Trends in Emergency Department Utilization

Increasing demand for non-urgent medical services provided in emergency departments is an unforeseen consequence of our present health care system. Factors in the organization, finance and payment of health services may account for escalating utilization rates. In this paper, patient characteristics, patterns of medical practice, present obligations of hospital emergency departments, and universal health insurance are examined to determine their influence on the demand for emergency department care.

Finally, methods for providing equally available and accessible health care services more appropriate to the primary health care demands seen in emergency departments are discussed.

     

The Pediatric Emergency Care Applied Research Network (PECARN): Rationale,Development, and First Steps*

Since its formal recognition as a medical specialty, the field of pediatric emergency medicine has made substantial advances with respect to its scope and sophistication. These advances have occurred in clinical practice as well as in the research base to improve clinical practice. There remain, however, many areas in emergency medical services for children (EMSC), in the out‐of‐hospital as well as the emergency department (ED) and hospital settings, that suffer from a lack of data to guide practice. In an effort to expand the quality and quantity of research in pediatric emergency care, the Pediatric Emergency Care Applied Research Network (PECARN) was created in October 2001. PECARN is the first federally funded national network for research in EMSC. PECARN is the result of Cooperative Agreement grants funded through the Health Resources and Services Administration (HRSA) with the purpose of developing an infrastructure capable of overcoming inherent barriers to pediatric EMSC research. Among these recognized barriers are low incidence rates of serious pediatric emergency events, the need for large numbers of children from varied backgrounds to achieve broadly representative study samples, lack of an infrastructure to test the efficacy of pediatric emergency care, and the need for a mechanism to translate study results into clinical practice. PECARN will serve as a national platform for collaborative research involving the continuum of care within the EMSC system, including out‐of‐hospital care, patient transport, ED and in‐hospital care, and rehabilitation. This article describes the history of EMSC, the need for a national collaborative research network in EMSC, the organization and development of PECARN, and the work plan for the Network.     

老年患者对急诊就医体验的满意度现状调查与分析

目的调查老年患者对急诊就医体验的满意度,结合临床实际分析原因,为提高老年患者就医体验满意度,改进医院的服务质量提供参考依据。方法选取2018年6月至2019年3月我院急诊就诊的老年患者900例,调查患者就医满意度现状。结果老年患者对医护人员提供及时帮助、医师技术、院内标识醒目清楚、科室布局合理、医护人员对您隐私尊重保护、急诊就诊分级、医护人员耐心介绍用药方法及注意事项、本次就医费用明白合理、我感觉到了医护人员给予我的尊重和安慰、候诊时间可以接受、挂号等待时间可以接受满意度较高。结论提高老年患者急诊就医体验满意度需进一步推进医疗服务的人性化建设,在简化就诊流程的同时照顾老年患者这一特殊群体,持续完善医疗费用的公开透明。     

Chronic medical illness, depression, and use of acute medical services among Medicare beneficiaries

BACKGROUND: This study assessed the relation of comorbid depressive syndrome with utilization of emergency department services and preventable inpatient hospitalizations among elderly individuals with chronic medical conditions. RESEARCH DESIGN: A cross-sectional study. SETTING: Individuals greater than or equal to 65 years of age living in the United States with Medicare part A and B fee-for-service coverage in 1999. SUBJECTS: A 5% random sample of elderly Medicare recipients (N = 1,238,895) of whom 60,382 (4.9%) met criteria for a depressive syndrome. MEASUREMENTS: Medicare beneficiaries were stratified based on the presence of at least 1 of the following medical conditions: coronary artery disease, diabetes mellitus, congestive heart failure, hypertension, prostate cancer, breast cancer, lung cancer, or colon cancer. For each stratum, we compared the odds of emergency department visits, all-cause hospitalization, and hospitalization for ambulatory care sensitive conditions (ACSC), conditions for which timely and effective medical care could decrease risk of hospitalization, for beneficiaries with and without a depressive syndrome. RESULTS: Compared with those without a depressive syndrome, beneficiaries with a depressive syndrome were more likely to be older, white, and female (P <0.001). For each of the 8 chronic medical conditions, elderly beneficiaries with a depressive syndrome were at least twice as likely to use emergency department services (range of adjusted odds ratios, 2.12-3.16; P <0.001); medical inpatient hospital services (range of adjusted odds ratios, 2.59-3.71; P <0.001); and medical inpatient hospital services associated with an ACSC (range of adjusted odds ratios, 1.72-2.68; P <0.001) as compared with those without a depressive syndrome. CONCLUSIONS: For elderly individuals with at least 1 chronic medical condition, the presence of a depressive syndrome increased the odds of acute medical service use, suggesting that improvements in clinical management, access to mental health services, and coordination of medical and mental health services could reduce utilization.     

Threats to the Health Care Safety Net

The American health care safety net is threatened due to inadequate funding in the face of increasing demand for services by virtually every segment of our society. The safety net is vital to public safety because it is the sole provider for first-line emergency care, as well as for routine health care of last resort, through hospital emergency departments (ED), emergency medical services providers (EMS), and public/free clinics. Despite the perceived complexity, the causes and solutions for the current crisis reside in simple economics. During the last two decades health care funding has radically changed, yet the fundamental infrastructure of the safety net has change little. In 1986, the Emergency Medical Treatment and Active Labor Act established federally mandated safety net care that inadvertently encouraged reliance on hospital EDs as the principal safety net resource. At the same time, decreasing health care funding from both private and public sources resulted in declining availability of services necessary to support this shift in demand, including hospital inpatient beds, EDs, EMS providers, on-call specialists, hospital-based nurses, and public hospitals/clinics. The result has been ED/hospital crowding and resource shortages that at times limit the ability to provide even true emergency care and threaten the ability of the traditional safety net to protect public health and safety. This paper explores the composition of the American health care safety net, the root causes for its disintegration, and offers short- and long-term solutions. The solutions discussed include restructuring of disproportionate share funding; presumed (deemed) eligibility for Medicaid eligibility; restructuring of funding for emergency care; health care for foreign nationals; the nursing shortage; utilization of a "health care resources commission"; "episodic (periodic)" health care coverage; best practices and health care services coordination; and government and hospital providers' roles. CONCLUSIONS: There is a base amount of funding that must be available to the American health care safety net to maintain its infrastructure and provide appropriate growth, research, development, and expansion of services. Fall below this level and the infrastructure will eventually crumble. America must patch the safety net with short-term funding and repair it with long-term health care policy and environmental changes.     

外籍患者门诊急诊创伤救治的护理模式探讨

目的 探讨涉外门诊急性外伤外籍患者的护理模式,以期进一步提升医院的涉外医疗服务水平.方法 收集2007年1月~2012年12月该院涉外门诊外籍患者的就诊资料,对1 624例急性外伤外籍患者实施多元、全程、优质的护理服务.结果 通过对1 624例急性外伤的外籍患者实施与国际接轨的护理服务,探索出一套既适合外籍患者需求,又符合我国医疗模式实际情况的应急护理模式,满足了外籍患者的应急护理服务需求.结论 将文化多样性和差异性融入护理工作中,以全球化的观点提供跨文化照护.     

Health network to improve elderly patients' flow in emergency department.

BACKGROUND: The French population has been growing older these past decades. The French Regional Health Organization System authorizes the creation of health networks in order to improve healthcare. We have developed since 2002 in our Tertiary Hospital Cochin, a health network inside Paris and its suburbs for the elderly to improve their flow from the emergency department. Our study, based on this organization, analyses the outcome of such a system. METHODS: From January 2002 to December 2002, we conducted a monocentric retrospective study from the emergency department including all polypathological elderly patients (older than 75 years) admitted for a medical purpose. We classified them according to triage level at arrival, their duration of stay in the emergency department and in the tertiary hospital/geriatric network and their in-hospital mortality. RESULTS: Elderly patients represented 12% of our recruitment of an overall number of 42 700 patients in 2002. Six hundred and ninety-nine (24.2%) patients needed admission in a geriatric field; 42.8% were hospitalized in our tertiary hospital and 57.2% in the geriatric network. The mean age was 86.5+/-6 years in the two groups. The triage scale shows that most elderly people needed rapid care in the emergency department. Our mean duration of stay in the emergency department was 11 h 30 min. No significant difference was observed in the two groups for the in-hospital duration of stay. Mortality rate was 10.2% with a significant difference in the two groups. CONCLUSION: We observed a decreasing number of elderly persons' admission in our tertiary hospital, allowing a specific activity in the referred medical units. Our contract with the geriatric hospital in the network favoured elderly patients' flow from the emergency department. The geriatric network hospitals could refer back any patient to the emergency department for emergent events.     

对临终关怀期患者家属心理支持的探索

我国已经加速进入老龄化社会，与之相适应的医疗养老卫生服务的需求也大大增加。介于昆明市社会福利院福利医院"医养结合"的性质和"生物-心理-社会"现代医学模式理念，心理科开展了临终关怀的临床实践。对于老年患者的躯体疾病的支持治疗是主要医护服务，同时对患者家属的心理支持也是工作的重要部分。经过临床心理科医护人员长期的临床工作，总结和发展出的适合临终老年患者家属的心理支持服务，逐渐探索形成了比较成熟的模式和经验，得出如下结论：对临终关怀期患者家属的心理支持非常具有必要性、可行性和重要性，能有效的提高临床服务水平和医患沟通的满意度。同时为了促进临终关怀服务的发展，临终关怀服务需要医学、护理学、心理学、社会学、法学、伦理学、教育学等多学科的共同参与。     

Review article: Paediatric status epilepticus in the pre‐hospital setting: An update

Paediatric status epilepticus (SE) is a medical emergency and a common critical condition confronting pre‐hospital providers. Management in the pre‐hospital environment is challenging but considered extremely important as a potentially modifiable factor on outcome. Recent data from multicentre clinical trials, quality observational studies and consensus documents have influenced management in this area, and is important to both pre‐hospital providers and emergency physicians. The objective of this review was to: (i) present an overview of the available evidence relevant to pre‐hospital care of paediatric SE; and (ii) assess the current pre‐hospital practice guidelines in Australia and New Zealand. The review outlines current definitions and guidelines of SE management, regional variability in pre‐hospital protocols within Australasia and aspects of pre‐hospital care that could potentially be improved. Contemporary data is required to determine current practice in our setting. It is important that paediatric neurologists, emergency physicians and pre‐hospital care providers are all engaged in future endeavours to improve clinical care and knowledge translation efforts for this patient group.     

Inadequate acute hospital beds and the limits of primary care and prevention

Metropolitan Australia is suffering from a serious shortage of acute hospital beds. Simplistic comparisons with the Organisation for Economic Co‐operation and Development bed numbers are misleading because of the hybrid Australian public/private hospital system. The unavailability of most private beds for acute emergency cases and urban/rural bed imbalances have not been adequately considered. There is a lack of advocacy for acute bed availability. This attitude permeates government, health professions and the health bureaucracy. Planners, politicians, analysts and the media have adopted false hopes of reducing acute demand by prevention and primary care strategies, vital as these services are to a balanced healthcare system. This paper directly challenges the ideology that says Australia depends too heavily on hospital‐based healthcare. Rebuilding the bed base requires recognition of the need for an adequate acute hospital service and strong advocacy for bed‐based care in the medical and nursing professionals who should be driving policy. The forces opposing bed‐based care are strong and solutions might include legislative definition of bed numbers and availability.     

Rationing and regionalisation of health care services: a critical care physician's opinion.

It is becoming apparent that we have created a demand for medical goods and services that threatens to overwhelm our health care system. Present fiscal policies for financing health care such as excluding a large portion of the population are clearly unacceptable to the public. Current reimbursement policies for health care providers are so murky and, in some cases, so conflicting that they could have been designed only as a method of rationing by inconvenience. Some improvements in the cost effectiveness of health care delivery are needed without increasing the administrative and regulatory bureaucracy currently feeding on itself. Regionalisation of medical services has proven to be cost-effective in the specialties of trauma and neonatology. There is accumulating evidence that this same concept, using severity of illness scoring as an objective marker of potential benefit, may maximise cost/benefit for medical and surgical critical care patients. However, multifaceted deterrents to the concept of regionalisation must be addressed, including reimbursement problems, logistics of bed occupancy and physician incentives to participate.     

Emergency medical services: Brazil

Emergency medical services in Brazil have been created to offer first aid, primary medical treatment, basic life support, stabilization and rapid transfer to the closest appropriate hospital and advanced life support. Pre-hospital emergency care in Brazil is divided into permanent and mobile services. Permanent care is provided by the pre-hospital network (basic health units, family health program, specialized clinics, diagnosis and therapy services, non-hospital emergency care units). The mobile medical services include: mobile emergency care service, fire department and private services. Emergency hospital care units (emergency departments) are classified into general and reference units. Details of these services are described.     

Bi-objective approach for placing ground and air ambulance base and helipad locations in order to optimize EMS response

Shortening the travel time of patient transfer has clinical implications for many conditions such as cardiac arrest, trauma, stroke and STEMI. As resources are often limited precise calculations are needed. In this paper we consider the location problem for both ground and aerial emergency medical services. Given the uncertainty of when patients are in need of prompt medical attention we consider these demand points to be uncertain. We consider various ways in which ground and helicopter ambulances can work together to make the whole process go faster. We develop a mathematical model that minimizes travel time and maximizes service level. We use a compromising programming method to solve this bi-objective mathematical model. For numerical experiments we apply our model to a case study in Lorestan, Iran, using geographical and population data, and the location of the actual hospital based in the capital of the province. Results show that low-accessibility locations are the main focus of the proposed problem and with mathematical modeling access to a hospital is vastly improved. We also found out that once the budget reaches a certain point which suffices for building certain ambulance bases more investments does not necessarily result in less travel time.     

Mental health consumers' with medical co‐morbidity experience of the transition through tertiary medical services to primary care

Medical comorbidity in people with long‐term mental illness is common and often undetected; however, these consumers frequently experience problems accessing and receiving appropriate treatment in public health‐care services. The aim of the present study was to understand the lived experience of mental health consumers with medical comorbidity and their carers transitioning through tertiary medical to primary care services. An interpretative, phenomenological analysis approach was used, and semistructured, video‐recorded, qualitative interviews were used with 12 consumers and four primary caregivers. Four main themes and related subthemes were abstracted from the data, highlighting consumer's and carers’ experience of transition through tertiary medical to primary care services: (i) accessing tertiary services is difficult and time consuming; (ii) contrasting experiences of clinician engagement and support; (iii) lack of continuity between tertiary medical and primary care services; and (iv) Mental Health Hospital Admission Reduction Programme (MH HARP) clinicians facilitating transition. Our findings have implications for organisational change, expanding the role of MH HARP clinicians (whose primary role is to provide consumers with intensive support and care coordination to prevent avoidable tertiary medical hospital use), and the employment of consumer and carer consultants in tertiary medical settings, especially emergency departments.     

Hospital Utilization among Persons with an Intellectual Disability,Ontario, Canada, 1995–2001

Background It has been suggested that persons with an intellectual disability consume a disproportionate amount of hospital services. Policy changes in Ontario in the 1970s and 1980s made it necessary for community health services to accommodate this population that formerly received most of its medical care in the institutions where they lived. It is frequently suggested that community health services are currently inadequate to care for this population. Methods The study was a retrospective analysis of routinely collected hospitalization data for persons living in Ontario with an intellectual disability, between 1995 and 2001. Results A substantial proportion of hospitalizations of persons with an intellectual disability were for mental disorders and dental diseases. Of all in‐hospital stays, one‐third were for mental disorders such as schizophrenia and depression. Of all day‐surgery admissions, almost 40% were for dental diseases corresponding to a high rate of dental procedures. The study also identified high ambulatory care‐sensitive condition hospitalization rates. In‐hospital surgical procedure rates, however, were low. Interpretation This study is the first to fully describe patterns of hospitalization for persons with an intellectual disability in Ontario, Canada. A recurring finding is the large discrepancy between statistics for persons with an intellectual disability and published data for the general population. The study limitations mean further research is required to confirm the results and to determine if persons with an intellectual disability are receiving the health care they are entitled to in Ontario.     

Do you see what I see: A mother's plea

There is sometimes dissonance between the medical services that the general public expects an ED to provide and the acute critical care that emergency clinicians hope to provide. One explanation for this is that the ED is both a territory and a meeting place for a cornucopia of clinicians, some of whom are not ED clinicians themselves. Roles are sometimes ambiguous and location‐specific. Recently, one Queensland mother believed that her son's suicide could have been prevented had emergency staff been better educated. This perspective aims to reflect on several pertinent questions: Should suicide risk be treated as a medical emergency? Is suicide prevention everyone's business? Is suicide risk assessment and management a core component of ED ? How common, precise and non‐stigmatising is the language around suicide? To what extent is that language underpinned by mythology rather than fact? For some, these will be inconvenient questions. How they are answered is undoubtedly framed within the language used when discussing suicide.     

Modeling factors influencing the demand for emergency department services in ontario: a comparison of methods

Background

Emergency departments are medical treatment facilities, designed to provide episodic care to patients suffering from acute injuries and illnesses as well as patients who are experiencing sporadic flare-ups of underlying chronic medical conditions which require immediate attention. Supply and demand for emergency department services varies across geographic regions and time. Some persons do not rely on the service at all whereas; others use the service on repeated occasions. Issues regarding increased wait times for services and crowding illustrate the need to investigate which factors are associated with increased frequency of emergency department utilization. The evidence from this study can help inform policy makers on the appropriate mix of supply and demand targeted health care policies necessary to ensure that patients receive appropriate health care delivery in an efficient and cost-effective manner. The purpose of this report is to assess those factors resulting in increased demand for emergency department services in Ontario. We assess how utilization rates vary according to the severity of patient presentation in the emergency department. We are specifically interested in the impact that access to primary care physicians has on the demand for emergency department services. Additionally, we wish to investigate these trends using a series of novel regression models for count outcomes which have yet to be employed in the domain of emergency medical research.

Methods

Data regarding the frequency of emergency department visits for the respondents of Canadian Community Health Survey (CCHS) during our study interval (2003-2005) are obtained from the National Ambulatory Care Reporting System (NACRS). Patients' emergency department utilizations were linked with information from the Canadian Community Health Survey (CCHS) which provides individual level medical, socio-demographic, psychological and behavioral information for investigating predictors of increased emergency department utilization. Six different multiple regression models for count data were fitted to assess the influence of predictors on demand for emergency department services, including: Poisson, Negative Binomial, Zero-Inflated Poisson, Zero-Inflated Negative Binomial, Hurdle Poisson, and Hurdle Negative Binomial. Comparison of competing models was assessed by the Vuong test statistic.

Results

The CCHS cycle 2.1 respondents were a roughly equal mix of males (50.4%) and females (49.6%). The majority (86.2%) were young-middle aged adults between the ages of 20-64, living in predominantly urban environments (85.9%), with mid-high household incomes (92.2%) and well-educated, receiving at least a high-school diploma (84.1%). Many participants reported no chronic disease (51.9%), fell into a small number (0-5) of ambulatory diagnostic groups (62.3%), and perceived their health status as good/excellent (88.1%); however, were projected to have high Resource Utilization Band levels of health resource utilization (68.2%). These factors were largely stable for CCHS cycle 3.1 respondents. Factors influencing demand for emergency department services varied according to the severity of triage scores at initial presentation. For example, although a non-significant predictor of the odds of emergency department utilization in high severity cases, access to a primary care physician was a statistically significant predictor of the likelihood of emergency department utilization (OR: 0.69; 95% CI OR: 0.63-0.75) and the rate of emergency department utilization (RR: 0.57; 95% CI RR: 0.50-0.66) in low severity cases.

Conclusion

Using a theoretically appropriate hurdle negative binomial regression model this unique study illustrates that access to a primary care physician is an important predictor of both the odds and rate of emergency department utilization in Ontario. Restructuring primary care services, with aims of increasing access to undersupplied populations may result in decreased emergency department utilization rates by approximately 43% for low severity triage level cases.     

规范化院前急救流程对急救质量的影响分析

【目的】探讨实施规范化院前急救流程对急救质量的影响。【方法】选取本院2015年7～12月实施规范化院前急救流程后的1494次院前急救案例作为观察组,2015年1～6月常规急救流程院前急救1308次案例作为对照组,比较两组的抢救成功率、院前干预次数、患者满意度、家属满意度、往返时间及医疗纠纷发生率。【结果】观察组院前测量心率及血压、心电图检查、快速血糖检测、监测呼吸频率、监测脉搏血氧饱和度、吸氧、GCS 评分、夹板固定等的抢救干预率均显著的高于对照组（ P ＜0．05）,两组院前急救收集既往病史、外伤止血率差异无统计学意义（ P ＞0．05）;观察组患者的抢救成功率94．85％、家属满意度95．85％均显著的高于对照组的92．74％、89．45％,且差异具有统计学意义（ P ＜0．05）;观察组的抢救患者往返时间与对照组比较差异无统计学意义（ P ＞0．05）,观察组患者的医疗纠纷发生率0．47％显著的低于对照组的1．15％（ P ＜0．05）。【结论】实施规范化院前急救流程有助于提高院前急救质量,应予以坚持。     

Review on pharmacological pain management in trauma patients in (pre‐hospital) emergency medicine in the Netherlands

Pain is one of the main complaints of trauma patients in (pre‐hospital) emergency medicine. Significant deficiencies in pain management in emergency medicine have been identified. No evidence‐based protocols or guidelines have been developed so far, addressing effectiveness and safety issues, taking the specific circumstances of pain management of trauma patients in the chain of emergency care into account. The aim of this systematic review was to identify effective and safe initial pharmacological pain interventions, available in the Netherlands, for trauma patients with acute pain in the chain of emergency care. Up to December 2011, a systematic search strategy was performed with MeSH terms and free text words, using the bibliographic databases CINAHL, PubMed and Embase. Methodological quality of the articles was assessed using standardized evaluation forms. Of a total of 2328 studies, 25 relevant studies were identified. Paracetamol (both orally and intravenously) and intravenous opioids (morphine and fentanyl) proved to be effective. Non‐steroidal anti‐inflammatory drugs (NSAIDs) showed mixed results and are not recommended for use in pre‐hospital ambulance or (helicopter) emergency medical services [(H)EMS]. These results could be used for the development of recommendations on evidence‐based pharmacological pain management and an algorithm to support the provision of adequate (pre‐hospital) pain management. Future studies should address analgesic effectiveness and safety of various drugs in (pre‐hospital) emergency care. Furthermore, potential innovative routes of administration (e.g., intranasal opioids in adults) need further exploration.