Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions

Urgent care centres for reducing the demand on emergency departments: a scoping review of published quantitative and qualitative studies

OBJECTIVES

To identify published studies that examined the impact of urgent care centres on the numbers of presentations to emergency departments (EDs), or explored the experiences and views of patients and practitioners regarding urgent care centres as alternative sources of health care and advice.

STUDY DESIGN

Scoping review of qualitative and quantitative studies published to 28 August 2024.

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, and CINAHL databases; grey literature searches.

DATA SYNTHESIS

Of 2698 potentially relevant publications, 51 met our inclusion criteria (30 quantitative studies; 21 qualitative studies). Urgent care centres of various types were led by general practitioners in 41 of 51 studies, primarily managed people with non-urgent conditions or minor illnesses in 34 studies and non-emergency but urgent conditions in eight, and nine of the 22 studies that discussed funding indicated that access to the centres was free of charge. The effect of urgent care centres on ED presentation numbers was mixed; all seven studies of after-hours clinics, one of two studies of 24-hour clinics, and four of five studies of walk-in centres reported reduced ED visit numbers; in eleven studies that reported effects on hospital admissions from the ED, they were lower in seven (studies of an urgent cancer care centre, four community health centres, and a general practitioner cooperative). Patient satisfaction with urgent care centres is generally as high as with other primary care services; they preferred them to EDs, and preferred personal triage to telephone triage. Reasons for people choosing urgent care centres included easier access and the unavailability of doctors or appointments elsewhere. Clinicians reported increased workload, mixed experiences with the coordination of care, concerns about unregistered or undocumented people using the services, and protocol confusion, particularly with respect to triage. Continuity of care was a concern for both clinicians and patients.

CONCLUSIONS

Urgent care centres, especially walk-in and after-hours clinics, can help reduce the number of ED presentations and reduce health care costs. Patient satisfaction with such clinics is high, but public health education could guide people to appropriate care for non-urgent health problems. Training in the management of conditions frequently seen in urgent care centres is needed to ensure consistent, effective care.

Factors associated with delayed order-to-administration time in the emergency department: a retrospective analysis

BACKGROUND

Timely medication administration in the emergency department (ED) is critical for improving patient outcomes. This study aimed to identify predictors of delayed order-to-administration (OTA) time, defined as exceeding 30 min for stat medications.

METHODS

A retrospective analysis was conducted in the ED of a 1,000-bed tertiary hospital. Patients aged 20 years or older who received stat medications between June 1 and August 31, 2020, were included. Only the first stat medication order per patient was analyzed. Data on patient demographics, triage characteristics, environmental factors, prescription details, and OTA times were extracted from the hospital's electronic medical record and nursing information system. Multivariable logistic regression with backward elimination was used to identify predictors of OTA delays.

RESULTS

Among the 11,429 patient visits included, 9.9% experienced OTA delays exceeding 30 min. Predictors of higher odds of delay included older age (adjusted odds ratio [aOR]: 1.01, 95% CI: 1.00-1.01), female sex (aOR: 1.49, 95% CI: 1.31-1.69), limited mobility (aOR: 1.38, 95% CI: 1.17-1.63 for ambulatory with assistance; aOR: 1.24, 95% CI: 1.03-1.48 for non-ambulatory patients), trauma (aOR: 1.35, 95% CI:1.09-1.66), hourly patient visits (aOR: 1.07, 95% CI: 1.05-1.10), concurrent intravenous fluid use (aOR:1.42, 95% CI:1.04-1.93), blood tests (aOR: 1.73, 95% CI: 1.30-2.30), radiography (aOR: 2.22, 95% CI: 1.87-2.64), and computed tomography (aOR: 1.57, 95% CI: 1.37-1.80). Reduced odds of delay were observed among patients with triage level 1 compared to level 3 (aOR 0.25, 95% CI:0.16-0.39), those arriving during night shifts compared to day shifts (aOR: 0.33, 95% CI: 0.18-0.63), and those receiving intramuscular medications compared to intravenous administration (aOR 0.71; 95% CI, 0.55-0.93).

CONCLUSIONS

Several patient, environmental, and diagnostic-related factors were associated with OTA delays in stat medication administration. Understanding these predictors may help inform strategies to optimize ED workflows. Further research is warranted to validate these findings in other ED settings.

CLINICAL TRIAL NUMBER

Not applicable.

Triage nurse-initiated orders in pediatric emergency care: A single-center retrospective cohort study of appendix and testicular ultrasounds

BACKGROUND

Triage nurse-initiated imaging orders (TNIO) are a promising strategy to improve emergency department (ED) efficiency and length of stay (LOS). However, limited data exists on the impact of TNIO ultrasounds in pediatric appendicitis and testicular torsion.

OBJECTIVES

This study aimed to measure the utilization of TNIO for appendix and testicular ultrasounds and evaluate their impact on LOS. Secondary objectives included assessing effects on time to pain interventions, time to antibiotics, return visits, departures prior to provider evaluation, and need for additional imaging.

METHODS

A single center, retrospective cohort study of patients aged 0-21 years old presenting to a pediatric ED from 2018 and 2023 who underwent appendix or testicular ultrasounds. Patients bypassing triage or who had pre-triage ultrasound orders were excluded. Patients were grouped by nurse-initiated or provider-initiated ultrasounds. Statistical analyses included descriptive statistics and multivariate regression.

RESULTS

Of 9594 appendix ultrasounds, 20.4 % were nurse-initiated, reducing LOS by 12.7 % (p < 0.001). Of 2525 testicular ultrasounds, 41.9 % were TNIO, reducing LOS by 6.4 % (p < 0.001). TNIO for appendicitis reduced time to antibiotics by 11.9 % (p < 0.001) but had no effect on time to pain control. TNIO patients had fewer return visits (p < 0.001) but higher rates of departures prior to provider evaluation (p < 0.001). Disparities were observed, with Non-Hispanic Black and Medicaid patients less likely to receive TNIO for appendicitis.

CONCLUSION

Triage nurse-initiated ultrasounds reduce LOS in cases of suspected appendicitis and testicular torsion. Implementing triage nurse-initiated imaging protocols could potentially optimize the care of pediatric patients with these conditions, ultimately improving ED efficiency.

Pediatric head trauma algorithm for head CT decision-making in the emergency department

BACKGROUND

Traumatic brain injury is a common cause of admission in Emergency Department (ED) for pediatric patients. The aim of this study was to evaluate the application of the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) algorithm in ED for head CT decision-making in pediatric patients. The secondary objective was to evaluate the impact of adherence to this protocol on ED crowding, length of stay, and boarding time.

METHODS

We conducted a retrospective study including children aged ≤ 15 years who were admitted in a level 2 trauma center ED for mild TBI from 1 January 2016 to 31 December 2019. Collected data included amnesia, symptoms, demographics, outcomes, length of ED stay, the patient's outcomes, including intracranial injuries (ICI) and injuries requiring neurosurgery.

RESULTS

A total of 1372 children with mild TBI were included. More than half of the patients were male (59.8%) and ≥ 2 years of age (63.2%). Most of the trauma events (58%) were caused by home injury. Neurosurgical consultation (59.4%) was the most common intervention in the ED. Only 4.3% of patients required neuroimaging and 7 children had intracranial hemorrhage, with only 1 requiring immediate neurosurgical intervention. There were no re-admissions for bleeding. The adoption of this protocol had no negative impact on crowding, and a reduction of ED length of stay.

CONCLUSIONS

The adoption of the PECARNE algorithm led to fewer brain computed tomography scans with good clinical outcomes without increasing crowding.

Urine Dipstick for the Diagnosis of Urinary Tract Infection in Febrile Infants Aged 2 to 6 Months

OBJECTIVE

Urine dipsticks can be performed at the point of care, whereas urinalysis requires laboratory analysis. We compared the accuracy of urine dipstick with urinalysis for the diagnosis of urinary tract infection (UTI) in febrile infants aged 2 to 6 months.

METHODS

We performed a cross-sectional study of previously healthy infants aged 2 to 6 months who presented to one of 5 emergency departments with a temperature greater than or equal to 38.0 °C and had a catheterized urine culture obtained. We defined a UTI with a urine culture growing greater than or equal to 50 000 colony-forming units (CFUs) per milliliter of a single bacterial uropathogen. Using receiver operator characteristic (ROC) curve analysis to select the optimal urine white blood cell (WBC) cut point, we compared positive urine dipstick (≥1+ leukocyte esterase or positive nitrite) to dichotomized urine WBC count for the diagnosis of UTI.

RESULTS

Of 9387 febrile infants who had a urine culture performed, 1044 (11%) had a UTI. Escherichia coli was the most common pathogen identified (923; 88.4%). The optimal urine WBC cut point was greater than or equal to 7 cells per high-power field (HPF). When compared with urine WBC count of greater than or equal to 7 cells per HPF, urine dipstick had a higher sensitivity (831/921 [90.2%] dipstick vs 738/880 [83.9%] urine WBC; difference 6.4%, 95% CI 3.8%-8.9%) and specificity (6352/6862 [92.6%] dipstick vs 3679/4231 [87.0%] urine WBC; difference 5.6%, 95% CI 4.7%-6.6%).

CONCLUSION

Urine dipstick is an accurate diagnostic test for UTI in febrile infants aged 2 to 6 months. Laboratory urinalysis may not be required to guide initial treatment decisions.

Implementing a re-structured response to behavioural disturbance in the emergency Department - A mixed methods evaluation

BACKGROUND

The increasing prevalence of violence in Emergency Departments (EDs) globally emphasises that the early detection of behavioural disturbance, the skilful application of de-escalation techniques and as a last resort, patient restraint, are vital to the safety and wellbeing of staff and patients. The findings from our previous research led four EDs across three sites to form a working party consisting of clinicians, educators, IT specialists, researchers, and security officers to design and implement a restructured approach to managing behavioural emergencies.

METHODS

This mixed methods study used surveys and interviews and the Theoretical Domains Framework (TDF) to evaluate the barriers and facilitators to implementing an intervention designed to manage behavioural emergencies. We collected 61 surveys and conducted 12 interviews with nurses, physicians and security staff.

RESULTS

The qualitative and quantitative data collected using the TDF pinpointed six facilitators and nine barriers for the implementation of the Code Black intervention. We were able to identify environmental, systemic and cultural factors that inhibited its implementation. Staff felt confident in their ability to apply the Code Black knowledge and skills and appreciative of efforts being made to improve safety. However, some remain unconvinced that behavioural change of staff will lead to safer outcomes.

CONCLUSION

The restructured approach is an effective containment of escalating aggression which ensures greater safety of patients and staff. However, the implementation of interventions in emergency care settings is complex. EDs have unique characteristics that influence sustainability and that need to be explored further to ensure the ongoing uptake of new practices. This paper demonstrates how to identify facilitators and barriers to change and provide evidence that may be used to drive implementation in the emergency care setting.

From triage to departure: Older adults' ED journey. A mixed methods study

BACKGROUND

Rising Emergency Department (ED) demand strains resources to assess and manage frail older adults. Allied health supports comprehensive care, disposition planning and patient safety in the ED but often intervenes late. This study investigated factors affecting allied health referrals and co-designed an early allied health frailty service.

METHODS

An explanatory sequential mixed-methods approach was used. Patient journey mapping of low acuity older ED patients was followed by stakeholder focus groups.

RESULTS

From triage, 20 older ED patients waited a mean of 110 minutes (SD 83 minutes) for doctor assessment, 123 minutes (SD 116 minutes) for an ED bed and 355 minutes (SD 297 minutes) for allied health assessment with a mean ED length of stay (LOS) of 685 minutes (SD 444 minutes). Qualitative analysis of focus group discussions identified perceived benefits of an early allied health service including shorter LOS, earlier disposition planning, increased staff confidence and streamlined decision making. Perceived barriers were lack of space, competing assessments with doctors and incomplete investigations. Perceived solutions were refining the inclusion criteria and staff education.

CONCLUSION

Allied health assessment occurred six hours post presentation, outside national targets. Opportunities and barriers identified supported the development of an earlier allied health frailty service.

Experience developing a pediatric medical chatbot in Singapore: a digital innovation for improved emergency care

This community case study explores the lessons learnt from the development of the Urgent Paediatric Advice Line (UPAL), a medical chatbot designed to address key challenges in pediatric healthcare, including emergency department (ED) overcrowding, health-seeking behavior, and health literacy. The chatbot was developed by pediatric specialists in collaboration with an AI-driven technology partner to provide caregivers with timely, accurate, and accessible guidance for managing pediatric health concerns. By helping parents assess the severity of their child's symptoms and navigate appropriate care pathways, UPAL aims to reduce unnecessary ED visits and improve health literacy. The development process employed an iterative, user-centered approach to refine the algorithm and enhance the user experience, with key challenges including balancing clinical reliability with user empathy. By offering evidence-based advice tailored to individual symptoms, UPAL empowers caregivers to make more informed decisions about their child's care. This case study highlights the potential of digital health solutions to empower caregivers, improve patient engagement, and increase healthcare access, particularly in pediatric settings. The study underscores the lessons for the field-namely the importance of interdisciplinary collaboration, continuous iterative development, patient-centered design, and active stakeholder engagement in creating effective digital health tools. Looking forward, future developments will include the incorporation of generative AI to provide more humanistic and personalized responses, as well as the creation of a post-discharge outreach module to provide proactive post-discharge support to caregivers, further enhancing healthcare delivery in a rapidly evolving digital landscape.

Interpretable machine learning models for prolonged Emergency Department wait time prediction

OBJECTIVE

Prolonged Emergency Department (ED) wait times lead to diminished healthcare quality. Utilizing machine learning (ML) to predict patient wait times could aid in ED operational management. Our aim is to perform a comprehensive analysis of ML models for ED wait time prediction, identify key feature importance and associations with prolonged wait times, and interpret prediction model clinical relevance among ED patients.

METHODS

This is a single-centered retrospective study. We included ED patients assigned an Emergency Severity Index (ESI) level of 3 at triage. Patient wait times were categorized as <30 minutes and ≥30 minutes (prolonged wait time). We employed five ML algorithms - cross-validation logistic regression (CVLR), random forest (RF), extreme gradient boosting (XGBoost), artificial neural network (ANN), and support vector machine (SVM) - for predicting patient prolonged wait times. Performance assessment utilized accuracy, recall, precision, F1 score, false positive rate (FPR), and false negative rate (FNR). Furthermore, using XGBoost as an example, model key features and partial dependency plots (PDP) of these key features were illustrated. Shapley additive explanations (SHAP) were employed to interpret model outputs. Additionally, a top key feature interaction analysis was conducted.

RESULTS

Among total 177,665 patients, nearly half of them (48.20%, 85,632) experienced prolonged ED wait times. Though all five ML models exhibited similar performance, minimizing FNR is associated with the most clinical relevance for wait time predictions. The top features influencing patient wait times and gaining the top ranked interactions were ED crowding condition and patient mode of arrival.

CONCLUSIONS

Nearly half of the patients experienced prolonged wait times in the ED. ML models demonstrated acceptable performance, particularly in minimizing FNR when predicting ED wait times. The prediction of prolonged wait times was influenced by multiple interacting factors. Proper application of ML models to clinical practice requires interpreting their predictions of prolonged wait times in the context of clinical significance.

Evaluating fairness of machine learning prediction of prolonged wait times in Emergency Department with Interpretable eXtreme gradient boosting

It is essential to evaluate performance and assess quality before applying artificial intelligence (AI) and machine learning (ML) models to clinical practice. This study utilized ML to predict patient wait times in the Emergency Department (ED), determine model performance accuracies, and conduct fairness evaluations to further assess ethnic disparities in using ML for wait time prediction among different patient populations in the ED. This retrospective observational study included adult patients (age ≥18 years) in the ED (n=173,856 visits) who were assigned an Emergency Severity Index (ESI) level of 3 at triage. Prolonged wait time was defined as waiting time ≥30 minutes. We employed extreme gradient boosting (XGBoost) for predicting prolonged wait times. Model performance was assessed with accuracy, recall, precision, F1 score, and false negative rate (FNR). To perform the global and local interpretation of feature importance, we utilized Shapley additive explanations (SHAP) to interpret the output from the XGBoost model. Fairness in ML models were evaluated across sensitive attributes (sex, race and ethnicity, and insurance status) at both subgroup and individual levels. We found that nearly half (48.43%, 84,195) of ED patient visits demonstrated prolonged ED wait times. XGBoost model exhibited moderate accuracy performance (AUROC=0.81). When fairness was evaluated with FNRs, unfairness existed across different sensitive attributes (male vs. female, Hispanic vs. Non-Hispanic White, and patients with insurances vs. without insurance). The predicted FNRs were lower among females, Hispanics, and patients without insurance compared to their counterparts. Therefore, XGBoost model demonstrated acceptable performance in predicting prolonged wait times in ED visits. However, disparities arise in predicting patients with different sex, race and ethnicity, and insurance status. To enhance the utility of ML model predictions in clinical practice, conducting performance assessments and fairness evaluations are crucial.

Predicting Inpatient Admissions From Emergency Department Triage Using Machine Learning: A Systematic Review

This study aimed to evaluate the quality of evidence for using machine learning models to predict inpatient admissions from emergency department triage data, ultimately aiming to improve patient flow management. A comprehensive literature search was conducted according to the PRISMA guidelines across 5 databases, PubMed, Embase, Web of Science, Scopus, and CINAHL, on August 1, 2024, for English-language studies published between August 1, 2014, and August 1, 2024. This yielded 700 articles, of which 66 were screened in full, and 31 met the inclusion and exclusion criteria. Model quality was assessed using the PROBAST appraisal tool and a modified TRIPOD+AI framework, alongside reported model performance metrics. Seven studies demonstrated rigorous methodology and promising in silico performance, with an area under the receiver operating characteristic ranging from 0.81 to 0.93. However, further performance analysis was limited by heterogeneity in model development and an unclear-to-high risk of bias and applicability concerns in the remaining 24 articles, as evaluated by the PROBAST tool. The current literature demonstrates a good degree of in silico accuracy in predicting inpatient admission from triage data alone. Future research should emphasize transparent model development and reporting, temporal validation, concept drift analysis, exploration of emerging artificial intelligence techniques, and analysis of real-world patient flow metrics to comprehensively assess the usefulness of these models.

Using In Situ Simulation to Identify Latent Safety Threats Prior to the Opening of Novel Patient Care Spaces in the Emergency Department

BACKGROUND

In the era of extreme emergency department (ED) boarding, hospital systems are using novel patient care areas to provide ongoing acute care. In any new patient care environment, there is a high risk for latent safety threats (LSTs), which can negatively affect patient outcomes. A series of in situ systems-based simulations were conducted to identify potential LSTs prior to the opening of a novel mobile care unit (MCU) in a tertiary hospital.

METHODS

After a needs assessment in conjunction with institutional leadership, a series of in situ interprofessional simulation sessions were developed to represent realistic scenarios in the MCUs. Simulations included low-frequency high-acuity patient care scenarios as well as high-frequency day-to-day encounters. Data were collected in structured systems-based debriefing sessions via trained observers, video recordings, and participant surveys, with a primary outcome of identifying potential LSTs. The LSTs were categorized and then stratified using the Survey Analysis for Evaluating Risk (SAFER) Matrix. One simulation was repeated after mitigation strategies were employed by institutional leadership.

RESULTS

A total of 117 staff participated in five simulation sessions. In the first round of simulations, 37 LSTs were identified, primarily in the categories of Environment/Wayfinding (13/37, 35.1%) and Communication (6/37, 16.2%). LSTs risk stratified using the SAFER Matrix provided prioritized feedback for hospital leadership to guide mitigation strategies prior to the opening of the new units. One LST was initially classified as high likelihood to harm on the SAFER Matrix. The simulated scenario involving this LST was repeated two weeks later with no further high-risk LSTs identified.

CONCLUSION

In situ simulations can serve as an effective tool to identify potential LSTs prior to the opening of novel patient care spaces.

When tomorrow comes too late-the silent threat: why people delay needed medical care in Türkiye

BACKGROUND

Healthcare demand procrastination is a public health concern in Türkiye, with limited research available. This study examines the prevalence of healthcare procrastination and identifies associated factors among patients at Pamukkale University Hospital.

METHODS

This cross-sectional study was conducted from 2 to 13 February 2023 in Denizli and involved 503 patients from 15 outpatient clinics. Data on sociodemographic characteristics, healthcare utilization and procrastination behaviors were collected via a structured questionnaire, including the Healthcare Demand Procrastination Scale (HDPS). Descriptive statistics and linear regression were used for analysis.

RESULTS

The participants had a mean age of 41.46 years (±15.34), with 52.9% being female. A significant 77.3% reported delaying healthcare despite needing it. The primary reasons for delays were difficulty in getting appointments (51.5%), long waiting times (21.9%) and COVID-19 concerns (19.9%). The mean HDPS score was 2.29 ± 0.65, indicating moderate procrastination. Regression analysis revealed that younger age (≤35 years) and rural residence significantly predicted higher HDPS scores, whereas receiving health information from professionals was linked to lower procrastination.

CONCLUSIONS

Healthcare procrastination is common among patients in Türkiye, particularly among younger individuals and rural residents. Improving healthcare accessibility, reducing wait times and implementing targeted interventions are essential to mitigate this issue and enhance health outcomes.

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.

Effects of emergency department length of stay on inpatient utilization and mortality

INTRODUCTION

The annual increase in emergency department (ED) visits in Taiwan has led to overcrowding in major hospitals and extended patient stays in the ED. International studies suggest that prolonged ED stays may influence healthcare costs and clinical outcomes for hospitalized patients. However, such investigations are scarce in Taiwan. This study aims to explore the effects of ED stay duration on inpatient medical utilization and mortality risk.

METHODS

This study analyzed data from 42,139 patients at a central Taiwan medical center, using generalized estimating equations (GEE) to evaluate hospital stay duration and costs. Logistic regression assessed mortality risks after hospitalization.

RESULTS

GEE analysis showed longer ED stays led to increased hospital stays: patients with 24-48 h in the ED had an additional 2.27 days (P < 0.001), and those with ≥ 48 h had an additional 3.22 days (P < 0.001). Logistic regression indicated higher mortality risks for patients with 24-48 h (OR = 1.73, P < 0.001) and ≥ 48 h (OR = 2.23, P < 0.001) in the ED compared to those with ≤ 2 h. Conversely, longer ED stays were associated with lower hospitalization costs; patients with ≥ 48 h in the ED incurred $1,211 less in costs compared to those with ≤ 2 h (P < 0.001). Logistic regression revealed that longer ED stays were linked to higher mortality risks, with patients staying 24-48 h in the ED showing an OR of 1.726 (P < 0.001) and those with ≥ 48 h an OR of 2.225 (P < 0.001).

CONCLUSION

Prolonged ED stays are associated with longer hospital stays, higher mortality risks, and lower hospitalization costs due to resource consumption in the ED. These findings highlight the need for strategies to reduce ED stay durations to improve patient outcomes and optimize resource use.

Effects of a Virtual Trauma Clinic on admissions and length of stay for minor to moderate trauma

OBJECTIVE

To investigate the feasibility of a Virtual Trauma Clinic (VTC) for patients with minor to moderate trauma, and evaluate patient satisfaction and outcomes.

METHODS

One hundred VTC patients were matched 1:1 with historical patients from the hospital trauma registry who received conventional care. Matching was based on age ± 5 years, sex, mechanism of injury, Injury Severity Score ± 2, trauma team activation and day of week of presentation. VTC patients were sent surveys on experience and outcome measures.

RESULTS

VTC was associated with reduced average hospital length of stay for admitted patients by 1.81 days (95% CI = -2.82, -0.79; P = 0.001) and reduced hospital admissions (odds ratio 0.26; 95% CI = 0.14, 0.48; P < 0.001). There was an avoidance of 199 inpatient bed days in total, with no trauma-related readmissions within 30 days post-hospital discharge. 92% of respondents (n = 22) rated the care they received from VTC as excellent or good. Patient-reported outcome surveys showed overall improvement in functional domains but evidence of ongoing disability, with persistent issues of pain and psychological distress at 1 month post-injury.

CONCLUSION

Patients with minor to moderate trauma have ongoing care needs with high rates of pain, psychological distress and disability remaining prevalent long after discharge. VTC provided an innovative strategy for hospital avoidance with high levels of patient satisfaction and no adverse effects on safety. The overall quality of care for these patients was enhanced through the provision of standardised, patient-centred and multidisciplinary follow-up.

Case management in emergency care: impact evaluation of the CARED Program

BACKGROUND

Hospitals face mounting pressure to reduce unplanned utilization amid rising healthcare demands from an aging population. The Case management for At-Risk patients in the Emergency Department (CARED) program is among the first ED transitional care strategies to focus on both frail older adults and emergency department (ED) re-attenders to reduce acute hospital utilization. This study aims to evaluate the effectiveness of the CARED program in reducing hospital (re)admissions and ED re-attendances within 30- and 60 days post-discharge.

METHODS

A retrospective, propensity-matched study was conducted from April 2022 to July 2023 in the ED of Ng Teng Fong General Hospital in Singapore. The CARED program identifies and enrols at-risk patients, i.e. frail older adults and patients who re-attend the ED within 30 days of hospital discharge, for a geriatric assessment. This is followed by multidisciplinary team care, discharge planning and right siting of care from the ED to community-based services by ED case managers. The primary outcomes were hospital (re)admissions and ED re-attendances within 30- and 60 days post-discharge. Secondary outcomes were cost avoidance and bed occupancy days from reduced acute hospital usage.

RESULTS

Nearest-neighbour 1:1 propensity score matching matched 1615 intervention group to 1615 control group. Baseline characteristics of the intervention and control groups did not differ significantly. Difference-in-differences (DID) analyses showed significantly lower 30-day (3.96%; 95% CI 2.71-5.23%) and 60-day (6.69%; 95% CI 5.47-7.91%) hospital admissions, as well as 30-day (4.89%; 95% CI 3.83-5.95%) and 60-day (6.50%; 95% CI 5.28-7.72%) ED re-attendances in the intervention group compared to the control group. Additionally, the reduced admission and ED re-attendance rates resulted in 30-day and 60-day inpatient admission costs avoidance [$1 553 548.96 (69.86%); 95% CI $1 525 827.76 to $1 581 270.15; P = .006; and $1 400 047.07 (32.56%); 95% CI $1 365 484.79 to $1434 609.37; P = .048, respectively], ED attendance costs avoidance [$25 849.92 (23.70%); 95% CI $25 091.93 to $26 607.89; P = .096; and $37 538.39 (18.09%); 95% CI $36 470.27 to $38 606.53; P = .086, respectively] and bed occupancy days saved (1212 days; 95% CI 1191.80 days to 1232.20 days; P = .003; and 1267 days; 95% CI 1242.58 days to 1291.42 days; P = .011, respectively).

CONCLUSION

CARED program effectively reduced unplanned hospital use within 30- and 60 days post-ED discharge for at-risk patients. It also significantly lowered inpatient admission and ED attendance costs and hospital bed occupancy days, highlighting its potential to improve patient outcomes and reduce healthcare expenses.

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.

Disposition of emergency department patients presenting with angiotensin-converting enzyme inhibitor-induced angioedema

BACKGROUND

Angiotensin-converting enzyme inhibitors (ACEI) are the most common cause of drug-induced angioedema in the United States. Our primary objective was to provide descriptive evidence regarding emergency department (ED) disposition of ACEI-induced angioedema patients. Our secondary objective was to evaluate unique patterns in those with ACEI-induced angioedema at a tertiary referral center, including demographics, details of those requiring intubation, length of inpatient stay, and allergy documentation.

METHODS

This was a retrospective study evaluating all cases of ACEI-induced angioedema at a large, regional academic medical center. We performed a medical record review to identify patients with ACEI-induced angioedema who presented to the ED from January 1, 2016, to December 31, 2022. A structured data abstraction process was utilized to select patients of interest, followed by descriptive statistics, chi-square tests and odds ratios for categorical data, and Kruskal Wallis tests for continuous data.

RESULTS

A total of 637 unique patient encounters met potential inclusion. After a substantial, standardized review, 94 patients met inclusion. During the study period, there were 94 patients presenting to the ED who were diagnosed as having angioedema secondary to an ACEI (90 patients) or angiotensin receptor blocker (ARB) (4 patients). Overall, 53 patients (56.38%) improved during their ED stay, and of those, 32 patients (60.38%) were discharged home. None of the 12 patients that worsened were sent home from the ED. Those who were discharged from the ED with a median stay of 4 h had no increased risk of return to the ED versus those who were admitted. The only treatment found to have statistical association with disposition was intramuscular epinephrine. Only 13 of 43 ED discharged patients (23.64%) had their ACEI/ARB documented in their allergy listings compared to 42 of 51 patients (76.36%) of admitted patients, odds ratio of failure to document was 0.0929 (95% CI, 0.0352 to 0.24512). Only one patient out of the total 94 returned to the ED due to recurrent angioedema symptoms during our study period and was subsequently discharged.

CONCLUSION

Our results indicated that at a large, tertiary care referral center, patients with ACEI-angioedema who did not exhibit severe symptoms were safely discharged home with low risk of early return visit to the ED. Severe symptoms were found to be any throat symptoms, voice change, drooling, worsening swelling, or complaints of dyspnea. Further, among those admitted, patients in our study had a short inpatient stay and were safely discharged with no documented early return visit to the ED.

Modulating patient output: rethinking the role of EM in the healthcare system

Overcrowding has become a significant issue in Emergency departments (EDs) around the world. Overcrowding contributes to a chaotic, unsafe and disorganized environment, increasing the burden on healthcare teams, and has led to deteriorating working conditions, with subsequent higher rates of burnout. This review aims to discuss different solutions to improve the process of patient discharge from the ED, either to an inpatient unit, another hospital, or to an outpatient setting, and the impact this component of patient flow can have on physician well being. The solutions presented in this paper have been chosen for their translatability to any setting, regardless of their geographical location.

The Integration of Nurse Practitioners Into Mass Gathering Medical Teams

Mass gathering events can greatly impact overburdened emergency medical service systems and emergency departments, which frequently experience staffing shortages and overcrowding. Nurse practitioners (NPs) were introduced into an event medicine team at mass gatherings to reduce emergency transports to local emergency departments as well as offering a "treat and release" disposition for patients presenting to medical tents. This study aimed to examine the impact of NPs at mass gathering events; 147 chart reviews were performed from 05/01/2023 to 09/30/2023 for all patients assessed by an NP at events staffed by an event medicine team; 60% of patients assessed by an NP were treated and released from the event, potentially reducing the number of patient transports and emergency department visits considerably. NPs can provide higher levels of care at events, treating common complaints such as heat-related illness, nausea, vomiting, minor trauma, and laceration repairs. Although this study did not compare data from events where NPs were not present versus when they were utilized to grasp the statistical impact their presence has had since their introduction to the team model, the study clearly shows the benefits NPs bring to mass gathering medical care. This is significant for emergency NPs as this research validates the need to include these providers in this new setting and role in which they can practice. More research is needed to compare patient outcomes with and without NPs present.

Hospitalization prediction from the emergency department using computer vision AI with short patient video clips

In this study, we investigate the performance of computer vision AI algorithms in predicting patient disposition from the emergency department (ED) using short video clips. Clinicians often use "eye-balling" or clinical gestalt to aid in triage, based on brief observations. We hypothesize that AI can similarly use patient appearance for disposition prediction. Data were collected from adult patients at an academic ED, with mobile phone videos capturing patients performing simple tasks. Our AI algorithm, using video alone, showed better performance in predicting hospital admissions (AUROC = 0.693 [95% CI 0.689, 0.696]) compared to models using triage clinical data (AUROC = 0.678 [95% CI 0.668, 0.687]). Combining video and triage data achieved the highest predictive performance (AUROC = 0.714 [95% CI 0.709, 0.719]). This study demonstrates the potential of video AI algorithms to support ED triage and alleviate healthcare capacity strains during periods of high demand.

Association of prolonged emergency department length of stay and venous thrombo-embolism prophylaxis and outcomes in trauma: A nation-wide secondary analysis

INTRODUCTION

The impact of prolonged emergency department length of stay (EDLOS) on appropriately timed pharmacological venous thromboembolism prophylaxis (VTEp) and VTE outcomes is unknown in trauma.

METHODS

Retrospective cohort study of adult patients admitted to civilian trauma centers participating in the American College of Surgeons' TQIP (2019-2021). Patients with severe solid organ, head, or spine injury, early hemorrhage control intervention, pre-existing home anticoagulation or bleeding disorder, inter-facility transfer or early discharge, and injury severity score ≤9 were excluded. Primary exposure was prolonged EDLOS ≥12 h from ED arrival to physical transfer to the wards. Primary outcome was time to first pharmacological VTEp, censored at 24 and 48 h.

RESULTS

A total of 191,031 patients were included, 3,827 remained in the ED ≥12 h. The median time to VTEp was 25 h (IQR 12-43). Prolonged EDLOS was associated with a 34 % and 21 % decrease in timely administration of VTEp at 24 (aHR 0.66, 95 % CI 0.61-0.72, P < 0.001) and 48 h (aHR 0.79, 95 % CI 0.74-0.84, P < 0.001), respectively. After propensity score matching, associations persisted at 24 (aHR 0.69, 95 % CI 0.61-0.77, P < 0.001) and 48 h (aHR 0.80, 95 % CI 0.74-0.86, P < 0.001). Absent VTEp by 24 h was associated with increased VTE odds (aOR 1.84, 95 % CI 1.62-2.08, P < 0.001).

CONCLUSION

Prolonged EDLOS delayed pharmacological VTEp in a nation-wide cohort of trauma patients. Absent VTEp, consequently, increased risk of in-hospital VTE, although future study is needed to validate these findings. Timely transfer of stable trauma patients to the floor may improve outcomes by facilitating appropriately timed VTEp administration and decreasing ED overcrowding.

Effects of opening a vertical care area on emergency medicine resident clinical experience

Background

Challenging clinical environments faced by emergency departments (EDs) have led to operational changes including implementation of vertical care units and fast-track units. Little is known regarding the impact of such units on resident physician clinical education.

Methods

A retrospective, observational study was performed at an urban quaternary care ED evaluating the effect of opening a vertical care unit with a triage physician directing lower acuity patients to be seen by physician associates (PAs)/advanced practice registered nurses (APRNs) on the following parameters: (1) percentage of patients seen by residents, (2) Emergency Severity Index (ESI) of patients seen by residents, (3) number of procedures performed by residents, (4) number of patients per shift seen by residents, (5) percentage of critical care patients seen by residents, and (6) percentage of behavioral health patients seen by residents.

Results

Comparing the implementation of the vertical care unit to the prior 3 months, postgraduate year (PGY)-1 residents had greater exposure to ESI Levels 1 and 2 (odds ratio [OR] 2.15) and more critical care (OR 2.58). PGY-2 and PGY-3 residents had a lower exposure to ESI 1 and 2 patients (PGY-2 OR 0.63, PGY-3 OR 0.61) and less critical care exposure (OR 0.64 for PGY-2 and OR 0.62 for PGY-3) after implementation. PGY-1 residents saw fewer behavioral health patients (OR 0.65) while the other two classes saw more (PGY-2 OR 1.64, PGY-3 OR 2.74). ESI 4 and 5 exposure decreased for all classes (PGY-1 OR 0.15, PGY-2 OR 0.86, PGY-3 OR 0.72). No significant difference was found in the proportion of patients treated by residents (p = 0.85) or the number of procedures performed by residents (p = 0.25) comparing the implementation of a vertical care unit to the prior 3 months.

Conclusions

This study suggests no detrimental effects of vertical care unit implementation on multiple resident education outcomes including the number and acuity level of patients seen as well as procedure numbers of resident trainees. While the outcomes measured did not show significant negative effect for the resident compliment as a whole, we noted changes to the distribution of patient acuity based on PGY level. Similar assessments are recommended to determine the educational impact of comparable operational changes in other EDs.

Elderly patients re-transferred from long-term care hospitals to emergency departments within 48 h

BACKGROUND & OBJECTIVES

The increasing proportion of elderly populations has led to a rise in chronic diseases and frequent transfers between long-term care hospitals (LTCHs) and emergency departments (EDs). This study investigates the patterns of risk factors of initial-transfers and subsequent re-transfers among patients aged 65 or older. Specifically, we focus on those re-transferred from LTCHs to EDs within 48 h of discharge, often without adequate treatment.

METHOD

This nationwide cross-sectional study used data from South Korea's National Emergency Department Information System (NEDIS) from January 1, 2017, to December 31, 2019. Patients aged 65 or older who were initially transferred from LTCHs to EDs and re-transferred within 48 h, were identified. Logistic regression was employed to analyze risk factors associated with re-transfers.

RESULTS

140,282 elderly patients were identified as having been transferred from LTCHs to EDs. Of these, 38,180 patients received emergency care in the EDs and were discharged back to LTCHs. Among them, 679 patients were returned to LTCHs after receiving acute treatment but revisited the EDs within 48 h. Hospital ward admission rates were higher for re-transferred patients (71.3%) compared to initial transfers (42.1%, p < 0.0001). Risk factors for re-transfer included male, nighttime admissions, and longer ED stays (> 6 h). Tertiary hospitals showed higher re-transfer rates to other facilities (13.1%) than general hospitals (2.9%).

CONCLUSION

This study reveals that many health outcomes worsen upon re-transfer compared to the initial-transfer. These findings underscore the need for a coordinated healthcare system that ensures elderly patients from long-term care facilities are initially sent to appropriate hospitals during the initial transfer, which could mitigate repeated ED visits and ensure timely care.

Caregiver Perspectives and Preferences Regarding Timely Access to Unscheduled Acute Care in Paediatric Urgent Care Centers: A Qualitative Evaluation of Save My Spot Tool

AIM

Explore caregiver (i.e., person who provides direct care for a child and was present at the time of their medical visit) perspectives and preferences regarding timely access to unscheduled acute care as well as barriers and facilitators of the use of an online appointment tool (i.e., Save My Spot) in a satellite children's hospital five urgent care centers in the United States.

DESIGN

A descriptive qualitative interview study.

METHODS

We conducted semi-structured interviews with 49 caregivers in a private room, in person and in conjunction with medical visits from June 2023 to the end of August 2023 after obtaining institutional ethical approvals. We employed deductive and inductive content analysis and used the MAXQDA data analysis tool.

RESULTS

Average caregiver age was 37 years. Most of the caregivers were female, white, and non-Hispanic and had low income. We identified three categories: (a) Caregiver preferences for using the Save My Spot online appointment tool and their reasons for buy-in, (b) ways of promoting the Save My Spot tool and (c) enhancing the accessibility of the Save My Spot tool.

CONCLUSION

The findings of this study suggest that when introduced successfully, caregivers adopt an online appointment tool and find it efficient in minimising wait times. Various approaches (e.g., social media, billboards) can be used to promote the tool to increase timely access to care.

IMPACT

This study provides valuable insights into the utilisation of an online appointment tool in the two hospital-based and three stand-alone neighbourhood urgent care centers of a large urban children's hospital. Future studies capturing different tools and populations are recommended to gain diverse understanding.

REPORTING METHODS

The study was reported following the Standards for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

Caregivers provided their perspectives and the Paediatric Emergency Medicine Disparities Working Group contributed to the interpretation of the study findings.

Improving Quality of Care for Vacation-Related Emergency Department Visits: A Narrative Review of Patient Satisfaction and Contributing Factors

Emergency departments (EDs) encounter substantial challenges during peak vacation periods, including increased patient volumes, limited access to medical histories, language and cultural barriers, insurance complexities, and disruptions in continuity of care. These factors strain emergency department operations, resulting in prolonged wait times, diagnostic errors, and compromised care quality. This study reviews the literature to identify patient satisfaction indicators and common challenges and evaluate strategies to improve patient outcomes during vacation-related emergency department visits. Findings highlight critical issues in staffing and resource allocation, leading to delayed care. Limited interoperability of electronic health records (EHRs) often prevents access to essential patient information, increasing diagnostic errors and unnecessary repeat testing. Language and cultural barriers contribute to higher rates of misdiagnosis and lower patient satisfaction, while insurance and payment issues create delays, particularly for out-of-network or international patients. Effective strategies to address these challenges include the use of predictive analytics for better forecasting of patient volumes, specialized triage protocols, public health education campaigns, and telemedicine for remote management of non-critical conditions. These interventions help reduce wait times, optimize resource allocation, and improve patient satisfaction. By implementing adaptive approaches, such as flexible staffing models and enhanced electronic health record use, healthcare systems can significantly improve care delivery and patient outcomes during vacation seasons.

Emergency department visit frequency and health care costs following implementation of an integrated practice unit for frequent utilizers

OBJECTIVES

The integrated practice unit (IPU) aims to improve care for patients with complex medical and social needs through care coordination, medication reconciliation, and connection to community resources. This study examined the effects of IPU enrollment on emergency department (ED) utilization and health care costs among frequent ED utilizers with complex needs.

METHODS

We extracted electronic health records (EHR) data from patients in a large health care system who had at least four distinct ED visits within any 6-month period between March 1, 2018, and May 30, 2021. Interrupted time series (ITS) analyses were performed to evaluate the impact of IPU enrollment on monthly ED visits and health care costs. A control group was matched to IPU patients using a propensity score at a 3:1 ratio.

RESULTS

We analyzed EHRs of 775 IPU patients with a control group of 2325 patients (mean [±SD] age 43.6 [±17]; 45.8% female; 50.9% White, 42.3% Black). In the single ITS analysis, IPU enrollment was associated with a decrease of 0.24 ED visits (p < 0.001) and a cost reduction of $466.37 (p = 0.040) in the first month, followed by decreases of 0.11 ED visits (p < 0.001) and $417.61 in costs (p < 0.001) each month over the subsequent year. Our main results showed that, compared to the matched control group, IPU patients experienced 0.20 more ED visits (p < 0.001) after their fourth ED visit within 6 months, offset by a reduction of 0.02 visits (p < 0.001) each month over the next year. No significant immediate or sustained increase in costs was observed for IPU-enrolled patients compared to the control group.

CONCLUSIONS

This quasi-experimental study of frequent ED utilizers demonstrated an initial increase in ED visits following IPU enrollment, followed by a reduction in ED utilization over subsequent 12 months without increasing costs, supporting IPU's effectiveness in managing patients with complex needs and limited access to care.

Workload of home care nurses: Italian adaptation, validity, and reliability of the National Aeronautics and Space Administration Task Load Index questionnaire

The aim of this study was to adapt the National Aeronautics and Space Administration Task Load Index (NASA-TLX) to the home care setting and translate and validate it in Italian. An online questionnaire containing the Italian version of the NASA-TLX adapted to the home care setting was administered to home care nurses to measure workload. Content Validity Index, Exploratory, and Confirmatory Factor Analyses were used to measure the psychometric characteristics of the modified NASA-TLX. The modified Italian version of NASA-TLX_HC-IT showed good psychometric characteristics in measuring the workload of home care nurses, with excellent fit indices. The reliability, calculated with Cronbach's alpha, was 0.73, indicating adequate reliability. A negative correlation between workload and job satisfaction among home care nurses, as well as a positive association between high workload and intention to leave the workplace, was verified. The modified Italian version of the NASA-TLX_HC-IT was confirmed to be a valid and reliable instrument to measure workload in home care nursing. Furthermore, the correlation between workload and the intention to leave the workplace among home care nurses was an important result that community nursing managers should consider preventing the shortage of home care nurses.

Characterizing a Common Phenomenon: Why do Trauma Patients Re-present to the Emergency Department?

INTRODUCTION

Trauma patients return to the emergency department (ED) at alarmingly high rates, despite not all patients requiring hospital resources. Reasons for ED re-presentation and associated risk factors have not been fully investigated.

METHODS

Retrospective cohort study of adult trauma admissions at an urban safety net level 1 trauma center (1/12018-12/312021). Risk factors for ED re-presentation were identified using purposeful selection and modeled using multivariable logistic regression.

RESULTS

Of 2491 patients, 19% returned within 30 d (N = 475). Most patients presented for uncontrolled pain (37%, N = 175), medical concerns (25%, N = 119), and infection (10%, N = 49). The readmission rates varied as follows: 18% for uncontrolled pain (N = 32), 42% for medical concerns (N = 50), and 67% for infection (N = 33). Risk factors for uncontrolled pain included depression/anxiety (adjusted odds ratio [aOR] 2.06, 95% confidence interval [CI] 1.39-3.05), substance use disorder (SUD) (aOR 1.65, 95% CI 1.12-2.43), and penetrating mechanism of injury (aOR 2.25, 95% CI 1.59-3.18). Risk factors for medical concerns included number of medical comorbidities (aOR 1.34, 95% CI 1.18-1.52), depression/anxiety (aOR 1.97, 95% CI 1.28-3.01), SUD (aOR 2.48, 95% CI 1.65-3.74), and nonhome discharge disposition (aOR 1.56, 95% CI 1.07-2.28). Risk factors for infection included non-English primary language (aOR 3.41, 95% CI 1.82-6.39), SUD (aOR 2.00, 95% CI 1.03-3.88), and nonhome discharge disposition (aOR 2.06, 95% CI 1.15-3.67).

CONCLUSIONS

Uncontrolled pain was the most common reason for re-presentation, although only a small fraction required readmission. Patients with penetrating injury may benefit from improved pain control. Primary care provider follow-up may help mitigate risk of medical disease exacerbation, and wound care instructions for non-English speaking patients may decrease re-presentation for infection.

How Healthcare Providers Decide on a Referral Location in Telephone Triage: A Cross-sectional Study

BACKGROUND

Approximately 25% of patients that present to the emergency department (ED) do so after contact with a healthcare professional. Many of these patients could be effectively managed in non-ED ambulatory settings. Aligning patients with safe and appropriate outpatient care has the potential to improve ED overcrowding, patient experience, outcomes, and costs. Little is understood about how healthcare providers approach triage decision-making and what factors influence their choices.

OBJECTIVES

To evaluate how providers think about patient triage, and what factors influence their decision-making when triaging patient calls.

DESIGN

Cross-sectional survey-based study in which participants make triage decisions for hypothetical clinical scenarios.

PARTICIPANTS

Healthcare providers in the specialties of internal medicine, family medicine, or emergency medicine within a large integrated healthcare system in the Southeast.

MAIN MEASURES

Differences in individual training and practice characteristics were used to compare observed differences in triage outcomes. Free-response data were evaluated to identify themes and factors affecting triage decisions.

KEY RESULTS

Out of 72 total participants, substantial variability in triage decision-making was observed among all patient cases. Attending physicians triaged 1.4 fewer cases to ED care compared with resident physicians (p < 0.001, 95% CI 0.62-2.1). Academic attendings demonstrated a trend toward fewer cases to ED care compared with community attendings (0.61, p = 0.188, 95% CI - 0.31-1.5). Qualitative data highlighted the complex considerations in provider triage and led to the development of a novel conceptual model to describe the cognitive triage process and the main influencing factors.

CONCLUSIONS

Triage decision-making for healthcare providers is influenced by many factors related to clinical resources, care coordination, patient factors, and clinician factors. The complex considerations involved yield variability in triage decisions that is largely unexplained by descriptive physician factors.

Nurses' Perception on the Hindrances of Triage System in Emergency Unit

Background: Despite the fact that several triage tools have been implemented globally, emergency care, including the triage system, is often one of the weakest parts of the health system in developing countries, as compared to developed countries. Moreover, emergency centers in African countries are very busy, often flooded by high load of trauma patients, chronic medical conditions, acute medical emergencies, and HIV-related conditions. These disease conditions precipitate the reasons for the prioritization of patients. In South Africa, studies conducted on the use of triage by nurses revealed that most patients are satisfied with the Nurse-led triage service provided in emergency departments (EDs). At the same time, some Nurses also see the South African Triage Scale (SATS) as one of the easiest Nurse-led triage tools. Aim: The study aimed at identifying the factors hindering the effective process of triage during care provision at a selected public hospital in KwaZulu-Natal (KZN). Methods: This study utilized a cross-sectional survey, employing a nonprobability convenience sampling to recruit its respondents. The recognition primed decision model formed the framework of the study. Ethical clearance was obtained from the University of KwaZulu-Natal Ethics Review Board, and ethics principles were carefully observed throughout the study. Results: Out of the 100 respondents, 89% (89) of the respondents perceived that various factors still impede the progress of triage, while 11% (11) of the respondents perceived that no factor impedes the progress of triage. Conclusion: The study indicates that several factors still hinder the effective process of triage. Based on the findings of the study, factors like overcrowding, Nurses waiting for doctors when they know what to do, lack of continuous professional development on triage system, inadequate experience, lack of confidence, and lack of adequate training on triage still impede the efficient triage system.

The Impact of International Classification of Disease-Triggered Prescription Support on Telemedicine: Observational Analysis of Efficiency and Guideline Adherence

BACKGROUND

Integrating decision support systems into telemedicine may optimize consultation efficiency and adherence to clinical guidelines; however, the extent of such effects remains underexplored.

OBJECTIVE

This study aims to evaluate the use of ICD (International Classification of Disease)-coded prescription decision support systems (PDSSs) and the effects of these systems on consultation duration and guideline adherence during telemedicine encounters.

METHODS

In this retrospective, single-center, observational study conducted from October 2021 to March 2022, adult patients who sought urgent digital care via direct-to-consumer video consultations were included. Physicians had access to current guidelines and could use an ICD-triggered PDSS (which was introduced in January 2022 after a preliminary test in the preceding month) for 26 guideline-based conditions. This study analyzed the impact of implementing automated prescription systems and compared these systems to manual prescription processes in terms of consultation duration and guideline adherence.

RESULTS

This study included 10,485 telemedicine encounters involving 9644 patients, with 12,346 prescriptions issued by 290 physicians. Automated prescriptions were used in 5022 (40.67%) of the consultations following system integration. Before introducing decision support, 4497 (36.42%) prescriptions were issued, which increased to 7849 (63.57%) postimplementation. The physician's average consultation time decreased significantly to 9.5 (SD 5.5) minutes from 11.2 (SD 5.9) minutes after PDSS implementation (P<.001). Of the 12,346 prescriptions, 8683 (70.34%) were aligned with disease-specific international guidelines tailored for telemedicine encounters. Primary medication adherence in accordance with existing guidelines was significantly greater in the decision support group than in the manual group (n=4697, 93.53% vs n=1389, 49.14%; P<.001).

CONCLUSIONS

Most of the physicians adopted the PDSS, and the results demonstrated the use of the ICD-code system in reducing consultation times and increasing guideline adherence. These systems appear to be valuable for enhancing the efficiency and quality of telemedicine consultations by supporting evidence-based clinical decision-making.

Elevated high-sensitive cardiac troponin T in emergency department patients: insights from a retrospective descriptive cohort study

BACKGROUND

High-sensitive cardiac troponin T (hs-cTnT) assessments are routinely conducted in German emergency departments (EDs). However, data describing a large number of ED patients with pathological hs-cTnT levels and subsequent clinical outcomes are limited.

METHODS

This retrospective descriptive analysis included 141.892 patients who presented to the interdisciplinary ED at Klinikum rechts der Isar in Munich, Germany, between January 2019 and December 2021. Patients with trauma diagnoses were excluded, focusing on those with elevated hs-cTnT levels. These patients were categorized into three groups based on the International Classification of Procedures in Medicine (ICPM): those with elevated hs-cTnT who received no coronary angiography (NCA), those who underwent diagnostic coronary angiography (DCA), and those who received percutaneous coronary intervention (PCI). The objective of this study was to characterize a large emergency department patient cohort and assess their subsequent clinical outcomes.

RESULTS

After initial Manchester Triage Sytem (MTS) categorization, 32.6% (46.307/141.892) of patients were identified as non-trauma cases. Of these, 9.9% (4.587/46.307) had hs-cTnT levels exceeding 14 ng/L. Within this subset, 70.4% (3.230/4.587) did not undergo coronary angiography, 15.4% (705/4.587) underwent DCA and 14.2% (652/4.587) received PCI. Chest pain occurred more frequently in the PCI group (28.0%, 160/652) compared to the DCA group (18.3%, 113/705) or NCA group (5.7%, 159/3230), p < 0.001. However, breathing problems occurred more frequently in the NCA group (23.2%, 647/3230) compared to the PCI group (17.7%, 101/652) or DCA group (21.8%, 135/705), p < 0.001. Also, collapse was more frequent in patients in the NCA group (4.0%, 112/3230) compared to the DCA group (3.4%, 21/705) or PCI group (3.5%, 20/652), p < 0.001. Overall, in-hospital mortality was significantly higher in the NCA group (7.9%, 256/3230) compared to the DCA group (2.3%, 16/705) or PCI group (4.1%, 27/652), p < 0.001.

CONCLUSION

Emergency patients with elevated hs-cTnT who did not undergo coronary angiography faced a higher risk of in-hospital mortality in our retrospective descriptive study. Given the heterogeneous nature of presenting complaints in emergency departments, identifying at-risk patients can pose challenges for treating physicians.

Experiences of individuals presenting to the emergency department for mental health reasons: A systematic mixed studies review

OBJECTIVE

Emergency departments the world over have seen substantial increases in the number of individuals presenting for mental health reasons. However, we have a limited understanding of their experiences of care. The aim of this review was to systematically examine and synthesise literature relating to the experiences of individuals presenting to emergency department for mental health reasons.

METHODS

We followed Pluye and Hong's seven-step approach to conducting a systematic mixed studies review. Studies were included if they investigated adult mental health experiences in emergency department from the users' perspective. Studies describing proxy, carer/family or care provider experiences were excluded.

RESULTS

Sixteen studies were included. Thematic synthesis identified three themes and associated subthemes. Theme 1 - ED staff can make-or-break and ED experience - comprised: Feeling understood and heard; Engaging in judgement-free interactions; Receiving therapeutic support; Being actively and passively invalidated for presenting to the ED; and Once a psych patient, always a psych patient. Theme 2 - Being in the ED environment is counter-therapeutic - comprised: Waiting for an 'extremely' long time; and Lacking privacy. Theme 3 was Having nowhere else to go.

CONCLUSIONS

The experiences described by individuals presenting to emergency department for mental health reasons were mostly poor. The results illustrate a need for increased mental health education and training for all emergency department staff. Employment of specialist and lived experience workers should also be prioritised to support more therapeutic relationships and emergency department environments. In addition, greater investment in mental health systems is required to manage the current crisis and ensure future sustainability.

An open-access dataset of emergency department admissions at a large teaching hospital in Iran

In recent years, the use of electronic health records (EHRs) has become increasingly prevalent in healthcare settings, including emergency departments (EDs). EHRs offer numerous advantages, such as improved documentation, streamlined communication, and enhanced patient care. Additionally, EHRs contain vital information about patient care and treatment outcomes, which opens up exciting research opportunities. The objective of this study was to present a database comprising information regarding patients admitted to the emergency department of a large hospital. In this study, we are introducing an open-access database sourced from the electronic health records of a general university hospital in Isfahan, Iran. The data were collected from patients admitted to the emergency department between March 2017 and March 2022, resulting in a database containing 143,582 ED stays. The database includes triage information, ED admission patients, and services. To ensure patient privacy, all patient-specific information has been removed from the records.

Development and content validation of a risk classification instrument

OBJECTIVE

Develop and validate the content of an instrument for patient risk classification in emergency services of Primary Health Care.

METHOD

The study included two stages: item generation and content validity. A literature review and retrospective analysis of medical records were conducted to create the instrument items. The Content Validity Ratio (CVR) was used to assess agreement among judges during content validation.

RESULTS

In the first and second rounds, 75 and 71 judges validated the risk classification instrument, respectively. The minimum adherence score for the latent variable item based on the final number of judges was 0.22 and 0.18; thus, 52 items, divided into three classification categories (red, orange, and yellow), were retained.

CONCLUSION

The instrument was considered valid regarding clarity, relevance, pertinence, and agreement regarding the severity indicated in the item.

Retrospective Cohort Analysis of the Relationship Between Emergency Department Length of Stay and Timing of First Laboratory Orders

Background The efficiency of patient management in the Emergency Department (ED) is critical for optimizing healthcare delivery. Provider in triage (PIT) and similar ED flow models attempt to expedite throughput by decreasing the amount of time between patient arrival and initial order placement. The exact relationship between ED length of stay (LOS) and the timing of the first laboratory order, however, is unclear. The varying speed at which clinicians of different ages place laboratory orders and move patients through an ED also is understudied.  Methods A retrospective analysis was conducted using SQL from the Clarity data archive to pull all patient encounters in 2023. Linear regression models using Analysis ToolPak in Microsoft Excel were used to create and examine the relationship between LOS and the timing of the first laboratory order. Secondary outcomes using the same models were created to analyze the impact of clinician age on LOS and the relationship between clinician age and the timing of first laboratory orders.  Results Two hundred sixty-nine thousand eight hundred and eight ED visits were reviewed across three academic and 17 community emergency departments. We report a weak but statistically significant positive relationship between the timing of the first laboratory order and LOS (R² = 0.0378, p < 0.001). Secondary outcomes indicated a very weak negative correlation between clinician age and LOS (R² ≈ 0, p < 0.001) and no significant relationship between clinician age and the timing of the first laboratory order (R² ≈ 0, p > 0.05). Conclusion The timing of the first laboratory order is a significant, albeit weak, predictor of LOS in the ED. Clinician age has minimal impact on LOS and does not significantly influence the timing of the first laboratory order.

Care in the Community: A COVID-19 initiative to reduce hospital re-presentations among community-dwelling people

OBJECTIVE

The COVID-19 pandemic has had a substantial impact on the utilisation of hospital and emergency department (ED) services. We examined the effect of a rapid response service on hospital re-presentations among people discharged from the ED and short-stay wards at a tertiary referral hospital.

METHODS

This retrospective cohort study compared 112 patients who completed the Care in the Community program with 112 randomly selected controls. Both cases and controls were discharged from hospital between September 2020 and June 2021. Intervention patients were evaluated by a multidisciplinary team, who implemented a goal-directed program of up to 4-weeks duration. Logistic regression, negative binomial regression and Cox proportional hazards regression were used to evaluate outcomes at 28 days and at 6 months.

RESULTS

The median time between referral and the first home visit was 3.9 days. In adjusted analyses, the intervention reduced hospital re-presentations at 28 days (odds ratio: .40, 95% confidence interval (CI): .17-.94) and lengthened the time to the first hospital re-presentation (hazard ratio: .59, 95% CI: .38-.92). Although the intervention did not reduce the total number of hospital re-presentations at 6 months (adjusted incidence rate ratio: .73, 95% CI: .49-1.08), it reduced total time spent in hospital by 303 days (582 vs. 885).

CONCLUSIONS

This study is among the first to investigate the effect of a community-based intervention on hospital re-presentations during the COVID-19 pandemic. It provides evidence that a sustainable 4-week intervention is associated with reduced hospital re-presentations and time spent in hospital.

Emergency Department Versus Primary Care Use: A Patient Perspective

Introduction

When faced with an acute illness, patients routinely make the decision of whether to present to their primary care physician (PCP) or the emergency department (ED). While the ED is known to be a high-cost component of the health care system, many ED visits include nonurgent ailments that could easily be treated within the medical home/primary care office. Particularly for patients who have an established PCP, the factors driving a preference for ED use remain poorly understood. The purpose of this study was to better understand patient motivation for visiting the ED rather than the PCP office.

Methods

This observational study aimed to take a qualitative look at the patient population using a health system ED in the city of Wilkes Barre, PA, from December 2021 to March 2022. We conducted 30 interviews of patients who recently visited the ED and analyzed the responses for recurring themes.

Results

Major themes included the benefit of the PCP-patient relationship, patients' preference for multiple sources of medical guidance, patients' subjectively justifying their symptoms as emergent, seeking emergent care despite perception of higher cost, and factoring in time spent at a health care facility waiting for answers.

Conclusions

This study contributes to further understanding of the values that drive ED use by using patient voice as a powerful tool to understand communities and local trends, which will allow health care systems to adapt and personalize protocols to their specific population.

From concept to reality: A comprehensive exploration into the development and evolution of a virtual emergency department

Emergency department (ED) overcrowding remains a persistent challenge in global public health, leading to detrimental outcomes for patients and healthcare professionals. Traditional approaches to improve this issue have been insufficient, prompting exploration of novel strategies such as virtual care interventions. Our team developed the first comprehensive statewide virtual ED in Australia, the Victorian Virtual Emergency Department, offering an alternative to in-person care for non-life-threatening emergencies. Here, we present the development and ongoing refinement of this pioneering virtual care service, aiming to provide insights for hospital administrators and policymakers seeking to implement patient-centric care solutions worldwide. By sharing our model of care, we hope to guide further work toward addressing the global problem of over crowded EDs.

Interventions to improve emergency department throughput and care delivery indicators: A systematic review and meta-analysis

BACKGROUND

Emergency department (ED) crowding has repercussions on acute care, contributing to prolonged wait times, length of stay, and left without being seen (LWBS). These indicators are regarded as systemic shortcomings, reflecting a failure to provide equitable and accessible acute care. The objective was to evaluate the effectiveness of interventions aimed at improving ED care delivery indicators.

METHODS

This was a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing ED interventions aimed at reducing key metrics of time to provider (TTP), time to disposition (TTD), and LWBS. We excluded disease-specific trials (e.g., stroke). We used Cochrane's revised tool to assess the risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations to rate the quality of evidence. The meta-analysis was performed using a random-effects model and Cochrane Q test for heterogeneity. Data were summarized as means (±SD) for continuous variables and risk ratios (RR) with 95% confidence intervals (CIs).

RESULTS

We searched MEDLINE, EMBASE, and other major databases. A total of 1850 references were scanned and 20 RCTs were selected for inclusion. The trials reported at least one of the three outcomes of TTD, TTP, or LWBS. Most interventions focused on triage liaison physician and point-of-care (POC) testing. Others included upfront expedited workup (ordering tests before full evaluation by a provider), scribes, triage kiosks, and sending notifications to consultants or residents. POC testing decreased TTD by an average of 5-96 min (high heterogeneity) but slightly increased TTP by a mean difference of 2 min (95% CI 0.6-4 min). Utilizing a triage liaison physician reduced TTD by 28 min (95% CI 19-37 min; moderate-quality evidence) and was more effective in reducing LWBS than routine triage (RR 0.76, 95% CI 0.66-0.88; moderate quality).

CONCLUSIONS

Operational strategies such as POC testing and triage liaison physicians could mitigate the impact of ED crowding and appear to be effective. The current evidence supports these strategies when tailored to the appropriate practice environment.

Factors affecting early antibiotic delivery in open tibial shaft fractures

INTRODUCTION

The incidence of infection in open tibial shaft injuries varies with the severity of the injury with rates ranging from roughly 2% for Gustilo-Anderson type I to nearly 43% for type IIIB fractures. As with all fractures, timely antibiotics administration in the emergency department (ED) is an essential component of fracture management and infection prevention. This study identifies factors associated with the expedient administration of antibiotics for open tibial shaft fractures.

METHODS

This retrospective study identified patients treated for open tibial shaft fractures at an academic level 1 trauma center between 2015 and 2021. Open fractures were identified by reviewing patient charts. We used chart reviews to gather demographics, fracture characteristics, postoperative outcomes, trauma activation, and time to antibiotic order, delivery, and operating room. Univariate analysis was used to compare patients who received antibiotics within 1 h of ED presentation to those who did not. Multivariate analysis was performed to investigate factors associated with faster delivery of antibiotics.

RESULTS

Among 70 ED patients with open tibial shaft fractures, 39 (56%) received early administration of antibiotics. Arrival at the ED via emergency medical service (EMS) as opposed to walking in (98% vs. 74%, p = 0.01) and trauma activation (90% vs. 52%, p < 0.001) were significantly more common in the early administration group than the late group. The early group had shorter intervals between antibiotic order and delivery (0.02 h vs. 0.35 h, p = 0.007). Multivariate analysis suggested that trauma activation, EMS arrival, and arrival during non-overnight shifts were independent predictors of a shorter time to antibiotic administration (odds ratios 11.9, 30.7, and 5.4, p = 0.001, 0.016, and 0.013, respectively).

DISCUSSION

Earlier antibiotic delivery is associated with non-overnight arrival at the ED, arrival via EMS, and a coordinated trauma activation. Our findings indicate that in cases where administering antibiotics is critical to achieving positive outcomes, it is advisable to initiate a coordinated trauma response. Furthermore, hospital personnel should be attentive to the need for rapid administration of antibiotics to patients with open fractures who arrive via walk-in or during late-night hours.

Multisystem factors contributing to redundant intracranial vascular imaging in the ED

PURPOSE

To evaluate the multisystem factors contributing to redundant neurovascular orders in the ED.

METHODS

This was an IRB-approved, retrospective study, performed at a single institution examining a 5-year history of redundant CTA/MRA head and neck (HN) exams performed in the ED for patients with no documented clinical change in mental status/neurological exam necessitating additional imaging. Factors contributing to redundant ordering including provider experience, synchronous order placement, and radiologist recommendations were examined. Additionally, the impact of duplicative imaging in terms of medical cost and ED length of stay was evaluated.

RESULTS

250 patients met inclusion criteria with both CTA/MRA of the HN performed during a single ED encounter (total 500 exams). 190 (76%) redundant exams were not recommended by a radiologist and contributed to an added ED length of stay of 3.6 h on average. Provider experience was not a significant contributing factor. 60 (24%) of redundant exams were recommended by a radiologist and were most frequently CTAs needed to clarify an area of artifact/high-grade stenosis/occlusion on a primary MRA exam.

CONCLUSION

Evaluation of contributing factors to redundant CTA/MRA HN exams ordering has highlighted multiple associated factors including provider experience, recommendations by radiologists for clarification of MRA findings, as well as systems processes related to synchronous CTA/MRA order placement.

What can be done about workplace wellbeing in emergency departments? 'There's no petrol for this Ferrari'

Workplace wellbeing encompasses all aspects of working life. Peak health organisations recognise that poor workplace wellbeing is costly, both to individuals and to the organisation, and the value in promoting healthy workplaces. Workplace wellbeing improves when its barriers are acknowledged and addressed, and protective factors are promoted. The Emergency Department (ED) is a place of intense and challenging activity, exacerbated by high workloads and overcrowding. This impacts negatively on patient care, staff safety and wellbeing. We held focus groups across four EDs to discuss barriers and enablers to wellbeing and found four core themes: Workplace Satisfaction; Barriers to Wellbeing; Organisational Culture that Prioritises Staff Wellbeing; Self-care and Self Compassion. From this, and existing literature, we collaboratively developed a contextualised staff wellbeing framework titled: 'Staff Wellbeing Good Practice Framework: From Surviving to Thriving, How to Protect your Wellbeing in the Emergency Department' that emphasises their values of Competence, Connection and Control.

Does initiating care in alternate care sites decrease time to disposition in the emergency department?

Objectives

During the coronavirus disease 2019 (COVID-19) pandemic surge, alternate care sites (ACS) such as the waiting room or hospital lobby were created amongst hospitals nationwide to help alleviate emergency department (ED) overflow. Despite the end of the pandemic surge, many of these ACS remain functional given the burden of prolonged ED wait times, with providers now utilizing the waiting room or ACS to initiate care. Therefore, the objective of this study is to evaluate if initiating patient care in ACS helps to decrease time to disposition.

Methods

Retrospective data were collected on 61,869 patient encounters presenting to an academic medical center ED. Patients with an emergency severity index (ESI) of 1 were excluded. The "pre-ACS" or control data consisted of 38,625 patient encounters from September 30, 2018 to October 1, 2019, prior to the development of ACS, in which the patient was seen by a physician after they were brought to an assigned ED room. The "post-ACS" study cohort consisted of 23,244 patient encounters from September 30, 2022 to October 1, 2023, after the initiation of ACS, during which patients were initially seen by a provider in an ACS. ACS at this institution included the three following areas: waiting room, ambulance waiting area, and a newly constructed ACS that was built next to the ED entrance on the first floor of the hospital. The newly constructed ACS consisted of 16 care spaces each containing an upright exam chair with dividers between each care space. Door-to-disposition time (DTD) was calculated by identifying the time when the patient entered the ED and the time when disposition was decided (admission requested or patient discharged). Using regression analysis, we compared the two data sets to determine significant differences among DTD time.

Results

The largest proportion of encounters were among ESI 3 patients, that is, 56.1%. There was a significant increase in median DTD for ESI 2 and 3 patients who were seen initially in an ACS compared to those who were not seen until they were in an assigned ER room. Specifically, there was a median increase of 40.9 min for ESI 2 patients and 18.8 min for ESI 3 patients who were seen initially in an ACS (p < 0.001). There was a 29-min decrease in median DTD for ESI 5 patients who were seen in ACS (p = 0.09).

Conclusions

Initiating patient care earlier in ACS did not appear to decrease DTD time for patients in the ED. Overall, the benefits of early initiation of care likely lie elsewhere within patient care and the ED throughput process.

Burden and Patterns of Electric Scooter-Related Injuries: Insights From 2 Polish Emergency Departments

BACKGROUND The widespread adoption of electric scooters (e-scooters) as a mode of urban transportation has led to a notable upsurge in e-scooter-related injuries globally. Variations in e-scooter regulations across countries contribute to differences in injury patterns. This study sought to investigate the healthcare burden posed by e-scooter-related injuries on emergency departments (EDs) in Poland, and to delineate the epidemiological and clinical features of these injuries. MATERIAL AND METHODS Medical records of patients who presented to 2 distinct EDs - in Poznań and Bydgoszcz, Poland - with injuries directly linked to e-scooter use were collected and retrospectively analyzed. RESULTS A total of 633 patients were admitted to the EDs due to e-scooter injuries during the study period, and 413 of these patients were further analyzed. The majority were males (64.65%), with a median age of 27 years. Most admissions occurred in the afternoon and nighttime (71.94%), with a higher incidence in the summer (46.73%). Falls were the most frequent mechanism of injury (74.09%), with the head and upper and lower extremities being the most frequently affected locations (36.08%, 29.78%, and 21.07%, respectively). Twelve patients (2.91%) confirmed recent alcohol consumption. Hospitalization costs were higher in cases involving alcohol use and among males. CONCLUSIONS The findings of this study underscore the significant strain exerted by e-scooter-related injuries on EDs in Poland. Injuries, notably to the head and limbs, carry significant long-term implications and strain healthcare resources. Collaboration with policymakers is crucial to ensure the safety of e-scooter users and appropriate healthcare resource allocation.

University students in Central Italy: do they follow proper dietary habits?

Background

Eating a healthy diet is acknowledged as one of the main factors in preventing malnutrition and non-communicable diseases. As young students represent a group more prone to poor dietary habits, the aim of this study was to analyse the dietary habits of a group of undergraduate students attending university in a city of central Italy, Siena.

Methods

4,700 students were invited to participate in a cross-sectional study completing an online self-administered questionnaire about their food habits. The obtained data were analysed by Microsoft Excel 2021 and Stata 17 software, through the Mann-Whitney and the Kruskal-Wallis test; a p-value < 0.05 was considered statistically significant.

Results

The students living at home consumed more fruit, vegetables, pasta, meat, fish, packaged foods, fruit juices, beer and wine; the only statistically significant differences were found for pizza and snacks. Even the gender influenced the consumption of many foods; women consumed more vegetables and coffee/tea, while males ate more pasta, meat, packaged foods, pizza, fries and beer.

Conclusions

With the transition from secondary school to university, students are continuously challenged to make healthful food choices and they must be self-disciplined to take care of themselves. It would be important for health campaigns to be promoted in young adults to help them make the right choices.

Rethinking patient flows in a changing healthcare system: a unified approach

Introduction

The management of chronic diseases poses a challenge to the National Health Service (NHS), but it can also offer an opportunity for a radical renovation of healthcare provision. To improve the appropriateness of healthcare settings, it is essential to adopt integrated approach in all healthcare settings.

Methods

This study was conducted at San Giovanni Bosco Hospital, in the area of the "Città di Torino" Local Health Authority, between June 2021 and December 2022. Its main goal was to manage hospital patient flows in an integrated manner in order to improve the efficiency of the entire healthcare system. The data were examined in terms of effectiveness in optimizing hospital flows.

Results

The data indicated that hospital outpatient activities can become more specialized by leveraging the greater technological potential that a hospital possesses. At San Giovanni Bosco Hospital, the hub of the "Città di Torino" Local Health Authority (ASL), differential patient pathways were established in order to enhance the efficiency of the entire system by deploying hospital staff in a community setting. Implementation of the Otorhinolaryngology pathway avoided the hospitalization of 249 patients, who would otherwise have added strain to the overall organization of the hub hospital, which is currently short of space.

Conclusions

A significant effort is needed in order to build an integrated network that provides patients with reliable and stable references. The approach adopted at San Giovanni Bosco Hospital resulted in an improvement in the use of both hospital and territorial facilities.

Impact of comorbidities in severely injured patients with blunt chest injury: A population-based retrospective cohort study

INTRODUCTION

Blunt chest injuries result in up to 10 % of major trauma admissions. Comorbidities can complicate recovery and increase the mortality rate in this patient cohort. A better understanding of the association between comorbidities and patient outcomes will facilitate enhanced models of care for particularly vulnerable groups of patients, such as older adults.

AIMS

i) compare the characteristics of severely injured patients with blunt chest injury with and without comorbidities and ii) examine the relationship between comorbidities and key patient outcomes: prolonged length of stay, re-admission within 28 days, and mortality within 30 days in a cohort of patients with blunt chest injury admitted after severe trauma.

METHODS

A retrospective cohort study using linked data from the NSW Trauma Registry and NSW mortality and hospitalisation records between 1st of January 2012 and 31st of December 2019.

RESULTS

After adjusting for potential confounding factors, patients with severe injuries, chest injuries, and comorbidities were found to have a 34 % increased likelihood of having a prolonged length of stay (OR = 1.34, 95 %I = 1.17-1.53) compared to patients with no comorbidities. There was no difference in 30-day mortality for patients with a severe chest injury who did or did not have comorbidities (OR = 1.05, 95 %CI = 0.80-1.39). No significant association was found between comorbidities and re-admission within 28 days.

CONCLUSION

Severely injured patients with blunt chest injury and comorbidities are at risk of prolonged length of stay.