Given the higher incidence of emergency conditions in older inhabitants, the global increase in aged population will pose a challenge for emergency services. In this study we examined the burden ...caused to emergency health care by the aged population.
Consecutive patients aged 80 years or over visiting a high-volume, collaborative emergency department (ED) between 2015 and 2016 were included. The key factors under analysis were the incidence of emergency conditions and costs associated with emergency care.
A total of 6944 patients (median age 85 years, range 80-104 years; 67% female) aged ≥80 years representing 1.5% of the local population, made 17,769 ED visits during the two-year observation period accounting for 15% of all ED visits. Forty-two percent (n = 2884) of patients had a single ED visit, whereas 8.2% (n = 570) made ≥5 ED visits/year for a total of 1400 visits (7.9%). Thirty-two percent of those aged ≥80 years required ED services each year. The number of ED visits increased with age (p < 0.001); and was 768/1000 person-years among octogenarians and 1007/1000 among nonagenarians, in comparison to 233/1000 among those aged < 80 years. One in five of the study population were discharged with non-specific diagnoses. Typical diagnoses included pneumonia (4.8%), malaise and fatigue (4.5%) and heart failure (4.3%). Non-specific diagnoses were frequent, and examination of patients with non-specific diagnoses incurred costs similar to or higher than those of other patients. The mean cost per ED visit in older patients was 422 €.
We demonstrated a high incidence of emergency department visits in older patients. While our aim was not to solve how the growing demand should be met, it seems unlikely that increasing ED resources is feasible. Instead, the focus should be on chronic care of the aged and prevention of potentially avoidable ED visits.
Background
In many countries emergency departments (EDs) are facing an increase in demand for services, long waits, and severe crowding. One response to mitigate overcrowding has been to provide ...primary care services alongside or within hospital EDs for patients with non‐urgent problems. However, it is unknown how this impacts the quality of patient care and the utilisation of hospital resources, or if it is cost‐effective. This is the first update of the original Cochrane Review published in 2012.
Objectives
To assess the effects of locating primary care professionals in hospital EDs to provide care for patients with non‐urgent health problems, compared with care provided by regularly scheduled emergency physicians (EPs).
Search methods
We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library; 2017, Issue 4), MEDLINE, Embase, CINAHL, PsycINFO, and King's Fund, from inception until 10 May 2017. We searched ClinicalTrials.gov and the WHO ICTRP for registered clinical trials, and screened reference lists of included papers and relevant systematic reviews.
Selection criteria
Randomised trials, non‐randomised trials, controlled before‐after studies, and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs attending to patients with non‐urgent conditions, as compared to the care provided by regularly scheduled EPs.
Data collection and analysis
We used standard methodological procedures expected by Cochrane.
Main results
We identified four trials (one randomised trial and three non‐randomised trials), one of which is newly identified in this update, involving a total of 11,463 patients, 16 general practitioners (GPs), 9 emergency nurse practitioners (NPs), and 69 EPs. These studies evaluated the effects of introducing GPs or emergency NPs to provide care to patients with non‐urgent problems in the ED, as compared to EPs for outcomes such as resource use. The studies were conducted in Ireland, the UK, and Australia, and had an overall high or unclear risk of bias. The outcomes investigated were similar across studies, and there was considerable variation in the triage system used, the level of expertise and experience of the medical practitioners, and type of hospital (urban teaching, suburban community hospital). Main sources of funding were national or regional health authorities and a medical research funding body.
There was high heterogeneity across studies, which precluded pooling data. It is uncertain whether the intervention reduces time from arrival to clinical assessment and treatment or total length of ED stay (1 study; 260 participants), admissions to hospital, diagnostic tests, treatments given, or consultations or referrals to hospital‐based specialist (3 studies; 11,203 participants), as well as costs (2 studies; 9325 participants), as we assessed the evidence as being of very low‐certainty for all outcomes.
No data were reported on adverse events (such as ED returns and mortality).
Authors' conclusions
We assessed the evidence from the four included studies as of very low‐certainty overall, as the results are inconsistent and safety has not been examined. The evidence is insufficient to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non‐urgent patients by GPs and NPs versus EPs in the ED to mitigate problems of overcrowding, wait times, and patient flow.
We examined the charges, their variability, and respective payer group for diagnosis and treatment of the ten most common outpatient conditions presenting to the Emergency department (ED).
We ...conducted a cross-sectional study of the 2006-2008 Medical Expenditure Panel Survey. Analysis was limited to outpatient visits with non-elderly, adult (years 18-64) patients with a single discharge diagnosis.
We studied 8,303 ED encounters, representing 76.6 million visits. Median charges ranged from $740 (95% CI $651-$817) for an upper respiratory infection to $3437 (95% CI $2917-$3877) for a kidney stone. The median charge for all ten outpatient conditions in the ED was $1233 (95% CI $1199- $1268), with a high degree of charge variability. All diagnoses had an interquartile range (IQR) greater than $800 with 60% of IQRs greater than $1550.
Emergency department charges for common conditions are expensive with high charge variability. Greater acute care charge transparency will at least allow patients and providers to be aware of the emergency department charges patients may face in the current health care system.
BACKGROUND Length of stay (LOS) in the emergency department (ED) should be measured and evaluated comprehensively as an important indicator of hospital emergency service. In this study, we aimed to ...analyze clinical characteristics of critically ill patients admitted to the ED and identify the factors associated with LOS. MATERIAL AND METHODS All patients with level 1 and level 2 of the Emergency Severity Index who were admitted to the ED from January 2018 to December 2019 were included in this retrospective study. The patients were divided into 2 groups: LOS ≥4 h and LOS <4 h. Variables were comprehensively analyzed and compared between the 2 groups. RESULTS A total of 19 616 patients, including 7269 patients in the LOS ≥4 h group and 12 347 patients in the LOS <4 group, were included. Advanced age, admission in winter and during the night shift, and diseases excluding nervous system diseases, cardiovascular diseases, and trauma were associated with higher risk of LOS. Nervous system diseases, cardiovascular diseases, trauma, and procedures including tracheal intubation, surgery, percutaneous coronary intervention, and thrombolysis were associated with lower risk of LOS. CONCLUSIONS Prolonged LOS in the ED was associated with increased age and admission in winter and during the night shift, while shortened LOS was associated with nervous system diseases, cardiovascular diseases, and trauma, as well as with procedures including tracheal intubation, surgery, percutaneous coronary intervention, and thrombolysis. Our findings can serve as a guide for ED physicians to individually evaluate patient condition and allocate medical resources more effectively.
Summary Objective To explore the reasons why nursing staff use the subjective “worried” Medical Emergency Team (MET) calling criterion and compare the outcomes of calls activated using the “worried” ...criterion with those calls activated using “objective” criteria such as vital sign abnormalities. Methods A descriptive study of MET calls in six acute hospitals over a 12 months period. Outcomes for “objective” and “worried” calls were compared. Results The “worried” criterion was used to activate 29% of 3194 MET calls studied; it was the single most common reason for a MET call. Half (51.7%) of the “worried” calls were related to problems with Airway, Breathing, Circulation or Neurology. ‘Breathing’ problems accounted for the largest proportion (35.2%). A low oxygen saturation by pulse oximetry (SpO2 ) ( n = 249, 26.9%) and ‘respiratory distress’ ( n = 133, 14.4%) were the most common reasons for a “worried” call. Only 1.1% (10) of calls triggered by the “worried” criteria had cardiac arrest as an outcome compared with 170 calls (7.6%) for “objective” criteria. The proportion of patients who remained in a general ward area after MET calls was higher for the “worried” calls. Conclusions The “worried” criterion was the most frequent reason for MET calls, implying a high degree of empowerment and independent action by nursing staff. Low SpO2 and respiratory distress were the most common causes for concern. There was a significant difference between MET calls triggered by “worried” criteria and “objective” criteria for outcomes immediately following MET ( p < 0.001). Further assessment and refinement of MET triggers particularly in relation to respiratory distress and pulse oximetry may be needed.
•A dynamic emergency route planning model for major chemical accidents was proposed.•The Dijkstra algorithm is modified to solve the multi-objective optimization problem for the emergency route ...selection.•An individual emergency risk classification method for major chemical accidents was obtained.
Combining scenario construction with the characteristics of individual emergency behavior is necessary for the emergency route planning of major chemical accidents. We investigated this challenging decision problem and constructed a multi-indicator emergency risk assessment method that considers the evacuation speed of different population types and health consequences caused by various risk components. We also designed a modified Dijkstra algorithm to solve this dynamic multi-objective route planning problem. The comparative experiment results demonstrated that the proposed algorithm performs relatively better than the traditional Dijkstra algorithm. Finally, we performed extensive case studies where our simulation results demonstrate that the proposed model provides reliable and practical emergency route planning services for various personnel types under different accident scenarios. Compared with the commonly used single-dimensional assessment method, this comprehensive and informative assessment of the emergency risks faced by the population in different regions could serve as a useful reference for the formulation and implementation of emergency plans in case of major chemical accidents.
Ill and injured children have unique needs that can be magnified when the child's ailment is serious or life-threatening. This is especially true in the out-of-hospital environment. Providing ...high-quality out-of-hospital care to children requires an emergency medical services (EMS) system infrastructure designed to support the care of pediatric patients. As in the emergency department setting, it is important that all EMS agencies have the appropriate resources, including physician oversight, trained and competent staff, education, policies, medications, equipment, and supplies, to provide effective emergency care for children. Resource availability across EMS agencies is variable, making it essential that EMS medical directors, administrators, and personnel collaborate with outpatient and hospital-based pediatric experts, especially those in emergency departments, to optimize prehospital emergency care for children. The principles in the policy statement "Pediatric Readiness in Emergency Medical Services Systems" and this accompanying technical report establish a foundation on which to build optimal pediatric care within EMS systems and serve as a resource for clinical and administrative EMS leaders.
Worldwide, 2.75 billion passengers fly on commercial airlines annually. When in-flight medical emergencies occur, access to care is limited. We describe in-flight medical emergencies and the outcomes ...of these events.
We reviewed records of in-flight medical emergency calls from five domestic and international airlines to a physician-directed medical communications center from January 1, 2008, through October 31, 2010. We characterized the most common medical problems and the type of on-board assistance rendered. We determined the incidence of and factors associated with unscheduled aircraft diversion, transport to a hospital, and hospital admission, and we determined the incidence of death.
There were 11,920 in-flight medical emergencies resulting in calls to the center (1 medical emergency per 604 flights). The most common problems were syncope or presyncope (37.4% of cases), respiratory symptoms (12.1%), and nausea or vomiting (9.5%). Physician passengers provided medical assistance in 48.1% of in-flight medical emergencies, and aircraft diversion occurred in 7.3%. Of 10,914 patients for whom postflight follow-up data were available, 25.8% were transported to a hospital by emergency-medical-service personnel, 8.6% were admitted, and 0.3% died. The most common triggers for admission were possible stroke (odds ratio, 3.36; 95% confidence interval CI, 1.88 to 6.03), respiratory symptoms (odds ratio, 2.13; 95% CI, 1.48 to 3.06), and cardiac symptoms (odds ratio, 1.95; 95% CI, 1.37 to 2.77).
Most in-flight medical emergencies were related to syncope, respiratory symptoms, or gastrointestinal symptoms, and a physician was frequently the responding medical volunteer. Few in-flight medical emergencies resulted in diversion of aircraft or death; one fourth of passengers who had an in-flight medical emergency underwent additional evaluation in a hospital. (Funded by the National Institutes of Health.).
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