A descriptive analysis of the impact of COVID-19 on Emergency Department attendance and visit characteristics in Singapore

Abstract Background: The coronavirus disease 2019 (COVID-19) has impacted the utilisation of Emergency Department (ED) services worldwide. This study aims to describe the changes in attendance of a single ED and corresponding patient visit characteristics before and during the COVID-19 period. Methods: In a single-centre retrospective cohort study, we used descriptive statistics to compare ED attendance, patient demographics and visit characteristics during the COVID-19 period (1 January – 28 June 2020) and its corresponding historical period in 2019 (2 January – 30 June 2019). Results: Mean ED attendance decreased from 342 visits/day in the pre-COVID-19 period, to 297 visits/day in the COVID-19 period. This was accompanied by a decline in presentations in nearly every ICD-10-CM diagnosis category except for respiratory-related diseases. Notably, we observed reductions in visits by critically ill patients and severe disease presentations during the COVID-19 period. We also noted a shift in ED patient case-mix from ‘Non-fever’ cases to ‘Fever’ cases, likely giving rise to two distinct trough-to-peak visit patterns during the pre-Circuit Breaker and Circuit Breaker period. Conclusions: This descriptive study revealed distinct ED visit trends across different time periods. The COVID-19 pandemic caused a reduction in ED attendances amongst patients with low-acuity conditions and those with highest priority for emergency care. This raises concern about treatment-seeking delays and possible impact on health outcomes. The downward trend in low-acuity presentations also presents learning opportunities for ED crowd management planning in a post-COVID-19 era.

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A Descriptive Analysis of the Impact of COVID-19 on Emergency Department Attendance and Visit Characteristics in Singapore

COVID ◽

10.3390/covid1040059 ◽

2021 ◽

Vol 1 (4) ◽

pp. 739-750

Author(s):

Mei Qiu Lim ◽

Seyed Ehsan Saffari ◽

Andrew Fu Wah Ho ◽

Johannes Nathaniel Min Hui Liew ◽

Boon Kiat Kenneth Tan ◽

...

Keyword(s):

Emergency Department ◽

Severe Disease ◽

Descriptive Analysis ◽

Circuit Breaker ◽

Historical Period ◽

Management Planning ◽

Crowd Management ◽

Patient Demographics ◽

Icd 10 ◽

The Impact

Background: The coronavirus disease 2019 (COVID-19) has impacted the utilisation of Emergency Department (ED) services worldwide. This study aims to describe the changes in attendance at a single ED and corresponding patient visit characteristics before and during the COVID-19 period. Methods: In a single-centre retrospective cohort study, we used descriptive statistics to compare ED attendance, patient demographics and visit characteristics during the COVID-19 period (1 January–28 June 2020) and its corresponding historical period in 2019 (2 January–30 June 2019). Results: The mean ED attendance decreased from 342 visits/day in the pre-COVID-19 period to 297 visits/day in the COVID-19 period. This was accompanied by a decline in presentations in nearly every ICD-10-CM diagnosis category except for respiratory-related diseases. Notably, we observed reductions in visits by critically ill patients and severe disease presentations during the COVID-19 period. We also noted a shift in the ED patient case-mix from ‘Non-fever’ cases to ‘Fever’ cases, likely giving rise to two distinct trough-to-peak visit patterns during the pre-Circuit Breaker and Circuit Breaker period. Conclusions: This descriptive study revealed distinct ED visit trends across different time periods. The COVID-19 pandemic caused a reduction in ED attendances amongst patients with low-acuity conditions and those with highest priority for emergency care. This raises concern about treatment-seeking delays and the possible impact on health outcomes. The downward trend in low-acuity presentations also presents learning opportunities for ED crowd management planning in a post-COVID-19 era.

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Interrupted time series design to evaluate ICD-9-CM to ICD-10-CM coding changes on trends in Colorado emergency department visits related to traumatic brain injury

Injury Epidemiology ◽

10.1186/s40621-021-00308-y ◽

2021 ◽

Vol 8 (1) ◽

Author(s):

Lauren Alexis De Crescenzo ◽

Barbara Alison Gabella ◽

Jewell Johnson

Keyword(s):

Public Health ◽

Traumatic Brain Injury ◽

Emergency Department ◽

Brain Injury ◽

Interrupted Time Series ◽

Emergency Department Visits ◽

Control And Prevention ◽

Icd 10 ◽

Ed Visits ◽

The Impact

Abstract Background The transition in 2015 to the Tenth Revision of the International Classification of Disease, Clinical Modification (ICD-10-CM) in the US led the Centers for Disease Control and Prevention (CDC) to propose a surveillance definition of traumatic brain injury (TBI) utilizing ICD-10-CM codes. The CDC’s proposed surveillance definition excludes “unspecified injury of the head,” previously included in the ICD-9-CM TBI surveillance definition. The study purpose was to evaluate the impact of the TBI surveillance definition change on monthly rates of TBI-related emergency department (ED) visits in Colorado from 2012 to 2017. Results The monthly rate of TBI-related ED visits was 55.6 visits per 100,000 persons in January 2012. This rate in the transition month to ICD-10-CM (October 2015) decreased by 41 visits per 100,000 persons (p-value < 0.0001), compared to September 2015, and remained low through December 2017, due to the exclusion of “unspecified injury of head” (ICD-10-CM code S09.90) in the proposed TBI definition. The average increase in the rate was 0.33 visits per month (p < 0.01) prior to October 2015, and 0.04 visits after. When S09.90 was included in the model, the monthly TBI rate in Colorado remained smooth from ICD-9-CM to ICD-10-CM and the transition was no longer significant (p = 0.97). Conclusion The reduction in the monthly TBI-related ED visit rate resulted from the CDC TBI surveillance definition excluding unspecified head injury, not necessarily the coding transition itself. Public health practitioners should be aware that the definition change could lead to a drastic reduction in the magnitude and trend of TBI-related ED visits, which could affect decisions regarding the allocation of TBI resources. This study highlights a challenge in creating a standardized set of TBI ICD-10-CM codes for public health surveillance that provides comparable yet clinically relevant estimates that span the ICD transition.

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The impact of the Covid-19 pandemic on the short and mid-term urological emergencies and the emergency department

Journal of Experimental and Clinical Medicine ◽

10.52142/omujecm.38.4.12 ◽

2021 ◽

Vol 38 (4) ◽

pp. 466-470

Author(s):

Hülya Yılmaz BAŞER ◽

Aykut BAŞER

Keyword(s):

Emergency Department ◽

Health Care Services ◽

Descriptive Analysis ◽

Relevant Information ◽

Medium Term ◽

Dynamic Changes ◽

Care Services ◽

The Impact ◽

Urological Emergencies

Dynamic changes are observed in the delivery of health care services due to the COVID-19 Pandemic. Its effect in the short term is a dramatic decrease in service, however, its effect in the medium and long term is unknown. In this study, we aimed to investigate the effects of the COVID-19 pandemic on emergency department and emergency urological surgery in the short and medium term during the 8-month period, and the reasons for possible changes. Emergency department operations, urology operations and emergency surgical procedures between April and November were compared as the 2020 pandemic period and the 2019 non-pandemic period. The relevant information was obtained from the hospital management information system. Descriptive analysis and statistical methods comparing the two periods were used. In the early stages of the pandemic, significant decreases were observed in both urology procedures and emergency department operations. In the medium period, while emergency department operations and urology consultations returned to the non-pandemic periods, there was no such a change in in emergency urological surgeries. In the medium-term effects of the pandemic, emergency department operations returned to the non-pandemic periods due to reasons such as patients' abuse of emergency departments in line with their requests for rapid diagnosis and treatment. In accordance with the changing nature of the pandemic, it is necessary to make different scheduling for emergency department operations and emergency surgeries.

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Analgesia for extremity fractures in the paediatric emergency department

Proceedings of Singapore Healthcare ◽

10.1177/2010105820915731 ◽

2020 ◽

Vol 29 (2) ◽

pp. 108-112

Author(s):

Siew Ming Tan ◽

Yong-Kwang Gene Ong ◽

Jen Heng Pek

Keyword(s):

Emergency Department ◽

Pain Score ◽

Lower Limb ◽

Key Management ◽

Current Practice ◽

Paediatric Emergency Department ◽

Patient Demographics ◽

Paediatric Emergency ◽

The Mean ◽

The Impact

Background: Extremity fractures are an important and common presentation at the Paediatric Emergency Department (PED). Provision of analgesia is a key management principle, but it is often suboptimal. Although there is an increase in awareness of this issue, the impact on current practice is not known. We aimed to review the current practice of providing analgesia for extremity fractures in the PED. Objective: Our objective was to determine the utilisation, adequacy and timeliness of analgesia provided for these patients. Methods: A retrospective study was carried out from November to December 2017. Patients with a diagnosis of extremity fracture involving the upper or lower limb were included. Information about patient demographics, diagnosis, pain score, analgesia use and clinical progress were collected for analysis. Results: There were 101 cases. The mean age was 8.5±4.2 years old, and 62 (61.4%) patients were male. There were 76 (75.3%) cases of fractures involving the upper limb, and 25 (24.7%) cases of fractures involving the lower limb. The mean pain score at presentation was 3.3±2.3. Analgesia was administered to only 10 (9.9%) patients, with oral paracetamol ( n=5; 5.0%) being the most common medication administered. The median time between arrival in the PED to analgesia administration was 69 minutes (range 25–328 minutes). Conclusions: Despite the increase in awareness, analgesia for these patients remains underutilised, inadequate and delayed. Further efforts at pain assessment, analgesia selection and administration are necessary to improve the provision of analgesia for these patients.

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PP40 Pre-hospital and emergency department analgesia for paediatric trauma – a survey of UK trauma centres and ambulance services supports consideration of alternatives such as ketamine

Emergency Medicine Journal ◽

10.1136/emermed-2021-999.40 ◽

2021 ◽

Vol 38 (9) ◽

pp. A16.3-A17

Author(s):

David Fish ◽

Fiona Bell ◽

Clare O’Connell ◽

Alison Walker ◽

Laura Evans ◽

...

Keyword(s):

Emergency Department ◽

Descriptive Analysis ◽

Hospital Setting ◽

Ambulance Service ◽

Trauma Centres ◽

Administration Routes ◽

Controlled Drugs ◽

Medical Directors ◽

Legislative Changes ◽

The Impact

BackgroundStudies have found that pre-hospital and emergency department (ED) analgesia for children is sub-optimal. In the pre-hospital setting, barriers include limited parenteral routes, education or clinical experience and practice legislation restricting the use of opioids by paramedics. Ketamine is safe and effective with multiple administration routes. It is not bound by the controlled drugs limitations in the pre-hospital setting, and is familiar to pre-hospital and ED practitioners.MethodsQuestionnaires were sent to all UK Ambulance Service Medical Directors and Paediatric Major Trauma Centres to establish current use of parenteral analgesics, and acceptability of alternatives in pre-hospital care such as ketamine. Descriptive analysis was undertaken.ResultsIntranasal opiates were the first line parenteral analgesics in injured children in all EDs. Frequent shortages of IN diamorphine resulted in more variability of second line choices, with 40% opting for another opioid. 96% of EDs would support the use of ketamine by pre-hospital clinicians, although concerns regarding inappropriate (IV) use and use by technician crews were raised. Most ED clinicians were unaware of the limited analgesic choices available to paramedics, with many suggesting alternative opiates as well as ketamine.All ambulance service directors recognised the need for alternative analgesics being made available. Without legislative changes, inhaled/IN agents or oral opiates were the only current options. All services were supportive of research to explore the use of ketamine by paramedics for injured children.ConclusionsThere is support for the addition of IN ketamine into paramedics’ repertoire of analgesics and recognition of potential benefit. However, there is a lack of experience and evidence around its use, thus warranting research to consider the impact on analgesic timeliness, adequacy and effectiveness. An analgesia ‘system of care’ which integrates pre- and in-hospital practice would be facilitated by the use of medicines effective in managing pain and familiar to practitioners in both settings.

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Trends in Hydroxyurea Utilization for the Treatment of Sickle Cell Anemia in Florida

Blood ◽

10.1182/blood-2019-125799 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 2293-2293

Author(s):

Vandy Black ◽

Jasmine A Mack ◽

Jaclyn Hall ◽

Heather Morris ◽

Elizabeth Shenkman ◽

...

Keyword(s):

Emergency Department ◽

Sickle Cell ◽

Sickle Cell Anemia ◽

Research Funding ◽

Emergency Department Visits ◽

Research Network ◽

Common Data Model ◽

Icd 10 ◽

Acute Healthcare ◽

The Impact

Background: Hydroxyurea (HU) has emerged as an important disease-modifying therapy for children and adults with sickle cell anemia (SCA), but has traditionally been underutilized. Consensus, evidence-based guidelines published by the National Heart, Lung, and Blood Institute (NHLBI) in 2014 recommended broadening the use of HU for SCA, but the impact of these recommendations on HU utilization is unknown. The objective of this abstract is to determine if HU utilization in children and adults with SCA living in Florida increased following publication of the 2014 Guidelines. We hypothesized that limitations in care coordination and implementation resulted in minimal increases in the rates of HU utilization. We further hypothesized that individuals living more than 45 minutes from a comprehensive sickle cell center would be less likely to be prescribed HU in the prior 12 months. Methods: This study is a cross sectional analysis utilizing the OneFlorida Clinical Data Research Network (CDRN), which provides access to electronic health record and claims data for over 15.4 million patient records standardized to the PCORnet Common Data Model v4.1. Possible SCA cases were identified by International Classification of Diseases, 9th (ICD-9) and 10th (ICD-10) revision codes. Patients were eligible if they were at least 9 months of age and had two or more health encounters in which an ICD-9 or ICD-10 code for SCA was used. The primary endpoint was one or more HU prescriptions written or filled in a given calendar year between 2012 and 2017. In order to examine trends in HU utilization, segmented regression analyses of an interrupted time series were conducted. Logistic regression was performed to identify patient characteristics independently associated with HU utilization in 2017. Covariates of interest included age, gender, acute healthcare utilization (emergency department visits and hospitalizations), and distance to comprehensive sickle cell care (defined by zip code+4). Adjusted Odds Ratios (OR) and 95% confidence intervals (CI) were reported. Thirteen comprehensive sickle cell centers were identified based on local expert opinion, review of the American Society of Hematology Find a Hematologist database, and involvement in recent multicenter clinical trials. Results: 9,532 unique patients were identified with a mean age in 2017 of 21 years (SD 17.6). 57.4% were female, 76.2% were Black, 6% were Hispanic, 65.2% had three or more acute healthcare visits, 23% lived more than 45 minutes from a comprehensive sickle cell center, and approximately 73% were insured by Medicaid. Between 2012 and 2017, there was a 4.7% increase in HU utilization (12.7% vs. 17.4%, p<0.0001); see figure for trends in prescriptions written per quarter for each year stratified by age. Patients 6-17 years (OR 1.95, 95% CI 1.71-2.22, p<0.0001) and 18-21 years (OR 2.32, 95% CI 1.89-2.85, P<0.0001) were more likely to be prescribed HU compared to patients 22 years of age and older. Patients less than 6 years of age were less likely to be prescribed HU (0.81, 95% CI 0.68-0.97, p=0.02). Males (OR 1.47, 95% CI 1.31-1.65, p<0.0001) and individuals with three or more acute healthcare visits in a year (OR 22.56, 95% CI 17.03-29.89, p<0.0001) were more likely to be prescribed HU. No differences in HU utilization in 2017 were identified for individuals living 45 minutes or more from a comprehensive sickle cell center (OR 0.89, 95% CI 0.78-1.02, P=0.09). Conclusions: These findings suggest there has been a slight, but statistically significant, increase in HU utilization in children and adults with SCA in Florida since publication of the 2014 NHLBI Guidelines. HU is being prescribed to more pediatric patients less than 18 years of age. However, HU remains drastically underutilized and appears to be preferentially prescribed to patients with three or more hospitalizations or emergency department visits per year. Additional research is needed to determine predictors of HU utilization and implementation strategies to improve prescribing rates. The OneFlorida CDRN provides an excellent resource to track quality metrics for SCA in Florida. Figure Disclosures Black: Micelle BioPharma: Research Funding; Prolong Pharmaceuticals: Consultancy; Sanofi: Consultancy; Sancilio and Company: Research Funding; NHLBI: Research Funding; Pfizer: Research Funding; Novartis: Research Funding; HRSA: Research Funding. OffLabel Disclosure: Hydroxyurea for children less than 2 years of age

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Impact of pharmacist discharge counseling on hospital readmission and emergency department visit

Journal of Hospital Administration ◽

10.5430/jha.v6n2p68 ◽

2017 ◽

Vol 6 (2) ◽

pp. 68 ◽

Cited By ~ 3

Author(s):

Tu Tran ◽

Saijal Khattar ◽

Tiffany T. Vu ◽

Maggie Potter ◽

Jane Hodding ◽

...

Keyword(s):

Emergency Department ◽

Hospital Readmission ◽

Community Hospital ◽

Descriptive Analysis ◽

Hospital Readmissions ◽

Outpatient Setting ◽

Transitions Of Care ◽

Study Objective ◽

Entire Cohort ◽

The Impact

Objective: The enactment of the Affordable Care Act (ACA) in 2010 imposes payment penalty on hospitals with high hospital readmission rates. In an effort to reduce readmissions, a pharmacist discharge counseling program was implemented to facilitate transition of care to the outpatient setting. Our study objective was to evaluate the impact of the program on hospital readmissions and visits to the emergency department (ED).Methods: This was a single-center, retrospective cohort study conducted at a not-for-profit, teaching community hospital with 462 total beds. Pharmacists provided counseling to patients discharged from the medicine floor between November 2013 and January 2014, and included those considered to be high-risk (e.g., taking 5 scheduled medications and had diseases such as congestive heart failure and diabetes mellitus). Descriptive analysis was performed and outcomes were compared between patients who did and did not receive pharmacist counseling.Results: Of a total of 889 discharged patients, 488 (55%) received counseling from a pharmacist. For the entire cohort, mean age was 55 ± 20 years; Charlson Comorbidity Index (CCI) score was 2.74 ± 2.95; and length of hospitalization was 4 ± 4 days. These parameters were not statistically different between the two groups. Within 30-days after hospital discharge, significantly fewer subjects who received counseling, compared with those who did not, were readmitted to the hospital (11.3% vs. 15%, p = .009) or visited the ED (10.6% vs. 15%, p = .005).Conclusions: Discharge counseling provided by pharmacists during transitions of care at a community hospital significantly reduced 30-day readmission and ED visit rates.

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LO54: A descriptive analysis of ED length of stay of admitted patients ‘boarded’ in the emergency department

CJEM ◽

10.1017/cem.2017.116 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S46

Author(s):

L. Salehi ◽

P. Phalpher ◽

R. Valani

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Descriptive Analysis ◽

High Volume ◽

Increased Risk ◽

Significant Difference ◽

Ed Overcrowding ◽

Day Of The Week ◽

The Mean ◽

The Impact

Introduction: Previous studies have shown a link between Emergency Department (ED) overcrowding and worse clinical outcomes, increased risk of in-hospital mortality, higher costs, and longer times to treatment. Prolonged ED Length of Stay (LoS) of admitted patients awaiting a bed on in-patient units has been identified as a major driver of ED overcrowding. The purpose of this study is to provide a descriptive analysis of ED LoS among admitted patients, and determine the impact of prolonged ED LoS on total hospital in-patient length of stay (IP LoS). Methods: We conducted a single-site retrospective study for the period between January 1-December 31, 2015 at a very high volume community hospital. All patients aged ≥18 years admitted from the ED to acute in-patient Medicine units were identified. We carried out overall descriptive analysis (including analysis of day-of-the-week variability) on ED LoS. The mean total IP LoS for those patients with ED LoS<12 hours, 12-24 hours, and ≥24 hours were calculated and analyzed using ANOVA and Tukey HSD tests. Results: A total of 6,961 individuals were admitted to the medical units over the 12-month period. The median and mean ED LoS for admitted patients were 22.9 hrs (IQR: 13.9 hrs- 33.1 hrs) and 25.6 hrs respectively. Using ANOVA, there was a statistically significant difference in means of ED LoS as a function of the day of the week (p<0.0001), with Mondays having the highest mean ED LoS (27.6 hrs), and Fridays having the lowest (23.1 hrs). The mean IP LoS for those with ED LoS<12 hours, 12-24 hours, and ≥24 hours, were 6.8 days, 6.9 days, and 8.5 days respectively, with a statistically significant difference between group means (p<0.0001). Multiple pairwise comparisons of group means showed a statistically significant (p<0.05) difference between mean IP LOS of those with an EDLOS≥24 hours and those with an EDLOS<24 hours. Conclusion: Preliminary results indicate that ED LoS≥24 hours among admitted patients was associated with an increase in total IP LoS.*In the next 1-2 months, we intend to explore the role of other independent variables (age, sex, comorbidity, isolation status, and telemetry) on total ED LoS, and its association with IP LoS.

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Management of Mental Health Patients Attending Victorian Emergency Departments

Australian & New Zealand Journal of Psychiatry ◽

10.1080/00048670701517934 ◽

2007 ◽

Vol 41 (9) ◽

pp. 759-767 ◽

Cited By ~ 48

Author(s):

Jonathan C. Knott ◽

Alex Pleban ◽

David Taylor ◽

David Castle

Keyword(s):

Mental Health ◽

Emergency Department ◽

Median Time ◽

Emergency Departments ◽

Significant Variation ◽

Mental Health Disorder ◽

Patient Demographics ◽

Mental Health Patients ◽

Optimal Patient Care ◽

Icd 10

Objective: To evaluate the management of mental health presentations to Victorian emergency departments. Method: An observational study in five Victorian emergency departments (four metropolitan and one regional). All patients with an ICD-10 discharge diagnosis for a predetermined mental health disorder were included. Data were collected on patient demographics, presentation, clinical management (emergency and mental health) and disposition. Results: There were 3702 patients enrolled (96.0% of all mental health presentations). At presentation 39.1% were intoxicated and 39.9% arrived by ambulance, 17.6% with the police. There was a significant variation (p <0.001) between sites for: the median time to be seen by a clinician (14 vs 43 min), the time between referral to and review by mental health services (15 vs 50 min), the median time in the emergency department (208 min vs 380 min), the proportion who spent >24 h in the emergency department (0.0% vs 11.6%) and disposition (proportion discharged home from ED 49.8% vs 63.5%). Conclusion: Important variations were identified in the management of patients with mental health presentations to Victorian emergency departments. This variation is most likely due to differing access to resources. All levels of administration must work with carers and patients to ensure that optimal patient care is provided at every site.

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Impact of the COVID-19 pandemic on osteoporotic vertebral fracture incidence and follow-up at the emergency department. A retrospective study of a tertiary hospital in southern Spain

10.22514/sv.2022.002 ◽

2022 ◽

Keyword(s):

Emergency Department ◽

Vertebral Fracture ◽

Tertiary Hospital ◽

Time Of Day ◽

Osteoporotic Vertebral Fracture ◽

Patient Demographics ◽

Follow Up Care ◽

Patient Groups ◽

The Impact

The COVID-19 pandemic has affected trauma practices all over the world. Despite the increasing number of studies focused on the epidemiology of vertebral fractures (VFs) in COVID-19 patients, the impact of the pandemic on the incidence of trauma pathologies at the emergency department (ED) remains unclear. In Spain, very few studies have explored how the pandemic has affected the care of patients with osteoporotic vertebral fracture (OVF) in the ED and on their follow-up. The aim of this work is to evaluate the impact on the demand for care and diagnosis of VF during the COVID-19 pandemic, as well as the repercussions on patient follow-up. A longitudinal retrospective observational study was designed comparing two cohorts (pre-COVID and COVID) of patients for whom an emergency computed tomography scan was requested due to suspected vertebral fracture. Information was gathered on patient demographics, number and type of OVFs, time of day at which the diagnosis was made, follow-up, and treatment received. Comparative analyses were performed between both patient groups, with stratification by time intervals according to the pandemic waves in the COVID cohort. A total of 581 eligible patients were included in the study. The analyzed cohorts included 288 patients (145 and 143 in the pre-COVID and COVID cohorts, respectively), with a mean age of 73.4 ± 13.8 years and 205 (71.4%) women. No significant differences were observed on most measured variables. In the COVID cohort, the group of patients who received follow up care had a significantly lower mean age than the group that did not receive follow up care (70.2 ± 12.7 vs 76.2 ± 14.1 years, respectively, p = 0.008). In conclusion, the COVID-19 pandemic has had little impact on the diagnosis and management of patients with OVF in our hospital. This could be explained by the specific characteristics of OVFs and the type of patients it affects. Our study has some limitations, mainly derived from its retrospective and single-center nature with a short follow-up interval.

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