scholarly journals Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: a retrospective cohort study

BMJ Open ◽  
2017 ◽  
Vol 7 (10) ◽  
pp. e016845 ◽  
Author(s):  
Kathryn Eastwood ◽  
Karen Smith ◽  
Amee Morgans ◽  
Johannes Stoelwinder
Keyword(s):  
Emergency Department ◽  
Hospital Admission ◽  
Emergency Care ◽  
Retrospective Cohort ◽  
Care Pathway ◽  
Cohort Analysis ◽  
Care Pathways ◽  
Telephone Triage ◽  
Alternative Care ◽  
Referral Service

ObjectiveTo investigate the appropriateness of cases presenting to the emergency department (ED) following ambulance-based secondary telephone triage.DesignA pragmatic retrospective cohort analysis of all the planned and unplanned ED presentations within 48 hours of a secondary telephone triage.SettingThe secondary telephone triage service, called the Referral Service, and the hospitals were located in metropolitan Melbourne, Australia and operated 24 hours a day, servicing 4.25 million people. The Referral Service provides an in-depth secondary triage of cases classified as low acuity when calling the Australian emergency telephone number.PopulationCases triaged by the Referral Service between September 2009 and June 2012 were linked to ED and hospital admission records (N=44,523). Planned ED presentations were cases referred to the ED following the secondary triage, unplanned ED presentations were cases that presented despite being referred to alternative care pathways.Main outcome measuresAppropriateness was measured using an ED suitability definition and hospital admission rates. These were compared with mean population data which consisted of all of the ED presentations for the state (termed the ‘average Victorian ED presentation’).ResultsPlanned ED presentations were more likely to be ED suitable than unplanned ED presentations (OR 1.62; 95% CI 1.5 to 1.7; p<0.001) and the average Victorian ED presentation (OR 1.85; 95% CI 1.01 to 3.4; p=0.046). They were also more likely to be admitted to the hospital than the unplanned ED presentation (OR 1.5; 95% CI 1.4 to 1.6; p<0.001) and the average Victorian ED presentation (OR 2.3, 95% CI 2.24 to 2.33; p<0.001). Just under 15% of cases diverted away from the emergency care pathways presented in the ED (unplanned ED attendances), and 9.5% of all the alternative care pathway cases were classified as ED suitable and 6.5% were admitted to hospital.ConclusionsSecondary telephone triage was able to appropriately identify many ED suitable cases, and while most cases referred to alternative care pathways did not present in the ED. Further research is required to establish that these were not inappropriately triaged away from the emergency care pathways.

scholarly journals Impact of emergency hospital admissions on patterns of primary care prescribing: a retrospective cohort analysis of electronic records in England

2020 ◽  
Vol 70 (695) ◽  
pp. e399-e405
Author(s):  
Rachel Denholm ◽  
Richard Morris ◽  
Sarah Purdy ◽  
Rupert Payne
Keyword(s):  
Hospital Admission ◽  
Retrospective Cohort ◽  
Hospital Admissions ◽  
Cohort Analysis ◽  
Post Discharge ◽  
Emergency Hospital ◽  
Obstetrics And Gynaecology ◽  
Emergency Hospital Admission ◽  
Retrospective Cohort Analysis ◽  
The Impact

BackgroundLittle is known about the impact of hospitalisation on prescribing in UK clinical practice.AimTo investigate whether an emergency hospital admission drives increases in polypharmacy and potentially inappropriate prescriptions (PIPs).Design and settingA retrospective cohort analysis set in primary and secondary care in England.MethodChanges in number of prescriptions and PIPs following an emergency hospital admission in 2014 (at admission and 4 weeks post-discharge), and 6 months post-discharge were calculated among 37 761 adult patients. Regression models were used to investigate changes in prescribing following an admission.ResultsEmergency attendees surviving 6 months (N = 32 657) had a mean of 4.4 (standard deviation [SD] = 4.6) prescriptions before admission, and a mean of 4.7 (SD = 4.7; P<0.001) 4 weeks after discharge. Small increases (<0.5) in the number of prescriptions at 4 weeks were observed across most hospital specialties, except for surgery (−0.02; SD = 0.65) and cardiology (2.1; SD = 2.6). The amount of PIPs increased after hospitalisation; 4.0% of patients had ≥1 PIP immediately before pre-admission, increasing to 8.0% 4 weeks post-discharge. Across hospital specialties, increases in the proportion of patients with a PIP ranged from 2.1% in obstetrics and gynaecology to 8.0% in cardiology. Patients were, on average, prescribed fewer medicines at 6 months compared with 4 weeks post-discharge (mean = 4.1; SD = 4.6; P<0.001). PIPs decreased to 5.4% (n = 1751) of patients.ConclusionPerceptions that hospitalisation is a consistent factor driving rises in polypharmacy are unfounded. Increases in prescribing post-hospitalisation reflect appropriate clinical response to acute illness, whereas decreases are more likely in patients who are multimorbid, reflecting a focus on deprescribing and medicines optimisation in these individuals. Increases in PIPs remain a concern.

scholarly journals Developing patient-centred, feasible alternative care for adult emergency department users with epilepsy: protocol for the mixed-methods observational ‘Collaborate’ project

BMJ Open ◽  
2019 ◽  
Vol 9 (11) ◽  
pp. e031696 ◽  
Author(s):  
Adam J Noble ◽  
Amy Mathieson ◽  
Leone Ridsdale ◽  
EA Holmes ◽  
Myfanwy Morgan ◽  
...  
Keyword(s):  
Emergency Department ◽  
Mixed Methods ◽  
Care Pathway ◽  
Knowledge Exchange ◽  
Discrete Choice Experiments ◽  
Nominal Group ◽  
Structured Interviews ◽  
Dissemination Strategy ◽  
Alternative Care ◽  
Trade Offs

IntroductionEmergency department (ED) visits for epilepsy are common, costly, often clinically unnecessary and typically lead to little benefit for epilepsy management. An ‘Alternative Care Pathway’ (ACP) for epilepsy, which diverts people with epilepsy (PWE) away from ED when ‘999’ is called and leads to care elsewhere, might generate savings and facilitate improved ambulatory care. It is unknown though what features it should incorporate to make it acceptable to persons from this particularly vulnerable target population. It also needs to be National Health Service (NHS) feasible. This project seeks to identify the optimal ACP configuration.Methods and analysisMixed-methods project comprising three-linked stages. In Stage 1, NHS bodies will be surveyed on ACPs they are considering and semi-structured interviews with PWE and their carers will explore attributes of care important to them and their concerns and expectations regarding ACPs. In Stage 2, Discrete Choice Experiments (DCE) will be completed with PWE and carers to identify the relative importance placed on different care attributes under common seizure scenarios and the trade-offs people are willing to make. The uptake of different ACP configurations will be estimated. In Stage 3, two Knowledge Exchange workshops using a nominal group technique will be run. NHS managers, health professionals, commissioners and patient and carer representatives will discuss DCE results and form a consensus on which ACP configuration best meets users’ needs and is NHS feasible.Ethics and disseminationEthical approval: NRES Committee (19/WM/0012) and King’s College London ethics Committee (LRS-18/19-10353). Primary output will be identification of optimal ACP configuration which should be prioritised for implementation and evaluation. A pro-active dissemination strategy will make those considering developing or supporting an epilepsy ACP aware of the project and opportunities to take part in it. It will also ensure they are informed of its findings.Project registration numberResearchregistry4723.

scholarly journals Viral Coinfection is Associated with Improved Outcomes in Emergency Department Patients with SARS-CoV-2

2021 ◽  
Vol 22 (6) ◽  
pp. 1262-1269
Author(s):  
Elizabeth Goldberg ◽  
Kohei Hasegawa ◽  
Alexis Lawrence ◽  
Jeffrey Kline ◽  
Carlos Camargo
Keyword(s):  
Emergency Department ◽  
Retrospective Cohort ◽  
Cohort Analysis ◽  
Long Term Outcomes ◽  
Viral Pathogens ◽  
Improved Outcomes ◽  
Retrospective Cohort Analysis ◽  
Short And Long Term ◽  
Emergency Department Patients

Introduction: Coinfection with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) and another virus may influence the clinical trajectory of emergency department (ED) patients. However, little empirical data exists on the clinical outcomes of coinfection with SARS-CoV-2 Methods: In this retrospective cohort analysis, we included adults presenting to the ED with confirmed, symptomatic coronavirus 2019 who also underwent testing for additional viral pathogens within 24 hours. To investigate the association between coinfection status with each of the outcomes, we performed logistic regression. Results: Of 6,913 ED patients, 5.7% had coinfection. Coinfected individuals were less likely to experience index visit or 30-day hospitalization (odds ratio [OR] 0.57; 95% confidence interval [CI], 0.36-0.90 and OR 0.39; 95% CI, 0.25–0.62, respectively). Conclusion: Coinfection is relatively uncommon in symptomatic ED patients with SARS-CoV-2 and the clinical short- and long-term outcomes are more favorable in coinfected individuals.

scholarly journals Implementation of an Evidence-Based Care Pathway for Emergency Department Management of Sickle Cell Vaso-Occlusive Crisis Leads to Improved Clinical Outcomes

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4678-4678
Author(s):  
Jennifer Yui ◽  
Scott A. Peslak ◽  
David Lambert ◽  
Eric Russell ◽  
Farzana Sayani
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Hospital Admission ◽  
Sickle Cell ◽  
Clinical Pathway ◽  
Care Pathway ◽  
Clinical Care ◽  
Evidence Based ◽  
Opioid Dose ◽  
Clinical Care Pathway

BACKGROUND Painful vaso-occlusive crises (VOC) are the most common reason for acute care utilization in patients with sickle cell disease (SCD), and the emergency department (ED) is often the site of initial management and treatment. Treatment guidelines recommend initiation of analgesia with parenteral opioids within 30 minutes of presentation, timely reassessment of pain, and additional opioids as needed every 15-30 minutes. These targets are infrequently met, resulting in uncontrolled pain, increased likelihood of hospital admission, and deterioration of physician-patient relationships. METHODS We undertook a multidisciplinary effort to improve the management of VOC in the ED, by development and implementation of an evidence-based clinical care pathway. The clinical pathway was implemented at the Hospital of the University of Pennsylvania in December 2018, with direct education of hematology and ED providers around the content of the clinical pathway, and availability of the pathway on the institutional intranet. Specific areas of focus in the pathway included appropriate triaging of patients as emergency severity index 2, timely administration of initial opioid dose, rapid reassessment and administration of additional opioid doses as needed, as well as appropriate laboratory evaluation and evaluation for other common and/or serious complications of SCD. Outcome measures included time from ED registration to administration of first opioid dose, time between administration of first opioid dose and second opioid dose, and proportion of patients discharged from the ED. Balance measures included rate of ED readmission and length of stay. RESULTS There were 602 ED visits from 103 unique patients in the study period, with 256 visits in the six-month period prior to pathway implementation and 346 visits in the six-month period after implementation. Following pathway implementation, time from registration to first opioid dose fell from 114 minutes to 93 minutes (p = 0.003). The proportion of patients receiving their first opioid dose within 60 minutes of registration increased from 19% to 33%. Time from administration of the first opioid dose to the second opioid dose improved from 117 minutes to 94 minutes (p = 0.002). The proportion of patients receiving their second opioid dose within 60 minutes of the first opioid dose increased from 27% to 37%. There was no change in the rate of hospital admission from the ED, or in the proportion of patients who left without being seen (p = 0.710). There was also no change in rate of ED readmissions (p = 0.138) or length of stay (p = 0.483). CONCLUSION Implementation of an evidence-based clinical care pathway in the ED for SCD patients presenting with VOC led to significant improvement in outcomes, with decreased time to first opioid dose and decreased time from first to second opioid dose. Nevertheless, very few patients received guideline-based care, particularly with the goal of time to first opioid dose of less than 30 minutes. While our data demonstrate that provider education and clinical pathways clearly improve the management of VOC in the ED, additional interventions will be required to target other barriers to optimal management, including implicit biases, negative provider attitudes, and social stigma surrounding SCD. Disclosures No relevant conflicts of interest to declare.

scholarly journals Early Bronchoscopy Improves Extubation Rates after Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Analysis

2021 ◽  
Vol 10 (14) ◽  
pp. 3055
Author(s):  
Gregor S. Zimmermann ◽  
Jana Palm ◽  
Anna Lena Lahmann ◽  
Friedhelm Peltz ◽  
Rainer Okrojek ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Cardiac Arrest ◽  
Hospital Admission ◽  
Retrospective Cohort ◽  
Cohort Analysis ◽  
Optimal Timing ◽  
Test Results ◽  
Microbiological Test ◽  
Retrospective Cohort Analysis ◽  
Hospital Cardiac Arrest

Background: Patients suffering from out-of-hospital cardiac arrest (OHCA) frequently receive a bronchoscopy after being admitted to the ICU. We investigated the optimal timing and the outcome in these patients. Methods: All patients who suffered from OHCA and were treated in our ICU from January 2013 to December 2018 were retrospectively analyzed. The data were collected from the patients’ medical files, and included duration of mechanical ventilation, antibiotics, microbiological test results and neurological outcome. The outcome was the effect of early bronchoscopy (≤48 h after administration) on the rate of intubated patients on day five and day seven. Results: From January 2013 to December 2018, 190 patients were admitted with OHCA. Bronchoscopy was performed in 111 patients out of the 164 patients who survived the first day. Late bronchoscopy >48 h was associated with higher rates of intubation on day five (OR 4.94; 95% CI 1.2–36.72, 86.7% vs. 55.0%, p = 0.036) and day seven (OR 4.96; 95% CI 1.38–24.69; 80.0% vs. 43.3%, p = 0.019). Conclusion: This study shows that patients who suffered from OHCA might have a better outcome if they receive a bronchoscopy early after hospital admission. Our data suggests an association of early bronchoscopy with a shorter intubation period.

scholarly journals Impact of patient isolation on emergency department length of stay: A retrospective cohort study using the Registry for Emergency Care

2020 ◽  
Vol 32 (6) ◽  
pp. 1034-1039
Author(s):  
Gerard M O'Reilly ◽  
Rob D Mitchell ◽  
Biswadev Mitra ◽  
Michael P Noonan ◽  
Ryan Hiller ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cohort Study ◽  
Length Of Stay ◽  
Emergency Care ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Patient Isolation
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