Weather patients will come?

OBJECTIVES: To determine whether weather conditions affect emergency department (ED) attendance and admissions from the ED. DESIGN AND SETTING: A retrospective observational study in a large metropolitan ED. MAIN OUTCOME MEASURES: ED attendance (total and via ambulance) and admissions to hospital from ED, as a function of weather variables. RESULTS: On warm, dry, sunny and good weather days there were significantly more ED attendances in total than there were on cool, rainy, dull and bad weather days, respectively (P < or = 0.001). There were significant correlations between ED attendance and temperature (r = 0.36, P < 0.001), rainfall (r = - 0.20, P < 0.001) and hours of sunshine (r = 0.17, P = 0.001). Attendance via ambulance was not affected by weather variables. Admissions from the ED were positively correlated with temperature (r = 0.15, P < 0.01) and negatively correlated with rainfall (r = - 0.12, P = 0.02). CONCLUSIONS: As there is a clear relationship between weather conditions and ED attendance, incorporating meteorological forecasting into emergency medicine training may improve ED scheduling. To improve the morale of ED staff coping with an onslaught of patients on good weather days, the ED environment should simulate sunny weather, with swimming pools, sun lamps, palm trees and Beach Boys music.     

Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis

OBJECTIVES: To study older patients presenting to the emergency department after a fall--factors associated with the fall, injuries sustained and outcome. DESIGN: A retrospective analysis using the Emergency Department Information System (EDIS), the Trauma Registry and the patient information database (CCIS), in addition to the patient's emergency and inpatient medical records. SETTING: Emergency department of a major inner city teaching hospital, 1 June-30 November 1997. PATIENTS: All patients over 65 years presenting to the emergency department (ED) after a fall, for whom complete medical records were available. RESULTS: Of 803 patients over 65 years presenting to the ED after a fall, complete records were available for 733 (91.3%) (283 men and 450 women). Extrinsic (accidental) causes were implicated in more than a third of falls (313 patients [42.7%]). A high proportion of the patients were living at home (520; 70.9%) and walking unaided (389; 53.1%). Although absolute numbers of women increased with age, men were as likely as women to present after a fall. Many patients had fallen before--39% of the men (111/283) and 24% of the women (110/450). In 78 patients (10.6%), alcohol misuse may have been a direct cause of the fall. The overall injury rate was 70.5% (517/733 patients), the most common injury being an isolated fracture (269/517 patients; 52.0%). In all, 419 patients (57.2%) were admitted to hospital, 48% (200/419) with a fracture and 52% (219/419) for investigation of the medical cause of the fall. The median length of hospital stay was 6 days (mean, 10.4 days; range, 1-129 days); 35% (146/419) of patients were in hospital for more than 10 days. CONCLUSION: Older patients presenting to the ED after a fall had high injury rates, high admission rates and often prolonged hospitalisation. About a third had fallen before. Patients at risk can be identified in the ED and referred to falls prevention programs.     

The potential lost hospital income from miscoded emergency department boarders in Ireland

Background

Emergency department (ED) boarders, namely patients who have been admitted under an in-patient service but remain on a trolley in the ED, have long been a problem in the Irish healthcare system.

Methods

We conducted a retrospective analysis of all ED boarders in Cork University Hospital (CUH) for a 6-month period from January to July 2011. Data were obtained from the Hospital In-Patient Enquiry Office (HIPE). The income generated by the hospital for a subset of these patients (January and February attendances) was obtained from the Finance Office in the hospital, based on diagnoses as recorded on the HIPE system. A convenience sample of two-thirds of the 39 acute hospitals nationally was surveyed to ascertain whether ED boarders were coded by individual HIPE offices as hospital in-patients or as ED attendees.

Results

A total of 806 patients were admitted to an in-patient service from January to July 2011 in CUH and subsequently discharged, having completed their entire stay in the ED. The income generated by a sub-sample of 228 patients (January and February ED boarders) was determined. The hospital was remunerated by €685,111 for these patients, i.e. an average income of €3,098 per patient. Only 8 hospitals of the 27 surveyed hospitals coded overnight ED Boarders as in-patients and were thus able to request income for these patients appropriately.

Conclusion

Discrepancies in coding of ED boarders may result in significant revenue losses for certain hospitals.     

The Impact of Inpatient Boarding on ED Efficiency: A Discrete-Event Simulation Study

In this study, a discrete-event simulation approach was used to model Emergency Department’s (ED) patient flow to investigate the effect of inpatient boarding on the ED efficiency in terms of the National Emergency Department Crowding Scale (NEDOCS) score and the rate of patients who leave without being seen (LWBS). The decision variable in this model was the boarder-released-ratio defined as the ratio of admitted patients whose boarding time is zero to all admitted patients. Our analysis shows that the Overcrowded⁺ (a NEDOCS score over 100) ratio decreased from 88.4% to 50.4%, and the rate of LWBS patients decreased from 10.8% to 8.4% when the boarder-released-ratio changed from 0% to 100%. These results show that inpatient boarding significantly impacts both the NEDOCS score and the rate of LWBS patient and this analysis provides a quantification of the impact of boarding on emergency department patient crowding.     

Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia

OBJECTIVE: To estimate the appropriateness of emergency department (ED) presentations by people aged>or=65 years living in residential care facilities. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study of older residents of residential care facilities who presented to the ED of the Royal Perth Hospital, Western Australia, between January and June 2002. Data were reviewed by an expert clinical panel. MAIN OUTCOME MEASURES: Appropriateness of ED presentation, presenting complaint, involvement of a general practitioner/locum doctor prior to transfer, proportion of patients admitted to hospital from the ED, survival to discharge. RESULTS: 541 residents aged>or=65 years were transferred by ambulance to the ED, comprising 8.3% of all ED presentations of people in this age group. The mean age of the study cohort was 83.7 years (SD, 7.0 years), of which 68% were women. Of the 541 presentations, 326 (60%) resulted in hospital admission, and of these, 276 (85%) survived to hospital discharge. Musculoskeletal disorders accounted for 25% of all presentations, and 22% were falls-related; pneumonia (11% of presentations) was the single largest presenting complaint. ED attendance was deemed "inappropriate" for 71/541 cases (13.1%; 95% CI, 10.5%-16.2%); in only 25% of ED presentations was a GP/locum doctor involved prior to transfer. CONCLUSIONS: The majority of ED presentations by aged care residents were considered to be appropriate, but there was scope for improvement in coordinating care between the hospital ED and residential care institutions.     

Avoidable attendance at accident and emergency by the elderly in Hong Kong.

Twenty per cent of Accident and Emergency department attendance by the elderly in a regional hospital in Hong Kong were deemed ''avoidable'' by the attending doctors. The ''avoidable'' attendants were younger and physically more independent than the appropriate attendants, and more of them were illiterate. Half of them attended the Accident and Emergency department for somatic complaints. Strategies to reduce these ''avoidable'' attendances should be formulated.     

The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments

OBJECTIVE: To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission. DESIGN: Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records. SETTING: Three tertiary metropolitan hospitals between July 2000 and June 2003. PARTICIPANTS: All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period. MAIN OUTCOME MEASURES: Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital. RESULTS: There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r=0.98; 95% CI, 0.79-1.00). An Overcrowding Hazard Scale>2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1-1.6), 1.3 (95% CI, 1.2-1.5) and 1.2 (95% CI, 1.1-1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale>2 compared with one of <3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1-1.1; P<0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1-1.3; P=0.01). CONCLUSIONS: Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.     

Developing machine learning models to personalize care levels among emergency room patients for hospital admission

ObjectiveTo develop prediction models for intensive care unit (ICU) vs non-ICU level-of-care need within 24 hours of inpatient admission for emergency department (ED) patients using electronic health record data.Materials and MethodsUsing records of 41 654 ED visits to a tertiary academic center from 2015 to 2019, we tested 4 algorithms—feed-forward neural networks, regularized regression, random forests, and gradient-boosted trees—to predict ICU vs non-ICU level-of-care within 24 hours and at the 24th hour following admission. Simple-feature models included patient demographics, Emergency Severity Index (ESI), and vital sign summary. Complex-feature models added all vital signs, lab results, and counts of diagnosis, imaging, procedures, medications, and lab orders.ResultsThe best-performing model, a gradient-boosted tree using a full feature set, achieved an AUROC of 0.88 (95%CI: 0.87–0.89) and AUPRC of 0.65 (95%CI: 0.63–0.68) for predicting ICU care need within 24 hours of admission. The logistic regression model using ESI achieved an AUROC of 0.67 (95%CI: 0.65–0.70) and AUPRC of 0.37 (95%CI: 0.35–0.40). Using a discrimination threshold, such as 0.6, the positive predictive value, negative predictive value, sensitivity, and specificity were 85%, 89%, 30%, and 99%, respectively. Vital signs were the most important predictors.Discussion and ConclusionsUndertriaging admitted ED patients who subsequently require ICU care is common and associated with poorer outcomes. Machine learning models using readily available electronic health record data predict subsequent need for ICU admission with good discrimination, substantially better than the benchmarking ESI system. The results could be used in a multitiered clinical decision-support system to improve ED triage.     

Process Modeling of Emergency Department Patient Flow: Effect of Patient Length of Stay on ED Diversion

A discreet event simulation methodology has been used to establish a quantitative relationship between Emergency Department (ED) performance characteristics, such as percent of time on ambulance diversion and the number of patients in queue in the waiting room, and the upper limits of patient length of stay (LOS). A simulation process model of ED patient flow has been developed that took into account a significant difference between LOS distributions of patients discharged home and patients admitted into the hospital. Using simulation model it has been identified that ED diversion could be negligible (less than ∼0.5%) if patients discharged home stay in ED not more than 5 h, and patients admitted into the hospital stay in ED not more than 6 h Using full factorial design of experiments with two factors and the model’s predicted percent diversion as a response function, other combinations of LOS upper limits have been determined that would result in low ED percent diversion as well. It has also been determined that if the number of patients exceeds 11 in queue in ED waiting room then the diversion percent is rapidly increasing.     

The effect of multidisciplinary case management on selected outcomes for frequent attenders at an emergency department

OBJECTIVE: To evaluate the effects of multidisciplinary case management (CM) on emergency department (ED) utilisation and psychosocial variables for frequent attenders at the ED. DESIGN: Retrospective cohort analysis, with the study population as historical controls and data analysed 12 months before and after CM intervention in the period 1 January 2000 - 31 December 2004. Subgroup analyses were performed according to primary problem categories: general medical, drug and alcohol, and psychosocial. SETTING: Inner urban tertiary hospital ED. PARTICIPANTS: Frequent ED attenders who received CM. MAIN OUTCOME MEASURES: ED attendances: length of stay, triage category, ambulance transport, disposition, attendances at the only two EDs nearby. Psychosocial factors: housing status, drug and alcohol use, and primary and community care engagement. RESULTS: 60 CM patients attended the ED on 1387 occasions. Total attendances increased after CM for the whole group (610 v 777, P = 0.055). Mean average length of stay (minutes) of the total study population and each subgroup was unaffected by CM (297 v 300, P = 0.8). Admissions for ED overnight observation increased as a result of CM (P = 0.025). CM increased scores for housing stability (P = 0.007), primary care linkage (P = 0.003), and community care engagement (P < 0.001) for the whole group and variously within subgroups. Drug and alcohol use was unaffected by CM. CONCLUSION: ED-initiated, multidisciplinary CM appears to increase ED utilisation and have a positive effect on some psychosocial factors for frequent attenders. A trend towards increased ED attendance and utilisation with CM may have implications for policies that seek to divert frequent attenders away from hospitals.     

Inappropriate utilization of emergency department services in Universiti Sains Malaysia hospital

Inappropriate utilization of Emergency Departments (ED) services may result in compromised management of patients requiring true emergency treatment. Significant attendance of non-emergency cases in ED was found in several countries. A cross-sectional study was conducted in Universiti Sains Malaysia Hospital (HUSM) to determine the proportion of the inappropriate cases and the utilization pattern by time (over 24 hours and within a week) and by diagnoses. A sample of 350 cases was randomly selected from ED-HUSM register of the year 2000. A decision flowchart, which was adopted from 4 guidelines, was applied to classify appropriate and inappropriate cases. There were 55% inappropriate cases in this study. The inappropriate cases increased considerably in early morning, late evening, during the weekend and early part of the week. Most common diagnoses of inappropriate cases were upper respiratory tract infections, mild acute gastroenteritis and urinary tract infections. Considerable attendance of inappropriate cases calls for interventions.     

Amphetamine-related presentations to an inner-city tertiary emergency department: a prospective evaluation

OBJECTIVE: To describe the prevalence, characteristics and outcomes of amphetamine-related presentations to a tertiary hospital emergency department (ED). DESIGN, SETTING AND PARTICIPANTS: Prospective observational study of amphetamine-related presentations to the ED of the Royal Perth Hospital (RPH), an adult, inner-city, tertiary referral hospital, between 3 August and 2 November 2005. For all patients presenting to the ED, the treating doctors were automatically prompted by the computerised data entry system to consider amphetamine use. MAIN OUTCOME MEASURES: Proportion of ED presentations related to amphetamine use; demographic features and usage practices of amphetamine users; characteristics of presentations and admissions; associated psychiatric illnesses and use of other drugs. RESULTS: Over the study period, there were 13 125 presentations, of which 156 (1.2%) were judged to be causally related to amphetamine use. Of those 156 patients, over half were habitual drug users (89 [57.1%] used amphetamines at least weekly), and the majority were men (111 [71.2%]). The mean age was 28 years (range, 16-55 years). Presentations were of high acuity: 104 patients [66.7%] were rated 1, 2 or 3 on the Australasian Triage Scale; 50 (32.1%) arrived by ambulance; and 25 (16.0%) arrived with police. The mean time spent in the ED was 6 h (range, 0.5-24 h). Fifty patients (32.1%) required sedation, and the likelihood of requiring sedation increased almost threefold if the heart rate was over 100 beats/min on presentation. Sixty-two patients (39.7%) were admitted and 58 (37.2%) required psychiatric evaluation. Repeat attendance was common, with 71 patients (45.5%) having previous amphetamine-related presentations to the RPH ED. CONCLUSIONS: Amphetamine-related presentations comprise 1.2% of all ED attendances and have a major impact on hospital EDs. Patients are often agitated and aggressive, require extensive resources, and frequently re-attend. The burden of amphetamine-related illnesses on EDs is likely to increase in the future.     

Acute asthma attack in children presenting to the emergency department. Survey of 96 cases

Throughout a 2-year period, children who presented at H?tel-Dieu de France emergency department (ED) with acute asthma were analyzed prospectively and data on their environment, family and personal history as well as treatment were recorded. Treatment delivered at the ED, response and further outcome were analyzed. Out of 2024 children aged less than 15 years, 96 (5%) had acute asthma attack. Their median age was 4 years and M/F ratio was 2:1. Median age at onset of asthma was 2 years. Only 66 patients were recognized as asthmatics and 20% were given regular inhaled daily treatment. Current attack was mild in 45%, moderate in 45% and severe in 10% of cases. Home treatment before ED admission was often inadequate. Nine patients required hospital admission after failure of treatment at the ED. Within a median follow-up of 12 months, half of the patients experienced further attacks sometimes requiring ED care (27%) or hospital admission (8%). These data highlight the fact that asthma in our country is still largely under recognized and inadequately treated.     

整形美容急诊病案管理的探索

应用Excel系统软件对我院2011年收治急诊患者的病案资料、各种登记进行回顾性研究分析。发现急诊病案存在患者基本信息不准确、收费不合理、归档不及时等问题。针对具有整形美容专科特点的急诊病案存在的问题和急诊患者的各项信息指标,结合急诊患者流量的统计,探索其规律,及时反馈给医院各级领导,采取预防性纠正措施,收效显著;并科学地调配仪器、设备、人员,最大限度地满足患者的各种医疗需求,获得社会效益和经济效益。促进整形美容专科急诊病案规范化、系统化、科学化、高效率的管理。     

我院血液内科抗菌药物利用分析

目的了解我院血液内科住院患者抗菌药使用情况,为临床经济合理用药提供参考。方法回顾性分析我院2011年9月-2012年2月血液内科住院患者抗菌药使用相关信息及数据,对其中注射及口服抗菌药的用药金额、用药频度（DDDs）、日均用药费用（DDC）及序号比进行分别计算,分析血液内科抗菌药临床应用情况。结果我院血液内科抗菌药使用注射剂以碳青霉烯类、头孢菌素类及其他β-内酰胺类为主,其中,碳青霉烯类以对肾脱氢肽酶稳定的美罗培南为主,头孢菌素类以头孢哌酮钠他唑巴坦钠为主,其他β-内酰胺类仅包含头孢米诺钠一个品种;碳青霉烯类及抗真菌类日均用药费用普遍较高;口服制剂以抗真菌类的氟康唑和伊曲康唑为主,其中,氟康唑的临床使用率高,价格较低,用药金额与用药频度同步性好,口服制剂中除伏立康唑外DDC都相对较低。结论我院血液内科抗菌药使用基本合理,应根据本科室感染特点,进一步合理选用抗菌药。     

How frequent is bystander cardiopulmonary resuscitation performed in the community of Kota Bharu, Malaysia?

INTRODUCTION: Bystander cardiopulmonary resuscitation (CPR) serves as a vital link to improve the chance of survival among the out-of-hospital cardiac arrest (OHA) patients. The frequency of bystander CPR in Malaysia is largely unknown. The aim of this study was to find out how frequently bystander CPR was performed among OHA patients with CPR performed at the Emergency Department (ED), Hospital Universiti Sains Malaysia (HUSM), prior to their arrival to the department. METHODS: In this one-year observational study, data was collected from cases of CPR performed in ED, HUSM. In the OHA category, a subanalysis was further performed to look into the frequency and effects of bystander CPR on achieving return of spontaneous circulation and survival to hospital admission. The categorical data collected was analysed using chi-square test or Fisher-exact test. RESULTS: Out of a total of 23 OHA patients that had CPR performed on arrival at the ED, HUSM, from March 2005 to March 2006, only two cases (8.7 percent) had bystander CPR performed. None of these two cases achieved return of spontaneous circulation. CONCLUSION: Although this study has many limitations, it does indicate that the frequency of bystander CPR is dismally low in our community and the mere fact that bystander CPR was reported to be done does not seem to translate into a higher chance of survival to admission. The quality and effectiveness of the technique is equally important.     

Factors influencing the presentation and care of elderly people in the emergency department.

OBJECTIVE: To provide Australian data from a community setting on the use of the Emergency Department by elderly persons. DESIGN: The paper describes three studies. Study 1 analyses patient admission patterns, and clinical data taken retrospectively from medical records for 1987. Studies 2 and 3 prospectively survey referral, transport, demographic profiles and clinical management practices in two patient samples taken during 1987 and 1988. SETTING: The Emergency Department of Sutherland Hospital, Sydney--a community based hospital of 374 beds. Patients: In study 1, we assessed 4609 hospital admissions of patients aged 60 years or more using ICD-9-CM coding. In Studies 2 and 3, samples of 74 patients aged 65 years or more and 100 patients aged 70 years or more who presented to the Emergency Department were assessed consecutively and prospectively. INTERVENTIONS: No specific interventions outside of usual Emergency Department routines were undertaken except for collection of demographic data. MAIN OUTCOME measures: Demographic characteristics, diagnostic categories, and referral, admissions and hospital separation data. RESULTS: In Study 1, of 4609 patients aged 60 years or more 3182 (69%) entered hospital via the Emergency Department. These 3182 represented 29% of total hospital admissions for that year. In Study 2 the male to female ratio was 32 to 42; the mean age was 78.16 years; 88% were pensioners; 20% had additional private insurance; 76% of women were widowed compared with 32% of men; 84% of the group lived in their own homes but, of these, 51% of women lived alone compared with 7.7% of men. The disease profile was that of acute organic disease in 97% of presentations. Ambulance transport to the Emergency Department was used by 65% of patients and Emergency Department facilities were used mostly during "working hours"; 64% of patients were admitted to hospital. The pre-hospital "activities of daily living" (ADL) functioning was assessed as being independent in 85%. In Study 3, the social and demographic profile was similar to Study 2. Fifty seven of the 100 patients used ambulance transport to the Emergency Department and this was initiated by a general practitioner in 13 instances. The general practitioner was the referring source in 28% of cases. Waiting times in the Emergency Department demonstrated a mean time from arrival to assessment by a medical officer of 30 minutes and a total time spent in the Emergency Department of 3 hours 4 minutes for those discharged home and 4 hours 24 minutes for those admitted. CONCLUSION: These studies demonstrate that the Emergency Department is a major area for care of the elderly and entry into the hospital system. Referral from a general practitioner and the use of ambulance transport from home to the Emergency Department are frequent pathways of care that may have important cost-benefit implications and deserve further study. The elderly in these studies appear to use the Emergency Department appropriately for acute medical/surgical need. The social profiles suggest that widowed women present a special case in terms of discharge plans for management.     

Bicycle-related injuries: a prospective study of 200 patients

INTRODUCTION: This study aims to evaluate the magnitude, mechanism, distribution and outcome of bicycle-related injuries managed at the Emergency Department, Al-Ain Hospital, United Arab Emirates. METHODS: 200 patients, who were treated at the emergency department of Al-Ain Hospital during the period of October 2001 to January 2003, were prospectively studied. A hard copy protocol was designed and data was collected on a daily basis. RESULTS: 175 patients (87.5 percent) were males. The average age was 16.1 +/- 13.7 years. Only two were wearing helmets (one percent). The majority of injuries occurred in the evening and was due to a fall from a bicycle in 163 patients (81.5 percent). 88 patients had lower limb injuries (44 percent), and 72 had head and neck injuries (36 percent). Only 31 patients (15.5 percent) needed hospitalisation. Of these, four (12.9 percent) were admitted to the intensive care unit. The mean (range) hospital stay was 6.3 (1-23) days. Patients who were admitted to the hospital were older males, involved in motor vehicle collisions, and had more head injuries. Three patients (1.5 percent) died. CONCLUSION: Bicyclists' head injuries, caused by a motor vehicle collision, are a main cause of hospital admission. Helmet compliance in our community is alarmingly low, indicating the need for legislation and education on the use of helmets.     

灰色数列预测模型在煤工尘肺预测中的应用

利用灰色数列预测模型对煤工尘肺年度患病人数进行了预测，同时与指数曲线模型和二次抛物线模型的预测效果进行了比较。结果表明：灰色数列预测模型外推性预测效果优于另外二种模型。