reached ≥16 patients, the factors associated with increased NEW admission hospital mortality were existing patients (TRU >1 hour) with SI ≥0.9, recent admissions (TRU ≤1 hour) with age ≥65, NEW admission age and prehospital GCS and SI (all p<0.05). CONCLUSION The mortality of incoming patients is not impacted by routine trauma centre overcapacity. In conditions of severe overcrowding, the number of admitted patients with shock physiology and a recent surge of elderly/debilitated patients may influence the mortality risk of a new trauma admission.
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Affiliation(s)
- William C Chiu
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - D B Powers
- Director, Craniomaxillofacial Trauma Program, Duke University Hospital, Durham, North Carolina, USA
| | - J M Hirshon
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - P F Hu
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - S Y Chen
- National Yunlin University of Science and Technology, Douliou, Taiwan
| | - H H Chen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - C F Mackenzie
- Shock Trauma and Anesthesiology Research - Organized Research Center (STAR-ORC), University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - C H Miller
- US Air Force Materiel Command, Wright-Patterson AFB, Ohio, USA
| | - J J DuBose
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA.,Center for Sustainment of Trauma and Readiness Skills - Baltimore, US Air Force Medical Service, Baltimore, Maryland, USA
| | | | - R Fang
- Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - T M Scalea
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
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19
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Haas NL, Larabell P, Schaeffer W, Hoch V, Arribas M, Melvin AC, Laurinec SL, Bassin BS. Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit. West J Emerg Med 2020; 21:532-537. [PMID: 32421498 PMCID: PMC7234716 DOI: 10.5811/westjem.2020.4.47475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022] Open
Abstract
Introduction Extubation of appropriate patients in the emergency department (ED) may be a strategy to avoid preventable or short-stay intensive care unit (ICU) admissions, and could allow for increased ventilator and ICU bed availability when demand outweighs supply. Extubation is infrequently performed in the ED, and a paucity of outcome data exists. Our objective was to descriptively analyze characteristics and outcomes of patients extubated in an ED-ICU setting. Methods We conducted a retrospective observational study at an academic medical center in the United States. Adult ED patients extubated in the ED-ICU from 2015–2019 were retrospectively included and analyzed. Results We identified 202 patients extubated in the ED-ICU; 42% were female and median age was 60.86 years. Locations of endotracheal intubation included the ED (68.3%), outside hospital ED (23.8%), and emergency medical services/prehospital (7.9%). Intubations were performed for airway protection (30.2%), esophagogastroduodenoscopy (27.7%), intoxication/ingestion (17.3%), respiratory failure (13.9%), seizure (7.4%), and other (3.5%). The median interval from ED arrival to extubation was 9.0 hours (interquartile range 6.2–13.6). One patient (0.5%) required unplanned re-intubation within 24 hours of extubation. The attending emergency physician (EP) at the time of extubation was not critical care fellowship trained in the majority (55.9%) of cases. Sixty patients (29.7%) were extubated compassionately; 80% of these died in the ED-ICU, 18.3% were admitted to medical-surgical units, and 1.7% were admitted to intensive care. Of the remaining patients extubated in the ED-ICU (n = 142, 70.3%), zero died in the ED-ICU, 61.3% were admitted to medical-surgical units, 9.9% were admitted to intensive care, and 28.2% were discharged home from the ED-ICU. Conclusion Select ED patients were safely extubated in an ED-ICU by EPs. Only 7.4% required ICU admission, whereas if ED extubation had not been pursued most or all patients would have required ICU admission. Extubation by EPs of appropriately screened patients may help decrease ICU utilization, including when demand for ventilators or ICU beds is greater than supply. Future research is needed to prospectively study patients appropriate for ED extubation.
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Affiliation(s)
- Nathan L Haas
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan, Department of Emergency Medicine, Division of Critical Care, Ann Arbor, Michigan.,Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Patrick Larabell
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - William Schaeffer
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Victoria Hoch
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Miguel Arribas
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Amanda C Melvin
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan, Department of Emergency Medicine, Division of Critical Care, Ann Arbor, Michigan
| | - Stephanie L Laurinec
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan, Department of Emergency Medicine, Division of Critical Care, Ann Arbor, Michigan
| | - Benjamin S Bassin
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan, Department of Emergency Medicine, Division of Critical Care, Ann Arbor, Michigan.,Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan
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Kilian A, Upton LA, Sheagren JN. Reorganizing the History of Present Illness to Improve Verbal Case Presenting and Clinical Diagnostic Reasoning Skills of Medical Students: The All-Inclusive History of Present Illness. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2020; 7:2382120520928996. [PMID: 32577531 PMCID: PMC7288808 DOI: 10.1177/2382120520928996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/28/2020] [Indexed: 06/11/2023]
Abstract
The Institute of Medicine states that most diagnostic errors are caused by flaws in clinician diagnostic thinking. Accurately inferring the correct diagnosis from the patient history is the best way to improve diagnostic accuracy and efficiency. Such an improvement is contingent upon training early phase medical learners how to organize data from a patient history to arrive at the most likely diagnosis of the patient's chief health concern (CC). We describe how organizing the traditional history of present illness into what our trainees have come to call the "All-Inclusive History of Present Illness" (AIHPI) by applying the Bayesian statistical concepts of chronologically sequencing, as suggested by Skeff, both relevant historical risks and known medical events generate a series of pre-event probabilities of the most likely disease causing a patient's CC. Our trainees have enthusiastically recognized that the AIHPI organization process helps them improve both their ability to deliver well-organized, succinct verbal case presentations and the efficiency of generating and communicating what they think is the most likely disease causing a patient's CC.
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Affiliation(s)
- Adam Kilian
- Division of Rheumatology, Department of
Internal Medicine, School of Medicine and Health Sciences, The George Washington University,
Washington, DC, USA
| | - Laura A Upton
- School of Medicine, Georgetown University,
Washington, DC, USA
| | - John N Sheagren
- College of Human Medicine, Michigan State
University, Grand Rapids, MI, USA
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21
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Estrada-Atehortúa AF, Zuluaga-Gómez M. Estrategias para la medición y el manejo de la sobreocupación de los servicios de urgencias de adultos en instituciones de alta complejidad con altos volúmenes de consulta. Revisión de la literatura. IATREIA 2019. [DOI: 10.17533/udea.iatreia.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
La sobreocupación de los servicios de urgencias es un problema global que cada vez afecta más las instituciones de salud que atienden pacientes de mediana y alta complejidad, haciendo que estos permanezcan más tiempo en una sala de espera con la consiguiente demora en los tiempos de atención, bajo nivel de satisfacción de los usuarios, retraso en la toma de ayudas diagnósticas, retrasos al definir altas del servicio y favorecimiento de complicaciones médicas, entre otros. Para mejorar esta situación se han desarrollado estrategias como la creación de unidades de observación, unidades fast track o asignación de citas prioritarias para los pacientes que no requieren una atención urgente, de modo adicional el triaje, los exámenes point of care y la vinculación de especialistas en medicina de urgencias. Todo esto con el fin de mejorar la calidad de la atención de los pacientes, evitar que se presenten eventos adversos durante su proceso y disminuir la sobreocupación del servicio.
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22
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Vorakulpipat C, Rattanalerdnusorn E, Sirapaisan S, Savangsuk V, Kasisopha N. A Mobile-Based Patient-Centric Passive System for Guiding Patients Through the Hospital Workflow: Design and Development. JMIR Mhealth Uhealth 2019; 7:e14779. [PMID: 31333195 PMCID: PMC6681638 DOI: 10.2196/14779] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/18/2019] [Accepted: 06/18/2019] [Indexed: 11/13/2022] Open
Abstract
Background A hospital is an unfamiliar place to patients because of its style, atmosphere, and procedures. These hospital characteristics cause patients to become confused about responding to protocols, which slows down the procedural flows. Some additional information technology infrastructure facilities and human resources may be needed to solve these problems. However, this solution needs high investment and cannot guarantee an accuracy of information sent to patients. To handle this limitation, EasyHos has been developed to help patients recognize their status (for example, “waiting for an appointment at 11am“) during their stay in a hospital using all existing infrastructure and hospital data and without changing existing hospital's process. Objective The objective of this study was to provide a design of the EasyHos system and the case study in hospitals in Thailand. The design is usable and repeatable for small- and medium-sized hospitals where internet infrastructure is in place. Methods The EasyHos system has been designed based on existing infrastructure, hospital data and hospital processes. The main components include mobile devices, existing hospital data, wireless communication network. The EasyHos was deployed at 2 hospitals in Thailand, one small and the other with a medium size. The experimental process was focused on solving the problem of unfamiliarity in the hospital. The criteria and pretest conditions regarding the unexpected problem have been defined before the experiment. Results The results are presented in terms of criteria, pretest conditions, posttest conditions in the hospitals. The posttest conditions show the experimental results and impact of the system on users such as hospital nurses/staff and patients. For example, the questions from patients were reduced by 83.3% after using EasyHos system while nurses/hospital staff had 5 min more to do their routine work each day. In addition, another impact is that hospitals can create new information values from existing data, which now can be visible and valuable to patients. Conclusions Hospitals' unexpected problems have been reduced by the EasyHos system. The EasyHos system has been developed with self-service and patient-centered concepts to assist patients with necessary information. The system makes interaction easier for nurses/hospital staff members and patients working or waiting in the hospital. The nurses/hospital staff members would have more time to do their routine works. Hospitals can easily set up the EasyHos system, which will have a low or nearly zero implementation cost.
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Affiliation(s)
| | | | | | - Visut Savangsuk
- National Electronics and Computer Technology Center, Pathumthani, Thailand
| | - Natsuda Kasisopha
- National Electronics and Computer Technology Center, Pathumthani, Thailand
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Alishahi Tabriz A, Birken SA, Shea CM, Fried BJ, Viccellio P. What is full capacity protocol, and how is it implemented successfully? Implement Sci 2019; 14:73. [PMID: 31319857 PMCID: PMC6637572 DOI: 10.1186/s13012-019-0925-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 07/09/2019] [Indexed: 11/18/2022] Open
Abstract
Background Full capacity protocol (FCP) is an internationally recognized intervention designed to address emergency department (ED) crowding. Despite FCP international recognition and positive effects on hospital performance measures, many hospitals, even the most crowded ones, have not implemented FCP. We conducted this study to identify the core components of FCP, explore the key barriers and facilitators associated with the FCP implementation, and provide practical recommendations on how to overcome those barriers. Methods To identify the core components of FCP, we used a non-experimental approach. We conducted semi-structured interviews with key informants (e.g., division chiefs, medical directors) involved in the implementation of FCP. We used the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis. We used a template analysis approach to determine the relevance of the CFIR constructs to implementing the FCP. We analyzed the responses to the interview questions about FCP definition and FCP key principles, compared different hospitals’ FCP official documents, and consulted with the original FCP developer. We then used an adaptation framework to categorize the core components of FCP into three main groups. Finally, we summarized practical recommendations for each barrier based on information provided by the interviewees. Results A total of 32 interviews were conducted. We observed that FCP has evolved from the idea of transferring boarded patients from ED hallways to inpatient hallways to a practical hospital-wide intervention with several components and multiple levels. The key determinant of successful FCP implementation was collaboration with inpatient nursing staff, as they were often reluctant to have patients boarded in inpatient hallways. Other determinants of successful FCP implementation were reaching consensus about the criteria for activation of each FCP level and actions in each FCP level, modifying the electronic health records system, restructuring the inpatient units to have adequate staffing and resources, complying with external regulations and policies such as fire marshal guidelines, and gaining hospital leaders’ support. Conclusions The key determinant in implementing FCP is creating a supportive and cooperative hospital culture and encouraging key stakeholders, including inpatient nursing staff, to acknowledge that crowding is a hospital-wide problem that requires a hospital-wide response. Electronic supplementary material The online version of this article (10.1186/s13012-019-0925-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amir Alishahi Tabriz
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 016 Beard Hall, 301 Pharmacy Lane, Chapel Hill, NC, 27599-7355, USA.
| | - Sarah A Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1103E McGavran-Greenberg, CB #7411, Chapel Hill, NC, 27599-7411, USA
| | - Christopher M Shea
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1103E McGavran-Greenberg, CB #7411, Chapel Hill, NC, 27599-7411, USA
| | - Bruce J Fried
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1103E McGavran-Greenberg, CB #7411, Chapel Hill, NC, 27599-7411, USA
| | - Peter Viccellio
- Department of Emergency Medicine, Stony Brook University, Health Sciences Center, Level 4 - Room 080, SUNY at Stony Brook, Stony Brook, NY, 11794-8350, USA
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Hsia RY, Sarkar N, Shen YC. Is Inpatient Volume Or Emergency Department Crowding A Greater Driver Of Ambulance Diversion? Health Aff (Millwood) 2019; 37:1115-1122. [PMID: 29985688 DOI: 10.1377/hlthaff.2017.1602] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Inpatient volume has long been believed to be a contributing factor to ambulance diversion, which can lead to delayed treatment and poorer outcomes. We examined the extent to which both daily inpatient and emergency department (ED) volumes at specified hospitals, and diversion levels (that is, the number of hours ambulances were diverted on a given day) at their nearest neighboring hospitals, were associated with diversion levels in the period 2005-12. We found that a 10 percent increase in patient volume was associated with a sevenfold greater increase in diversion hours when the volume increase occurred among inpatients (5 percent) versus ED visitors (0.7 percent). When the next-closest ED experienced mild, moderate, or severe diversion, the study hospital's diversion hours increased by 8 percent, 23 percent, and 44 percent, respectively. These findings suggest that efforts focused on managing inpatient volume and flow might reduce diversion more effectively than interventions focused only on ED dynamics.
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Affiliation(s)
- Renee Y Hsia
- Renee Y. Hsia ( ) is a professor in the Department of Emergency Medicine and a core faculty member at the Philip R. Lee Institute for Health Policy Studies, both at the University of California, San Francisco
| | - Nandita Sarkar
- Nandita Sarkar is a postdoctoral research analyst at the National Bureau of Economic Research in Cambridge, Massachusetts
| | - Yu-Chu Shen
- Yu-Chu Shen is a professor in the Graduate School of Business and Public Policy, Naval Postgraduate School, in Monterey, California, and a faculty research fellow at the National Bureau of Economic Research
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Abstract
OBJECTIVE: The overload of pediatric emergency units around the world has become an increasing problem for patients and health care professionals alike. Researching the features of pediatric emergency services will provide the necessary information for creating an effective emergency medical system, increasing patient satisfaction, and reducing the treatment costs. In this study; we aimed to check the admissions in pediatric emergency rooms, evaluate the effectiveness of emergency service, and develop suitable strategies to increase the amount and quality of medical service given in pediatric emergency rooms. METHODS: In this retrospective study, the records of 296,858 (51.2% female, 48.8% male) patient admissions in the emergency rooms and 384,171 (46.3% female, 53.7% male) admissions in the outpatient clinics of eight hospitals between January 2015 and June 2015 were scanned. Out of these hospitals, two facilities were research and training hospitals. RESULTS: The average age of patients who were admitted to the emergency room was 89.1 (±21.3) months and the average age of patients admitted to the outpatient clinics was 87.2 (±18.7) months. Upper respiratory tract infection was the most frequent (44.23%) diagnosis in the emergency rooms and most of these infected patients (63.67%) had been admitted to the two training and research hospitals that provide an advanced level of health care. Also, the patient requests for diagnosis were determined to be significantly high in emergency rooms. CONCLUSION: Proper understanding of the scope of emergency services is very important in order to provide fast and effective healthcare to the patients who get admitted to emergency rooms and maintain appropriate and judicious use of the resources of emergency rooms.
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Abir M, Goldstick JE, Malsberger R, Williams A, Bauhoff S, Parekh VI, Kronick S, Desmond JS. Evaluating the impact of emergency department crowding on disposition patterns and outcomes of discharged patients. Int J Emerg Med 2019; 12:4. [PMID: 31179922 PMCID: PMC6354348 DOI: 10.1186/s12245-019-0223-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Crowding is a major challenge faced by EDs and is associated with poor outcomes. OBJECTIVES Determine the effect of high ED occupancy on disposition decisions, return ED visits, and hospitalizations. METHODS We conducted a retrospective analysis of electronic health records of patients evaluated at an adult, urban, and academic ED over 20 months between the years 2012 and 2014. Using a logistic regression model predicting admission, we obtained estimates of the effect of high occupancy on admission disposition, adjusted for key covariates. We then stratified the analysis based on the presence or absence of high boarder patient counts. RESULTS Disposition decisions during a high occupancy hour decreased the odds of admission (OR = 0.93, 95% CI: [0.89, 0.98]). Among those who were not admitted, high occupancy was not associated with increased odds of return in the combined (OR = 0.94, 95% CI: [0.87, 1.02]), with-boarders (OR = 0.96, 95% CI: [0.86, 1.09]), and no-boarders samples (OR = 0.93, 95% CI: [0.83, 1.04]). Among those who were not admitted and who did return within 14 days, disposition during a high occupancy hour on the initial ED visit was not associated with a significant increased odds of hospitalization in the combined (OR = 1.04, 95% CI: [0.87, 1.24]), the with-boarders (OR = 1.12, 95% CI: [0.87, 1.44]), and the no-boarders samples (OR = 0.98, 95% CI: [0.77, 1.24]). CONCLUSION ED crowding was associated with reduced likelihood of hospitalization without increased likelihood of 2-week return ED visit or hospitalization. Furthermore, high occupancy disposition hours with high boarder patient counts were associated with decreased likelihood of hospitalization.
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Affiliation(s)
- Mahshid Abir
- Department of Emergency Medicine, Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, NCRC Bldg. 10 Rm G016, 2800 Plymouth Road, Ann Arbor, MI, 48109-2800, USA. .,RAND Corporation, Santa Monica, CA, USA.
| | - Jason E Goldstick
- Department of Emergency Medicine, Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, NCRC Bldg. 10 Rm G016, 2800 Plymouth Road, Ann Arbor, MI, 48109-2800, USA
| | | | | | - Sebastian Bauhoff
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Vikas I Parekh
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Steven Kronick
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey S Desmond
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
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Backer HD, D'Arcy NT, Davis AJ, Barton B, Sporer KA. Statewide Method of Measuring Ambulance Patient Offload Times. PREHOSP EMERG CARE 2018; 23:319-326. [PMID: 30257596 DOI: 10.1080/10903127.2018.1525456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Ambulance patient offload time (APOT) also known colloquially as "Wall time" has been described in various jurisdictions but seems to be highly variable. Any attempt to improve APOT requires the use of common definitions and standard methodology to measure the extent of the problem. METHODS An Ambulance Offload Delay Task Force in California developed a set of standard definitions and methodology to measure APOT for transported 9-1-1 patients. It is defined as the time "interval between the arrival of an ambulance at an emergency department and the time that the patient is transferred to an ED gurney, bed, chair or other acceptable location and the ED assumes responsibility for care of the patient." Local EMS agencies voluntarily reported data according to the standard methodology to the California EMS Authority (State agency). RESULTS Data were reported for 9-1-1 transports during 2017 from 9 of 33 local EMS Agencies in California that comprise 37 percent of the state population. These represent 830,637 ambulance transports to 126 hospitals. APOT shows significant variation by EMS agency with half of the agencies demonstrating significant delays. Offload times vary markedly by hospital as well as by region. Three-fourths of hospitals detained EMS crews more than one hour, 40% more than two hours, and one-third delayed EMS return to service by more than three hours. CONCLUSION This first step to address offload delays in California consists of standardized definitions for data collection to address the significant variability inherent in obtaining data from 33 local agencies, hundreds of EMS provider agencies, and 320 acute care hospital Emergency Departments that receive 9-1-1 ambulance transports. The first year of standardized data collection of ambulance patient offload times revealed significant ambulance patient offload time delays that are not distributed uniformly, resulting in a substantial financial burden for some EMS providers in California.
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Hospital Disaster Preparedness in Switzerland Over a Decade: A National Survey. Disaster Med Public Health Prep 2018; 13:433-439. [PMID: 29973301 DOI: 10.1017/dmp.2018.59] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The present study aimed to provide a comprehensive assessment of Swiss hospital disaster preparedness in 2016 compared with the 2006 data. METHODS A questionnaire was addressed in 2016 to all heads responsible for Swiss emergency departments (EDs). RESULTS Of the 107 hospitals included, 83 (78%) returned the survey. Overall, 76 (92%) hospitals had a plan in case of a mass casualty incident, and 76 (93%) in case of an accident within the hospital itself. There was a lack in preparedness for specific situations: less than a third of hospitals had a specific plan for nuclear/radiological, biological, chemical, and burns (NRBC+B) patients: nuclear/radiological (14; 18%), biological (25; 31%), chemical (27; 34%), and burns (15; 49%), and 48 (61%) of EDs had a decontamination area. Less than a quarter of hospitals had specific plans for the most vulnerable populations during disasters, such as seniors (12; 15%) and children (19; 24%). CONCLUSIONS The rate of hospitals with a disaster plan has increased since 2006, reaching a level of 92%. The Swiss health care system remains vulnerable to specific threats like NRBC. The lack of national legislation and funds aimed at fostering hospitals' preparedness to disasters may be the root cause to explain the vulnerability of Swiss hospitals regarding disaster medicine. (Disaster Med Public Health Preparedness. 2019;13:433-439).
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Amodio E, d'Oro LC, Chiarazzo E, Picco C, Migliori M, Trezzi I, Lopez S, Rinaldi O, Giupponi M. Emergency department performances during overcrowding: the experience of the health protection agency of Brianza. AIMS Public Health 2018; 5:217-224. [PMID: 30280113 PMCID: PMC6141554 DOI: 10.3934/publichealth.2018.3.217] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/26/2018] [Indexed: 11/18/2022] Open
Abstract
Background: Hospital emergency departments (ED) can contribute to improve health outcomes and reduce costs of health care system. This study evaluated ED admissions during a twelve months period, analyzing characteristics of patients who underwent to emergency care in order to understand factors involved in ED overcrowding and promote adequate management. Methods: This retrospective study analyzed a twelve months window, with in-depth focus on December/January when almost all EDs reported overcrowding. All ED admissions were recorded in electronic schedules including: demographic characteristics, time/date of the access, incoming triage code, diagnosis, performed procedures, discharge, time/date of discharge. A backward multivariable logistic regression model was used to estimate relationships between investigated variables and ED pattern mortality. Results: A total of 416,299 ED admissions were analyzed. During the overcrowded period there was an increase in patients admissions (+32 patients per day, p = 0.0079) with a statistically significant rise of critical patients (+1.7% yellow codes and +0.7% red codes, p < 0.001) and older subjects (+1.4% patients aged 75 or more years, p < 0.001). Moreover, there were statistically significant increases in waiting times and in length of visits, a higher percentage of patients who were hospitalized (13.3% vs. 12.2%, p < 0.001), left ED (4.46% vs. 4.15%, p < 0.001) and died (0.27% vs. 0.17%, p < 0.0001). This latter result maintained a marginal statistical significance (OR = 1.16, 95% CI = 0.98–1.38, p = 0.075) after adjustment for confounding. Conclusion: Our study highlights that ED crowding can determine measurable worsening in ED services and patient outcomes as mortality, waiting times, lengths of stay, percentage of abandonment without being seen and, probably, costs. Thus, address ED crowding has to be considered an important public health priority requiring policymakers involvement.
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Affiliation(s)
- Emanuele Amodio
- Health Protection Agency of Brianza (Italy), Viale Elvezia n.2 Monza (MB) 20900
| | | | | | - Carlo Picco
- AREU-Urgency Emergency Regional Agency, Lombardy
| | | | - Isabella Trezzi
- Health Protection Agency of Brianza (Italy), Viale Elvezia n.2 Monza (MB) 20900
| | - Silvano Lopez
- Health Protection Agency of Brianza (Italy), Viale Elvezia n.2 Monza (MB) 20900
| | - Oliviero Rinaldi
- Health Protection Agency of Brianza (Italy), Viale Elvezia n.2 Monza (MB) 20900
| | - Massimo Giupponi
- Health Protection Agency of Brianza (Italy), Viale Elvezia n.2 Monza (MB) 20900
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Abstract
OBJECTIVE The aim of the study was to evaluate the pediatric emergency department (PED) in a main teaching hospital. METHODS Retrospective review of all children presented to PED at King Abdulaziz University Hospital from September to November 2014 was performed. We classified priority into the following 5 stages: 1, need resuscitation; 2, emergent; 3, urgent; 4, less urgent; and 5, nonurgent. RESULTS A total of 2567 children (58.9% boys) attended PED for 3 months. Toddler age group was the highest. Respiratory complaints were the commonest (36%), followed by gastrointestinal complaints (20%). The majority were classified as priority 3 (52.3%) and priority 4 (30.7%). The admission rate was 12.3% and the mean (range) length of stay (LOS) was 5.85 (0.2-25) hours. Saudi nationals were less likely to wait for 5 hours or longer, less likely to be admitted, but more likely to leave PED without being evaluated. There was a negative correlation between higher priorities and time from triage to PED. There was a positive correlation between the higher priorities and LOS. CONCLUSIONS Most children who were seen in PED were priority 3 and therefore needed to be seen. However, a considerable percentage of priority 4 and 5 could have been seen in ambulatory clinics. Most lower priorities were Saudi nationals who were most likely to leave without being seen. Prolonged LOS, overcrowding, and high percentage of admission are the main challenges.
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Influence of demographic changes on the number of visits to hospital emergency departments: 13 years’ experience. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Influencia de los cambios demográficos en la frecuentación de urgencias hospitalarias: 13 años de experiencia. An Pediatr (Barc) 2018; 88:322-328. [DOI: 10.1016/j.anpedi.2017.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/26/2017] [Accepted: 06/30/2017] [Indexed: 11/24/2022] Open
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Emergency Overcrowding Impact on the Quality of Care of Patients Presenting with Acute Stroke. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2017; 2:e3. [PMID: 31172066 PMCID: PMC6548098 DOI: 10.22114/ajem.v0i0.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: Emergency overcrowding is defined as when the amount of care required for patients overcomes the available amount. This can cause delays in delivering critical care in situations like stroke. Objective: The aim of this study was to assess the possible impact of emergency department (ED) crowding on the quality of care for acute stroke patients. Methods: In this cross-sectional prospective study, all patients with symptoms of acute stroke presenting to the ED of educational hospitals were enrolled. All patients were assessed and examined by the emergency medicine (EM) residents on shift and a questionnaire was filled out for them. The amount of time that passed from the first triage to performing the required interventions and delivering health services were recorded by the triage nurse. ED crowding was measured by the occupancy rate. Then, the correlation between all of the variables and ED crowding level were calculated. Results: The average daily bed occupancy rate was 184.9 ± 54.3%. The median time passed from the first triage to performing the interventions were as follows: the first EM resident visit after 34 min, the first neurologic visit after 138 min, head CT after 134 min, ECG after 104 min and ASA administration after 210 min. There was no statistically significant relationship between the ED occupancy rate and the time elapsed before different required health services in the management of stroke patients either throughout an entire day or during each 8-hour interval (p > 0.05). Conclusion: In the current study, the ED occupancy rate was not significantly correlated with the time frame associated with management of admitted acute stroke patients.
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Juang WC, Huang SJ, Huang FD, Cheng PW, Wann SR. Application of time series analysis in modelling and forecasting emergency department visits in a medical centre in Southern Taiwan. BMJ Open 2017; 7:e018628. [PMID: 29196487 PMCID: PMC5719313 DOI: 10.1136/bmjopen-2017-018628] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Emergency department (ED) overcrowding is acknowledged as an increasingly important issue worldwide. Hospital managers are increasingly paying attention to ED crowding in order to provide higher quality medical services to patients. One of the crucial elements for a good management strategy is demand forecasting. Our study sought to construct an adequate model and to forecast monthly ED visits. METHODS We retrospectively gathered monthly ED visits from January 2009 to December 2016 to carry out a time series autoregressive integrated moving average (ARIMA) analysis. Initial development of the model was based on past ED visits from 2009 to 2016. A best-fit model was further employed to forecast the monthly data of ED visits for the next year (2016). Finally, we evaluated the predicted accuracy of the identified model with the mean absolute percentage error (MAPE). The software packages SAS/ETS V.9.4 and Office Excel 2016 were used for all statistical analyses. RESULTS A series of statistical tests showed that six models, including ARIMA (0, 0, 1), ARIMA (1, 0, 0), ARIMA (1, 0, 1), ARIMA (2, 0, 1), ARIMA (3, 0, 1) and ARIMA (5, 0, 1), were candidate models. The model that gave the minimum Akaike information criterion and Schwartz Bayesian criterion and followed the assumptions of residual independence was selected as the adequate model. Finally, a suitable ARIMA (0, 0, 1) structure, yielding a MAPE of 8.91%, was identified and obtained as Visitt=7111.161+(at+0.37462 at-1). CONCLUSION The ARIMA (0, 0, 1) model can be considered adequate for predicting future ED visits, and its forecast results can be used to aid decision-making processes.
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Affiliation(s)
- Wang-Chuan Juang
- Department of Emergency, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Information Management, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Sin-Jhih Huang
- Department of Emergency, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Fong-Dee Huang
- Department of Emergency, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Pei-Wen Cheng
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Physical Therapy, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Shue-Ren Wann
- Department of Emergency, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Mahmoudian-Dehkordi A, Sadat S. A Generic Simulation Model of the Relative Cost-Effectiveness of ICU Versus Step-Down (IMCU) Expansion. J Intensive Care Med 2017; 35:191-202. [PMID: 29088994 DOI: 10.1177/0885066617737303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many jurisdictions are facing increased demand for intensive care. There are two long-term investment options: intensive care unit (ICU) versus step-down or intermediate care unit (IMCU) capacity expansion. Relative cost-effectiveness of the two investment strategies with regard to patient lives saved has not been studied to date. METHODS We expand a generic system dynamics simulation model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to estimate the long-term effects of expanding ICU versus IMCU beds on patient lives saved under a common assumption of 2.1% annual increase in hospital arrivals. Two alternative policies of expanding ICU by two beds versus introducing a two-bed IMCU are compared over a ten-year simulation period. Russel equation is used to calculate total cost of patients' hospitalization. Using two possible values for the ratio of ICU to IMCU cost per inpatient day and four possible values for the percentage of patients transferred from ICU to IMCU found in the literature, nine scenarios are compared against the baseline scenario of no capacity expansion. RESULTS Expanding ICU capacity by two beds is demonstrated as the most cost-effective scenario with an incremental cost-effectiveness ratio of 3684 (US $) per life saved against the baseline scenario. Sensitivity analyses on the mortality rate of patients in IMCU, direct transfer of IMCU-destined patients to the ward upon completing required IMCU length of stay in the ICU, admission of IMCU patient to ICU, adding two ward beds, and changes in hospital size do not change the superiority of ICU expansion over other scenarios. CONCLUSIONS In terms of operational costs, ICU beds are more cost effective for saving patients than IMCU beds. However, capital costs of setting up ICU versus IMCU beds should be considered for a complete economic analysis.
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Affiliation(s)
- Amin Mahmoudian-Dehkordi
- Lazaridis School of Business and Economics, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Somayeh Sadat
- Health Systems Engineering Program, Faculty of Industrial and Systems Engineering, Tarbiat Modares University, Tehran, Iran
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Diplock G, Ward J, Stewart S, Scuffham P, Stewart P, Reeve C, Davidson L, Maguire G. The Alice Springs Hospital Readmission Prevention Project (ASHRAPP): a randomised control trial. BMC Health Serv Res 2017; 17:153. [PMID: 28219383 PMCID: PMC5319097 DOI: 10.1186/s12913-017-2077-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/08/2017] [Indexed: 12/18/2022] Open
Abstract
Background Hospitals are frequently faced with high levels of emergency department presentations and demand for inpatient care. An important contributing factor is the subset of patients with complex chronic diseases who have frequent and preventable exacerbations of their chronic diseases. Evidence suggests that some of these hospital readmissions can be prevented with appropriate transitional care. Whilst there is a growing body of evidence for transitional care processes in urban, non-indigenous settings, there is a paucity of information regarding rural and remote settings and, specifically, the indigenous context. Methods This randomised control trial compares a tailored, multidimensional transitional care package to usual care. The objective is to evaluate the efficacy of the transitional care package for Indigenous and non-Indigenous Australian patients with chronic diseases at risk of recurrent readmission with the aim of reducing readmission rates and improving transition to primary care in a remote setting. Patients will be recruited from medical and surgical admissions to Alice Springs Hospital and will be followed for 12 months. The primary outcome measure will be number of admissions to hospital with secondary outcomes including number of emergency department presentations, number of ICU admissions, days alive and out of hospital, time to primary care review post discharge and cost-effectiveness. Discussion Successful transition from hospital to home is important for patients with complex chronic diseases. Evidence suggests that a coordinated transitional care plan can result in a reduction in length of hospital stay and readmission rates for adults with complex medical needs. This will be the first study to evaluate a tailored multidimensional transitional care intervention to prevent readmission in Indigenous and non-Indigenous Australian residents of remote Australia who are frequently admitted to hospital. If demonstrated to be effective it will have implications for the care and management of Indigenous Australians throughout regional and remote Australia and in other remote, culturally and linguistically diverse populations and settings. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12615000808549- Retrospectively registered on 4/8/15. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2077-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gabrielle Diplock
- Monash University and Baker IDI Heart & Diabetes Institute, Melbourne, Australia.
| | - James Ward
- South Australian Health & Medical Research Institute, Adelaide, Australia
| | - Simon Stewart
- Monash University and Baker IDI Heart & Diabetes Institute, Melbourne, Australia
| | - Paul Scuffham
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | | | - Carole Reeve
- Alice Springs Hospital, Alice Springs, Australia
| | - Lea Davidson
- Alice Springs Hospital, Alice Springs, Australia
| | - Graeme Maguire
- Monash University and Baker IDI Heart & Diabetes Institute, Melbourne, Australia
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Mazer LM, Storage T, Bereknyei S, Chi J, Skeff K. A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication. J Gen Intern Med 2017; 32:182-188. [PMID: 27896691 PMCID: PMC5264687 DOI: 10.1007/s11606-016-3928-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/21/2016] [Accepted: 11/08/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patient history-taking is an essential clinical skill, with effects on diagnostic reasoning, patient-physician relationships, and more. We evaluated the impact of using a structured, timeline-based format, the Chronology of Present Illness (CPI), to guide the initial patient interaction. OBJECTIVE To determine the feasibility and impact of the CPI on the patient interview, written notes, and communication with other providers. DESIGN Internal medicine residents used the CPI during a 2-week night-float rotation. For the first week, residents interviewed, documented, and presented patient histories according to their normal practices. They then attended a brief educational session describing the CPI, and were asked to use this method for new patient interviews, notes, and handoffs during the second week. Night and day teams evaluated the method using retrospective pre-post comparisons. PARTICIPANTS Twenty-two internal medicine residents in their second or third postgraduate year. INTERVENTION An educational dinner describing the format and potential benefits of using the CPI. MAIN MEASURES Retrospective pre-post surveys on the efficiency, quality, and clarity of the patient interaction, written note, and verbal handoff, as well as open-ended comments. Respondents included night-float residents, day team residents, and attending physicians. KEY RESULTS All night-float residents responded, reporting significant improvements in written note, verbal sign-out, assessment and plan, patient interaction, and overall efficiency (p < 0.05). Day team residents (n = 76) also reported increased clarity in verbal sign-out and written note, improved efficiency, and improved preparedness for presenting the patient (p < 0.05). Attending physician ratings did not differ between groups. CONCLUSIONS Resident ratings indicate that the CPI can improve key aspects of patient care, including the patient interview, note, and physician-physician communication. These results suggest that the method should be taught and implemented more frequently.
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Affiliation(s)
- Laura M Mazer
- Goodman Surgical Education Center, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3552, Stanford, CA, 94305, USA.
| | - Tina Storage
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Lane 154, Stanford, CA, 94305, USA
| | - Sylvia Bereknyei
- Goodman Surgical Education Center, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3552, Stanford, CA, 94305, USA.,Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Lane 154, Stanford, CA, 94305, USA.,Research and Evaluation, Office of Medical Education, Stanford University School of Medicine, 1070 Arastradero Rd, Rm 219, Palo Alto, CA, 94304, USA
| | - Jeffrey Chi
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Lane 154, Stanford, CA, 94305, USA
| | - Kelley Skeff
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Lane 154, Stanford, CA, 94305, USA
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Han CY, Lin CC, Goopy S, Hsiao YC, Barnard A, Wang LH. Waiting and hoping: a phenomenographic study of the experiences of boarded patients in the emergency department. J Clin Nurs 2016; 26:840-848. [PMID: 27805751 DOI: 10.1111/jocn.13621] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2016] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To understand the experiences and concerns of patients in the emergency department during inpatient boarding. BACKGROUND Boarding in the emergency department is an increasingly common phenomenon worldwide. Emergency department staff, patients and their families become more stressed as the duration of boarding in the emergency department increases. Yet, there is limited knowledge of the experiences and concerns of boarded patients. DESIGN The qualitative approach of phenomenography was used in the study. METHODS The phenomenographic study was conducted in one emergency department that treats approximately 15,000 patients each month. Twenty emergency department boarding patients were recruited between July-September 2014. Semi-structured interviews were used for data collection. The seven steps of qualitative data analysis for a phenomenographic study - familiarisation, articulation, condensation, grouping, comparison, labelling and contrasting - were employed to develop an understanding of participants' experiences and concerns during their inpatient boarding in the emergency department. RESULTS The perceptions that emerged from the data were collected into four categories of description of the phenomenon of emergency department boarding patients: a helpless choice; loyalty to specific hospitals and doctors; an inevitable challenge of life; and distrust of the healthcare system. The outcome space for the emergency department boarding patients was waiting and hoping for a cure. CONCLUSION The experiences and concerns of emergency department boarding patients include physical, psychological, spiritual and health system dimensions. It is necessary to develop an integrated model of care for these patients. RELEVANCE TO CLINICAL PRACTICE Understanding the experiences and concerns of patients who are placed on boarding status in the ED will help emergency healthcare professionals to improve the quality of emergency care. There is a need to develop a care model and associated intervention measures for emergency department patients during the boarding process. The results of this study will help health regulatory authorities to develop an appropriate emergency department boarding system so that patients receive better emergency care.
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Affiliation(s)
- Chin-Yen Han
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.,Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Chun-Chih Lin
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.,Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Suzanne Goopy
- Faculty of Nursing, University of Calgary, Calgary, Canada
| | - Ya-Chu Hsiao
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.,Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Alan Barnard
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Li-Hsiang Wang
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan
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Khalifa M, Zabani I. Utilizing health analytics in improving the performance of healthcare services: A case study on a tertiary care hospital. J Infect Public Health 2016; 9:757-765. [PMID: 27663517 DOI: 10.1016/j.jiph.2016.08.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 07/24/2016] [Accepted: 08/31/2016] [Indexed: 11/28/2022] Open
Abstract
Among the most common and chronic problems in the healthcare system worldwide is the crowding of emergency rooms (ER); leading to many serious complications. King Faisal Specialist Hospital and Research Center utilized health analytics methods to identify areas of deficiency and suggest potential improvements to ER performance. The project implemented solutions and monitored two indicators; ER length of stay (LOS), reflecting efficiency, and percentage of patients leaving without treatment, reflecting effectiveness of the ER. A retrospective analysis of 26,948 ER encounters in 2014 was done in January 2015. Analytics techniques were used to suggest process redesign based on results. Two recommendations were implemented; a Fast-Track for lower acuity ER patients and an internal waiting area, for those patients who can stay vertical and spare an ER bed. 32.8% of ER patients had lower acuity levels and less than 0.5% of them were admitted to the hospital. After implementing the two solutions, the total ER LOS was reduced from 20h in 2014 to less than 12h in 2016; 40% improvement. The percentages of patients left without being seen stayed around 3.5%, while the percentages of patients left before complete treatment was significantly reduced from 13.5% in 2014 to 5.5% in 2016. Consequently, the total percentage of patients left without treatment was reduced from 17% in 2014 to 9% in 2016, with 50% improvement. All other factors were the same, including numbers of ER visits, Patient Acuity Level, working staff, working hours, and the count of ER beds. Health analytics methods can be used to identify areas of deficiency, potential improvements, and recommend effective solutions to positively enhance ER performance. More solutions should be examined such as team triaging, patients palmar scanning, and placing a physician in triage. Additionally, more indicators should be monitored, such as the effectiveness of ER treatment-including the rates of revisits.
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Affiliation(s)
- Mohamed Khalifa
- King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia.
| | - Ibrahim Zabani
- King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia.
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Mahmoudian-Dehkordi A, Sadat S. Sustaining critical care: using evidence-based simulation to evaluate ICU management policies. Health Care Manag Sci 2016; 20:532-547. [PMID: 27216611 DOI: 10.1007/s10729-016-9369-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 05/10/2016] [Indexed: 10/21/2022]
Abstract
Intensive Care Units (ICU) are costly yet critical hospital departments that should be available to care for patients needing highly specialized critical care. Shortage of ICU beds in many regions of the world and the constant fire-fighting to make these beds available through various ICU management policies motivated this study. The paper discusses the application of a generic system dynamics model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to explore the dynamics of intended and unintended consequences of such ICU management policies under a natural disaster crisis scenario. ICU management policies that can be implemented by a single hospital on short notice, namely premature transfer from ICU, boarding in ward, and general ward admission control, along with their possible combinations, are modeled and their impact on managerial and health outcome measures are investigated. The main insight out of the study is that the general ward admission control policy outperforms the rest of ICU management policies under such crisis scenarios with regards to reducing total mortality, which is counter intuitive for hospital administrators as this policy is not very effective at alleviating the symptoms of the problem, namely high ED and ICU occupancy rates that are closely monitored by hospital management particularly in times of crisis. A multivariate sensitivity analysis on parameters with diverse range of values in the literature found the superiority of the general ward admission control to hold true in every scenario.
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Affiliation(s)
| | - Somayeh Sadat
- Health Systems Engineering Program, Faculty of Industrial and Systems Engineering, Tarbiat Modares University, Tehran, Iran.
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Shen YC, Hsia RY. Do patients hospitalised in high-minority hospitals experience more diversion and poorer outcomes? A retrospective multivariate analysis of Medicare patients in California. BMJ Open 2016; 6:e010263. [PMID: 26988352 PMCID: PMC4800138 DOI: 10.1136/bmjopen-2015-010263] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/11/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE We investigated the association between crowding as measured by ambulance diversion and differences in access, treatment and outcomes between black and white patients. DESIGN Retrospective analysis. SETTING We linked daily ambulance diversion logs from 26 California counties between 2001 and 2011 to Medicare patient records with acute myocardial infarction and categorised patients according to hours in diversion status for their nearest emergency departments on their day of admission: 0, <6, 6 to <12 and ≥ 12 h. We compared the amount of diversion time between hospitals serving high volume of black patients and other hospitals. We then use multivariate models to analyse changes in outcomes when patients faced different levels of diversion, and compared that change between black and white patients. PARTICIPANTS 29,939 Medicare patients from 26 California counties between 2001 and 2011. MAIN OUTCOME MEASURES (1) Access to hospitals with cardiac technology; (2) treatment received; and (3) health outcomes (30-day, 90-day, and 1-year death and 30-day readmission). RESULTS Hospitals serving high volume of black patients spent more hours in diversion status compared with other hospitals. Patients faced with the highest level of diversion had the lowest probability of being admitted to hospitals with cardiac technology compared with those facing no diversion, by 4.4% for cardiac care intensive unit, and 3.4% for catheterisation laboratory and coronary artery bypass graft facilities. Patients experiencing increased diversion also had a 4.3% decreased likelihood of receiving catheterisation and 9.6% higher 1-year mortality. CONCLUSIONS Hospitals serving high volume of black patients are more likely to be on diversion, and diversion is associated with poorer access to cardiac technology, lower probability of receiving revascularisation and worse long-term mortality outcomes.
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Affiliation(s)
- Yu-Chu Shen
- Graduate School of Business and Public Policy, Naval Postgraduate School, Monterey, California, USA
- National Bureau of Economic Research, Cambridge, Massachusetts, USA
| | - Renee Y Hsia
- Department of Emergency Medicine and Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California, USA
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Erenler AK, Akbulut S, Guzel M, Cetinkaya H, Karaca A, Turkoz B, Baydin A. Reasons for Overcrowding in the Emergency Department: Experiences and Suggestions of an Education and Research Hospital. Turk J Emerg Med 2016; 14:59-63. [PMID: 27331171 PMCID: PMC4909875 DOI: 10.5505/1304.7361.2014.48802] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 03/13/2014] [Indexed: 11/29/2022] Open
Abstract
Objectives In this study, we aimed to determine the causes of overcrowding in the Emergency Department (ED) and make recommendations to help reduce length of stay (LOS) of patients in the ED. Methods We analyzed the medical data of patients admitted to our ER in a one-year period. Demographic characteristics, LOS, revisit frequency, and consultation status of the patients were determined. Results A total of 163,951 patients were admitted to our ED between January 1, 2013, and December 31, 2013. In this period 1,210 patients revisited the ED within 24 hours. A total of 38,579 patients had their treatment in the observation room (OR) of the ED and mean LOS was found to be 164.1 minutes. Cardiology was the most frequently consulted specialty. Mean arrival time of the consultants in ED was 64 minutes. Conclusions Similar to EDs in other parts of the world, prolonged length of stay in the ED, delayed laboratory and imaging tests, delay of consultants, and lack of sufficient inpatient beds are the most important causes of overcrowding in the ED. Some drastic measures must be taken to minimize errors and increase satisfaction ratio.
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Affiliation(s)
- Ali Kemal Erenler
- Department of Emergency, Samsun Training and Research Hospital, Samsun
| | - Sinan Akbulut
- Department of Emergency, Samsun Training and Research Hospital, Samsun
| | - Murat Guzel
- Department of Emergency, Samsun Training and Research Hospital, Samsun
| | - Halil Cetinkaya
- Department of Emergency, Samsun Training and Research Hospital, Samsun
| | - Alev Karaca
- Department of Emergency, Samsun Training and Research Hospital, Samsun
| | - Burcu Turkoz
- Department of Emergency, Samsun Training and Research Hospital, Samsun
| | - Ahmet Baydin
- Department of Emergency, Ondokuz Mayis University Faculty of Medicine, Samsun
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Abstract
BACKGROUND Analysis of the causes of death in children in the pediatric emergency department (ED) may aid the development of management and prevention practices. OBJECTIVE To identify the causes of death in Spanish pediatric EDs and to analyze the management of these children in the prehospital and hospital settings. METHODS This was a retrospective descriptive multicenter survey including all patients whose death was certified in 18 Spanish pediatric EDs between 2008 and 2013. RESULTS During the study period, 3 542 426 episodes were registered in the EDs. Of these, 54 patients died (mortality rate: 1.5/100 000 visits). Data of 53 patients are analyzed (male 36, 67%, 31 younger than 2 years old and 43.3% nonpreviously healthy children). The main causes of death were related to their previous illnesses (24.5%), sudden infant death syndrome (20.7%), and traumatism (18.8%).Prehospital cardiopulmonary resuscitation (CPR) was performed in 31 patients, and exclusively by health workers in 19 patients. In 35 patients, the parents witnessed the event and seven began CPR.Thirty children were transferred to the pediatric EDs by medical transport (56.6%) and all of them received prehospital CPR (vs. one patient out of 23 arrived in a nonmedical transportation).In 37 patients, CPR was performed in the pediatric EDs. Overall, CPR lasted 40±23 min (range, 10-120 min). CPR was not performed in seven patients at any time. CONCLUSION The main causes of death in Spanish pediatric EDs are related to previous illnesses, sudden infant death syndrome, and nonintentional lesions. Several actions have to be considered to improve the quality of care of these children in prehospital and emergency settings.
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Rabin E, Patrick L. Specialist availability in emergencies: contributions of response times and the use of ad hoc coverage in New York State. Am J Emerg Med 2015; 34:687-93. [PMID: 26868050 DOI: 10.1016/j.ajem.2015.12.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 12/18/2015] [Accepted: 12/20/2015] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Nationwide, hospitals struggle to maintain specialist on-call coverage for emergencies. We seek to further understand the issue by examining reliability of scheduled coverage and the role of ad hoc coverage when none is scheduled. METHODS An anonymous electronic survey of all emergency department (ED) directors of a large state. Overall and for 10 specialties, respondents were asked to estimate on-call coverage extent and "reliability" (frequency of emergency response in a clinically useful time frame: 2 hours), and use and effect of ad hoc emergency coverage to fill gaps. Descriptive statistics were performed using Fisher exact and Wilcoxon sign rank tests for significance. RESULTS Contact information was obtained for 125 of 167 ED directors. Sixty responded (48%), representing 36% of EDs. Forty-six percent reported full on-call coverage scheduled for all specialties. Forty-six percent reported consistent reliability. Coverage and reliability were strongly related (P<.01; 33% reported both), and larger ED volume correlated with both (P<.01). Ninety percent of hospitals that had gaps in either employed ad hoc coverage, significantly improving coverage for 8 of 10 specialties. For all but 1 specialty, more than 20% of hospitals reported that specialists are "Never", "Rarely" or "Sometimes" reliable (more than 50% for cardiovascular surgery, hand surgery and ophthalmology). CONCLUSIONS Significant holes in scheduled on-call specialist coverage are compounded by frequent unreliability of on-call specialists, but partially ameliorated by ad hoc specialist coverage. Regionalization may help because a 2-tiered system may exist: larger hospitals have more complete, reliable coverage. Better understanding of specialists' willingness to treat emergencies ad hoc without taking formal call will suggest additional remedies.
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Affiliation(s)
- Elaine Rabin
- Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Lisa Patrick
- Southern California Permanente Medical Group, San Diego, CA.
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Hess S, Sidler P, Chmiel C, Bögli K, Senn O, Eichler K. Satisfaction of health professionals after implementation of a primary care hospital emergency centre in Switzerland: A prospective before–after study. Int Emerg Nurs 2015; 23:286-93. [DOI: 10.1016/j.ienj.2015.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 04/09/2015] [Accepted: 04/09/2015] [Indexed: 10/23/2022]
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46
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Racial/ethnic disparities in children's emergency mental health after economic downturns. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2015; 41:334-42. [PMID: 23397232 DOI: 10.1007/s10488-013-0474-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
African American children-more than other race/ethnicities-rely on emergency psychiatric care. One hypothesized cause of this overrepresentation involves heightened sensitivity to economic downturns. We test whether the African American/white difference in psychiatric emergency visits increases in months when the regional economy contracts. We applied time-series methods to California Medicaid claims (1999-2008; N = 7.1 million visits). One month following mass layoffs, African American youths use more emergency mental health services than do non-Hispanic whites. Economic downturns may provoke or uncover mental disorder especially among African American youth who by and large do not participate in the labor force.
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Shen YC, Hsia RY. Ambulance diversion associated with reduced access to cardiac technology and increased one-year mortality. Health Aff (Millwood) 2015; 34:1273-80. [PMID: 26240239 PMCID: PMC4591852 DOI: 10.1377/hlthaff.2014.1462] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ambulance diversion, which occurs when a hospital emergency department (ED) is temporarily closed to incoming ambulance traffic, is an important system-level interruption that causes delays in treatment and potentially lower quality of care. There is little empirical evidence investigating the mechanisms through which ambulance diversion might affect patient outcomes. We investigated whether ambulance diversion affects access to technology, likelihood of treatment, and ultimately health outcomes for Medicare patients with acute myocardial infarction in twenty-six California counties. We found that patients whose nearest hospital ED had significant ambulance diversions experienced reduced access to hospitals with cardiac technology. This led to a 4.6 percent decreased likelihood of revascularization and a 9.8 percent increase in one-year mortality compared to patients who did not experience diversion. Policy makers may wish to consider creating a policy to specifically manage certain time-sensitive conditions that require technological intervention during periods of ambulance diversion.
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Affiliation(s)
- Yu-Chu Shen
- Yu-Chu Shen is a professor of economics at the Graduate School of Business and Public Policy, Naval Postgraduate School, and a faculty research fellow at the National Bureau of Economic Research, in Monterey, California
| | - Renee Y Hsia
- Renee Y. Hsia is a professor in the Department of Emergency Medicine and Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco
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Saghafian S, Austin G, Traub SJ. Operations research/management contributions to emergency department patient flow optimization: Review and research prospects. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/19488300.2015.1017676] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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49
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Jones CMC, Wasserman EB, Li T, Shah MN. Acceptability of Alternatives to Traditional Emergency Care: Patient Characteristics, Alternate Transport Modes, and Alternate Destinations. PREHOSP EMERG CARE 2015; 19:516-23. [DOI: 10.3109/10903127.2015.1025156] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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50
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Jovic L, Bianchi E, Decouflet S, Loizeau V, Amiot P, Teixeira M. Nurses in France: Between Autonomy and Subordination in Front Line Care. Glob Qual Nurs Res 2015; 2:2333393615584550. [PMID: 28462308 PMCID: PMC5342282 DOI: 10.1177/2333393615584550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 02/12/2015] [Accepted: 02/12/2015] [Indexed: 11/16/2022] Open
Abstract
In France, medical practitioners are aware that the practice of the delivery of primary care by nurses occurs in other countries. However, there is disagreement about how to implement this practice. This aspect of the issue of front line care has not yet been studied in France. In this article, our aim is to identify to what extent the delivery of primary care by nurses is considered acceptable by doctors and nurses working in hospital emergency departments and in public and private health centers. The results of our research provide a picture of opinions that exist among doctors and nurses. These opinions highlight practices that are outside the current regulations and present perspectives, which range from conditionally in favor to unfavorable. Such opinions contribute to our knowledge because they are derived from the professionals directly involved and describe what is acceptable in this particular context.
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Affiliation(s)
- Ljiljana Jovic
- Univ Paris Diderot, Sorbonne Paris Cité, UMR-S 1123, F-75019 PARIS, France.,Agence Régionale de Santé Ile-de-France, Paris, France
| | - Evelyne Bianchi
- Institut de Formation en Soins Infirmiers, Paris, France.,Assistance Publique Hopitaux de Paris, Hopital Robert Debré, F-75019 Paris, France
| | - Sylvie Decouflet
- Centre de Santé, Direction de l'Action Sociale, de l'Enfance et de la Santé, Mairie de Paris, France
| | - Valérie Loizeau
- Centre Hospitalier Intercommunal Poissy-Saint-Germain, France
| | - Patricia Amiot
- Centre Hospitalier Intercommunal Poissy-Saint-Germain, France
| | - Maria Teixeira
- Univ Paris Diderot, Sorbonne Paris Cité, UMR-S 1123, F-75019 PARIS, France.,Assistance Publique Hopitaux de Paris, Hopital Robert Debré, F-75019 Paris, France
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