For several decades, overcrowding in emergency departments (EDs) has been intensifying due to the increased number of patients seeking care in EDs. Demand growth is partly due to misuse of EDs by ...patients who seek care for nonurgent problems. This study explores the reasons why people with nonurgent complaints choose to come to EDs, and how ED health professionals perceive the phenomenon of "nonurgency".
Semi-structured interviews were conducted in 10 EDs with 87 nonurgent patients and 34 health professionals. Interviews of patients revealed three themes: (1) fulfilled health care needs, (2) barriers to primary care providers (PCPs), and (3) convenience. Patients chose EDs as discerning health consumers: they preferred EDs because they had difficulties obtaining a rapid appointment. Access to technical facilities in EDs spares the patient from being overwhelmed with appointments with various specialists. Four themes were identified from the interviews of health professionals: (1) the problem of defining a nonurgent visit, (2) explanations for patients' use of EDs for nonurgent complaints, (3) consequences of nonurgent visits, and (4) solutions to counter this tendency.
Studies on the underlying reasons patients opt for the ED, as well as on their decision-making process, are lacking. The present study highlighted discrepancies between the perceptions of ED patients and those of health professionals, with a special focus on patient behaviour. To explain the use of ED, health professionals based themselves on the acuity and urgency of medical problems, while patients focused on rational reasons to initiate care in the ED (accessibility to health care resources, and the context in which the medical problem occurred). In spite of some limitations due to the slightly outdated nature of our data, as well as the difficulty of categorizing nonurgent situations, our findings show the importance of conducting a detailed analysis of the demand for health care. Understanding it is crucial, as it is the main determining factor in the utilization of health care resources, and provides promising insights into the phenomenon of ED usage increase. For reforms to be successful, the process of decision-making for unscheduled patients will have to be thoroughly investigated.
Emergency manuals (EMs), context-relevant sets of cognitive aids or crisis checklists, have been used in high-hazard industries for decades, although this is a nascent field in health care. In the ...fall of 2012, Stanford clinically implemented EMs, including hanging physical copies in all Stanford operating rooms (ORs) and training OR clinicians on the use of, and rationale for, EMs. Although simulation studies have shown the effectiveness of EMs and similar tools when used by OR teams during crises, there are little data on clinical implementations and uses. In a subset of clinical users (ie, anesthesia residents), the objectives of this pilot study were to (1) assess perspectives on local OR safety culture regarding cognitive aid use before and after a systematic clinical implementation of EMs, although in the context of long-standing resident simulation trainings; and (2) to describe early clinical uses of EMs during critical events.
Surveys collecting both quantitative and qualitative data were used to assess clinical adoption of EMs in the OR. A pre-implementation survey was e-mailed to Stanford anesthesia residents in mid-2011, followed by a post-implementation survey to a new cohort of residents in early 2014. The post-implementation survey included pre-implementation survey questions for exploratory comparison and additional questions for mixed-methods descriptive analyses regarding EM implementation, training, and clinical use during critical events since implementation.
Response rates were similar for the pre- and post-implementation surveys, 52% and 57%, respectively. Comparing post- versus pre-implementation surveys in this pilot study, more residents: agreed or strongly agreed "the culture in the ORs where I work supports consulting a cognitive aid when appropriate" (73.8%, n = 31 vs 52.9%, n = 18, P = .0017) and chose more types of anesthesia professionals that "should use cognitive aids in some way," including fully trained anesthesiologists (z = -2.151, P = .0315). Fifteen months after clinical implementation of EMs, 19 respondents (45%) had used an EM during an actual critical event and 15 (78.9% of these) agreed or strongly agreed "the EM helped the team deliver better care to the patient" during that event, with the rest neutral. We present qualitative data for 16 of the 19 EM clinical use reports from free-text responses within the following domains: (1) triggering EM use, (2) reader role, (3) diagnosis and treatment, (4) patient care impact, and (5) barriers to EM use.
Since Stanford's clinical implementation of EMs in 2012, many residents' self-report successful use of EMs during clinical critical events. Although these reports all come from a pilot study at a single institution, they serve as an early proof of concept for feasibility of clinical EM implementation and use. Larger, mixed-methods studies will be needed to better understand emerging facilitators and barriers and to determine generalizability.
ObjectivesTo investigate the suitability of the German version of the Manchester Triage System (MTS) as a potential tool to redirect emergency department (ED) patients to general practitioner care. ...Such tools are currently being discussed in the context of reorganisation of emergency care in Germany.DesignProspective cohort study.SettingSingle centre University Hospital Emergency Department.ParticipantsAdult, non-surgical ED patients.ExposureA non-urgent triage category was defined as a green or blue triage category according to the German version of the MTS.Primary and secondary outcome measuresSurrogate parameters for short-term risk (admission rate, diagnoses, length of hospital stay, admission to the intensive care unit, in-hospital and 30-day mortality) and long-term risk (1-year mortality).ResultsA total of 1122 people presenting to the ED participated in the study. Of these, 31.9% (n=358) received a non-urgent triage category and 68.1% (n=764) were urgent. Compared with non-urgent ED presentations, those with an urgent triage category were older (median age 60 vs 56 years, p=0.001), were more likely to require hospital admission (47.8% vs 29.6%) and had higher in-hospital mortality (1.6% vs 0.8%). There was no significant difference observed between non-urgent and urgent triage categories for 30-day mortality (1.2% n=4 vs 2.2% n=15; p=0.285) or for 1-year mortality (7.9% n=26 vs 10.5% n=72; p=0.190). Urgency was not a significant predictor of 1-year mortality in univariate (HR=1.35; 95% CI 0.87 to 2.12; p=0.185) and multivariate regression analyses (HR=1.20; 95% CI 0.77 to 1.89; p=0.420).ConclusionsThe results of this study suggest the German MTS is unsuitable to safely identify patients for redirection to non-ED based GP care.Trial registration numberU1111-1119-7564; Post-results
•A literature review of ED simulations for normal and disaster conditions is presented.•The systematic classification covers 106 reviewed papers.•It provides an insight for researchers on ED ...simulation modelling.
Hospital emergency departments (HEDs) are the most critical units since they undertake a vital health care mission. It is required for these departments to find out rational solution methods in case of issues occurred in normal and disaster times. Simulation is an effective method to improve policies on operational, tactical and strategic decisions about EDs. The main reasons prompting us to do this study are to reveal the importance of simulation for disaster preparedness of EDs and the innovative aspects of recent ED simulation applications unlike the available literature surveys. This systematic and comprehensive review study can provide an insight for researchers on ED simulation modeling in terms of showing current state and gaps to be focused in the future.
Not all patients who call the ambulance service are subsequently transported to hospital. In 2018, a quarter of deployments of an emergency ambulance in Bavaria were not followed by patient ...transport. This study describes factors that influence patient transport rates.
This is a retrospective cross-sectional study based on data from all Integrated Dispatch Centres of the Free State of Bavaria in 2018. Included were ambulance deployments without emergency physician involvement, which were subdivided into ambulance deployments without transport and ambulance deployments with transport. The proportion of transported patients were determined for the primary reasons for deployment and for the different community types. On-scene time was compared for calls with and without patient transport. Differences were tested for statistical significance using Chi
tests and the odds ratio was calculated to determine differences between groups.
Of 510,145 deployments, 147,621 (28.9%) could be classified as ambulance deployments without transport and 362,524 (71.1%) as ambulance deployments with transport.The lowest proportion of patients transported was found for activations where the fire brigade was involved ("fire alarm system" 0.6%, "fire with emergency medical services" 5.4%) and "personal emergency response system active alarm" (18.6%). The highest transport rates were observed for emergencies involving "childbirth/delivery" (96.9%) and "trauma" (83.2%). A lower proportion of patients is transported in large cities as compared to smaller cities or rural communities; in large cities, the odds ratio for emergencies without transport is 2.02 95% confidence interval 1.98-2.06 referenced to rural communites. The median on-scene time for emergencies without transport was 20.8 min (n = 141,052) as compared to 16.5 min for emergencies with transport (n = 362,524). The shortest on-scene times for emergencies without transport were identified for activations related to "fire alarm system" (9.0 min) and "personal emergency response system active alarm" (10.6 min).
This study indicates that the proportion of patients transported depends on the reason for deployment and whether the emergency location is urban or rural. Particularly low transport rates are found if an ambulance was dispatched in connection with a fire department operation or a personal emergency medical alert button was activated. The on-scene-time of the rescue vehicle is increased for deployments without transport. The study could not provide a rationale for this and further research is needed. Trial registration This paper is part of the study "Rettungswageneinsatz ohne Transport" "Ambulance deployment without transport" (RoT), which was registered in the German Register of Clinical Studies under the number DRKS00017758.
Mental health presentations to the emergency department (ED) have increased, and the emergency department has become the initial contact point for people in a mental health crisis. However, there is ...mounting evidence that the ED is not appropriate nor effective in responding to people in mental health crises. Insufficient attention has been paid to the subjective experience of people seeking support during a mental health crisis. This review aims to describe the qualitative literature involving the subjective experiences of people presenting to the ED during a mental health crisis. The method was guided by Arksey and O’Malley’s framework for scoping studies and included keyword searches of PsycINFO, CINAHL, Medline and Embase. A narrative analysis, drawing on the visual tool of journey mapping, was applied to summarise the findings. Twenty-three studies were included. The findings represent the experience of accessing EDs, through to the impact of treatment. The review found points of opportunity that improve people’s experiences and characteristics associated with negative experiences. The findings highlight the predominance and impact of negative experiences of the ED and the incongruence between the expectations of people presenting to the ED and the experience of treatment.
Friday, Nov 13, 2015. It's 2130 h when the Assistance Publique-Hôpitaux de Paris (APHP) is alerted to the explosions that have just occurred at the Stade de France, a stadium in Saint-Denis just ...outside Paris. Within 20 min, there are shootings at four sites and three bloody explosions in the capital. At 2140 h, a massacre takes place and hundreds of people are held hostage for 3 h in Bataclan concert hall.
Children with chronic medical conditions rely on complex management plans for problems that cause them to be at increased risk for suboptimal outcomes in emergency situations. The emergency ...information form (EIF) is a medical summary that provides rapid access to critical information to physicians and other members of the health care team so that optimal emergency medical care can be provided. This statement describes an updated approach to EIFs and the information they contain. Essential common data elements are reviewed, integration with electronic health records is discussed, and broadening the rapid availability and use of health data for all children and youth is proposed. A broader approach to data accessibility and use could extend the benefits of rapid access to critical information for all children receiving emergency care as well as further facilitating emergency preparedness during disaster management.
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