Interhospital transfers of patients with surgical emergencies: areas for improvement

Objective: To review mortality associated with interhospital transfers of patients with surgical emergencies from rural and peripheral metropolitan areas. Design: A retrospective case note review. Setting: All hospitals within an area health service including metropolitan and rural hospitals. Subjects: All patients with a surgical emergency who died in hospital after interhospital transfer within an area health service. Main outcome measures: Factors associated with death and interhospital transfer. Results: In total, 22 patients were identified. The mean age was 77 years. Thirty‐six per cent of patients were assessed by a surgeon prior to transfer. The mean time taken for transfer was five hours. Ten patients were physiologically unstable prior to transfer. No medical escort accompanied these patients. Four patients deteriorated during the transport process. Seventy‐three per cent of patients arrived out of normal working hours. Fifty per cent of patients required an operation within 24 hours of arrival. All of these patients had significant medical co‐morbidities. Seventy‐two per cent of these operations were performed out of hours as an emergency case. Twenty‐three per cent did not receive any operative intervention or intensive care admission at the tertiary referral centre. Forty‐one per cent of deaths were related to peritonitis and intra‐abdominal soiling. Conclusions: Hospital systemic issues associated with mortality included extensive time delays in transfers, an inadequate transport process and frequent out‐of‐hours emergency operations. Patient features related to mortality included advanced age, significant medical co‐morbidity and surgical pathology with a poor prognosis. Improvements concerning interhospital transfers of patients should address both systemic and patient issues.     

Trends in paediatric injury rates using emergency department based injury surveillance

Objective: The primary aim of this study was to develop a method of calculating paediatric injury rate from Emergency Department injury surveillance data and use this to describe trends in paediatric injury. This study also aimed to establish whether triage category could be used as an indicator of severity. Methods: Prospective observational study of paediatric injury in Brisbane, Australia from 1998 to 2005 using Emergency Department injury surveillance data. Injury incidence was calculated using postcode restriction, census data and analysis of injury surveillance data quality and alternative hospital presentations. Results: The incidence of Emergency Department injury presentation increased by 56% between 1998 and 2005. The incidence of injury (adjusted for ascertainment and other hospital presentations) increased from 5,323/100,000/year to 8,316/100,000/year (p<0.01). The overall incidence of admission increased from 1,066/100,000/year to 1,238/100,000/year (p<0.01). The incidence of injury presentations triaged as urgent or above increased by 16% over the study period (2,348/100,000/year to 2,723/100,000/year, p<0.01). Conclusion: Injury incidence can be determined using Emergency Department injury surveillance data and triage category is a useful indicator of injury severity. Paediatric emergency department injury presentations, including serious injury, increased significantly between 1998 and 2005. Implications: The methodology used in this study is easily repeatable and could be used to evaluate injury prevention interventions. The prevention and management of injury should be directed by accurate injury incidence data.     

Do new workforce roles reduce waiting times in ED? A difference-in-difference evaluation using hospital administrative data

This paper evaluates the effect of introducing two new workforce roles under a pilot program conducted in Victoria, Australia. The trial took place at a regional hospital's emergency department (ED) between 1 July 2008 and 30 June 2009. The evaluation is based on three outcome measures: waiting time (in minutes) at ED before treatment; proportion of presentations with waiting time on target; and length of stay (in days), for ED presentations that led to in-patient admissions. The technique of difference-in-differences analysis is used. A total of 142,980 patient records from the pilot hospital and three comparison hospitals were extracted from the Victorian Emergency Minimum Dataset (VEMD). Further, 21,925 records of patients whose ED presentations led to in-patient admissions were extracted from the Victorian Admitted Episodes Dataset (VAED). The evaluation finds the piloted roles have lowered waiting time and raised the proportion of on-target presentations. These effects were found to be the strongest for less urgent triage categories. However, the evidence on in-patient length of stay was mixed. The results provide positive evidence that new workforce roles can be effective in improving the efficiency of emergency care delivery.     

Calibrating urgency: triage decision-making in a pediatric emergency department

Triage, the first step in the assessment of emergency department patients, occurs in a highly dynamic environment that functions under constraints of time, physical space, and patient needs that may exceed available resources. Through triage, patients are placed into one of a limited number of categories using a subset of diagnostic information. To facilitate this task and standardize the triage decision process, triage guidelines have been implemented. However, these protocols are interpreted differently by highly experienced (expert) nurses and less experienced (novice) nurses. This study investigates the process of triage; the factors that influence triage decision-making, and how the guidelines are used in the process. Using observations and semi-structured interviews of triage nurses, data was collected in the pediatric emergency department of a large Canadian teaching hospital. Results show that in emergency situations (1) triage decisions were often non-analytic and based on intuition, particularly with increasing expertise, and (2) guidelines were used differently by nurses during the triage process. These results suggest that explicit guideline information becomes internalized and implicitly used in emergency triage practice as nurses gain experience. Implications of these results for nursing education and training, and guideline development for emergency care are discussed.     

A holistic client-centred program for vulnerable frequent hospital attenders: cost efficiencies and changed practices

Objective: A small percentage of Australians frequently attend hospital emergency departments (ED) with potentially avoidable health crises. These individuals are termed ‘vulnerable’ due to their complex health and social needs. When these needs are unmanaged, unnecessary ED and hospital‐admission costs are incurred. A holistic community‐based program was developed to engage a cohort of vulnerable individuals in strategies to improve their health and health behaviours, and health service use. Methods: A purposive sample of frequent ED attendees was identified in one Australian metropolitan health region. Core program elements included working with clients within their environment, problem solving, empowerment, education, goal setting and mentoring. Evaluation data included services provided for, and time spent with, clients; hospital admission and emergency department attendances and related costs; client engagement data; mental health measures; client stories and participant interviews. Results: Data was analysed from 37 clients. On average, staff spent 34 hours with each client, costing approximately $1,700 each. Significant improvements resulted in client health and health behaviours. Crisis emergency department and inpatient admissions decreased, and planned outpatient clinic use increased. Conclusion: Low‐cost community‐based intervention for frequent ED attendees has the potential for significant tertiary hospital savings.     

Lung cancer: An exploration of patient and general practitioner perspectives on the realities of care in rural Western Australia

Objective: This study investigates if the pattern of diagnostic testing for suspected lung cancer, stage at diagnosis, patterns of specialist referral and treatment options offered to people in rural Western Australia are similar to those in the metropolitan area. It then explores the barriers to quality care in rural areas as perceived by GPs and patients. Methods: There was a review of GP records to obtain clinical and referral information and an in‐depth interview with patients and GPs concerning their perspectives of the quality of care. Results/Discussion: We selected age and sex‐matched samples of 22 rural and 21 metropolitan patients. Rural patients had more symptoms and took longer to consult their GPs, leading to later diagnosis and fewer treatment options. They experienced longer waits for specialist consultation and underwent less diagnostic testing. The GPs always referred lung cancer patients to a specialist, usually a respiratory physician. Teaching hospitals were preferred because of their comprehensive facilities and multidisciplinary teams. Rural GPs reported distance, time and availability of appointments as barriers; they also raised concerns about late confirmation of diagnosis. Rural and metropolitan patients were equally satisfied with their quality of care, but rural patients desired more information and better communication between hospital and GPs. Facilities for rural patients at some metropolitan hospitals were criticised. In conclusion, rural patients received a different care pattern from metropolitan patients and they and their GPs raised concerns about the equity and quality of lung cancer care.     

Measuring Rural Hospital Quality

CONTEXT: Increased interest in the measurement of hospital quality has been stimulated by accrediting bodies, purchaser coalitions, government agencies, and other entities. PURPOSE: This paper examines quality measurement for hospitals in rural settings. We seek to identify rural hospital quality measures that reflect quality in all hospitals and that are sensitive to the rural hospital context. METHODS: We develop a conceptual model for measuring rural hospital quality, with a focus on the special issues posed by the rural hospital context for quality measurement. With the assistance of a panel of rural hospital and hospital quality measurement experts, we review hospital quality measures from national and rural organizations for their fit to rural hospitals. FINDINGS: Based on this analysis, we recommend an initial core set of quality measures relevant for rural hospitals with less than 50 beds. This core set of 20 measures includes 11 core measures from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) related to community acquired pneumonia, heart failure, and acute myocardial infarction; 1 measure related to infection control; 3 measures related to medication dispensing and teaching; 2 procedure-related measures; 1 financial measure; and 2 other measures related to the use of advance directives and emergency department monitoring of trauma vital signs. CONCLUSION: Based on the special measurement needs posed by the rural hospital context, we suggest avenues for future quality measure development for core rural hospital functions (eg, triage, stabilization, and transfer, and emergency care) not considered in existing quality measurement sets.     

Implementation of a triage score system in an emergency room in Timergara,Pakistan

Following implementation of the South African Triage Scale (SATS) system in the emergency department (ED) at the District Headquarter Hospital in Timergara, Pakistan, we 1) describe the implementation process, and 2) report on how accurately emergency staff used the system. Of the 370 triage forms evaluated, 320 (86%) were completed without errors, resulting in the correct triage priority being assigned. Fifty completed forms displayed errors, but only 16 (4%) resulted in an incorrect triage priority being assigned. This experience shows that the SATS can be implemented successfully and used accurately by nurses in an ED in Pakistan.     

ECHO: the Western Australian Emergency Care Hospitalisation and Outcome linked data project

OBJECTIVE: To describe and assess the quality of the data resources linked for the Western Australian Emergency Care Hospitalisation and Outcome (ECHO) project. METHODS: The ECHO project links electronic records from the WA Emergency Department Information System to the St John Ambulance Service Pre-Hospital Care Database, the WA Hospital Morbidity Data System and the WA Mortality Database. Linkages are created using standard probabilistic matching techniques with extensive clerical review. Commencing with all metropolitan Perth public emergency departments from July 2000, these linkages will be updated annually for at least five successive years. The proportion of actual linkages between emergency department records and ambulance, admission and death records was assessed in comparison to expected linkage rates. RESULTS: Of 578,200 total emergency department records, there were 144,897 emergency presentations recorded as arriving by ambulance, of which 135,332 (93.4%) were linked to an ambulance record pertaining to the same episode. Of the 165,650 presentations recorded as admitted, 162,216 (97.9%) were linked to a hospital morbidity record relating to the same episode. Furthermore, 96.2% of the 2,084 cases recorded as 'dead on arrival' and 98.9% of the 624 cases recorded as 'died in emergency' were linked to a corresponding death record. CONCLUSIONS: Linkage quality consistent with international standards has been achieved, resulting in an information infrastructure capable of supporting an extensive research agenda focusing on the interaction and outcomes of both pre-hospital and within-hospital emergency medical care services.     

Emergency Care Utilization Among Pregnant Medicaid Recipients in North Carolina: An Analysis Using Linked Claims and Birth Records

Objectives To estimate the rate of pregnancy-associated emergency care visits and identify maternal and pregnancy characteristics associated with high utilization of emergency care among pregnant Medicaid recipients in North Carolina. Methods A retrospective cohort study using linked Medicaid hospital claims and birth records of 107,207 pregnant Medicaid recipients who delivered a live-born infant in North Carolina between January 1, 2008 and December 31, 2009. Rates were estimated per 1000 member months of Medicaid coverage. High utilization was defined as?≥?4 visits. Emergency care visits included encounters in the emergency department or obstetric triage unit during pregnancy that did not result in hospital admission. Results During the study period, 57.5% of pregnant Medicaid recipients sought emergency care at least once during pregnancy. There were 171,909 emergency care visits with an overall rate of 202.3 visits per 1000 member months. Among the subset of pregnant women with Medicaid coverage for the majority of their pregnancy (n?=?75,157), 18.1% were high utilizers. High emergency care utilization was associated with young age, black race, lower education, tobacco use, late preterm delivery, multifetal gestation, and having?≥?1 comorbidity. Threatened labor and abdominal pain were the leading indications for visits. Conclusion Utilization of hospital-based emergency care services was common in this cohort of pregnant Medicaid recipients. Additional research is needed to assess the drivers for accessing care through the emergency department, and to examine differences in pregnancy outcomes and health care costs between high and low utilizers.

     

思维导图预检分诊培训在急诊护理人员中应用效果分析

目的探讨急诊护理人员应用思维导图预检分诊培训的效果。方法选取2018年1月—2019年1月在该院急诊工作的护理人员23名作为对照组,并选择2019年2月—2020年2月在该院急诊工作的护理人员23名作为试验组。对照组实施传统分诊培训模式,试验组实施思维导图预检分诊培训,对比两组培训后的预检分诊总分及预检分诊中各维度评分。结果试验组预检分诊总分显著优于对照组,差异有统计学意义(P<0.05);试验组认知行为、直觉、经验和技术信心及评判性思维等预检分诊项目评分显著优于对照组,差异有统计学意义(P<0.05)。结论在急诊护理人员中应用思维导图预检分诊培训,显著提高预检分诊效率,同时提高护理人员在工作中的决策能力。     

Efficacy of the emergency unit's filter function in patients with psychiatric symptoms

The fundamental functions of the recently established emergency units/departments include the initial assessment, triage, commencement of treatment and referral for admission to the hospital. Aim: The aim of the study was to analyze psychiatric cases assessed at the department of emergency with particular reference to misdiagnoses and the reasons why emergency physicians failed to reach correct diagnoses. Method: This is a chart review of patients with psychiatric diagnoses evaluated at the Department of Emergency, Mohács City Hospital during 2006. These patients were followed through the electronic database of the hospital and their socio-demographic and clinical characteristics were analyzed. Results: Of the 596 patients who were considered primarily psychiatric cases during 2006, 289 (49%) were admitted to the psychiatric ward, 182 (30%) were referred to outpatient treatment, and 125 (21%) were misdiagnosed and proved to be non-psychiatric emergencies and eventually ended up in other wards (75 patients in internal medicine, 20 in neurology, 12 in intensive care, and 18 in other units). Conclusion: Overall, the diagnostic and triage functions of the department of emergency were satisfactory in psychiatric cases. Medical emergencies that were frequently mistaken for psychiatric cases (e.g. atypical pneumonia, sensory aphasia) deserve particular attention. The authors emphasize the importance of the close collaboration of different medical areas involved in emergency assessment and treatment.     

Rural Health Policy: A Limited-service Rural Hospital Model: The Freestanding Emergency Department

A rural hospital that has been downsized to a freestanding emergency department is an important model in that it offers a possible solution to a community's need to have emergency-care services locally available. This model could include other important local services, such as skilled-nursing and outpatient services. This study looks at the financial feasibility of a rural hospital shutting down acute-care services and maintaining emergency services. Expenses were determined, and changes to revenue and expenses were estimated. Reimbursement was assumed static. Medicare cost reports and hospital financial disclosure reports were used in investigating three model categories: an urgent-care clinic with emergency services; a hospital-based emergency department with an outpatient clinic; a hospital-based emergency department with an outpatient clinic and a hospital-based skilled-nursing facility. Even with best-case assumptions regarding continued reimbursement, results show only a small increase in net income and, in two cases, large losses compared with the size of the hospital operations. A subsidy would be required from the community or an affiliated hospital or network for the model to remain financially stable. The regulatory barriers to implementation are noted, as well as the potential problems with the human aspects of implementation--staffing, recruitment and retention, professional education and quality. If the model rural hospital is an affiliate or partner with one or more health care facility, which could assist with financial and staffing needs, it may be feasible.     

Life-threatening emergencies: patterns of demand and response of a regional emergency medical services system

This study focused on the nature and disposition of life-threatening emergencies. The data were drawn from hospital records (1,266 cases) from a 15-county area in the southeastern United States, consisting of a central metropolitan area surrounded by predominantly rural counties. The most important finding was that rural emergency departments transferred 7.4 percent of their patients. This proportion seems particularly low in light of emergency department categorizations and physician training data for the area. It may suggest underutilization of the region's resources by rural emergency care providers. Over a third of the life-threatening emergencies studied were cardiovascular, 17.9 percent medical, 13.3 percent trauma, and 9.7 percent neurological. The emergency department mortality rate for rural hospitals (11.5 percent) was nearly twice that of nonrural hospitals (6.8 percent).     

非战争军事行动野战方舱医院门急诊模块使用与分析

目的:探讨方舱医院门急诊布局及人员配置。方法:门急诊分开,建立急诊绿色通道;设立门诊挂号分诊区,由医疗组各专科医生出正常门诊,随伤员流动情况调整出诊医生人数;成立中心换药室及特诊帐篷。结果:某部野战方舱医院在2008年赴四川绵竹,2010年赴青海玉树抗震救灾执行任务中,采取此门急诊布局及人员配置,对患者的预控、分诊、治疗、技术操作和抢救等做到了救治质量零缺陷。结论:此种门急诊布局及人员配置,适应非战争军事行动方舱医院的门急诊管理,极大地提高了方舱医院的救治能力。     

Retrieval Principles for Rural GPs

ABSTRACT: The isolated rural general practitioner will, from time to time, be faced with a critically ill patient or medical emergency which requires a higher level of care than can be provided locally. These patients need to be resuscitated, stabilised and transferred to another centre and therefore may need to be escorted by medical personnel. Retrieval services aim to provide a level of expertise and equipment which can be taken to the patient so that management of the patient is optimised prior to transport and continued during transport. The medical retrieval teams which operate from Sydney are:

相似文献   

急诊科分诊及预见性护理

目的探讨急诊科分诊和预见性护理在临床应用的效果。方法回顾性分析该院急诊科2011年6—12月实施传统护理的368例患者和2012年1—6月急诊科护理实施预见性护理的412例患者,分别是定为对照组和实验组,观察分诊准确率,并发症和病死率。结果实验组患者的分诊情况、并发症发生率和死亡情况均较对照组有明显改善和提高,两者存在明显差异性。结论急诊科患者实行急诊分诊和预见性护理,有效地降低了致残率和并发症的发生,提高了治疗和护理的效果。     

Corneal metallic foreign body injuries due to suboptimal ocular protection

Retrospective review of 100 consecutive presentations of metallic corneal foreign body to the Royal Victorian Eye and Ear Hospital emergency department was undertaken between November and December 2009. The majority of the patients (97%) were male with a mean age of 42 ± 13 years (range 19-73 years). The most common mode of injury was grinding (88%). Nearly half (45%) of patients were wearing "safety eye wear" at the time of injury. Combination of 25-gauge needle and burr was the commonest method employed for removal of foreign body. Overall, 88% (n = 88) cases healed with corneal scar at the site of corneal foreign body and 1 case developed bacterial keratitis. Metallic corneal foreign bodies are common presentations to the emergency department and may be related to inadequate implementation of occupational safety measures.     

Measuring socio-economic inequalities in the presentation of injuries to a paediatric A&E department: the importance of an epidemiological approach

OBJECTIVES: To contrast the socio-economic pattern of childhood injuries presenting to a paediatric accident and emergency (A&E) department revealed by using both a numerator-based and a denominator-based approach to the analysis of injury surveillance data. METHODS: Injury surveillance data collected during 1997-1998 at a Glasgow children's hospital A&E department were analysed. Socio-economic status was measured using Carstairs' deprivation index. Data from West Glasgow postcode sectors only were analysed in order to optimize epidemiological validity. Socio-economic patterning of injury was investigated in two ways-numerator-based and denominator-based. RESULTS: A total of 12,762 children (0-14 years) living in West Glasgow attended the A&E department of the Royal Hospital for Sick Children over the study period. Both analytical approaches showed a clear and statistically significant excess of injury presentations in children from more deprived postcode sectors, but the variation appeared much greater in the numerator-based rather than the denominator-based approach. In regression analysis, however, only the denominator-derived rates showed a statistically significant linear trend across deprivation categories. CONCLUSION: The most appropriate and accurate means of measuring the extent of socio-economic (and other) inequalities in injury risk is to adopt a population-based rather than numerator-based perspective on the data collected by injury surveillance systems.