Study objective Reasons for recurrent emergency department (ED) visits have been examined primarily through administrative data review. Inclusion of patients’ perspectives of reasons for ED return ...may help inform future initiatives aimed at reducing recurrent utilization. The objective of this study is to describe the personal experiences and challenges faced by patients transitioning home after an ED discharge. Methods We performed semistructured qualitative interviews of adult patients with an unscheduled return to the ED within 9 days of an index ED discharge. Questions focused on problems with the initial discharge process, medications, outpatient care access, social support, and health care decisionmaking. Themes were identified with a modified grounded theory approach. Results Sixty interviews were performed. Most patients were satisfied with the discharge process at the index discharge, but many had complaints about the clinical care delivered, including insufficient evaluation and treatment. The primary reason for returning to the ED was fear or uncertainty about their condition. Most patients had a primary care physician, but they rarely visited a physician before returning to the ED. Patients cited convenience and more expedited evaluations as primary reasons for seeking care in the ED versus the clinic. Conclusion Postdischarge factors, including perceived inability to access timely follow-up care and uncertainty and fear about disease progression, are primary motivators for return to the ED. Many patients prefer hospital-based care because of increased convenience and timely results. Further work is needed to develop alternative pathways for patients to ask questions and seek guidance when and where they want.
Study objective Despite focus during the past decade about the need to design a more patient-centered US health care system, patients have been minimally engaged to define what they want from it. Our ...objective is to engage patients to identify individual-defined priority outcomes on discharge from the emergency department (ED) and individually tailored interventions to help achieve their outcomes. Methods We used qualitative semistructured interviews with patients with diabetes mellitus or cardiovascular disease who were being discharged from 2 EDs. Questions focused on reasons for seeking ED care, expectations about ED visits, and goals and needs for the days after ED discharge. Themes were identified with a modified grounded theory approach. Results Forty patients participated. Patients identified uncertainty about the significance of their symptoms and fear as a result of this uncertainty as primary drivers for their ED visit. Their primary expectation about the visit was receiving a diagnosis and reassurance. The most prominent postdischarge need was answers about the cause of their symptoms and what to expect. Patients were concerned about ability to access follow-up services because of lack of time to navigate the system, transportation, and priority scheduling needs. Suggestions for improvement focused on contacting patients (physically or virtually) once they were home and offering them expedited outpatient evaluations. Primary limitations included enrollment of patients within a single health system and only those with certain chronic conditions, both potentially limiting generalizability. Conclusion Many patients have ongoing needs that are often not addressed during ED discharge. These needs are based on ongoing uncertainty about the cause of their symptoms and what to expect, and result in feelings of fear. Work is needed to develop approaches to alleviate patient fear and uncertainty and to equip providers with the capabilities and resources needed to adequately address these needs.
Study objective Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the ...association between mode of out-of-hospital transport (police department versus emergency medical services EMS) and mortality among patients with penetrating trauma in Philadelphia. Methods This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index. Results Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval CI 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio OR 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police. Conclusion We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care.
Abstract Background Wide variation in out-of-hospital cardiac arrest (OHCA) survival has been reported, with low survival in urban settings. We sought to describe the epidemiology of OHCA in ...Philadelphia, Pennsylvania, the fifth largest U.S. city, and identify potential areas for targeted interventions to improve survival. Methods and Results Retrospective chart review of adult, non-traumatic, OHCA occurring in Philadelphia between 2008 and 2012. We determined incidence and epidemiological factors including: demographics, initial cardiac rhythm, bystander cardiopulmonary resuscitation, automated external defibrillator use, return of spontaneous circulation and 30-day survival. 5,198 cases of adult, non-traumatic OHCA were identified. The incidence was 81.5/100,000. The majority of cases occurred in a residence (76.2%); 30.4% were witnessed events; the initial cardiac rhythm was pulseless ventricular tachycardia or ventricular fibrillation in 6.2% of cases, pulseless electrical activity in 21.0%, asystole in 38.3% and was unknown or undocumented in the remaining 34.5%. Multivariate logistic regression analysis demonstrated increased 30-day survival with younger age, shockable cardiac rhythms, and daytime arrest. 30-day survival was 8.1% for EMS-assessed patients and 8.6% for EMS-transported patients. Conclusions Philadelphia's reported incidence is consistent with urban settings although the survival rate is higher than other urban centers.
We engaged in a 1-year process to develop a conceptual model representing an episode of acute, unscheduled care. Acute, unscheduled care includes acute illnesses (eg, nausea and vomiting), injuries, ...or exacerbations of chronic conditions (eg, worsening dyspnea in congestive heart failure) and is delivered in emergency departments, urgent care centers, and physicians’ offices, as well as through telemedicine. We began with a literature search to define an acute episode of care and to identify existing conceptual models used in health care. In accordance with this information, we then drafted a preliminary conceptual model and collected stakeholder feedback, using online focus groups and concept mapping. Two technical expert panels reviewed the draft model, examined the stakeholder feedback, and discussed ways the model could be improved. After integrating the experts’ comments, we solicited public comment on the model and made final revisions. The final conceptual model includes social and individual determinants of health that influence the incidence of acute illness and injury, factors that affect care-seeking decisions, specific delivery settings where acute care is provided, and outcomes and costs associated with the acute care system. We end with recommendations for how researchers, policymakers, payers, patients, and providers can use the model to identify and prioritize ways to improve acute care delivery.
Access to Emergency Care in the United States Carr, Brendan G., MD, MA, MS; Branas, Charles C., PhD; Metlay, Joshua P., MD, PhD ...
Annals of emergency medicine,
08/2009, Letnik:
54, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Study objective Rapid access to emergency services is essential for emergency care–sensitive conditions such as acute myocardial infarction, stroke, sepsis, and major trauma. We seek to determine US ...population access to an emergency department (ED). Methods The National Emergency Department Inventories–USA was used to identify the location, annual visit volume, and teaching status of all EDs in the United States. EDs were categorized as any ED, by patient volume, and by teaching status. Driving distances, driving speeds, and out-of-hospital times were estimated with validated models and adjusted for population density. Access was determined by summing the population that could reach an ED within the specified intervals. Results Overall, 71% of the US population has access to an ED within 30 minutes, and 98% has access within 60 minutes. Access to teaching hospitals was more limited, with 16% having access within 30 minutes and 44% within 60 minutes. Rural states had lower access to all types of EDs. Conclusion Although the majority of the US population has access to an ED, there are regional disparities in ED access, especially by rurality. Future efforts should measure the relationship between access to emergency services and outcomes for emergency care–sensitive conditions. The development of a regionalized emergency care delivery system should be explored.
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