MP31: Safely reducing emergency physician admission rate through audit and feedback

Background: Most admissions to hospitals occur through the emergency department (ED). The impact of emergency physicians’ decisions to admit a patient to hospital can have wide ranging effects on health care spending, hospital congestion and patient outcomes. A growing body of evidence shows that outpatient management of conditions such as diverticulitis, heart failure and pulmonary embolism is both safe, effective and can reduce costs. Aim Statement: To support emergency staff in making safe, informed decisions to appropriately reduce admission rates without increasing the rate of patients returning and being admitted. Measures & Design: Significant variability in admission rates between emergency physicians exists and no correlation between actual and self-reported admission rates is observed. One means to change behavior is through audit and feedback, however a Cochrane review on this topic concluded that it was only effective if specific conditions were met; findings which were incorporated into this project. An audit tool was created comparing individual physicians’ admission and “bounce back” rates to their peers. The tools contained averages for the individual and site for admission and bounce back rates and were shared with physicians every 2 months. Physicians were divided into three equal groups, low, medium and high admitters and targets established. Department heads met with high admitters. Evaluation/Results: The project was started in September 2016. Admission rates in the three physician groups were compared in the ten months before September 2016 (prior) and after January 2017 (post). September to December 2016 was considered the “rollout” period and not included in the analysis. Significance was tested using a Permutation test and a p-value cut off level of 5%. Nine emergency departments took part. Seven sites experienced a significant decrease in the admission rate of top admitters, three showed a significant increase in the rate of low admitters and two showed a significant increase in the rate of medium admitters. Pooled results showed a decrease in the admission rates of the top admitters and no significant change to the medium or low admitters. Discussion/Impact: Comparing the pre- and post-periods yielded a decrease in admissions of 773 patients on an annualized basis. The impact of the change in the top five highest admitters at the biggest three hospitals estimated an annualized beds savings of 25.3 beds.

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THE IMPACT OF THE ROCHESTER NEIGHBORHOOD HEALTH CENTER ON HOSPITALIZATION OF CHILDREN, 1968 TO 1970

PEDIATRICS ◽

10.1542/peds.51.5.833 ◽

1973 ◽

Vol 51 (5) ◽

pp. 833-839

Author(s):

Michael Klein ◽

Klaus Roghmann ◽

Kenneth Woodward ◽

Evan Charney

Keyword(s):

Health Center ◽

Comparison Group ◽

Admission Rate ◽

Team Approach ◽

Target Area ◽

Admission Rates ◽

Respiratory Infectious Diseases ◽

Physician Availability ◽

Hospital Days ◽

The Impact

The admission patterns of children to area hospitals was studied. The study design allowed for comparisons between actual users of the health center, nonusers who lived in the target area and a comparison group. During the second year of operation, the admission rate of health center users was only 33 versus 67 per thousand for nonusers and 39 per thousand for the comparison group. Comparing the first two years, hospital days per thousand among users dropped by approximately half. Due to higher admission rates and longer average stays, nonusers had a rate of 2.5 times that of the users for hospital days per thousand. The rate for the comparison group remained constant. Users had fewer admissions for respiratory infectious diseases and more admissions for surgical restorative procedures. These trends were not present for the nonusers or for the comparison group. Despite extensive outreach, physician availability, and the team approach, the health center continued to have a large number of child admissions who reached the hospital without referral (the "leakers").

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Impact of a specialist service in the Emergency Department on admission, length of stay and readmission of patients presenting with falls, syncope and dizziness

QJM ◽

10.1093/qjmed/hcaa261 ◽

2020 ◽

Author(s):

K Jusmanova ◽

C Rice ◽

R Bourke ◽

A Lavan ◽

C G McMahon ◽

...

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Admission Rate ◽

Readmission Rates ◽

Specialist Service ◽

Admission Rates ◽

Potential Benefits ◽

Bed Days ◽

The Mean ◽

The Impact

Summary Background Up to half of patients presenting with falls, syncope or dizziness are admitted to hospital. Many are discharged without a clear diagnosis for their index episode, however, and therefore a relatively high risk of readmission. Aim To examine the impact of ED-FASS (Emergency Department Falls and Syncope Service) a dedicated specialist service embedded within an ED, seeing patients of all ages with falls, syncope and dizziness. Design Pre- and post-cohort study. Methods Admission rates, length of stay (LOS) and readmission at 3 months were examined for all patients presenting with a fall, syncope or dizziness from April to July 2018 (pre-ED-FASS) inclusive and compared to April to July 2019 inclusive (post-ED-FASS). Results There was a significantly lower admission rate for patients presenting in 2019 compared to 2018 [27% (453/1676) vs. 34% (548/1620); X2 = 18.0; P < 0.001], with a 20% reduction in admissions. The mean LOS for patients admitted in 2018 was 20.7 [95% confidence interval (CI) 17.4–24.0] days compared to 18.2 (95% CI 14.6–21.9) days in 2019 (t = 0.98; P = 0.3294). This accounts for 11 344 bed days in the 2018 study period, and 8299 bed days used after ED-FASS. There was also a significant reduction in readmission rates within 3 months of index presentation, from 21% (109/1620) to 16% (68/1676) (X2 = 4.68; P = 0.030). Conclusion This study highlights the significant potential benefits of embedding dedicated multidisciplinary services at the hospital front door in terms of early specialist assessment and directing appropriate patients to effective ambulatory care pathways.

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The Impact of Milieu Nurse–Client Shift Assignments on Monthly Restraint Rates on an Inpatient Child/Adolescent Psychiatric Unit

Journal of the American Psychiatric Nurses Association ◽

10.1177/1078390319834358 ◽

2019 ◽

Vol 26 (1) ◽

pp. 86-91 ◽

Cited By ~ 3

Author(s):

Stefani Rae Magnowski ◽

Sandra Cleveland

Keyword(s):

Statistical Significance ◽

Nurse Staffing ◽

P Value ◽

Chart Audit ◽

Psychiatric Unit ◽

Chart Audits ◽

Evidenced Based ◽

The Individual ◽

The Impact

INTRODUCTION: Restraints in the inpatient child/adolescent psychiatric population pose a threat to client safety and quality of care. Nurses are key in reducing restraints through implementation of evidenced-based interventions to improve quality and safety. AIM: To identify the impact of milieu nurse–client shift assignments on monthly restraint rates when compared with individual nurse–client shift assignments on an inpatient child/adolescent psychiatric unit. METHODS: A quantitative, retrospective, comparative project design was used. The sample included all inpatient child/adolescent clients admitted to the child/adolescent psychiatric unit between the months of January–May 2016 and 2017 who were physically or mechanically restrained. Retrospective chart audits were conducted, and information transcribed onto an adapted chart audit tool by Edwards et al. (2006). Monthly restraint rates were compared using the Mann–Whitney U test. A p value of <.05 was used to determine statistical significance. RESULTS: The Mann–Whitney U test revealed statistical significance between the impact that the individual nurse–client shift assignments ( Mdn = 61.2, n = 6) and the milieu nurse–client shift assignments ( Mdn = 6.8, n = 6) had on monthly restraint rates, U = .000, z = −2.88, p = .004, r = .83. CONCLUSION: Use of milieu nurse–client shift assignments are associated with lower monthly restraint rates when compared to individual nurse–client shift assignments. Milieu nurses provide structure, safety, consistency, and security, leading to early intervention and de-escalation of clients who display aggressive behaviors. Nurse staffing structures also need to be optimized to meet the needs of this population.

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152 Implementation of Older Persons Rapid Assessment Hub (OPRAH) in the Emergency Department (ED)

Age and Ageing ◽

10.1093/ageing/afz103.89 ◽

2019 ◽

Vol 48 (Supplement_3) ◽

pp. iii17-iii65

Author(s):

Comfort Adedokun ◽

Rosa McNamara ◽

Nessa O’Herlihy

Keyword(s):

Older Adults ◽

Emergency Department ◽

Older People ◽

Rapid Assessment ◽

Admission Rate ◽

Clinical Decision ◽

Admission Rates ◽

Clinical Decision Unit ◽

Medical Referral ◽

The Impact

Abstract Background The Emergency Department (ED) is where most people, including older adults in crises, seek care. OPRAH was introduced in order to meet the needs of our changing population. The unit was developed out of existing resources within the ED and cohorts both older patients and staff to an area more suitable to carry out assessments. Methods We used a quality improvement framework to develop our service. OPRAH is led by an ED GEM (Geriatric Emergency Medicine) consultant, staffed using the existing ED team, housed within footprint of the ED as part of the Clinical Decision Unit (CDU) with the addition of an HCA (healthcare assistant) as required. To determine the impact of the service on admissions of older adults, we collated patient records prospectively. These were reviewed and coded by senior ED professionals blinded to outcomes, to determine medical-referral rate for admission in these cohort. Results In the first 3 weeks of implementation, 76 patients were assessed. Four were admitted and 2 transferred to other hospitals. Mean age was 83 years ranging 66-103 years with an average of 262 minutes in the ED prior to OPRAH admission. Blinded coders review determined 53 (76%) of these patients would have been referred for admission. The majority of the remainder would have completed their care in the ED, as they were not eligible for admission to CDU. Conclusion Introduction of OPRAH to the ED has improved access for older people to short-stay ED led care and reduced admission rates. We have identified a trend towards fewer episodes where care by in-house teams is completed within the ED. We are in an early phase of this project. Nonetheless, it is evident that by redesigning how we assess older people in the ED and using available outpatient resources, we could impact on admission rate and length of stay in the ED without compromising patient care. Implementation has increased the use of the integrated care team, hospital and community MDT (multidisciplinary team).

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African Gene Flow Reduces Beta-Ionone Anosmia/Hyposmia Prevalence in Admixed Malagasy Populations

Brain Sciences ◽

10.3390/brainsci11111405 ◽

2021 ◽

Vol 11 (11) ◽

pp. 1405

Author(s):

Harilanto Razafindrazaka ◽

Veronica Pereda-Loth ◽

Camille Ferdenzi ◽

Margit Heiske ◽

Omar Alva ◽

...

Keyword(s):

Gene Flow ◽

African Ancestry ◽

Sensory Perception ◽

Population Level ◽

P Value ◽

Individual Level ◽

Specific Anosmia ◽

Odorant Molecule ◽

The Individual ◽

The Impact

While recent advances in genetics make it possible to follow the genetic exchanges between populations and their phenotypic consequences, the impact of the genetic exchanges on the sensory perception of populations has yet to be explored. From this perspective, the present study investigated the consequences of African gene flow on odor perception in a Malagasy population with a predominantly East Asian genetic background. To this end, we combined psychophysical tests with genotype data of 235 individuals who were asked to smell the odorant molecule beta-ionone (βI). Results showed that in this population the ancestry of the OR5A1 gene significantly influences the ability to detect βI. At the individual level, African ancestry significantly protects against specific anosmia/hyposmia due to the higher frequency of the functional gene (OR ratios = 14, CI: 1.8–110, p-value = 0.012). At the population level, African introgression decreased the prevalence of specific anosmia/hyposmia to this odorous compound. Taken together, these findings validate the conjecture that in addition to cultural exchanges, genetic transfer may also influence the sensory perception of the population in contact.

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An Innovative Approach for Decreasing Fall Trauma Admissions from Geriatric Living Facilities: Preliminary Investigation

The American Surgeon ◽

10.1177/000313481508101232 ◽

2015 ◽

Vol 81 (12) ◽

pp. 1279-1283

Author(s):

Tracy Evans ◽

Brian Gross ◽

Katelyn Rittenhouse ◽

Carissa Harnish ◽

Ashley Vellucci ◽

...

Keyword(s):

Fall Prevention ◽

Trauma Center ◽

Intervention Program ◽

Intervention Group ◽

Admission Rate ◽

High Rate ◽

P Value ◽

Level Ii ◽

Control Intervention ◽

The Impact

Geriatric living facilities have been associated with a high rate of falls. We sought to develop an innovative intervention approach targeting geriatric living facilities that would reduce geriatric fall admissions to our Level II trauma center. In 2011, a Trauma Prevention Taskforce visited 5 of 28 local geriatric living facilities to present a fall prevention protocol composed of three sections: fall education, risk factor identification, and fall prevention strategies. To determine the impact of the intervention, the trauma registry was queried for all geriatric fall admissions attributed to patients living at local geriatric living facilities. The fall admission rate (total fall admissions/total beds) of the pre-intervention period (2010–2011) was compared with that of the postintervention period (2012–2013) at the 5 intervention and 23 control facilities. A P value < 0.05 was considered statistically significant. From 2010 to 2013, there were 487 fall admissions attributed to local geriatric living facilities (intervention: 179 fall admissions; control: 308 fall admissions). The unadjusted fall rate decreased at intervention facilities from 8.9 fall admissions/bed pre-intervention to 8.1 fall admissions/bed postintervention, whereas fall admission rates increased at control sites from 5.9 to 7.7 fall admissions/bed during the same period [control/intervention odds ratio (OR), 95% confidence interval (CI) = 1.32, 1.05–1.67; period OR, 95%CI = 1.55,1.18–2.04, P = 0.002; interaction of control/intervention group and period OR 95% CI = 0.68, 0.46–1.00, P = 0.047]. An aggressive intervention program targeting high-risk geriatric living facilities resulted in a statistically significant decrease in geriatric fall admissions to our Level II trauma center.

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The bimodal rise and fall acute coronary syndromes curves paralleling COVID-19 outbreaks

European Heart Journal ◽

10.1093/eurheartj/ehab724.1458 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

D Trabattoni ◽

G Teruzzi ◽

P M Ravagnani ◽

G Santagostino Baldi ◽

P Montorsi ◽

...

Keyword(s):

Cardiogenic Shock ◽

Hospital Admission ◽

Clinical Outcomes ◽

Acute Coronary Syndromes ◽

Hospital Admissions ◽

Admission Rate ◽

Nasopharyngeal Swab ◽

Admission Rates ◽

Coronary Syndromes ◽

The Impact

Abstract Introduction Preliminary reports from the early phase of COVID-19 epidemic in Italy reported a dramatic reduction in hospital admission rates for acute coronary syndromes (ACS) coupled with longer times from symptoms onset to hospital presentation. Purpose To assess the impact of COVID-19 on hospital admission rates and ACS patterns, as well as time to presentation and clinical outcomes, following the acute pandemic phase in 2020 compared to previous year. Methods We conducted a single institution retrospective analysis conducted in a cardiovascular hub serving a large metropolitan area in Italy. Number and monthly distribution of hospital admissions for ACS from January 1 to December 31, 2020 were compared to the respective figures in 2019. Baseline clinical features, time from symptoms onset to hospital admission and main clinical outcomes were collected. Results A total of 599 ACS cases were recorded in 2020 vs. 386 cases in 2019, with a net 55% increase. ACS presentation rate in 2020 showed a bimodal pattern, paralleling the most contagious outbreak periods (Figure 1). SARS-CoB-2 nasopharyngeal swab or specific antibody tests were positive in 34 (5.7%) patients. Time from symptoms onset to hospital presentation tended to be longer in 2020 than in 2019, being two-fold longer during the peak epidemic phase (February 21-May 3, 2020; median time 2.0 vs. 5.0 hours, p=0.030). The proportion of late-presenting STEMI (>8 hrs from symptoms onset) was higher in 2020 compared to 2019 (30% vs. 18%, p=0.003),as well as higher was in-hospital mortality (15% in 2020 vs 6% in 2019, p=0.001), partly due to a three-fold increase in cardiogenic shock on ACS presentation. Conclusions ACS admission rate significantly increased during the 2020 COVID-19 epidemic outbreak for several reasons only partially explained by a SARS-CoV-2 infection trigger effect on ACS. Longer presentation times and higher rates of cardiogenic shock and mortality were observed, urging the need health-care systems to keep a high priority on cardiovascular emergencies response networks. FUNDunding Acknowledgement Type of funding sources: None. Figure 1

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Impact of the introduction of a universal childhood influenza vaccination programme on influenza-related admissions to paediatric intensive care units in England

BMJ Open Respiratory Research ◽

10.1136/bmjresp-2018-000297 ◽

2018 ◽

Vol 5 (1) ◽

pp. e000297 ◽

Cited By ~ 1

Author(s):

Pia Hardelid ◽

Melpo Kapetanstrataki ◽

Lee Norman ◽

Sarah J Fleming ◽

Paula Lister ◽

...

Keyword(s):

Intensive Care ◽

Influenza Vaccination ◽

Vaccination Programme ◽

Winter Season ◽

Admission Rate ◽

Paediatric Intensive Care ◽

Childhood Vaccination ◽

Admission Rates ◽

Significant Difference ◽

The Impact

IntroductionA universal childhood influenza vaccination programme was introduced in the UK in September 2013. We examine the impact of the gradual introduction of this programme on influenza-related paediatric intensive care unit (PICU) admission rates in England.MethodsWe extracted data on all influenza-related admissions to PICUs in England in resident children aged 0–15 years old between October 2003 and March 2017 from the Paediatric Intensive Care Audit Network (PICANet) database. We estimated influenza-associated PICU admission rates per 100 000 children by age group, sex and winter season (October to March), and used Poisson regression models to estimate incidence rate ratios (IRRs) in the winter seasons since the introduction of universal childhood vaccination compared with the two winters before the introduction of the programme (2011–2013).ResultsWe identified 929 influenza-related PICU admissions among 873 children. 48.3% of admissions were among children aged less than 2 years old. The influenza-associated PICU admission rate was 1.32 per 100 000 children (95% CI 1.23 to 1.40). We identified a significant increase in influenza PICU admissions in the winters following the introduction of the universal childhood vaccination programme compared with the winters of 2010/2011–2012/2013 among children aged <5 years old: IRR 1.58 (1.05, 2.37) in children <1 year, 2.71 (1.43, 5.17) in 1 year-olds and 1.98 (1.18, 3.31) in children 2–4 years old. No significant difference was found among children aged 5–15 years.ConclusionThe universal childhood influenza vaccination has not yet reduced the influenza-associated burden on PICUs in England during its early phase of introduction. Monitoring of influenza PICU admission rates needs to continue in England to assess the long-term impact of universal paediatric influenza vaccination. Linkage between PICANet and national infection surveillance databases would better enable such monitoring.

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Blood pressure parameters and the development of congestive heart failure among hypertensive patients at Kiambu County Hospital, Kenya

The East and Central Africa Medical Journal ◽

10.33886/ecamj.v4i1.174 ◽

2020 ◽

Vol 4 (1) ◽

pp. 6-10

Author(s):

Isabell Mac’oduol ◽

Joseph Thigiti ◽

Lydia Maingi

Keyword(s):

Heart Failure ◽

Blood Pressure ◽

Congestive Heart Failure ◽

Pulse Pressure ◽

Admission Rate ◽

Blood Parameters ◽

County Hospital ◽

Hypertensive Patients ◽

Admission Rates ◽

The Individual

Introduction: Global incidence of heart failure is on increase. Heart failure has been shown to be on the increase with 1-3% admission rates globally and a 3-7% admission rate in the African hospitals. Hypertension (HTN) has been shown to play a pivotal role in the evolution and syndrome of heart failure where it is mostly non- ischemic in origin yet there are few studies on the association of the individual blood parameters and heart failure. Objective: The study assessed the individual blood pressure parameters as prognosticators of congestive heart failure (CHF) in hypertensive patients. Method: A retrospective study was carried out at Kiambu County Hospital, on 205 heart failure patients who met the Framingham Criteria. The parameters observed included the time of onset of CHF, systolic/ diastolic blood pressure, pulse pressure and their duration to the development of CHF. Multivariable cox proportional hazard regression models were used to determine the effects of individual blood pressure parameters relative to the onset of CHF. Results: Overall, 205 patients were eligible for the study. Median time to CHF was estimated to be 4 years (range: 1-18), median age of CHF development was 65.7 years with a 68.8% female preponderance. Pulse pressure of 55- 60 mm Hg (AHR: 2.21; 95%CI: 1.16-4.21), hypertension duration of 5-10 years (AHR: 0.14; 95%CI: 0.088-0.223) and over 10 years (AHR: 0.023; 95%CI: 0.010-0.050) were significantly associated with the development of CHF. Conclusion: Pulse pressure is a better prognosticator of CHF in hypertensive patients with a hazard ratio of 2.2 times more likely in patients with a pulse pressure of 55- 60 mmHg than those below 55mm Hg.

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Impact of Corona Virus On Total Share In All Company Sectors In Indonesia Stock Exchange

International Journal of Science, Technology & Management ◽

10.46729/ijstm.v2i6.386 ◽

2021 ◽

Vol 2 (6) ◽

pp. 1939-1945

Author(s):

An Suci Azzahra ◽

Ayu Wirdha Ningsih

Keyword(s):

Permutation Test ◽

Stock Exchange ◽

P Value ◽

Corona Virus ◽

First Case ◽

Significant Difference ◽

Before And After ◽

Level Of Significance ◽

Company Sector ◽

The Impact

The purpose of this study is to analyze the impact of the corona virus on total shares in all company sectors on the Indonesia Stock Exchange. This study examines whether there are differences in total shares before and after Covid-19 was announced in Indonesia. The data consists of total shares on January 31, 2020 (30 days before the announcement of COVID-19) and total shares on March 31, 2020 (30 days after the announcement of COVID-19) for all company sectors on the IDX. The method used is descriptive quantitative. The analysis technique in this study consists of descriptive statistics and hypothesis testing using the nonparametric MANOVA method on the STATCAL software. The results showed that there was a significant difference in the total shares before and after the announcement of the first case of covid-19 in Indonesia in sectors 1, 3, 4, 6, 7, 8 and 9, indicated by a significant value per company sector in all sectors < 0, 05, while for sectors 2 and 5 there is no significant difference. The value of the permutation test p-value is 0.01, i.e. < 0.05 level of significance, it can be concluded that overall, there is a significant difference in total shares 30 days before and after the announcement of COVID-19.

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