International perspectives on emergency department crowding

Implementing "ER is for Emergencies" Practice Guideline to Reduce Nonemergent Emergency Department Visits

INTRODUCTION

More than half of all health care visits in the United States occur in the emergency department. These visits are the result of systems and policies that reduce primary care access. Patient linkage to primary care services is essential for improved health outcomes and effective emergency department care. This project aimed to implement a patient education and navigation program in a rural emergency department to reduce nonemergent emergency department visits and nurse workload and to improve patient enrollment in primary care patient-centered medical homes.

METHODS

The project used a pretest-posttest design to determine the impact of the "ER is for Emergencies" clinical guideline on nonemergent emergency department visits and patient enrollment. The modified Need for Recovery Survey used a paired group analysis to assess the project's impact on nurse workload and job satisfaction.

RESULTS

A convenience sample of 38 primarily Black/African American (N = 35) and Medicaid-insured patients (N = 16) received nurse-led education and a referral to a patient-centered medical home. A comparison of pre- and postintervention chart reviews demonstrated a significant reduction in nonemergent emergency department visits after the intervention (P < .01) and improved participant enrollment in the patient-centered medical home (P = .04). Furthermore, the intervention was associated with reduced nurse-reported workload and stress (N = 7; P < .007).

CONCLUSION

The results of this quality improvement project are consistent with the broader literature that multimodal interventions can effectively reduce nonemergent emergency department visits and link patients to primary care. Multimodal interventions and policy solutions targeting structural inequities are urgently needed to support access to primary care and reduce nonemergent ED use.

Exploring care pathways of patients conveyed by emergency medical services (EMS) through electronic health records

BACKGROUND

Emergency Medical Services (EMS) and Emergency Departments (ED) have reported increased patient volumes in the last decades. Despite high rates of non-conveyance decisions, unnecessary conveyances by EMS still occur. The aim of this study was to explore care pathways of conveyed patients by EMS through registry data.

METHODS

This was a retrospective cohort study of EMS patients in Finland. The primary outcomes were EMS recontacts and visits to a primary health care facility or ED within seven days. The secondary outcome was mortality within one week. Univariate and multivariable associations between the outcome variables and categorical variables were analysed with logistic regression. Results are presented with odds ratios (ORs) together with 95% confidence intervals (CIs) and p-values.

RESULTS

The conveyed patients' visits to health care facilities were mainly brief. EMS arrival during night-time (20:00-08:00) (OR 1.69; 95% CI 1.59 to 1.80), in urban area (OR 1.21; 95% CI 1.13 to 1.29) and alcohol use (OR 2.55; 95% CI 2.26 to 2.86) predicted short ED visits (< 24 h). 77% of the patients were discharged from primary health care within one hour (median 22 min, IQR 18-60). After EMS conveyance and visit to the ED or primary health care facility, 10.5% of the patients were readmitted within one week. Non-urgent patients (OR 1.26; 95% CI 1.14 to 1.39), an EMS mission at night (OR 1.36; 95% CI 1.24 to 1.50), and based on univariate analyses, the usage of alcohol (OR 1.26; 95% CI 1.09 to 1.45) increased the likelihood of a readmission. 449 patients of all conveyed EMS patients (n = 20376) died within one week (2.2%).

CONCLUSIONS

EMS non-conveyance reduces patient flow in EDs, but there is a possibility that more could be done related to unnecessary conveyances to health care facilities, especially in urban areas and at night. The pathway analyses of post conveyance re-contacts show that a small number of patients burden the system. Further in-depth studies are needed to understand of unnecessary conveyances, find solutions, and provide repeated users the appropriate care.

Validating obstetric triage systems, what are we really measuring - A modified Delphi process introducing outcome measures for obstetric emergency triage systems

BACKGROUND

Obstetric emergency triage is more complex than general emergency triage, since the pregnant woman, the fetus and labour status all must be assessed. It is a relatively new branch of triage and is not an integrated part of obstetric emergency care in Sweden. As in general emergency triage, there is no definition of true acuity for obstetric emergency patients. This makes validation of triage systems difficult and results in unclear capacity to identify patients requiring urgent attention. Predominately applied surrogate outcome measures do not reflect acuity at the time of triage and are often affected by organisational factors. The study aims to develop a set of weighted surrogate outcome measures representing acuity at the time of triage, enabling construct validation of obstetric triage systems.

METHODS

A four-round modified Delphi process was performed at a single tertiary obstetrics department. Seven obstetricians and three midwives participated in round 1, while only obstetricians participated in rounds 2-4 based on the profession's competence. The consensus level for rounds 2-4 was predefined at 100%.

RESULTS

A set of 31 immediate obstetrician-initiated interventions at the emergency department, for a patient presenting with an urgent condition, were defined. The interventions reflect acuity level at the time of triage and with minimum interference or influence by context. The outcomes were weighted at three levels, stratifying urgency in the most severe presentations of these conditions.

CONCLUSION

As true acuity in a patient seeking emergency care has not been defined, outcome measures reflecting true acuity at the time of triage should be applied when validating triage systems. Previous studies on validity in obstetric triage systems are scarce and inconclusive regarding internal and external validity. The outcome measures developed in this study may serve as a template for validating obstetric triage systems implemented in similar contexts.

Artificial intelligence-driven forecasting and shift optimization for pediatric emergency department crowding

Objective

This study aimed to develop and evaluate an artificial intelligence (AI)-driven system for forecasting Pediatric Emergency Department (PED) overcrowding and optimizing physician shift schedules using machine learning operations (MLOps).

Materials and Methods

Data from 352 843 PED admissions between January 2018 and May 2023 were analyzed. Twenty time-series forecasting models-including classical methods and advanced deep learning architectures like Temporal Convolutional Network, Time-series Dense Encoder and Reversible Instance Normalization, Neural High-order Time Series model, and Neural Basis Expansion Analysis-were developed and compared using Python 3.8. Starting in January 2023, an MLOps simulation automated data updates and model retraining. Shift schedules were optimized based on forecasted patient volumes using integer linear programming.

Results

Advanced deep learning models outperformed traditional models, achieving initial R2 scores up to 75%. Throughout the simulation, the median R2 score for all models was 44% after MLOps-based model selection, the median R2 improved to 60%. The MLOps architecture facilitated continuous model updates, enhancing forecast accuracy. Shift optimization adjusted staffing in 69 out of 84 shifts, increasing physician allocation by up to 30.4% during peak hours. This adjustment reduced the patient-to-physician ratio by an average of 4.32 patients during the 8-16 shift and 4.40 patients during the 16-24 shift.

Discussion

The integration of advanced deep learning models with MLOps architecture allowed for continuous model updates, enhancing the accuracy of PED overcrowding forecasts and outperforming traditional methods. The AI-driven system demonstrated resilience against data drift caused by events like the COVID-19 pandemic, adapting to changing conditions. Optimizing physician shifts based on these forecasts improved workforce distribution without increasing staff numbers, reducing patient load per physician during peak hours. However, limitations include the single-center design and a fixed staffing model, indicating the need for multicenter validation and implementation in settings with dynamic staffing practices. Future research should focus on expanding datasets through multicenter collaborations and developing forecasting models that provide longer lead times without compromising accuracy.

Conclusions

The AI-driven forecasting and shift optimization system demonstrated the efficacy of integrating AI and MLOps in predicting PED overcrowding and optimizing physician shifts. This approach outperformed traditional methods, highlighting its potential for managing overcrowding in emergency departments. Future research should focus on multicenter validation and real-world implementation to fully leverage the benefits of this innovative system.

Association between patient characteristics and recommendations by medical on-call service 116117 in Germany: a cross sectional observational study

BACKGROUND

Use of emergency departments has increased in recent years. Different efforts address this problem, eg, medical on-call services. The basis of the DEMAND intervention is computer-assisted initial telephone assessment implemented at regional associations of statutory health insurance physicians in Germany. In this intervention, recommendations for healthcare settings were given over the telephone by medical staff. Recommendations were provided using the software SmED which calculates neural networks. This study aimed to analyse if patient characteristics are associated with the output of the intervention, ie, specific setting recommendations.

METHODS

Between January 2020 and March 2021, patients aged 18 years and older of the DEMAND intervention from eight intervention sites received a standardised postal survey. Recommended and used settings, and data on sociodemography, health status at the time of the emergency call, past health service use, and health literacy were collected by self-report. Multilevel, multivariable logistic regression models adjusted for random effects at the level of regions and months of observation within regions were conducted.

RESULTS

Of 9473 contacted individuals, 1756 (18.5 %) participated in the survey. Median age was 66 years, 59.0% were women and 30.2% living alone. The most frequently recommended service was emergency home visits (40.1%). Recommendations for this setting were associated with worse self-rated health (odds ratio 0.67, 95% confidence interval: 0.55/0.81, p < 0.001). Telephone counselling was associated with lower age (0.71, 0.59/0.85, p < 0.001), lower subjective treatment urgency (0.65, 0.51/0.82, p < 0.001) and health problems not classified as symptoms and complaints (0.41, 0.25/0.68, p = 0.001) or infections (0.22, 0.09/0.57, p = 0.002). Emergency departments were associated with better self-rated health (1.37, 1.11/1.70, p = 0.003) and health problems classified as injuries (3.12, 1.67/5.83, p < 0.001). Rescue service were associated with higher age (1.44, 1.15/1.81, p = 0.002) and higher subjective treatment urgency (2.51, 1.83/3.43, p < 0.001). General practices were associated with lower subjective treatment urgency (0.58, 0.44/0.76, p < 0.001) and health problems not classified as injuries (0.26, 0.10/0.68, p = 0.006). Emergency practices were associated with lower age (0.60, 0.48/0.74, p < 0.001), and specialist practices were associated with health problems classified as symptoms or complaints (3.75, 1.49/9.45, p = 0.005).

CONCLUSIONS

Most associations between patient characteristics and recommendations were comprehensible and in line with the aim of the intervention. However, it should be clarified why patients with better self-rated health were more likely to receive recommendations for emergency departments.

Factors that predict emergency department length of stay in analysis of national data

OBJECTIVE

This study used a nationwide database to identify and analyze factors that influence emergency department (ED) length of stay (LOS) and improve the efficiency of emergency care.

METHODS

This retrospective study analyzed data from the National Emergency Department Information System (NEDIS) database in Korea: 25,578,263 ED visits from 2018 to 2022. Patient demographics, clinical characteristics, and ED operational variables were examined. Univariate and multivariate logistic regression analyses were used to assess the associations between the variables and prolonged ED LOS, defined as 6 hours or more.

RESULTS

Among the 25,578,263 patients, the median ED LOS was 2.1 hours (interquartile range, 1.050-3.830 hours), with 12.6% experiencing a prolonged ED LOS. Elderly patients (aged ≥65 years) were significantly more likely than younger patients to experience prolonged ED LOS (adjusted odds ratio [aOR], 1.415; 95% confidence interval [CI]: 1.411-1.419). Patients transferred from other hospitals (aOR, 1.469; 95% CI, 1.463-1.474) and those arriving by emergency medical services (aOR, 1.093; 95% CI, 1.077-1.108) also had high odds of prolonged LOS. Conversely, pediatric patients had a low likelihood of extended stay (aOR, 0.682; 95% CI, 0.678-0.686). Severe illness, including sepsis (aOR, 1.324; 95% CI, 1.311-1.340) and COVID-19 infection (aOR, 1.413; 95% CI, 1.399-1.427), was strongly associated with prolonged LOS.

CONCLUSION

Prolonged ED LOS is influenced by a combination of patient demographics, clinical severity, and systemic factors. Targeted interventions for older adults, severe illness, and operational inefficiencies such as hospital transfers are essential for reducing ED LOS and improving overall emergency care delivery.

Probabilistic prediction of arrivals and hospitalizations in emergency departments in Île-de-France

BACKGROUND

Forecasts of future demand is foundational for effective resource allocation in emergency departments (EDs). As ED demand is inherently variable, it is important for forecasts to characterize the range of possible future demand. However, extant research focuses primarily on producing point forecasts using a wide variety of prediction algorithms. In this study, our objective is to generate point and interval predictions that accurately characterize the variability in ED demand using ensemble methods that combine predictions from multiple base algorithms based on their empirical performance.

METHODS

Data consisted in daily arrivals and subsequent hospitalizations at 72 emergency departments in Île-de-France from 2014-2018. Additional explanatory variables were collected including public and school holidays, meteorological variables, and public health trends. One-day ahead point and 80% interval predictions of arrivals and hospitalizations were produced by predicting the 10%, 50%, and 90% quantiles of the forecast distribution. Quantile prediction algorithms included methods such as ARIMAX, variations of random forests, and generalized additive models. Ensemble predictions were then formed using Exponentially Weighted Averaging, Bernstein Online Aggregation, and Super Learning. Prediction intervals were post-processed using Adaptive Conformal Inference techniques. Point predictions were evaluated by their Mean Absolute Error (MAE) and Mean Absolute Percentage Error (MAPE), and 80% interval predictions by their empirical coverage and mean interval width.

RESULTS

For point forecasts, ensemble methods achieved lower average MAE and MAPE than any of the base algorithms. All of the base algorithms and ensemble methods yielded prediction intervals with near optimal empirical coverage after conformalization. For hospitalizations, the shortest mean interval widths were achieved by the ensemble methods.

CONCLUSIONS

Ensemble methods yield joint point and prediction intervals that adapt to individual EDs and achieve better performance than individual algorithms. Conformal inference techniques improve the performance of the prediction intervals.

Does Calm Always Follow the Storm? A Comprehensive Temporal Analysis of Emergency Department Visits in Northern Italy Before and After the COVID-19 Pandemic

BACKGROUND/OBJECTIVES

Emergency department (ED) crowding has become a pressing global concern exacerbated by the COVID-19 pandemic. No studies have addressed this issue in Europe during the post-pandemic period so far. This study examined ED visit volumes, patient acuity, hospital admission rates, emergency vehicle arrivals, and crowding metrics before, during, and after the pandemic.

METHODS

We conducted a retrospective descriptive study including data on all ED visits in the Lombardy Region of Italy from January 2019 to December 2023. Furthermore, an inferential statistical analysis was performed to compare ED trends between 2019 and 2023.

RESULTS

During the analyzed period, there were 15,515,128 visits across all Lombardy EDs. ED visits dropped from 3,514,426 in 2019 to 2,380,005 in 2020, then rebounded to 3,464,756 in 2023. In 2019, triage code distribution was 9.9% white, 68.7% green, 19.0% yellow, and 1.9% red. During the pandemic, the proportion of white and green codes decreased. By 2023, these comprised 80.7% of the total. The percentage of admitted patients was 11.9% in 2019, rose to 16.2% in 2020, and returned to 11.4% in 2023. The median ED length of stay (EDLOS) for admitted patients in 2023 was 5.2 h (IQR [2.1-17.4]), compared to 3.8 h (IQR [1.6-8.6]) in 2019 (p-value < 0.01). The median EDLOS for discharged patients in 2023 was 2.7 h (IQR [1.4-4.9]), compared to 2.4 h (IQR [1.3-4.4]) in 2019 (p-value < 0.01). The rate of patients leaving before completing treatment was 5.0% in 2019 and peaked at 6.8% in 2023 (p-value < 0.01).

CONCLUSIONS

In 2023, ED visits in Lombardy increased, compared to the pandemic period, but remained below 2019 levels. The proportion of high-acuity codes and hospital admissions was slightly lower than in 2019. However, ED crowding metrics worsened. The high levels of lower-acuity visits and the deterioration in crowding metrics highlight systemic challenges within the healthcare system.

Identifying the Main Bottlenecks in the Workflow of Saudi Arabian Emergency Departments (EDs)

Background: Crowded emergency departments (EDs) adversely affect patient care and healthcare efficiency, leading to prolonged wait times, delayed treatments, and increased medical errors. This issue also diminishes patient satisfaction and disrupts hospital operations. In Saudi Arabia, ED overcrowding impacts response times and staff morale, highlighting the need for efficient patient flow processes to ensure timely and effective care. Objectives: The aim of this study is to identify the main bottlenecks in the workflow of Saudi Arabian EDs from patient arrival to disposition. Design: A retrospective quantitative study analyzed data from 753 patients across multiple hospitals in Saudi Arabia's EDs to identify workflow bottlenecks. Using SPSS and AMOS for data analysis, various statistical methods, including ANOVA and structural equation modeling (SEM), were employed to evaluate key performance metrics and their influence on the total length of stay (LOS). Results: The Doctor to Decision Time is the most significant bottleneck, followed by the Triage to Doctor Time. CTAS3 and CTAS4 categories experience the most significant delays across multiple stages. In addition, the default model in AMOS 29 shows an excellent fit, indicating that reducing delays in Decision to Disposition Time (estimate = 0.840) and Doctor to Decision Time (estimate = 0.442) is crucial for improving the total LOS in the ED. Conclusion: This study identifies significant inefficiencies in the ED workflow in Saudi Arabia, particularly in the Doctor to Decision Time and Triage to Doctor Time stages, and recommends streamlining consultation protocols, enhancing medication delivery, expediting lab and radiology services, and increasing staffing to improve operational efficiency and patient outcomes. Faster bed turnover reduces Decision to Disposition Time and frees up ED beds. Adequate staffing improves triage, evaluation times, and care quality. Well-trained nurses enhance patient interactions and reduce delays. Standardized guidelines ensure timely treatment. Effective communication and teamwork improve patient flow and reduce bottlenecks.

Correlation Between Emergency Department Crowding and Adverse Occurrences in an Academic Hospital: A Retrospective Cohort Study

Background

Emergency care predominantly involves the treatment of abrupt clinical status deteriorations, illness exacerbation, and potentially life-threatening injuries. However, crowding and excessive delays in the emergency department (ED) affect the quality of care and are associated with undesirable outcomes.

Objective

This study aimed to determine the association of emergency department (ED) crowding with patient outcomes at a teaching hospital in Saudi Arabia's Central Province.

Methods

Using a retrospective chart review of electronic medical records, we extracted mortality, morbidity, and safety events-related data of all adult, pediatric, and obstetric patients who presented to the King Abdullah Bin Abdulaziz University Hospital (KAAUH) emergency department (ED) between January 2019 and December 2022. Based on the emergency department (ED) census, these data were cross-referenced by date with the emergency department (ED) situation.

Results

Sixty patients had safety events; medication-related safety events were the most prevalent (38%), followed by care-coordination events (30%). Twenty cases of mortality and morbidity were reported. Crowding significantly affected adverse medication-related and care-coordination events (p = 0.0212), with a more significant effect on moderate safety events than on mild safety events (p = 0.0348). Influence of emergency department (ED) crowding (p = 0.3740) was on mortality or morbidity outcomes was detected. The data was extracted from a total of 139176 emergency visits for all categories.

Conclusion

In Saudi Arabia, emergency department (ED) crowding signifies a critical healthcare crisis, potentially compromising quality of care. Our findings provide evidence of increased errors in medication, care coordination, and medical care due to emergency department (ED) crowding. Implementing micro and macro-level strategies to reduce emergency department (ED) crowding could help improve patient outcomes.

Factors associated with hospital revisitation within 7 days among patients discharged at triage: a case-control study

BACKGROUND AND IMPORTANCE

Existing data are limited for determining the medical conditions best suited for an emergency department (ED) redirection strategy in a heterogeneous, nonurgent patient population.

OBJECTIVE

The aim was to establish factors associated with hospital revisits within 7 days among patients discharged or redirected by a triage team.

DESIGN, SETTINGS, AND PARTICIPANTS

An observational single-center case-control study was conducted at the Tampere University Hospital ED for the full calendar year of 2019. The cases comprised unplanned hospital revisits within 7 days of being discharged or redirected by triage, while the controls were discharged or redirected but did not revisit.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was an unplanned hospital revisit within 7 days. A subgroup analysis was conducted for revisits leading to hospitalization. Basic demographics, comorbidities before triage, and triage visit characteristics were considered as predictive factors for the revisit. A backward stepwise conditional logistic regression analysis was performed.

MAIN RESULTS

During the calendar year of 2019, there were a total of 92 406 ED visits. Of these, 7216 (7.8%) visits were discharged or redirected by triage, and 6.5% ( n  = 467) of all these patients revisited. Of the revisiting patients, 25% ( n  = 117) were hospitalized. In multivariable analysis, higher age was associated with both revisitation [odds ratio (OR): 1.01, 95% confidence interval (CI): 1.00-1.02] and hospitalization (OR: 1.02, 95% CI: 1.00-1.04). Furthermore, using other visits as a reference, abdominal pain was associated with revisitation and hospitalization (OR: 3.70, 95% CI: 2.24-6.11 and OR: 5.28, 95% CI: 2.08-13.4, respectively).

CONCLUSION

Higher age and abdominal pain were associated with hospital revisitation and hospitalization within 7 days among patients directly discharged or redirected by the triage team. Regardless of the triage system in use, there might be patient groups that should be evaluated more cautiously if a triage-based discharge or redirection strategy is to be considered.

Emergency department crowding: An examination of older adults and vulnerability

Emergency departments in many nations worldwide have been struggling for many years with crowding and the subsequent provision of care in hallways and other unconventional spaces. While this issue has been investigated and analyzed from multiple perspectives, the ethical dimensions of the place of emergency department care have been underexamined. Specifically, the impacts of the place of care on patients and their caregivers have not been robustly explored in the literature. In this article, a feminist ethics and human geography framing is utilized to argue that care provision in open and unconventional spaces in the emergency department can be unethical, as vulnerability can be amplified by the place of care for patients and their caregivers. The situational and pathogenic vulnerability of patients can be heightened by the place of the emergency department and by the constraints to healthcare providers' capacity to promote patient comfort, privacy, communication, and autonomy in this setting. The arrangements of care in the emergency department are of particular concern for older adults given the potential increased risks for vulnerability in this population. As such, hallway healthcare can reflect the normalized inequities of structural ageism. Recommendations are provided to address this complicated ethical issue, including making visible the moral experiences of patients and their caregivers, as well as those of healthcare providers in the emergency department, advocating for a systems-level accounting for the needs of older adults in the emergency department and more broadly in healthcare, as well as highlighting the need for further research to examine how to foster autonomy and care in the emergency department to reduce the risk for vulnerabilities.

Emergency department crowding in the Netherlands; evaluation of a real-time ambulance diversion dashboard

BACKGROUND

Emergency department (ED) crowding is a growing concern worldwide and associated with negative effects. In 2013, 68% of Dutch ED-managers experienced crowding on several days of the week. This resulted into the introduction in phases of an ambulance diversion dashboard, in order to influence ED input. Increasing numbers of Dutch EDs have implemented this dashboard, visualizing regional ambulance diversions by means of a traffic light.

METHODS

This is a descriptive study of a nationwide online survey of Dutch EDs, conducted between January and October 2023. It included both qualitative and quantitative questions. The outcomes and analysis are derived from descriptive data of respondents' experience of crowding as well as their usage and perceived effectiveness of the ambulance diversions dashboard.

RESULTS

At the time of the survey, 62 of 82 Dutch EDs (75.6%) actually used the dashboard, of which 56 EDs responded (90.3% response rate). 69.7% Of ED managers experienced ED crowding more than three times a week. Of the respondents using the dashboard, 52.8% reported it only occasionally alleviates ED inflow. The purported reasons are the limited number of patients affected by the red light (ambulance diversion) and the presence of regional crowding. The effects of the orange light (impending ambulance diversion) on ED input differ greatly among hospitals, mostly due to their own internal agreements. In accordance, many respondents (53.6%) expressed dissatisfaction with the resources available to them to alleviate crowding.

CONCLUSION

After conducting a national survey, ED crowding is reported as a persisting nationwide problem with its prevalence largely unchanged since the introduction of the ambulance diversion dashboard. Most hospitals reported having insufficient resources to alleviate it. The effects of the ambulance diversion dashboard to decrease crowding are apparently limited because it affects a small portion of total ED presentations and because of the influence of regional crowding. The main function of the orange light is to increase ED throughput and output rather than reducing ED input.

Impact of the Advanced Practice Nurse in Triage of Primary Care Emergency Departments

INTRODUCTION

This study aimed to compare the time spent on episodes seen by primary care emergency departments before (2017) and after (2019) the inclusion of an advanced practice nurse in patient classification.

METHODS

Records from 3 primary care emergency departments in 2017 (n = 18,663) and 2019 (n = 22,632) were compared using Student t and chi-square tests. Waiting time for classification, classification time, and total time spent in the consultation area were compared for total episodes, levels of priority, reasons for consultation, and previous clinical processes.

RESULTS

Mean waiting time decreased in 2019 for all episodes (P < .001), priorities IV (P < .001) and V (P < .001), respiratory (P < .001) and skin and subcutaneous tissue diseases (P = .015), and previous chronic processes (P = .042). Mean classification time increased in 2019 for all episodes (P < .001); priorities III (P < .001), IV (P < .001), and V (P = .045); several reasons for consultation, and previous processes. Mean total time spent in the consultation area decreased in 2019 for all (P = .002), priority V (P < .001), skin and subcutaneous tissue diseases (P = .010), and fever episodes (P = .021).

DISCUSSION

The inclusion of nurses with advanced nursing practice roles reduces the waiting time and length of stay in the emergency department, but increases the classification time, which could be linked to early interventions.

Characteristics of High Utilizer Patients in the Emergency Department at a University Hospital in the Kingdom of Bahrain

BACKGROUND

Emergency departments (EDs) around the world are facing a crippling crisis of overcrowding, a complex problem caused by a variety of factors. One contributing factor is the overutilization of EDs by patients with frequent visits.

OBJECTIVE

This study aims at measuring the prevalence of this phenomenon and better understanding the characteristics of high utilizers.

METHODS

A retrospective review was conducted in a tertiary care teaching hospital, for patients aged 14 years and above during the year 2022. The definition of a high utilizer is set as any patient that fits the inclusion criteria with four or more visits to the ED during 1 year.

RESULTS

The prevalence of high utilizers in our ED is 3.9%, accounting for 12.1% of visits in 2022, where 135 was the highest number of visits made by one patient. Visits mostly consisted of level 3, Yellow (48.9%) and level 4, Green (42.8%) triage. The top three chief complaints were sore throat (16.8%), unwell adult (15.1%), and abdominal pain (12.8%). The total length of stay was 3.6 ± 3.2 h in the ED. Time of arrival was observed; 23.9% presented at night, 37.8% in the morning, and 38.8% in the evening.

CONCLUSIONS

The prevalence rate of high utilizers was found to be 3.9% in our study, falling within the range based on literature. Due to the parallel issues raised by many studies, the importance of developing convenient corrective strategies and conducting further national-based studies to get better insight of high utilizers is required.

[The utilization of ophthalmological emergency departments is on the rise : 14-year results from a German tertiary university outpatient department]

BACKGROUND

The increasing congestion in emergency departments of all specialties is one of the most pressing challenges of our time.

OBJECTIVE

The aim of this study is to make a well-founded contribution to the development of emergency case numbers in the tertiary sector (specialist clinics) of German ophthalmology. From this, the need to develop new control and triage mechanisms for ophthalmology can be derived.

MATERIAL AND METHODS

Retrospectively, > 140,000 emergency treatment cases at the University Eye Hospital Tübingen in the period from 1 January 2010 to 31 December 2023 were analyzed. Sub-analyses were conducted to quantify the impact of the COVID-19 pandemic and differences between weekend and weekday visits. In addition, a questionnaire survey on the referral status of emergency consultations at off-peak times and at weekends was conducted in 2022.

RESULTS

The number of emergency consultations more than doubled between 2010 and 2023 and more than tripled at weekends. The peak load, which is relevant for guaranteeing treatment, has increased to the same extent. In the long term, a shift in emergency treatment from core to off-peak times can be observed, particularly at weekends. The majority of consultations (up to 87%) take place without a referral from a doctor. In 2023, the treatment figures returned to the level before the start of the COVID-19 pandemic.

DISCUSSION

The emergency outpatient clinic at the University Eye Hospital is increasingly exposed to a double burden: providing treatment for emergency cases with specialist referrals and at the same time acting as a catchment basin for general emergencies. New control and triage mechanisms are urgently needed to ensure good care in the long term.

The Need for a New Approach to MCI Readiness in the Era of Emergency Department and Hospital Crowding

Emergency department (ED) visit volumes have increased since 2007, with crowding in the United States reaching its highest levels in 2022. During this same period, mass casualty incidents (MCIs) have increased dramatically, both in frequency and severity, across the United States. Resuscitation of trauma patients is a time-sensitive process that requires immediate patient assessment by coordinated clinical teams in order to successfully diagnose and manage life-threatening injuries. To make resuscitation spaces immediately available for incoming patients, typical MCI plans call for rapidly relocating ED patients from their rooms into hallways or transferring them to open inpatient areas. With current levels of crowding, however, such alternate care spaces are often already in use and traditional MCI plans are increasingly unrealistic. With ED crowding worsening and the frequency of MCIs rising, there is a worrisome risk that EDs could fail in their efforts to save patients due to insufficient resources and spaces to meet the demands of critically injured patients. Hospitals must use innovative, novel response strategies to ensure sufficient patient care spaces in a short timeframe to save the most lives possible. In this commentary, we describe the use of buffer zones to help EDs mobilize an effective response to MCIs in the current context of severe hospital crowding.

Evaluation of problems arising in emergency services from the perspectives of medical and criminal law: The example of Türkiye

Introduction

In recent years, the field of medical malpractice has attracted growing attention, and despite the long history of research in this area, aspects of this phenomenon remain unexplored. In this paper, we aimed to explore the issue of medical malpractice, focusing on cases involving healthcare professionals working in emergency services in Türkiye. We examine the surge in medical malpractice lawsuits, the consequences of such cases, and the prevalence of criminal liability faced by healthcare professionals.

Materials and methods

A comprehensive analysis of healthcare-related cases from 2017 to 2022 was carried out using the electronic decision database "LEGALBANK." We scrutinized these cases from both medical and criminal law perspectives, aiming to shed light on the complex dynamics of medical malpractice in emergency services.

Results

The findings reveal that professionals in emergency services are confronted with a considerable number of criminal cases. Among these cases, doctors are the most frequently implicated, followed by nurses, midwives, ambulance drivers, and other healthcare professionals. The crimes attributed to these professionals vary but primarily include involuntary manslaughter, misuse of public duty, forgery of documents, and reckless injury.

Discussion

In Türkiye, there is a notable prevalence of investigations conducted in emergency services and criminal cases involving healthcare professionals in this field. This dual prominence underscores the unique significance of examining medical malpractice from the perspectives of both criminal law and medicine within the Turkish context. This study categorizes the multifaceted challenges of medical malpractice as human-related, system-related, and legal, offering valuable insights into the intricate landscape of this phenomenon in Türkiye's emergency services.

Conclusion

This research contributes to a deeper understanding of medical malpractice, particularly its criminal dimensions in the Turkish context, and thereby calls for improved healthcare, enhanced patient safety, and error prevention in emergency settings.

Effectiveness and Stakeholder Views of Community-Based Allied Health on Acute Care Utilization: A Mixed Methods Review

The aim of this mixed methods systematic review was to synthesize contemporary evidence on effectiveness of community-based allied health (AH) services on acute care utilizations and views from relevant stakeholders. An a priori protocol was registered with PROSPERO [CRD42023437013]. Inclusion criteria were: (a) stand-alone interventions led by practitioners/graduates from one or more target AH professions (audiology, exercise physiology, diabetes educator, nutrition and dietetics, occupational therapy, physiotherapy, podiatry, psychology, social work, and speech pathology); (b) examined acute care utilization-related outcomes with/without perceptions of relevant stakeholders; and (c) published after 2010 and in English. Eligible studies were identified from: (a) bibliographic databases (MEDLINE, Embase, EmCare, PsycINFO, CINAHL complete, and the Cochrane Library) (September 19, 2023); (b) online databases (ProQuest Central and ProQuest Dissertations & Theses Global) and theses repository (Trove) (September 20, 2023); (c) Google and Google Scholar (October 17-18, 2023); and (d) citation searching. A modified version of McMaster Critical Appraisal Tools and McGill Mixed Methods Appraisal Tool were used to assess methodological quality. Data synthesis was through convergent segregated approach. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation. There were 67 included papers. The integrated quantitative and qualitative findings demonstrated mixed evidence, likely influenced by the heterogeneity of the evidence base, for the effectiveness of AH services on acute care utilizations. Patients and their carers were largely positive about these services, highlighting opportunities to build on these experiences. The certainty of evidence for patient-important outcomes was however "very low", emphasizing cautious interpretation. The findings of this review shed light on the breadth and scope of AH in the community sector, and its potential impact on the acute sector. Further investment in, and ongoing research on, community-based AH can strengthen primary healthcare and relieve pressure on the acute sector.

Prediction of emergency department presentations for acute coronary syndrome using a machine learning approach

The relationship between weather and acute coronary syndrome (ACS) incidence has been the subject of considerable research, with varying conclusions. Harnessing machine learning techniques, our study explores the relationship between meteorological factors and ACS presentations in the emergency department (ED), offering insights into seasonal variations and inter-day fluctuations to optimize patient care and resource allocation. A retrospective cohort analysis was conducted, encompassing ACS presentations to Dutch EDs from 2010 to 2017. Temporal patterns were analyzed using heat-maps and time series plots. Multivariable linear regression (MLR) and Random Forest (RF) regression models were employed to forecast daily ACS presentations with prediction horizons of one, three, seven, and thirty days. Model performance was assessed using the coefficient of determination (R²), Mean Absolute Error (MAE), and Mean Absolute Percentage Error (MAPE). The study included 214,953 ACS presentations, predominantly unstable angina (UA) (94,272; 44%), non-ST-elevated myocardial infarction (NSTEMI) (78,963; 37%), and ST-elevated myocardial infarction (STEMI) (41,718; 19%). A decline in daily ACS admissions over time was observed, with notable inter-day (estimated median difference: 41 (95%CI = 37-43, p = < 0.001) and seasonal variations (estimated median difference: 9 (95%CI 6-12, p = < 0.001). Both MLR and RF models demonstrated similar predictive capabilities, with MLR slightly outperforming RF. The models showed moderate explanatory power for ACS incidence (adjusted R² = 0.66; MAE (MAPE): 7.8 (11%)), with varying performance across subdiagnoses. Prediction of UA incidence resulted in the best-explained variability (adjusted R² = 0.80; MAE (MAPE): 5.3 (19.1%)), followed by NSTEMI and STEMI diagnoses. All models maintained consistent performance over extended prediction horizons. Our findings indicate that ACS presentation exhibits distinctive seasonal changes and inter-day differences, with marked reductions in incidence during the summer months and a distinct peak prevalence on Mondays. The predictive performance of our model was moderate. Nonetheless, we obtained good explanatory power for UA presentations. Our model emerges as a potentially valuable supplementary tool to enhance ED resource allocation or future predictive models predicting ACS incidence in the ED.

[Motives of patients presenting independently at the emergency department-a prospective monocentric observational study]

BACKGROUND

In the ongoing professional, societal, and political discussion, the hypothesis is repeatedly put forward that a large portion of patients who independently visit the emergency department could also be treated in other care settings such as by a general practitioner, the statutory medical on-call service, or in emergency clinics. Various reasons are cited for why these alternative care settings are not utilized in these cases.

OBJECTIVES

This study investigates the motives of patients who presented independently at the emergency department, as well as the socio-demographic parameters of this study cohort.

MATERIALS AND METHODS

The survey was carried out as part of a prospective monocentric observational study of internal medicine patients at a university emergency department.

RESULTS

A total of 1086 patients were included in the study. In total, 33% of the study participants visited the emergency department based on a physician's recommendation or referral instead of opting for an alternative care option. The main reason for visiting the emergency department was the subjectively assessed urgency of their symptoms. Among the patients who presented independently at the emergency department, 28% required further inpatient care during the course of treatment. Awareness of alternative care pathways, such as utilizing emergency medical services, seeking care from the statutory medical on-call service, or visiting an emergency clinic, was low.

CONCLUSIONS

Emergency departments remain an important point of contact for patients who present there independently, without being brought by emergency medical services. The motives behind why patients choose a visit to the emergency department over treatment in an alternative care setting vary. If alternatives are to be used instead of emergency departments, structures first need to be established or expanded.

Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing

STUDY OBJECTIVE

Boarding admitted patients in emergency departments (EDs) is a national crisis that is worsening despite potential financial disadvantages. The objective of this study was to assess costs associated with boarding.

METHODS

We conducted a prospective, observational investigation of patients admitted through an ED for management of acute stroke at a large, urban, academic, comprehensive stroke center hospital. We employed time-driven activity-based costing methodology to estimate cost for patient care activities during admission and aggregated results to estimate the total cost of boarding versus inpatient care. Primary outcomes were total daily costs per patient for medical-surgical (med/surg) boarding, med/surg inpatient care, ICU boarding, and ICU inpatient care.

RESULTS

The total daily cost per patient with acute stroke was US$1856, for med/surg boarding versus US$993 for med/surg inpatient care and US$2267, for ICU boarding versus US$2165, for ICU inpatient care. These differences were even greater when accounting for costs associated with traveler nurses. ED nurses spent 293 min/d (mean) caring for each med/surg boarder; inpatient nurses spent 313 min/d for each med/surg inpatient. ED nurses spent 419 min/d caring for each ICU boarder; inpatient nurses spent 787 min/d for each ICU inpatient. Neurology attendings and residents spent 25 and 52 min/d caring for each med/surg boarder versus 62 minutes and 90 minutes for each med/surg inpatient, respectively.

CONCLUSION

Using advanced cost-accounting methods, our investigation provides novel evidence that boarding of admitted patients is financially costly, adding greater urgency for elimination of this practice.

Characteristics and outcomes of emergency department patients across health care systems: an international multicenter cohort study

BACKGROUND

A wide variation of emergency medical system configurations across countries has limited the value of comparison of quality and performance measures in the past. Furthermore, lack of quantitative data on EDs prevents definition of the problems and possibilities for data driven improvement of quality of care. Therefore, the objective is to describe and compare Emergency Department (ED) populations and characteristics, and their outcomes in the Netherlands, Denmark and Australia, using a recently developed template for uniform reporting of standardized measuring and describing of care provided in the ED (structure, staffing and governance, population, process times and outcomes).

METHODS

This international multicenter cohort included all consecutive ED visits from National Quality Registries or Databases from participating sites from three countries. Patient and ED characteristics (using the template for uniform reporting) and relevant clinical outcomes were described and compared per country.

RESULTS

We included 212,515 ED visits in the Netherlands, 408,673 in Denmark and 556,652 in Australia. Patient characteristics differed markedly, with Australian ED patients being younger, less often triaged as "immediate", and less often triaged with the high-risk chief complaints "feeling unwell" compared to Danish and Dutch patients. ED characteristics mainly differed with respect to the mean annual census per ED (Netherlands 26,738 (SD 2630), Denmark 36,675 (SD 12974), Australia 50,712 (4884)), median (IQR) lengths of stay of patients discharged home (Netherlands 2.1 (1.4-3.1); Denmark 2.8 (1.7-5.0); Australia 3.3 (2.0-5.0) hrs) and proportion of hospitalizations (ranging from 30.6 to 39.8%). In-hospital mortality was 4.0% in Australia, higher compared to the Netherlands and Denmark (both 1.6%). Not all indicators of the framework were available in all registries.

CONCLUSIONS

Patient and ED characteristics and outcomes varied largely across countries. Meaningful interpretation of outcome differences across countries could be improved if quality registries would more consistently register the measures of the recently developed template for uniform reporting.

[Forced centralized allocation in the emergency department-what has the COVID-19 pandemic changed?]

BACKGROUND

IVENA eHealth (IVENA, interdisziplinärer Versorgungsnachweis, mainis IT-Service GmbH, Offenbach am Main, Germany) supports the coordination of emergency admissions by providing real-time data on treatment options in hospitals. Overload or technical problems can lead to hospitals having to temporarily deregister parts or the entire emergency department, which can lead to acute admissions. The COVID-19 pandemic may have further exacerbated the situation, which was analyzed as part of this study.

METHODS

This descriptive analysis used the IVENA eHealth information technology (IT) system to examine the occupancy and acute occupancy figures in the Munich ambulance service area from 2016-2022. Particular attention was paid to inpatient (SC II) and shock room + admissions in the specialties of internal medicine, neurology, trauma surgery and urology, as well as the development of acute occupancies, especially after the COVID-19 pandemic.

RESULTS

During the COVID-19 pandemic in 2020, the number of patients in the surveyed specialist areas fell by 23.7% (2021: -15% and 2022: -11% compared to 2019). The proportion of acute admissions fell in 2020 compared to 2019 (5.9% acute admissions vs. 6.8%) and rose disproportionately in 2021 (7.7% vs. 6.8%) and 2022 (24.9% vs. 6.8%).

CONCLUSION

There are many reasons for the increase in acute admissions, including the increase in inpatient admissions, the bottleneck in transferring patients (exit block) and the shortage of staff in the healthcare system. The COVID-19 pandemic has exacerbated some of these problems, which could explain the increase in acute admissions. A combination of different solutions is now needed to ensure adequate emergency care.

Improving emergency department flow by introducing four interventions simultaneously. A quality improvement project

BACKGROUND

Emergency department (ED) crowding is a widespread issue with adverse effects on patient care and outcomes.

LOCAL PROBLEM

ED crowding exacerbates wait times and compromises patient care, prompting opportunities for internal process improvement.

METHOD

Over one week, the ED flow project team implemented four interventions, including an additional triage station, to optimize patient flow. We compared triage times, length of stay, crowding levels, and patient experiences with two control periods.

RESULTS

During peak hours, waiting times to triage decreased significantly with a median of 20 min (IQR 15-30) in the project week and 26 min (IQR 18-37) in the control weeks. Self-referrals decreased, while general practitioner referrals remained unchanged. Individual patient length of stay was unaffected, but crowding reduced notably during the project week. We found no difference in patient experiences between the periods.

CONCLUSION

The interventions contributed to reduced crowding and improved patient flow. The dedication of the ED flow project team and the ED nurses was crucial to these outcomes. An additional triage station during peak hours in the ED was established as a structural change.

Diagnostic Performance of Point-of-Care High-Sensitivity Troponin in the Exclusion of Non-ST-Elevation Myocardial Infarction in the Emergency Department

BACKGROUND

This study evaluates the diagnostic performance of high-sensitivity troponin using point-of-care testing (POCT) devices compared with main laboratory measurements for ruling out non-ST-elevation myocardial infarction (NSTEMI) in emergency department (ED) patients presenting with non-traumatic chest pain.

METHODS

This multicenter, observational, prospective, non-interventional study was conducted in two Spanish hospitals from 1 June to 31 December 2023 and included adult patients presenting with non-traumatic chest pain admitted to the ED. High-sensitivity troponin levels were measured using both the Siemens Atellica® VTLi POCT device and main laboratory testing, with data collected on analytical results and measurement times.

RESULTS

Of the 201 patients who met the inclusion criteria, a significant correlation was observed between the POCT and laboratory assays. The area under the curve (AUC) of the ROC curve was consistently greater than 0.9, indicating a high diagnostic accuracy for ruling out NSTEMI. In addition, measurement times were significantly reduced using POCT compared to the core laboratory.

CONCLUSION

These results suggest that high-sensitivity troponin POCT devices offer comparable diagnostic performance to traditional laboratory methods for the diagnosis of NSTEMI in the emergency department, potentially speeding up clinical decisions and optimizing resource utilization.

Non-emergency department (ED) interventions to reduce ED utilization: a scoping review

BACKGROUND

Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs.

METHODS

This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population.

RESULTS

Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions.

CONCLUSION

A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.

An explainable machine learning framework for predicting the risk of buprenorphine treatment discontinuation for opioid use disorder among commercially insured individuals

OBJECTIVES

Buprenorphine is an effective evidence-based medication for opioid use disorder (OUD). Yet premature discontinuation undermines treatment effectiveness, increasing the risk of mortality and overdose. We developed and evaluated a machine learning (ML) framework for predicting buprenorphine care discontinuity within 12 months following treatment initiation.

METHODS

This retrospective study used United States (US) 2018-2021 MarketScan commercial claims data of insured individuals aged 18-64 who initiated buprenorphine between July 2018 and December 2020 with no buprenorphine prescriptions in the previous six months. We measured buprenorphine prescription discontinuation gaps of ≥30 days within 12 months of initiating treatment. We developed predictive models employing logistic regression, decision tree classifier, random forest, extreme gradient boosting, Adaboost, and random forest-extreme gradient boosting ensemble. We applied recursive feature elimination with cross-validation to reduce dimensionality and identify the most predictive features while maintaining model robustness. For model validation, we used several statistics to evaluate performance, such as C-statistics and precision-recall curves. We focused on two distinct treatment stages: at the time of treatment initiation and one and three months after treatment initiation. We employed SHapley Additive exPlanations (SHAP) analysis that helped us explain the contributions of different features in predicting buprenorphine discontinuation. We stratified patients into risk subgroups based on their predicted likelihood of treatment discontinuation, dividing them into decile subgroups. Additionally, we used a calibration plot to analyze the reliability of the models.

RESULTS

A total of 30,373 patients initiated buprenorphine and 14.98% (4551) discontinued treatment. C-statistic varied between 0.56 and 0.76 for the first-stage models including patient-level demographic and clinical variables. Inclusion of proportion of days covered (PDC) measured after one month and three months following treatment initiation significantly increased the models' discriminative power (C-statistics: 0.60 to 0.82). Random forest (C-statistics: 0.76, 0.79 and 0.82 with baseline predictors, one-month PDC and three-months PDC, respectively) outperformed other ML models in discriminative performance in all stages (C-statistics: 0.56 to 0.77). Most influential risk factors of discontinuation included early stage medication adherence, age, and initial days of supply.

CONCLUSION

ML algorithms demonstrated a good discriminative power in identifying patients at higher risk of buprenorphine care discontinuity. The proposed framework may help healthcare providers optimize treatment strategies and deliver targeted interventions to improve buprenorphine care continuity.

Application of a Human Factors Systems Approach to Healthcare Control Centres for Managing Patient Flow: A Scoping Review

Over the past decade, healthcare systems have started to establish control centres to manage patient flow, with a view to removing delays and increasing the quality of care. Such centres-here dubbed Healthcare Capacity Command/Coordination Centres (HCCCs)-are a challenge to design and operate. Broad-ranging surveys of HCCCs have been lacking, and design for their human users is only starting to be addressed. In this review we identified 73 papers describing different kinds of HCCCs, classifying them according to whether they describe virtual or physical control centres, the kinds of situations they handle, and the different levels of Rasmussen's [1] risk management framework that they integrate. Most of the papers (71%) describe physical HCCCs established as control centres, whereas 29% of the papers describe virtual HCCCs staffed by stakeholders in separate locations. Principal functions of the HCCCs described are categorised as business as usual (BAU) (48%), surge management (15%), emergency response (18%), and mass casualty management (19%). The organisation layers that the HCCCs incorporate are classified according to the risk management framework; HCCCs managing BAU involve lower levels of the framework, whereas HCCCs handling the more emergent functions involve all levels. Major challenges confronting HCCCs include the dissemination of information about healthcare system status, and the management of perspectives and goals from different parts of the healthcare system. HCCCs that take the form of physical control centres are just starting to be analysed using human factors principles that will make staff more effective and productive at managing patient flow.

Experiences of implementing and working with obstetric emergency triage: A qualitative study among Swedish midwifes, auxiliary nurses, and obstetricians

INTRODUCTION

Obstetric emergency triage is a relatively new form of emergency triage and is not yet implemented in Sweden. Adaptations enables safe assessment of the childbearing woman, fetus and labor status. Failure to identify severely ill childbearing women and women post childbirth has repeatedly led to adverse outcomes. Introducing obstetric emergency triage constitutes a profound alteration in management that may challenge preconceived notions on how to provide best care. This study aimed at exploring and describing obstetric staff's experiences of working with obstetric emergency triage.

MATERIALS AND METHODS

Thirteen obstetricians, midwives and auxiliary nurses at an obstetric emergency department in eastern Sweden were recruited by purposeful sampling. Individual qualitative interviews underwent inductive qualitative content analysis according to Graneheim and Lundman.

RESULTS

An overarching theme - A new mindset - emerged from the analysis, comprising the four categories: Implications for the individual caregiver's own work, An improved organization, Improved patient care. Initial skepticism to triage changed towards a positive attitude during implementation, identifying barriers and facilitators for successful implementation.

CONCLUSIONS

This first study exploring Swedish obstetric staff's perception of obstetric emergency triage as a working method suggests that, given time for implementation, a new mindset in obstetric emergency care might develop. Triage provides structure and a sense of control through a clear and quick overview of childbearing women seeking emergency care and enhances teamwork by improving communication. Triage directs attention toward aberrations and promotes reflection and action, improving patient safety.

"I do not know the advantages of having a general practitioner" - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care

BACKGROUND

Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP.

METHOD

Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis.

RESULTS

Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity.

CONCLUSION

Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00023480; date: 2020/11/27.

Patients' pathways to the emergency department: a scoping review

BACKGROUND

Emergency department (ED) crowding is a common healthcare issue with multiple causes. One important knowledge area is understanding where patients arrived from and what care they received prior to ED admission. This information could be used to inform strategies to provide care for low acuity patients outside of the hospital and reduce unnecessary ED admissions. The aim of this scoping review was to provide a comprehensive overview of global published research examining the acute care trajectory of all ED patients.

METHODS

The scoping review was performed according to the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive literature search was performed to identify studies describing where patients arrived from and/or whose pathway of care was before an ED visit. The search was conducted in MEDLINE, Embase, and the Cochrane Library from inception through December 5th, 2022. Two reviewers independently screened the records.

RESULTS

Out of the 6,465 records screened, 14 studies from Australia, Canada, Haiti, Norway, Sweden, Switzerland, Belgium, Indonesia, and the UK met the inclusion criteria. Four studies reported on where patients physically arrived from, ten reported how patients were transported, six reported who referred them, and six reported whether medical care or advice was sought prior to visiting an ED.

CONCLUSION

This scoping review revealed a lack of studies describing patients' pathways to the ED. However, studies from some countries indicate that a relatively large proportion of patients first seek care or guidance from a primary care physician (PCP) before visiting an ED. However, further research and published data are needed. To improve the situation, we recommend the development and implementation of a template for the uniform reporting of factors outside the ED, including where the patient journey began, which healthcare facilities they visited, who referred them to the ED, and how they arrived.

[Redirection of patients from the emergency department to ambulatory care: a feasibility study]

BACKGROUND

§ 120 para. 3b SGB V mandates the Federal Joint Committee to define guidelines for the initial assessment of self-referred walk-in patients as well as for the redirection of patients who can be treated by office-based physicians. A corresponding streaming and redirection process was tested in a feasibility study at the RoMed Clinic Rosenheim.

MATERIALS AND METHODS

For the duration of the study, triage nurses of the emergency department (ED) first assessed self-referred walk-in patients with the Manchester Triage System (MTS). Patients in categories green and blue who did not obviously need the ED's resources were additionally assessed by health professionals of the Association of Statutory Health Insurance Physicians of Bavaria using the software Structured Initial Medical Assessment in Germany (SmED). Patients with a recommendation for non-hospital medical treatment were streamed to the out-of-hours practice on campus or were redirected to a physician office after video consultation with an office-based physician. Patient pathways were documented and a qualitative survey using semistructured guided interviews of all stakeholder groups was carried out.

RESULTS

1,091 self-referred walk-in patients were included. Direct streaming to the ED occurred in 525 cases,13 refused to participate. Based on SmED, 24 additional patients were referred to the ED, 514 patients were streamed to the out-of-hours practice, 23 received a video consultation and five left the ED. After video consultation, eight patients were redirected to a physician's office, 10 were discharged, and five referred to the ED of which one did not want an office-based physician. No returnees from practices to the ED were identified. Generally, the redirection process was evaluated positively in the interviews (n=18). In particular, potential for technical improvement was identified.

CONCLUSION

Overall, the results indicate the feasibility of the redirection process and high acceptance levels. Using SmED in addition to MTS appeared useful before redirection but not necessary for streaming on campus. Redirection to physician offices can help reduce strain on the ED when the out-of-hours practice is not operating. In addition to arranging acute care appointments, video consultations offer an additional potential to treat patients. In a follow-up study, a broader range of patients should be included and appropriateness of redirection decisions should be evaluated.

Diagnosing an overcrowded emergency department from its Electronic Health Records

Emergency department overcrowding is a complex problem that persists globally. Data of visits constitute an opportunity to understand its dynamics. However, the gap between the collected information and the real-life clinical processes, and the lack of a whole-system perspective, still constitute a relevant limitation. An analytical pipeline was developed to analyse one-year of production data following the patients that came from the ED (n = 49,938) at Uppsala University Hospital (Uppsala, Sweden) by involving clinical experts in all the steps of the analysis. The key internal issues to the ED were the high volume of generic or non-specific diagnoses from non-urgent visits, and the delayed decision regarding hospital admission caused by several imaging assessments and lack of hospital beds. Furthermore, the external pressure of high frequent re-visits of geriatric, psychiatric, and patients with unspecified diagnoses dramatically contributed to the overcrowding. Our work demonstrates that through analysis of production data of the ED patient flow and participation of clinical experts in the pipeline, it was possible to identify systemic issues and directions for solutions. A critical factor was to take a whole systems perspective, as it opened the scope to the boundary effects of inflow and outflow in the whole healthcare system.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Emergency department overcrowding and its associated factors at HARME medical emergency center in Eastern Ethiopia

Introduction

Emergency department (ED) overcrowding has become a significant concern as it can lead to compromised patient care in emergency settings. Various tools have been used to evaluate overcrowding in ED. However, there is a lack of data regarding this issue in resource-limited countries, including Ethiopia. This study aimed to validate NEDOCS, assess level of ED overcrowding and identify associated factors at HARME Medical Emergency Center, located in Hiwot Fana Comprehensive Specialized Hospital, Harar, Ethiopia.

Methods

A cross-sectional study was conducted at the HARME Medical Emergency Center, Hiwot Fana Comprehensive Specialized Hospital, involving a total of 899 patients during 120 sampling intervals. The area under the receiver operating characteristic curves (AUC) was calculated to evaluate the agreement between objective and subjective assessments of ED overcrowding. A multivariable logistic regression analysis was employed to identify factors associated with ED overcrowding and statistically significant association was declared using 95 % confidence level and a p-value < 0.05.

Results

The interrater agreement showed a strong correlation with a Cohen's kappa (κ) of 0.80. The National Emergency Department Overcrowding Study Score demonstrated a strong association with subjective assessments from residents and case team nurses, with an AUC of 0.81 and 0.79, respectively. According to residents' perceptions, ED were considered overcrowded 65.8 % of the time. Factors significantly associated with ED overcrowding included waiting time for triage (AOR: 2.24; 95 % CI: 1.54-3.27), working time (AOR: 2.23; 95 % CI: 1.52-3.26), length of stay (AOR: 2.40; 95 % CI: 1.27-4.54), saturation level (AOR: 2.35; 95 % CI: 1.31-4.20), chronic illness (AOR: 2.19; 95 % CI: 1.37-3.53), and abnormal pulse rate (AOR: 1.52; 95 % CI: 1.06-2.16).

Conclusion

The study revealed that ED were overcrowded approximately two-thirds of the time.

Emergency physician personnel crisis: a survey on attitudes of new generations in Slovenia

BACKGROUND

Emergency departments globally are overburdened, and emergency medicine residency is losing popularity among students and physicians. This raises concerns about the collapse of a life-saving system. Our goal was to identify the key workforce reasoning and question medical staff employment behavior.

METHODS

This was a prospective cross-sectional study. In December 2022, medical students and pre-residency doctors in Slovenia were invited to complete a web-based questionnaire. The data were analyzed using T-test, chi-square test, Mann‒Whitney-Wilcoxon tests, and principal component analysis. Open-ended questions were hand-categorized.

RESULTS

There were 686 participatns who clicked on the first page and 436 of those finished the survey. 4% of participants gave a clear positive response, while 11% responded positively regarding their decision to pursue emergency medicine residency. The popularity of emergency medicine decreases significantly among recent medical school graduates upon their initial employment. People who choose emergency medicine are less concerned about its complexity and pressure compared to others. Most respondents preferred 12-hour shift lengths. The preferred base salary range for residents was I$ 3623-4529, and for specialists, it was I$ 5435-6341. The sample's primary personal priorities are achieving a satisfactory work-life balance, earning respect from colleagues, and engaging in academic activities. Factors that attract individuals to choose emergency medicine include high hourly wages, establishment of standards and norms, and reduced working hours.

CONCLUSIONS

Our findings indicate that enhancing compensation, establishing achievable standards and norms, facilitating a beneficial work-life equilibrium, providing assistance with initial property acquisition, stimulating participation in deficit residency programs, fostering collegiality among peers, restricting the duration of shifts, and enabling pension accrual may be imperative in attracting more individuals to pursue emergency medicine residency.

Appropriateness of the Emergency Referrals Made by Primary Care Clinicians: A cross-sectional review of referral notes

Objectives

This study aimed to evaluate the appropriateness of the emergency referrals made by primary care clinicians and determine the factors contributing to inappropriate referrals.

Methods

This cross-sectional study utilises referral notes review between October 2019 and March 2020. Patients referred to Khawla Hospital's emergency department by a primary care clinician in Muscat Governorate were randomly selected; their referral notes were reviewed by five family physicians. The appropriateness of the referrals was evaluated according to the primary care referral protocol. Any referral that deviated from the protocol was classified as inappropriate. The prevalence and characteristics of inappropriate referrals were identified, and the factors contributing to inappropriate referral were determined using multivariable logistic regression.

Results

In total, 591 referrals were reviewed; 354 (59.9%) of them were classified as inappropriate due to inadequate medical notes (291, 82.2%), lack of provisional diagnosis (176, 49.7%), misdirected to a non-concerned emergency (30, 8.4%) or misclassification of urgency (107 [30.2%] were classified as urgent and 45 [12.7%] as routine). After adjusting for multiple variables, insufficient clinical notes, unavailability of referral guidelines and lack of expertise were found to be strong determinants of inappropriate referral, with an odds ratio of 62.52 (95% confidence interval [CI]: 32.04-121.96), 2.88 (95% CI: 1.40-5.92) and 9.37 (95% CI: 4.09-21.43), respectively.

Conclusion

While most of the referrals required emergency management, the majority were inappropriate, mainly due to insufficient clinical documentation. Inadequate clinical notes and lack of national guidelines and expertise were found to be strong predictors of inappropriate emergency referrals.

Variations in the intended utilization of emergency care in case of gastrointestinal diseases

Frequent utilization of emergency care and overcrowded emergency departments (EDs) are highly relevant topics due to their harmful consequences for patients and staff. The present study examines variations of intended health care use in urgent and non-urgent cases among the general population. In a cross-sectional telephone survey, a sample of N = 1,204 adults residing in Hamburg, Germany, was randomly drawn. At the beginning of the survey, one of 24 different vignettes (case stories) describing symptoms of inflammatory gastrointestinal diseases were presented to the participants. The vignettes varied in sex (male/female), age (15, 49, 72 years), daytime (Tuesday morning, Tuesday evening), and urgency (low, high). Participants were asked in an open-ended question about their primal intended utilization if they or their children would be affected by such symptoms. Overall, about 14 % chose emergency facilities (ED, ambulance, emergency practice) despite presentation of non-urgent conditions (n = 602). Intended emergency care use varied considerably even if the degree of urgency was comparable. Adolescence, male sex, and symptoms occurring in the evening were associated with increased ED and ambulance use. Inappropriate utilization of ED and ambulance (analyses regarding utilization due to non-urgent problems) was more often observed among male respondents and those with a migration background (1st generation). Information campaigns focused on emergency care use and reorganisation of emergency care wards are possible interventions.

Lifting the curtain on the emergency department crisis: a multi-method reception study of Larry Saves the Canadian Healthcare System

BACKGROUND

Despite growing evidence of the potential of arts-based modalities to translate knowledge and spark discussion on complex issues, applications to health policy are rare. This study explored the potential of a research-based theatrical video to increase public capacity and motivation to engage with the complex issues that make Emergency Department wait times such an intractable problem.

METHODS

Larry Saves the Canadian Healthcare System is a digital musical micro-series developed from extensive research examining system-level causes of Emergency crowding and the ineffectiveness of prevailing approaches. We released individual episodes and a revised full-length version on YouTube, using organic promotion strategies and paid advertising. We used YouTube Analytics to track views, engagement and viewer demographics, and content-analyzed viewer comments. We also conducted five university-based screenings; 92 students completed questionnaires, rating Larry on 16 descriptors using a 7-point Likert scale.

RESULTS

From June 2022 through May 2023, Larry garnered over 100,000 views (76,752 of the full-length version, 35,535 of episodes), 1329 likes, 2780 shares, and 139 comments. Views and watch time were higher among women and positively associated with age. Among YouTube comments, the predominating themes were praise for the video and criticism of the healthcare system. Many commenters applauded the show's accuracy, humor, and/or resonance with their experience; several shared healthcare horror stories. Students overwhelmingly agreed with all positive and disagreed with all negative descriptors, and nearly unanimously deemed the video informative, thought-provoking, and entertaining. Most also affirmed that it had increased their knowledge, interest, and confidence to participate in discussions about healthcare issues. Neither gender, primary language, nor employment in healthcare predicted ratings, but graduate students and those 25+ years old evaluated the video most positively.

DISCUSSION

These findings highlight the promise of research-informed musical satire to inform and invigorate discourse on an urgent health policy problem. Larry has reached tens of thousands of viewers, garnered excellent feedback, and received high student ratings. Further research should directly assess educational and behavioural outcomes and explore what facilitative strategies could maximize this knowledge translation product's potential to foster informed, impactful policy dialogue.

Emergency department crowding increases 10-day mortality for non-critical patients: a retrospective observational study

The current evidence suggests that higher levels of crowding in the Emergency Department (ED) have a negative impact on patient outcomes, including mortality. However, only limited data are available about the association between crowding and mortality, especially for patients discharged from the ED. The primary objective of this study was to establish the association between ED crowding and overall 10-day mortality for non-critical patients. The secondary objective was to perform a subgroup analysis of mortality risk separately for both admitted and discharged patients. An observational single-centre retrospective study was conducted in the Tampere University Hospital ED from January 2018 to February 2020. The ED Occupancy Ratio (EDOR) was used to describe the level of crowding and it was calculated both at patient's arrival and at the maximum point during the stay in the ED. Age, gender, Emergency Medical Service transport, triage acuity, and shift were considered as confounding factors in the analyses. A total of 103,196 ED visits were included. The overall 10-day mortality rate was 1.0% (n = 1022). After controlling for confounding factors, the highest quartile of crowding was identified as an independent risk factor for 10-day mortality. The results were essentially similar whether using the EDOR at arrival (OR 1.31, 95% CI 1.07-1.61, p = 0.009) or the maximum EDOR (OR 1.27, 95% CI 1.04-1.56, p = 0.020). A more precise, mortality-associated threshold of crowding was identified at EDOR 0.9. The subgroup analysis did not yield any statistically significant findings. The risk for 10-day mortality increased among non-critical ED patients treated during the highest EDOR quartile.

Perceived treatment urgency of common mental disorders in the German population

Perceived treatment urgency of mental disorders are important as they determine utilization of health care. The aim was to analyze variations in perceived treatment urgency in cases of psychosis (adolescents), alcoholism (adults), and depression (older adults) with two levels of severity each by characteristics of the case and the respondents. A telephone survey (N = 1200) with vignettes describing cases of psychosis, alcoholism, and depression was conducted in Hamburg, Germany. Vignettes varied by symptom severity and sex. Perceived treatment urgency was assessed by three items. A sum scale was calculated. Linear regression models were computed to analyze differences in perceived urgency by characteristics of the case (severity, sex) and the respondents (sex, age, education, migration background, illness recognition, personal affliction). Perceived treatment urgency was significantly higher in severe cases and varied by education. Additionally, regarding psychosis, estimated urgency varied significantly by correct illness recognition. With regard to depression, perceived urgency differed significantly by age and correct illness recognition. Interaction effects between case severity and sociodemographic characteristics of the respondents, personal affliction, and correct recognition of the disorder were found. The identified differences should be considered in the development of interventions on mental health literacy with regard to adequate urgency assessment.

The pattern of emergency department length of stay in Saudi Arabia: an epidemiological Nationwide analyses of secondary surveillance data

Background

Emergency department length of stay is a vital performance indicator for quality and efficiency in healthcare. This research aimed to evaluate the length of stay patterns in emergency departments across Saudi Arabia and to identify predictors for extended stays. The study used secondary data from the Ministry of Health's Ada'a program.

Methods

Using a retrospective approach, the study examined data from the Ada'a program on emergency department length of stay from September 2019 to December 2021. These data covered 1,572,296 emergency department visits from all regions of Saudi Arabia. Variables analyzed included quality indicators, year of visit, shift time, hospital type, and data entry method. The analysis was conducted using multiple linear regression.

Results

The study found that the median length of stay was 61 min, with significant differences among related predictors. All associations were significant with a value of p of less than 0.001. Compared to 2019, the length of stay was notably shorter by 28.5% in 2020 and by 44.2% in 2021. Evening and night shifts had a shorter length of stay by 5.9 and 7.8%, respectively, compared to the morning shift. Length of stay was lower in winter, summer, and fall compared to spring. Patients in levels I and II of the Canadian Triage and Acuity Scales had longer stays than those in level III, with those in level I reaching an increase of 20.5% in length of stay. Clustered hospitals had a longer length of stay compared to the non-clustered ones. Pediatric hospitals had a 15.3% shorter stay compared to general hospitals. Hospitals with data entered automatically had a 14.0% longer length of stay than those entered manually. Patients admitted to the hospital had a considerably longer length of stay, which was 54.7% longer compared to non-admitted patients. Deceased patients had a 20.5% longer length of stay than patients discharged alive.

Conclusion

Data at the national level identified several predictors of prolonged emergency department length of stay in Saudi Arabia, including shift time, season, severity level, and hospital type. These results underline the necessity of continuous monitoring and improvement efforts in emergency departments, in line with policy initiatives aiming to enhance patient outcomes in Saudi Arabia.

Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic

STUDY OBJECTIVE

We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022.

METHODS

We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states.

RESULTS

Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day.

CONCLUSION

ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

Motives behind low-acuity geriatric emergency medicine attenders: a picture from free healthcare system

BACKGROUND

Current evidence about the low-acuity ED visits of old patients has been generated in various healthcare systems; however, this is not a well-researched area in middle-income countries by patients' perspectives.

METHODS

A study of 231 patients attending the ED of a tertiary public hospital was conducted using a structured questionnaire from June to August 2021. Eligible patients were community-dwelling, aged > 65 years, who presented with lower clinical urgency. The questionnaire tool was developed using questions from available studies on health service utilization. Additional commentary was obtained from the patients regarding on the reasons for attending the ED and was administered on weekdays between 8:00 am and 5:30 pm.

RESULTS

The study included 221 patients over 65 years of age, with a mean age of 72.21 ± 4.2. A total of 58.4% of the patients thought that they should be examined urgently, 15.4% had symptoms that had lasted more than one month, and 59% requested emergency imaging. Patients preferred the ED via treatment, imaging, transportation opportunities of emergency department, past negative experiences, and access problems with family medicines or appointment problems with specialist outpatient clinics with expectations of continuity of care.

CONCLUSION

Old individuals have unique healthcare needs, and the motives behind this group of patients with low-acuity problems to apply to the ED is complex. As one of the key objectives of healthcare policies is to make sure that patients are assessed at proper time and place, studies that consider patient perspectives might lead to accurate conclusions for this aim.

Fast track to stroke unit for patients not eligible for acute intervention, a case-control register study on 1066 patients

Stroke patients not eligible for acute intervention often have low priority and may spend long time at the emergency department (ED) waiting for admission. The aim of this retrospective case-control register study was to evaluate outcomes for such "low priority" stroke patients who were transported via Fast Track directly to the stroke unit, according to pre-specified criteria by emergency medical service (EMS). The outcomes of Fast Track patients, transported directly to stroke unit (cases) were compared with the outcomes of patients who fulfilled these critera for Fast Track, but instead were transported to the ED (controls). In all, 557 cases and 509 controls were identified. The latter spent a mean time of 237 min in the ED before admission. The 90-day mortality rate was 12.9% for cases and 14.7% for controls (n.s.). None of the secondary outcome events differed significantly between the groups: 28-day mortality rate; death rate during hospitalisation; proportion of pneumonias, falls or pressure ulcers; or health-related outcomes according to the EQ-5D-5L questionnaire. These findings indicates that the Fast Track to the stroke unit by an EMS is safe for selected stroke patients and could avoid non-valuable time in the ED.

Applying Andersen's healthcare utilization model to assess factors influencing patients' expectations for diagnostic tests at emergency department visits during the COVID-19 pandemic

Background

The uncertainties surrounding the COVID-19 pandemic led to a surge in non-urgent emergency department (ED) attendance among people presenting with upper respiratory tract infection (URTI) symptoms. These non-urgent visits, often manageable in primary care, exacerbated ED overcrowding, which could compromise the quality of ED services. Understanding patients' expectations and the reasons for these ED visits is imperative to mitigate the problem of ED overcrowding. Hence, we assessed the factors influencing patients' expectations for diagnostic tests during their ED visits for uncomplicated URTI during different phases of the pandemic.

Methods

We conducted a cross-sectional study on adults with URTI symptoms seeking care at four public EDs in Singapore between March 2021 and March 2022. We segmented the study period into three COVID-19 pandemic phases-containment, transition, and mitigation. The outcome variables are whether patients expected (1) a COVID-19-specific diagnostic test, (2) a non-COVID-19-specific diagnostic test, (3) both COVID-19-specific and non-COVID-19-specific diagnostic tests, or (4) no diagnostic test. We built a multinomial regression model with backward stepwise selection and classified the findings according to Andersen's healthcare utilization model.

Results

The mean age of participants was 34.5 (12.7) years. Factors (adjusted odds ratio [95% confidence interval]) influencing expectations for a COVID-19-specific diagnostic test in the ED include younger age {21-40 years: (2.98 [1.04-8.55])}, no prior clinical consultation (2.10 [1.13-3.89]), adherence to employer's health policy (3.70 [1.79-7.67]), perceived non-severity of illness (2.50 [1.39-4.55]), being worried about contracting COVID-19 (2.29 [1.11-4.69]), and during the transition phase of the pandemic (2.29 [1.15-4.56]). Being non-employed influenced the expectation for non-COVID-19-specific diagnostic tests (3.83 [1.26-11.66]). Factors influencing expectations for both COVID-19-specific and non-COVID-19-specific tests include younger age {21-40 years: (3.61 [1.26-10.38]); 41-60 years: (4.49 [1.43-14.13])}, adherence to employer's health policy (2.94 [1.41-6.14]), being worried about contracting COVID-19 (2.95 [1.45- 5.99]), and during the transition (2.03 [1.02-4.06]) and mitigation (2.02 [1.03-3.97]) phases of the pandemic.

Conclusion

Patients' expectations for diagnostic tests during ED visits for uncomplicated URTI were dynamic across the COVID-19 pandemic phases. Expectations for COVID-19-specific diagnostic tests for ED visits for uncomplicated URTI were higher among younger individuals and those worried about contracting COVID-19 during the COVID-19 pandemic. Future studies are required to enhance public communications on the availability of diagnostic services in primary care and public education on self-management of emerging infectious diseases such as COVID-19.

How Emergency Medicine Residents Have Conversations About Life-Sustaining Treatments in Critical Illness: A Qualitative Study Using Inductive Thematic Analysis

STUDY OBJECTIVE

The inherent pressures of high-acuity, critical illness in the emergency department create a unique environment whereby acute goals-of-care discussions must be had with patients or substitute decision makers to rapidly decide between divergent treatment paths. Among university-affiliated hospitals, resident physicians are often conducting these highly consequential discussions. This study aimed to use qualitative methods to explore how emergency medicine residents make recommendations regarding life-sustaining treatments during acute goals-of-care discussions in critical illness.

METHODS

Using qualitative methods, semistructured interviews were conducted with a purposive sample of emergency medicine residents in Canada from August to December 2021. Inductive thematic analysis of the interview transcripts was conducted using line-by-line coding, and key themes were identified through comparative analysis. Data collection continued until thematic saturation was reached.

RESULTS

Seventeen emergency medicine residents from 9 Canadian universities were interviewed. Two factors guided residents' treatment recommendations (a duty to provide a recommendation and the balance between disease prognosis and patient values). Three factors influenced residents' comfort when making recommendations (time constraints, uncertainty, and moral distress).

CONCLUSION

While conducting acute goals-of-care discussions with critically ill patients or their substitute decision makers in the emergency department, residents felt a sense of duty to provide a recommendation informed by an intersection between the patient's disease prognosis and the patient's values. Their comfort in making these recommendations was limited by time constraints, uncertainty, and moral distress. These factors are important for informing future educational strategies.