Predictors of Repeat Emergency Department Visits by Elders

Objective: To determine which characteristics of older patients who use a hospital ED are associated with repeat visits during the 90 days following the index visit.
Methods: The study was conducted in the ED of a 400-bed university-affiliated acute care community hospital in Montreal. Patients aged ≥75 years who visited the ED between 08:00 and and 16:00 on a convenience sample of days over an 8-week period (July and August 1994) were assessed using a questionnaire, physical and cognitive status instruments, and a functional problem checklist. The hospital's administrative database was used to identify repeat visits during the 90 days following the ED visit. The representativeness of the sample was assessed by analyses of ED visits made by 4,466 persons aged ≥65 years during a 12-month period (September 1993 to August 1994) using the hospital's administrative database.
Results: 256 patients aged ≥75 years visited the ED during the study period and 167 were assessed. Of these, 54 (32%) were admitted to the hospital. Among the 113 patients released from the ED, 27 (24%) made repeat visits during the next 90 days. In univariate analyses, repeat visits were significantly associated with the number of functional problems, cognitive impairment, and previous ED visits. In multiple logistic regression, male gender, living alone, and number of functional problems were independent predictors of repeat visits. In the administrative data analyses, nighttime arrival to the ED for the index visit was significantly associated with repeat visits.
Conclusions: Self-reported risk factors can help to identify a group of elders likely to make repeated ED visits; the development of a screening instrument incorporating questions on these problems and implementation of appropriate interventions might improve these patients' quality of life and reduce the demand for further ED care in this age group.     

End-tidal Carbon Dioxide Monitoring during Procedural Sedation

OBJECTIVE: To prospectively determine whether end-tidal carbon dioxide (ETCO2) monitors can detect respiratory depression (RD) and the level of sedation in emergency department (ED) patients undergoing procedural sedation (PS). METHODS: This was a prospective observational study conducted in an urban county hospital of adult patients undergoing PS. Patients were monitored for vital signs, depth of sedation per the physician by the Observer's Assessment of Alertness/Sedation scale (OAA/S), pulse oximetry, and nasal-sample ETCO2 during PS. Respiratory depression was defined as an oxygen saturation <90%, an ETCO2 >50 mm Hg, or an absent ETCO2 waveform at any time during the procedure. The physician also determined whether protective airway reflexes were lost during the procedure and assisted ventilation was required, or whether there were any other complications. Rates of RD were compared with the physician assessment of airway loss and between agents using chi-square statistics. Spearman's rho analysis was used to determine whether there was a correlation between ETCO2 and the OAA/S score. RESULTS: Seventy-four patients were enrolled in the study. Forty (54.1%) received methohexital, 21 (28.4%) received propofol, ten (13.5%) received fentanyl and midazolam, and three (4.1%) received etomidate. Respiratory depression was seen in 33 (44.6%) patients, including 47.5% of patients receiving methohexital, 19% receiving propofol (p = 0.008), 80% receiving fentanyl and midazolam, and 66.6% receiving etomidate. No correlation between OAA/S and ETCO2 was detected. Eleven (14.9%) patients required assisted ventilation at some point during the procedure, all of whom met the criteria for RD. Pulse oximetry detected 11 of the 33 patients with RD. Post-hoc analysis revealed that all patients with RD had an ETCO2 >50 mm Hg, an absent waveform, or an absolute change from baseline in ETCO2 >10 mm Hg. CONCLUSIONS: There was no correlation between ETCO2 and the OAA/S score. Using the criteria of an ETCO2 >50 mm Hg, an absolute change >10 mm Hg, or an absent waveform may detect subclinical RD not detected by pulse oximetry alone. The ETCO2 may add to the safety of PS by quickly detecting hypoventilation during PS in the ED.     

Trauma systems and emergency medicine

The impact of trauma is a major public health challenge which is likely to escalate in the early 21st century. A systematic approach to this problem is required. This review explains the conceptual framework that defines a trauma system, gives a brief historical perspective and describes some of the essential elements of the system which should make a difference to patient outcome. Emergency physicians are well placed to play a leading role in the development and implementation of trauma systems.     

Psychological well‐being and psychosocial work environment characteristics among emergency medical and nursing staff

The aim of this study was to determine if the effect of psychosocial work environment on psychological well‐being was different for doctors and nurses who work in emergency departments in Spain. A cross‐sectional survey was carried out among 945 emergency doctors and nurses staff from Spain. The outcome variable was the psychological well‐being measured by two dimensions of SF‐36 Health Survey (SF‐36) (mental health, vitality) and one dimension of Maslach's Burnout Inventory (emotional exhaustion). The explanatory variable was the psychosocial work environment evaluated according to Karasek and Johnson's demand‐control model that includes the dimensions of psychological demands, job control, supervisor social support and co‐workers' social support. The adjusted odds ratios and their 95 per cent confidence intervals were calculated by logistic regression. The prevalence of low vitality, bad mental health and high emotional exhaustion was higher among doctors than nurses. Exposure to high psychological demands increased the probability of low vitality, bad mental health and high emotional exhaustion among doctors and nurses. Low job control and low co‐workers' social support at work were associated with poor psychological well‐being only among doctors. Low job supervisors' social support increased the risk of bad mental health among doctors and of high emotional exhaustion among nurses. There is a different effect of psychosocial work environment on psychological well‐being between doctors and nurses. Copyright © 2007 John Wiley & Sons, Ltd.     

An Educator''s Guide to Teaching Emergency Medicine to Medical Students

There is a need for every medical school graduate to handle emergencies as they arise in the daily practice of medicine. Emergency medicine (EM) educators are in a unique position to provide students with basic life support skills, guidance in assessing the undifferentiated patient, and exposure to the specialty of EM during all years of medical school. Emergency physicians can become involved in a variety of education experiences that can supplement the preclinical curriculum and provide access to our specialty at an early stage. A well-designed course in the senior year allows students to develop critical thinking and patient management skills that are necessary for any medical career path. It can ensure that all medical students are exposed to the skills essential for evaluating and stabilizing the acutely ill patient. To implement this type of course, learning objectives and evaluation methods must be set when the curriculum is developed. An effective course combines didactic and clinical components that draw on the strengths of the teaching institution and faculty of the department. A structured clerkship orientation session and system for feedback to students are essential in nurturing the development of student learners. This article provides an approach to assist the medical student clerkship director in planning and implementing EM education experiences for students at all levels of training, with an emphasis on the senior-year rotation.     

Physician assistants in academic radiology: the harborview experience

We describe a model of how physician assistants can be used in an academic medical center to expand radiologist productivity, and to enhance the departmental academic and educational missions. At Harborview Medical Center, following a training program and graduated responsibility under supervision, physician assistants provide initial interpretation of radiology studies, consultation to referring physicians, and perform less complicated interventional procedures. Acceptance of physician assistants by the radiologists, radiology residents, and referring physicians has been high. Although the impact of physician assistants on departmental clinical productivity is difficult to measure, our data suggest that radiologists are more efficient when physician assistants are assigned to service, both in terms of numbers of studies interpreted, and timeliness of reporting and billing. As a result of the success of our program, we believe that physician assistants can have an important role in radiology practice.     

Using Queueing Theory to Increase the Effectiveness of Emergency Department Provider Staffing

Objectives: Significant variation in emergency department (ED) patient arrival rates necessitates the adjustment of staffing patterns to optimize the timely care of patients. This study evaluated the effectiveness of a queueing model in identifying provider staffing patterns to reduce the fraction of patients who leave without being seen. Methods: The authors collected detailed ED arrival data from an urban hospital and used a Lag SIPP queueing analysis to gain insights on how to change provider staffing to decrease the proportion of patients who leave without being seen. The authors then compared this proportion for the same 39‐week period before and after the resulting changes. Results: Despite an increase in arrival volume of 1,078 patients (6.3%), an average increase in provider hours of 12 hours per week (3.1%) resulted in 258 fewer patients who left without being seen. This represents a decrease in the proportion of patients who left without being seen by 22.9%. Restricting attention to a four‐day subset of the week during which there was no increase in total provider hours, a reallocation of providers based on the queueing model resulted in 161 fewer patients who left without being seen (21.7%), despite an additional 548 patients (5.5%) arriving in the second half of the study. Conclusions: Timely access to a provider is a critical dimension of ED quality performance. In an environment in which EDs are often understaffed, analyses of arrival patterns and the use of queueing models can be extremely useful in identifying the most effective allocation of staff.     

SOS抢救护理小组的组建与实施

介绍了上海交通大学附属一院SOS抢救护理小组的组建、运营和管理,提高了抢救病人的医护应急速度、效率和质量、并有利于护理队伍的培养和急救护理学的发展。     

护理人文关怀在急诊患者中的应用研究

目的:探讨人文关怀在急诊护理过程中的应用效果.方法:选定100名我科接诊的急诊患者作为研究对象,随机分为两组,每组各50例.A组在护理过程中实施人文关怀,B组在护理过程中不施加人文关怀.以患方满意度作为观察指标,对两组进行比较.结果:A组患方满意度是98%,B组患方满意度是84%.两组比较有显著性差异(X2=4.3956.P=0.0360).结论:在急诊护理过程中,护士应尽可能为患者提供人文关怀,并贯穿于整个护理服务的全过程,使急诊病人及家属满意度与急诊护理质量不断提高,并减少护患纠纷,以利于患者掌握健康知识并早日康复.     

Ⅰ期前后路手术治疗下颈椎骨折脱位

目的 评价Ⅰ期前后路手术治疗下颈椎骨折脱位伴关节突绞锁的可行性和近期临床效果.方法 对27例下颈椎骨折脱位伴关节突绞锁的患者,Ⅰ期行后路复位和前路减压植骨内固定术,定期X线摄片观察损伤节段的稳定性和融合率,观察有无并发症发生,以ASIA分级判定脊髓功能的恢复情况.结果 随访6～32个月(平均21.5个月),27例患者均获得了完全复位,损伤节段稳定,颈椎高度和生理曲度维持良好,融合率为100%,内固定位置良好,无植骨块脱出或钢板、螺钉松动、断裂等并发症,脊髓功能平均提高1.4级,无一例患者出现神经症状加重.结论 Ⅰ期前后路手术治疗下颈椎骨折脱位伴关节突绞锁可获得满意的复位、彻底的减压和即刻稳定性的重建,有利于脊髓功能的恢复,近期临床疗效满意.