Inappropriate ED visits: patient responsibility or an attribution bias?

Do patients referred to emergency departments after being assessed in primary care differ from other ED patients? Retrospective analysis of a random sample from two German metropolitan EDs

BACKGROUND

To assess differences between patients referred to emergency departments by a primary care physician (PCP) and those presenting directly and the impact of referral on the likelihood of admission.

DESIGN OF STUDY

Retrospective cohort study.

SETTING

EDs of two nonacademic general hospitals in a German metropolitan region.

PARTICIPANTS

Random sample of 1500 patients out of 80,845 presentations during the year 2019.

RESULTS

Age was 55.8 ± 22.9 years, and 51.4% was female. A total of 34.7% presented by emergency medical services (EMS), and 47.7% were walk-ins. One-hundred seventy-four (11.9%) patients were referred by PCPs. Referrals were older (62.4 ± 20.1 vs 55.0 ± 23.1 years, p < .001) and had a higher Charlson Comorbidity Index (CCI) (3 (1-5) vs 2 (0-4); p < .001). Referrals received more ultrasound examinations independently from their admission status (27.6% vs 15.7%; p < .001) and more CT and laboratory investigations. There were no differences in sex, Manchester Triage System (MTS) category, or pain-scale values. Referrals presented by EMS less often (9.2% vs 38.5%; p < .001). Admission rates were 62.6% in referrals and 37.1% in non-referrals (p < .001). Referral (OR 3.976 95% CI: 2.595-6.091), parenteral medication in ED (OR 2.674 (1.976-3.619)), higher MTS category (1.725 (1.421-2.093)), transport by EMS (1.623 (1.212-2.172)), abnormal vital parameters (1.367 (0.953-1.960)), higher CCI (1.268 (1.196-1.344)), and trauma (1.268 (1.196-1.344)) were positively associated with admission in multivariable analysis, whereas ultrasound in ED (0.450 (0.308-0.658)) and being a nursing home resident (0.444 (0.270-0.728)) were negatively associated.

CONCLUSION

Referred patients were more often admitted. They received more laboratory investigations, ultrasound examinations, and computed tomographies. Difficult decisions regarding the necessity of admission requiring typical resources of EDs may be a reason for PCP referrals.

Mask use among health care workers and feelings of safety at work pre- and post- COVID-19 vaccine

Background

Correct mask use can prevent the spread of COVID-19 and hospitals require correct mask use. Despite this, there is variation in mask use among health care workers (HCW). Incorrect mask use may lead to increased infections and decreased feelings of safety. The purpose of this study was to determine variation in mask use among HCW as well as feelings of safety from exposure to COVID-19 when around colleagues before and after COVID-19 vaccine roll out.

Methods

This study used direct observation to assess mask use in patient-facing areas before and after COVID-19 vaccine. A staff survey was used to assess feelings of safety.

Results

Over 1,600 mask observations showed increased compliance from 94.6% to 97.5% (P = .001). Three hundred survey responses showed significantly increased feelings of safety (P < .001) after vaccine roll out, and 203 free-text responses with respondant reasoning were categorized into 6 themes.

Discussion

Understanding mask use behaviors and safety attitudes of HCW can help improve policies, workplace culture, and reduce HCW to HCW infections.

Conclusions

Correct mask use was a highly adopted habit in patient-facing areas. The COVID-19 vaccine led to significantly increased feelings of safety among HCW, though the diverging narratives seen in the survey may be helpful to consider when crafting safety interventions.

Non-COVID-19 patients in times of pandemic: Emergency department visits, hospitalizations and cause-specific mortality in Northern Italy

The COVID-19 pandemic forced healthcare services organization to adjust to mutating healthcare needs. Not exhaustive data are available on the consequences of this on non-COVID-19 patients. The aim of this study was to assess the impact of the pandemic on non-COVID-19 patients living in a one-million inhabitants' area in Northern Italy (Bologna Metropolitan Area-BMA), analyzing time trends of Emergency Department (ED) visits, hospitalizations and mortality. We conducted a retrospective observational study using data extracted from BMA healthcare informative systems. Weekly trends of ED visits, hospitalizations, in- and out-of-hospital, all-cause and cause-specific mortality between December 1st, 2019 to May 31st, 2020, were compared with those of the same period of the previous year. Non-COVID-19 ED visits and hospitalizations showed a stable trend until the first Italian case of COVID-19 has been recorded, on February 19th, 2020, when they dropped simultaneously. The reduction of ED visits was observed in all age groups and across all severity and diagnosis groups. In the lockdown period a significant increase was found in overall out-of-hospital mortality (43.2%) and cause-specific out-of-hospital mortality related to neoplasms (76.7%), endocrine, nutritional and metabolic (79.5%) as well as cardiovascular (32.7%) diseases. The pandemic caused a sudden drop of ED visits and hospitalizations of non-COVID-19 patients during the lockdown period, and a concurrent increase in out-of-hospital mortality mainly driven by deaths for neoplasms, cardiovascular and endocrine diseases. As recurrencies of the COVID-19 pandemic are underway, the scenario described in this study might be useful to understand both the population reaction and the healthcare system response at the early phases of the pandemic in terms of reduced demand of care and systems capability in intercepting it.

What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care

BACKGROUND

Despite calls to study how healthcare providers' emotions may impact patient safety, little research has addressed this topic. The current study aimed to develop a comprehensive understanding of emergency department (ED) providers' emotional experiences, including what triggers their emotions, the perceived effects of emotions on clinical decision making and patient care, and strategies providers use to manage their emotions to reduce patient safety risks.

METHODS

Employing grounded theory, we conducted 86 semi-structured qualitative interviews with experienced ED providers (45 physicians and 41 nurses) from four academic medical centres and four community hospitals in the Northeastern USA. Constant comparative analysis was used to develop a grounded model of provider emotions and patient safety in the ED.

RESULTS

ED providers reported experiencing a wide range of emotions in response to patient, hospital, and system-level factors. Patients triggered both positive and negative emotions; hospital and system-level factors largely triggered negative emotions. Providers expressed awareness of possible adverse effects of negative emotions on clinical decision making, highlighting concerns about patient safety. Providers described strategies they employ to regulate their emotions, including emotional suppression, distraction, and cognitive reappraisal. Many providers believed that these strategies effectively guarded against the risk of emotions negatively influencing their clinical decision making.

CONCLUSION

The role of emotions in patient safety is in its early stages and many opportunities exist for researchers, educators, and clinicians to further address this important issue. Our findings highlight the need for future work to (1) determine whether providers' emotion regulation strategies are effective at mitigating patient safety risk, (2) incorporate emotional intelligence training into healthcare education, and (3) shift the cultural norms in medicine to support meaningful discourse around emotions.