Emergency medicine in Belarus

Belarus is a small eastern European nation between Poland and Russia. Except for the lingering effects of Chernobyl radiation contamination, its system of health care and, in particular, emergency care has received little attention in the world literature. Emergency medical care is organized similarly to that provided in Russia and other European countries. A well-coordinated Emergency Medical Services (EMS) system exists, and many ambulance teams include a physician. Most emergency care is provided in an area of the hospital designated as the reception area, the equivalent of a U. S. emergency department (ED). Unlike the practice in U.S. EDs, many patients have a minimal evaluation after admission to the actual ward or hospital ICU. Emergency Medicine has not been officially organized as a specialty. Opportunities exist for interchange and discussion on the delivery of emergency care.     

Pressure area care in primary care: issues in equipment provision

The pressure area care needs of primary care patients are becoming more complex due to changes in health care provision. Enabling patients to remain in their own home and allowing them some independence even though they are at high risk of developing pressure damage, relies on the nurse's knowledge of prevention strategies and equipment provision locally. This article discusses the key issues in relation to the provision of pressure-relieving equipment in a rural care trust in England, and how the trust has overcome the problem of equipment failure, especially out of hours and weekends.     

Patient perceptions of hospital care: building confidence,

Aim The aim of this study was to understand how people evaluate and make sense of their experience of hospital care.
Method Narrative interviews were conducted with 18 patients between 4–6 weeks after an episode of inpatient care or day surgery. Participants were deliberately sampled from a population who participated in a hospital-wide audit which took place during 1 week in June 1995. Sampling criteria ensured a mix of age, gender, type of, and reason for, admission. The interviews were audiotaped, transcribed and analysed using grounded theory.
Findings Three categories: 'feeling informed', 'valued as an individual', and 'at home' contributed to a core category: 'building confidence, faith and trust'. Notably, confidence and trust were determined as much by observations of the care given to other people, as the care the participants themselves had received.
Conclusions More attention needs to be given to understanding the complex social and reflective process which underpin patient judgements about quality of care.     

23-hour care centre: changing the culture of care.

AIM: A 23-hour Care Centre was created at a principal referral hospital in Sydney in 2003. Its primary aim was to provide efficient and high quality care to patients requiring a brief stay in hospital for surgical or medical procedures, within one coordinated unit. DESIGN: The features underlying the 23-hour Care Centre as an innovative model of care were the clinical guideline driven approach and nurse-initiated discharge. All patients, emergency and elective as well as surgical and medical, who fitted the following criteria were admitted as '23-hour patients' to the Centre. The criteria were: absolute expectation of discharge within 24 hours; pre-admission screening by a nurse screener (if elective admission); agreed clinical guideline in place; and, agreement to protocol-based, nurse-initiated discharge. RESULTS: Following the first three months of the 23-hour Care Centre, 1601 patients utilised the 23-hour Care Centre as follows: 593 day only patients, 410 DOSA (day of surgery admission) patients and 598 23-hour patients. Excluding inappropriate admissions, overall discharge compliance was 83%. CONCLUSION: From the results generated throughout the trial it has become evident that the new clinical area offers a workable system of health care delivery for patients who require a brief stay in hospital, as it promotes an efficient use of hospital beds and services without compromising patient outcomes. However, further research is required to compare the efficiency and outcomes of care directly with that provided by the traditional inpatient hospital system.     

Use of emergency observation and assessment wards: a systematic literature review

Introduction: Observation and assessment wards allow patients to be observed on a short-term basis and permit patient monitoring and/or treatment for an initial 24–48 hour period. They should permit concentration of emergency activity and resources in one area, and so improve efficiency and minimise disruption to other hospital services. These types of ward go under a variety of names, including observation, assessment, and admission wards. This review aims to evaluate the current literature and discuss assessment/admission ward functionality in terms of organisation, admission criteria, special patient care, and cost effectiveness.

Methods: Search of the literature using the Medline and BIDS databases, combined with searches of web based resources. Critical assessment of the literature and the data therein is presented.

Results: The advantages and disadvantages of the use of assessment/admission wards were assessed from the current literature. Most articles suggest that these wards improve patient satisfaction, are safe, decrease the length of stay, provide earlier senior involvement, reduce unnecessary admissions, and may be particularly useful in certain diagnostic groups. A number of studies summarise their organisational structure and have shown that strong management, staffing, organisation, size, and location are important factors for efficient running. There is wide variation in the recommended size of these wards. Observation wards may produce cost savings largely relating to the length of stay in such a unit.

Conclusion: All types of assessment/admission wards seem to have advantages over traditional admission to a general hospital ward. A successful ward needs proactive management and organisation, senior staff involvement, and access to diagnostics and is dependent on a clear set of policies in terms of admission and care. Many diagnostic groups benefit from this type of unit, excluding those who will inevitably need longer admission. Vigorous financial studies have yet to be undertaken in the UK. Definitions of observation, assessment, and admission ward are suggested.

     

A GITATED D ELIRIUM AND S UDDEN D EATH : T WO C ASE R EPORTS

Objective. To determine the chemicals involved in fire department hazardous materials (hazmat) responses and analyze the concomitant emergency medical services' patient care needs. Methods. The setting was a mid-sized metropolitan area in the southwestern United States with a population base of 400,000 and an incorporated area of 165 square miles. The authors conducted a retrospective evaluation of all fire department hazmat reports, with associated emergency medical services patient encounter forms, and in-patient hospital records from January 1, 1992, through December 31, 1994. Results. The fire department hazardous materials control team responded to 468 hazmat incidents, involving 62 chemicals. The majority of incidents occurred on city streets, with a mean incident duration of 46 minutes. More than 70% of the responses involved flammable gases or liquids. A total of 32 incidents generated 85 patients, 53% of whom required transport for further evaluation and care. Most patients were exposed to airborne toxicants. Only two patients required hospital admission for carbon monoxide poisoning. Conclusion. Most hazmat incidents result in few exposed patients who require emergency medical services care. Most patients were exposed to airborne toxicants and very few required hospitalization. Routine data analysis such as this provides emergency response personnel with the opportunity to evaluate current emergency plans and identify areas where additional training may be necessary.     

Utilization review. Emergency medicine implications.

The medical profession has made utilization review a priority in its efforts to limit health care expenditures. In emergency medicine this has ranged from initiatives to limit inappropriate emergency department visits to guidelines to limit emergency department testing and criteria to limit hospital admissions. The emergency department observation unit is an area in which the emergency physicians follow these practice guidelines without compromising patient care. The emergency department utilization review/quality assurance committee is a management tool by which emergency physicians monitor and implement these strategies for cost-effective patient care.     

Community health equipment loans: developing a clinical prioritization system

This project aimed to develop an objective method for making equipment loans to home-based patients using a prioritisation system based on clinical need. An action research approach was selected as the most appropriate method because of the collaborative nature of the project. It involved working mainly with community nurses using questionnaires, focus groups, telephone and direct interviews. An important part of the process was a workshop with all stakeholders to involve them in decision-making. The resulting unique clinical referral form was implemented successfully. The research also highlighted existing attitudes and perceptions of the equipment loans service among health professionals. The new clinical referral form has improved service provision, is more equitable and now allows decisions to be made using agreed clinical criteria. The results of the research have been disseminated locally in the process of integration of NHS and social services equipment loans. This is a unique example of collaboration between community nursing practitioners, primary care trust managers and researchers producing a measurable difference to patient care.     

A urological urgent assessment unit service evaluation in a United Kingdom hospital

What are the experiences, evaluations and satisfaction levels of service users requiring ambulatory, urgent and emergency urological care who attended a newly implemented urology assessment unit (UAU) in a National Health Service (NHS) hospital in the United Kingdom (UK)? A UAU within an acute care setting was set up for ambulatory, emergency and urgent urological care. The objectives of the unit was to improve patient satisfaction, divert patients from the emergency department, provide an area for early specialist review, allow earlier discharge from hospital and prevent unnecessary admissions to hospital. The aim of this service evaluation (SE) was to evaluate the service user experience and satisfaction when attending this unit. Surgical assessment units are well-supported in terms of reducing admissions and diverting patients from emergency departments, however, there is little published research regarding units specifically for urology. Important sources involved in urological care delivery and services advocate their implementation but there remains very little published evidence to support this. Opinion pieces and short case studies have yielded positive results. No research was found that has looked into patient satisfaction, experience and feedback of these units in any detail. A SE was conducted involving sending a postal questionnaire to a random selection of 150 patients who attended the UAU. The questionnaire contained a set of 13 Likert-style questions with additional free text open-ended questions for provision of further clarification and service user expression. Questions around age, reason for admission and accessibility to the UAU were also included. The Likert-style and demographic questions were analysed by quantifying responses to percentages and the open-ended responses were analysed thematically. The questionnaire response rate of 51% was seen from 76 respondents and these were most commonly over 71 years old (47%). The most common reasons for attending were urinary retention, infection and post-operative urological problems. Of these, 22% did not need to see a doctor and were treated and discharged by the urology nurse practitioner. The care on the UAU was rated highly and generally found to be preferable over the care provided by emergency departments (ED) and general practitioners (GP) family doctors and patients were grateful to avoid being admitted to hospital. Patients appreciated easy access to specialist care and knowledge. Good levels of communication were highlighted as important. Open-ended response themes included; nursing, doctors, environment, access, communication, specialist access, preventing ED attendances and hospital admissions. Participants rated the care from the nurses and doctors highly; there was a focus on appreciating seeing a specialist directly and avoiding admission to hospital. They were satisfied with being able to avoid attending their GP or ED, and generally preferred the unit over these routes of care. There are multiple areas within emergency and urgent urological care that require further research.     

The ED‐inpatient dashboard: Uniting emergency and inpatient clinicians to improve the efficiency and quality of care for patients requiring emergency admission to hospital

Patients who require emergency admission to hospital require complex care that can be fragmented, occurring in the ED, across the ED‐inpatient interface (EDii) and subsequently, in their destination inpatient ward. Our hospital had poor process efficiency with slow transit times for patients requiring emergency care. ED clinicians alone were able to improve the processes and length of stay for the patients discharged directly from the ED. However, improving the efficiency of care for patients requiring emergency admission to true inpatient wards required collaboration with reluctant inpatient clinicians. The inpatient teams were uninterested in improving time‐based measures of care in isolation, but they were motivated by improving patient outcomes. We developed a dashboard showing process measures such as 4 h rule compliance rate coupled with clinically important outcome measures such as inpatient mortality. The EDii dashboard helped unite both ED and inpatient teams in clinical redesign to improve both efficiencies of care and patient outcomes.     

Prehospital noninvasive pressure support ventilation for acute cardiogenic pulmonary edema.

Severe acute cardiogenic pulmonary edema (ACPE) can successfully be treated with noninvasive pressure support ventilation (NIPSV) in a clinical setting. Whether prehospital NIPSV starting early at patients' home and being continued until hospital arrival is feasible and improves ACPE emergency care is examined in this study. End points of the study were oxygen saturation at hospital admission and clinical outcome. Twenty-three patients suffering from severe cardiac pulmonary edema with severe dyspnea, an oxygen saturation of less than 90% and basal rales were included in this controlled prospective randomized trial. All patients received standard medical treatment and 10 patients were additionally treated with NIPSV (pressure support level, 12 cmH2O; positive endexpiratory pressure, 5 cmH2O; FiO2, 0.6) whereas the other patients received oxygen (8 l/min) via Venturi face mask. Improvement in oxygen saturation was significantly faster in the NIPSV group and oxygen saturation was higher at the time of the hospital admission (NIPSV=97.3+/-0.8%; standard=89.5+/-2.7%, P=0.002). A trend toward higher troponin T levels was seen in the standard treatment group. The need for intensive care treatment did not differ, and one patient of each treatment group died in hospital. No complications were noted during the treatment with NIPSV. Prehospital NIPSV is feasible and able to improve emergency management of ACPE.     

Failure to Validate a Predictive Model for Refusal of Care to Emergency-department Patients

Objective: To determine whether previously developed triage criteria for refusal of care to patients presenting to an emergency department (ED) with nonurgent problems could be validated for an independent patient population.
Methods: A convenience sample of 534 adults presenting to a municipal hospital ED between July 1, 1992, and October 15, 1992, who met preestablished criteria for refusal of care were entered into a prospective, observational, cohort study. The single target outcome variable was hospitalization. In order to optimize the criteria's performance, both the triage nurse and the physician caring for the patient had to agree that all criteria for "refusal of care" were specifically met. No patient was refused care, nor was a patient's management or disposition interfered with in any way by the investigators. All patients were followed until hospital admission or release from the ED.
Results: Six (1.1%) of 534 patients (95% CI 0.4–2.4) who met the criteria for refusal of care were hospitalized. This represents a greater than 50-fold difference in incidence of hospitalization when compared with that found by other investigators, who reported that only 0.02% (95% CI 0.0004–0.04) of those patients who were refused care subsequently required hospitalization (p < 10–7).
Conclusion: The authors were unable to validate a previously developed predictive model for refusal of care to patients presenting to an ED. Refusal of care to selected ED patients based on current guidelines is not a viable solution to overcrowding. Alternative strategies must be sought.     

Equestrian injuries: A five-year review

A retrospective chart review was conducted to define the demographic and injury patterns of patients presenting to the emergency department (ED). The setting is a rural/small urban tertiary care center with approximately 40,1100 visits per year. All patients presenting to the ED from January 1986 through December 1990 with equestrian-related injuries were enrolled in the study. Measurements included age, sex, mechanism of injury, injury or injuries diagnosed, admission to the hospital, morbidity, and morality. A total of 142 patients met the inclusion criteria. The majority of Injuries occurred when the patient fell from a horse. There were also a large number of injuries associated with handling the horse. Most injuries were minor, but 15% required hospital admission. There were no deaths. In conclusion, equestrian activities are associated with a risk of serious injury to both riders and handlers of horses. Education of both the public and primary care physicians should focus on injury prevention.     

Validation of the 2001 American Thoracic Society criteria for severe community-acquired pneumonia

STUDY OBJECTIVE: Ewig et al. proposed a new definition of severe community-acquired pneumonia in 1999, which was adopted by the American Thoracic Society in 2001. We evaluated this definition in an independent population of emergency department patients. DESIGN: We compared the 2001 American Thoracic Society definition of severe community-acquired pneumonia using emergency department data to intensive care unit (ICU) admission, use of mechanical ventilation, and administration of vasopressors. SETTING: LDS Hospital, a tertiary care, university-affiliated hospital with 520 total beds and 68 ICU beds in Salt Lake City, UT. PATIENTS: We studied 980 consecutive emergency department patients with a radiographically confirmed diagnosis of pneumonia between June 1995 and June 1999. Of these patients, 498 were admitted to the hospital, immunocompetent, and without a "do-not-resuscitate" order within 24 hrs of admission. MEASUREMENTS AND MAIN RESULTS: Forty-seven patients met the criteria for severe community-acquired pneumonia in the emergency department and were admitted to the ICU. Three hundred eighty patients did not meet the criteria and were admitted to a hospital unit. Nineteen patients met the definition but were admitted to a hospital unit; only one required subsequent ICU admission. Two of the 19 died after a do-not-resuscitate order was entered >24 hrs after admission; the remainder recovered. Fifty-two patients were triaged to the ICU but did not initially meet the definition of severe pneumonia. Sixteen of these 52 patients required mechanical ventilation, 13 of the 16 within 24 hrs of admission to the ICU. The sensitivity for the 2001 American Thoracic Society definition in our population was 44%, specificity was 95%, positive predictive value was 71%, and negative predictive value was 88%. CONCLUSION: The 2001 American Thoracic Society definition of severe community-acquired pneumonia had high specificity but lower sensitivity in our population compared with the derivation population. Additional factors not reflected in the definition may contribute to ICU admission and the need for mechanical ventilation.     

Provider-in-triage prediction of hospital admission after brief patient interaction

Background and objectivesWe sought to determine if emergency physician providers working in the triage area (PIT) of the ED could accurately predict the likelihood of admission for patients at the time of triage. Such predictions, if accurate, could decrease the time spent in the ED for patients who are admitted to the hospital by hastening downstream workflow.MethodsThis is a prospective cohort study of PIT providers at a large urban hospital. Physicians were asked to predict the likelihood of admission and confidence of prediction for patients after evaluating them in triage. Measures of predictive accuracy were calculated, including sensitivity, specificity, and area under the receiver operator characteristic (AUROC).Results36 physicians (20 attendings, 16 residents) evaluated 340 patients and made predictions. The average patient age was 48 (range 18–94) and 52% were female. Seventy-three patients (21%) were admitted (5% observation, 85% general care/telemetry, 7% progressive care, 3% ICU). The sensitivity of determining admission for the entire cohort was 74%, the specificity was 84%, and the AUROC was 0.81. When physicians were at least 80% confident in their predictions, the predictions improved to sensitivity of 93%, specificity of 96%, and AUROC 0.95 (Graph 1).ConclusionThe accuracy of physician providers-in-triage of predicting hospital admission was very good when those predictions were made with higher degrees of confidence. These results indicate that while general predictions of admission are likely inadequate to guide downstream workflow, predictions in which the physician is confident could provide utility.