Leaving The Emergency Department Without Being Seen or Without Complete Treatment; A Study From Saudi Arabia

Background, The attitude of Leaving the emergency department (ED) without being seen or without completing treatment is attributed to prolonged waiting time. The impact of such behaviour and fate of such patients remain undetermined. Aim This study aimed to investigate the prevalence of Left Without Being Seen (LWBS) and Left Without Completing Treatment (LWCT), analyse the contributing factors for such behaviour and the mortality rate within one week of leaving the ED. Methods A retrospective observational study was performed in a tertiary hospital in Riyadh, Saudi Arabia, for three months. All adult patients of more than 14 years of age who visited the ED and LWBS or LWCT were included. Patients were seen by physicians and triaged-out, and those who were directed towards the outpatient clinic were excluded. Patients were asked about the reason for leaving, and their intention to return to the same ED again via call. Results The total number of LWBS and LWCT was 286 patients, with a response rate of 75%. The mean age was 45.8 years. About 46.6% sought medical help within seven days of leaving ED. However, the mortality rate was nil. Many patients (69.3%) reported their intention to revisit the same ED in the near future. A positive correlation was found between increasing age and admission within the same seven days’ period. Conclusion Prolonged waiting time is a public health concern that needs management strategies, the number of patients whom LWBS and LWCT require continuous monitoring and exploration.

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Exploring overcrowding trends in an inner city emergence department in the UK before and during COVID-19 epidemic

BMC Emergency Medicine ◽

10.1186/s12873-021-00438-y ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

J. Panovska-Griffiths ◽

J. Ross ◽

S. Elkhodair ◽

C. Baxter-Derrington ◽

C. Laing ◽

...

Keyword(s):

Emergency Department ◽

Waiting Time ◽

Number Of Patients ◽

Before And After ◽

Ed Overcrowding ◽

University College London ◽

Flow Through ◽

Indirect Impacts ◽

The Uk ◽

The Impact

Abstract Background The COVID-19 pandemic and the associated lockdowns have caused significant disruptions across society, including changes in the number of emergency department (ED) visits. This study aims to investigate the impact of three pre-COVID-19 interventions and of the COVID-19 UK-epidemic and the first UK national lockdown on overcrowding within University College London Hospital Emergency Department (UCLH ED). The three interventions: target the influx of patients at ED (A), reduce the pressure on in-patients’ beds (B) and improve ED processes to improve the flow of patents out from ED (C). Methods We collected overcrowding metrics (daily attendances, the proportion of people leaving within 4 h of arrival (four-hours target) and the reduction in overall waiting time) during 01/04/2017–31/05/2020. We then performed three different analyses, considering three different timeframes. The first analysis used data 01/04/2017–31/12–2019 to calculate changes over a period of 6 months before and after the start of interventions A-C. The second and third analyses focused on evaluating the impact of the COVID-19 epidemic, comparing the first 10 months in 2020 and 2019, and of the first national lockdown (23/03/2020–31/05/2020). Results Pre-COVID-19 all interventions led to small reductions in waiting time (17%, p < 0.001 for A and C; an 9%, p = 0.322 for B) but also to a small decrease in the number of patients leaving within 4 h of arrival (6.6,7.4,6.2% respectively A-C,p < 0.001). In presence of the COVID-19 pandemic, attendance and waiting time were reduced (40% and 8%; p < 0.001), and the number of people leaving within 4 h of arrival was increased (6%,p < 0.001). During the first lockdown, there was 65% reduction in attendance, 22% reduction in waiting time and 8% increase in number of people leaving within 4 h of arrival (p < 0.001). Crucially, when the lockdown was lifted, there was an increase (6.5%,p < 0.001) in the percentage of people leaving within 4 h, together with a larger (12.5%,p < 0.001) decrease in waiting time. This occurred despite the increase of 49.6%(p < 0.001) in attendance after lockdown ended. Conclusions The mixed results pre-COVID-19 (significant improvements in waiting time with some interventions but not improvement in the four-hours target), may be due to indirect impacts of these interventions, where increasing pressure on one part of the ED system affected other parts. This underlines the need for multifaceted interventions and a system-wide approach to improve the pathway of flow through the ED system is necessary. During 2020 and in presence of the COVID-19 epidemic, a shift in public behaviour with anxiety over attending hospitals and higher use of virtual consultations, led to notable drop in UCLH ED attendance and consequential curbing of overcrowding. Importantly, once the lockdown was lifted, although there was an increase in arrivals at UCLH ED, overcrowding metrics were reduced. Thus, the combination of shifted public behaviour and the restructuring changes during COVID-19 epidemic, maybe be able to curb future ED overcrowding, but longer timeframe analysis is required to confirm this.

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EP.WE.338Ambulatory Ultrasound Scans Reduce Inpatient Admissions During COVID-19: A Need for the Expansion of Ambulatory Services

British Journal of Surgery ◽

10.1093/bjs/znab308.040 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

L Cornett ◽

S Davidson ◽

K McElvanna

Keyword(s):

Emergency Department ◽

Waiting Time ◽

Retrospective Review ◽

First Line ◽

Average Waiting Time ◽

Number Of Patients ◽

Line Imaging ◽

Ambulatory Services ◽

The Impact

Abstract Aim With the increased need to manage patients out of hospital during COVID-19, it was anticipated that need for ambulatory imaging would increase. This study aimed to assess the demand for ambulatory ultrasounds (US) during the COVID-19 pandemic and the impact on inpatient admissions. Methods A retrospective review of patients presenting to the Emergency Department (ED) between 12th July – 23rd August 2020 who required an US as first line imaging. Electronic Care Records were used to collect data regarding type of US i.e., inpatient, or ambulatory, time taken for ambulatory US and outcome after imaging. The same period in 2019 was assessed for comparison. Results In 2020, 100 patients required an US compared to 88 in 2019. 37% (37/100) of which were discharged for an ambulatory US, compared to 14.8% (13/88) in 2019 (p = 0.006). The average waiting time for an ambulatory US in 2019 was 2 days, this increased to 7 days in 2020. Following ambulatory US in 2020 43.2% (16/37) required further outpatient imaging or assessment; similar outcomes were seen in 2019 with 46.2% (6/13). Overall, there was a 150% increase in the use of ambulatory US, with a 26% decrease in admissions in 2020 vs. 2019. Conclusions There was a significant increase in the number of patients discharged from ED to undergo an ambulatory US resulting in reduced inpatient admissions. This increase in demand is reflected by the prolonged waiting time highlighting the requirement for expansion of ambulatory services to meet this clinical need.

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The Impact of COVID-19 on the Service of Emergency Department

Healthcare ◽

10.3390/healthcare9101295 ◽

2021 ◽

Vol 9 (10) ◽

pp. 1295

Author(s):

Shaia Alharthi ◽

Modi Al-Moteri ◽

Virginia Plummer ◽

Abdulellah Al Thobiaty

Keyword(s):

Emergency Department ◽

Saudi Arabia ◽

Phase 1 ◽

Waiting Times ◽

Phase 2 ◽

Patient Acuity ◽

Number Of Patients ◽

The Subject ◽

The Impact ◽

Insight Into

(1) Introduction: the COVID-19 pandemic significantly impacted the number and acuity of emergency departments (ED) patients, specifically those with non-COVID-19-related health problems. However, the exact impact of the COVID-19 pandemic on ED services is the subject of comprehensive debate. (2) Aim: to gain insight into the consequences of the first wave of the COVID-19 pandemic based on non-COVID-19 presentations and patient acuity using the Canadian Triage and Acuity Scale (CTAS). (3) Method: in Phase 1, the ED records of one of the main regional non-COVID-19 hospitals in Saudi Arabia were retrospectively audited from August 2020 to February 2021—after the first wave of COVID-19—then compared to information collected for the same period in previous year. Phase 2 included calculating the waiting time to identify delays and issues that may impact the triage effectiveness. (4) Results: a change across all CTAS levels was observed post the 1st wave of COVID-19 pandemic. Specifically, there was an increase in the number of patients presenting as higher acuity (CTAS 1 and 2) and a decrease in patients presenting as lower acuity (CTAS 4 and 5). Longer waiting times for patients presenting to ED were also reported. Specifically, 83% of patients presenting as higher acuity experienced a delay. (5) Conclusion: further studies are required to investigate association between the 1st wave of COVID-19 and patient presentations and/or acuity or patient demand and ED capacity.

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Factors Influencing Waiting Time as Key of Patient Satisfaction in the Emergency Department in King Fahd Armed Forces Hospital, Saudi Arabia

International Journal of Business and Management ◽

10.5539/ijbm.v12n5p79 ◽

2017 ◽

Vol 12 (5) ◽

pp. 79

Author(s):

Omar Zayyan Alsharqi ◽

Mai AlBarakati ◽

Abdul Aziz AlQamdi ◽

Hussein Mohammad Al-Borie ◽

Alaeddin Mohammad Khalaf Ahmad

Keyword(s):

Emergency Department ◽

Saudi Arabia ◽

Waiting Time ◽

Adult Population ◽

Armed Forces ◽

Organizational Management ◽

Primary Data ◽

Close Monitoring ◽

Factors Influencing ◽

The Impact

The current research investigated the factors influencing the waiting time in the emergency department (ED) in King Fahd Armed Forces Hospital in Jeddah city, Saudi Arabia. We have decided to evaluate the impact of multiple factors in the waiting time in the ED. These factors are derived from three main variables. The independent variables include the organizational, management and staffing factors, whereas the dependent variable is represented by the waiting time. The method used to collect primary data was quantitative, through a research questionnaire, which was administered in the ED of King Fahd Armed Forces Hospital. A purposive sampling strategy was used to choose the participants in this research. In total, approximately 130,000 patients per year, these patients include the adult population, paediatrics, obstetrics and gynaecology who participated in this study. Using the sample size table, the researcher distributed 384 research questionnaires. The research retrieved 308 valid questionnaires, which was a rate of 80.2%. The results confirm significant influence of the organizational, management and staffing factors in the ED waiting time. Furthermore, the results also show various possibilities for future approaches to improve the waiting time. In this research, we concluded that these factors affect the waiting time in ED either in a positive or negative way, and we should take action to correct or improve the service provided to the patient visiting the ED. We recommend that a clear policy should be implemented regarding the availability of the wheelchairs, finding a direct channel with the medical administration office and the hospital administration regarding the time delay in speciality physicians to evaluate the ED patient. Regarding the difficulty in finding a bed in the ED, we recommend that the ED administration should maintain close monitoring, writing daily reports to the medical administration regarding any patient admitted in the ED under the care of the medical department to ensure a fast response in solving this problem.

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Applying quality improvement principles to improve accident and emergency department overcrowding and flow in Rwanda: a case study

Journal of Hospital Administration ◽

10.5430/jha.v4n5p47 ◽

2015 ◽

Vol 4 (5) ◽

pp. 47 ◽

Cited By ~ 3

Author(s):

Jean Claude Byiringiro ◽

Rex Wong ◽

Caroline Davis ◽

Jeffery Williams ◽

Joseph Becker ◽

...

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Success Factors ◽

Low Cost ◽

Post Intervention ◽

Triage System ◽

Accident And Emergency ◽

Number Of Patients ◽

Accident And Emergency Department ◽

The Impact

Few case studies exist related to hospital accident and emergency department (A&E) quality improvement efforts in lowerresourced settings. We sought to report the impact of quality improvement principles applied to A&E overcrowding and flow in the largest referral and teaching hospital in Rwanda. A pre- and post-intervention study was conducted. A linked set of strategies included reallocating room space based on patient/visitor demand and flow, redirecting traffic, establishing a patient triage system and installing white boards to facilitate communication. Two months post-implementation, the average number of patients boarding in the A&E hallways significantly decreased from 28 (pre-intervention) to zero (post-intervention), p < .001. Foot traffic per dayshift hour significantly decreased from 221 people to 160 people (28%, p < .001), and non-A&E related foot traffic decreased from 81.4% to 36.3% (45% decrease, p < .001). One hundred percent of the A&E patients have been formally triaged since the implementation of the newly established triage system. Our project used quality improvement principles to reduce the number of patients boarding in the hallways and to decrease unnecessary foot traffic in the A&E department with little investment from the hospital. Key success factors included a collaborative multidisciplinary project team, strong internal champions, data-driven analysis, evidence-based interventions, senior leadership support, and rapid application of initial implementation learnings. Results to date show the application of quality improvement principles can help hospitals in resource-limited settings improve quality of care at relatively low cost.

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845. Impact of the COVID-19 Pandemic on Routine HIV Screening in an Emergency Department

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.1040 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S513-S513

Author(s):

Elizabeth A Aguilera ◽

Gilhen Rodriguez ◽

Gabriela P Del Bianco ◽

Gloria Heresi ◽

James Murphy ◽

...

Keyword(s):

Emergency Department ◽

Screening Program ◽

Medical Center ◽

Hiv Infections ◽

Hiv Screening ◽

Opt Out ◽

Number Of Patients ◽

Confirmatory Tests ◽

Routine Hiv Screening ◽

The Impact

Abstract Background The Emergency Department (ED) at Memorial Hermann Hospital (MHH) - Texas Medical Center (TMC), Houston, Texas has a long established screening program targeted at detection of HIV infections. The impact of the COVID-19 pandemic on this screening program is unknown. Methods The Routine HIV screening program includes opt-out testing of all adults 18 years and older with Glasgow score > 9. HIV 4th generation Ag/Ab screening, with reflex to Gennius confirmatory tests are used. Pre-pandemic (March 2019 to February 2020) to Pandemic period (March 2020 to February 2021) intervals were compared. Results 72,929 patients visited MHH_ED during the pre-pandemic period and 57,128 in the pandemic period, a 22% decline. The number of patients tested for HIV pre-pandemic was 9433 and 6718 pandemic, a 29% decline. When the pandemic year was parsed into first and last 6 months interval and compared to similar intervals in the year pre pandemic, 39% followed by 16% declines in HIV testing were found. In total, 354 patients were HIV positives, 209, (59%) in the pre-pandemic and 145 (41%) in the pandemic period.The reduction in new HIV infections found was directly proportional to the decline in patients visiting the MHH-ED where the percent of patients HIV positive was constant across intervals (2.21% vs 2.26%). Demographic and outcome characteristics were constant across the compared intervals. Conclusion The COVID -19 pandemic reduced detection of new HIV infections by screening in direct proportion to the reduction in MHH-ED patient visits. The impact of COVID-19 pandemic decreased with duration of the pandemic. Disclosures All Authors: No reported disclosures

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Evaluating alcohol intoxication management services: the EDARA mixed-methods study

Health Services and Delivery Research ◽

10.3310/hsdr08240 ◽

2020 ◽

Vol 8 (24) ◽

pp. 1-214 ◽

Cited By ~ 1

Author(s):

Simon C Moore ◽

Davina Allen ◽

Yvette Amos ◽

Joanne Blake ◽

Alan Brennan ◽

...

Keyword(s):

Emergency Department ◽

Emergency Departments ◽

Alcohol Intoxication ◽

Ethnographic Study ◽

Acute Alcohol Intoxication ◽

Front Line ◽

Night Time ◽

Number Of Patients ◽

The Impact ◽

Management Services

Background Front-line health-care services are under increased demand when acute alcohol intoxication is most common, which is in night-time environments. Cities have implemented alcohol intoxication management services to divert the intoxicated away from emergency care. Objectives To evaluate the effectiveness, cost-effectiveness and acceptability to patients and staff of alcohol intoxication management services and undertake an ethnographic study capturing front-line staff’s views on the impact of acute alcohol intoxication on their professional lives. Methods This was a controlled mixed-methods longitudinal observational study with an ethnographic evaluation in parallel. Six cities with alcohol intoxication management services were compared with six matched control cities to determine effects on key performance indicators (e.g. number of patients in the emergency department and ambulance response times). Surveys captured the impact of alcohol intoxication management services on the quality of care for patients in six alcohol intoxication management services, six emergency departments with local alcohol intoxication management services and six emergency departments without local alcohol intoxication management services. The ethnographic study considered front-line staff perceptions in two cities with alcohol intoxication management services and one city without alcohol intoxication management services. Results Alcohol intoxication management services typically operated in cities in which the incidence of acute alcohol intoxication was greatest. The per-session average number of attendances across all alcohol intoxication management services was low (mean 7.3, average minimum 2.8, average maximum 11.8) compared with the average number of emergency department attendances per alcohol intoxication management services session (mean 78.8), and the number of patients diverted away from emergency departments, per session, required for services to be considered cost-neutral was 8.7, falling to 3.5 when ambulance costs were included. Alcohol intoxication management services varied, from volunteer-led first aid to more clinically focused nurse practitioner services, with only the latter providing evidence for diversion from emergency departments. Qualitative and ethnographic data indicated that alcohol intoxication management services are acceptable to practitioners and patients and that they address unmet need. There was evidence that alcohol intoxication management services improve ambulance response times and reduce emergency department attendance. Effects are uncertain owing to the variation in service delivery. Limitations The evaluation focused on health service outcomes, yet evidence arose suggesting that alcohol intoxication management services provide broader societal benefits. There was no nationally agreed standard operating procedure for alcohol intoxication management services, undermining the evaluation. Routine health data outcomes exhibited considerable variance, undermining opportunities to provide an accurate appraisal of the heterogenous collection of alcohol intoxication management services. Conclusions Alcohol intoxication management services are varied, multipartner endeavours and would benefit from agreed national standards. Alcohol intoxication management services are popular with and benefit front-line staff and serve as a hub facilitating partnership working. They are popular with alcohol intoxication management services patients and capture previously unmet need in night-time environments. However, acute alcohol intoxication in emergency departments remains an issue and opportunities for diversion have not been entirely realised. The nurse-led model was the most expensive service evaluated but was also the most likely to divert patients away from emergency departments, suggesting that greater clinical involvement and alignment with emergency departments is necessary. Alcohol intoxication management services should be regarded as fledgling services that require further work to realise benefit. Future work Research could be undertaken to determine if a standardised model of alcohol intoxication management services, based on the nurse practitioner model, can be developed and implemented in different settings. Future evaluations should go beyond the health service and consider outcomes more generally, especially for the police. Future work on the management of acute alcohol intoxication in night-time environments could recognise the partnership between health-care, police and ambulance services and third-sector organisations in managing acute alcohol intoxication. Trial registration Current Controlled Trials ISRCTN63096364. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 24. See the NIHR Journals Library website for further project information.

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Management of the Geriatric Patient

10.2310/im.1556 ◽

2018 ◽

Author(s):

Michelle Martinchek

Keyword(s):

Weight Loss ◽

Management Strategies ◽

Outpatient Setting ◽

Nursing Facilities ◽

Geriatric Syndromes ◽

Contributing Factors ◽

Team Members ◽

Patients At Risk ◽

Management Techniques ◽

The Impact

Geriatric syndromes are complex conditions in older adults that often have many contributing factors. Examples of common geriatric syndromes include cognitive impairment, delirium, falls, frailty, weight loss, and pressure ulcers. Identifying the patients at risk for these syndromes and enacting preventive measures are also important to try to reduce the impact that many of these syndromes may have on outcomes. These syndromes can happen across many different care settings including in the community, outpatient setting, hospital, and nursing facilities. Once these syndromes are identified, management techniques often include multifactorial approaches and use both nonpharmacologic and pharmacologic means. Management strategies may include assistance from interdisciplinary team members, families, and caregivers of the patient. This review contains 30 references, 4 figures, and 4 tables. Key Words: cognition, delirium, dementia, fall, frailty, gait, geriatric, malnutrition, pressure ulcer, weight loss

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Geographic Disparity in the United States Heart Allocation System

Analytics, Operations, and Strategic Decision Making in the Public Sector - Advances in Public Policy and Administration ◽

10.4018/978-1-5225-7591-7.ch004 ◽

2019 ◽

pp. 65-87

Author(s):

Fatemeh Karami ◽

Mehdi Nayebpour ◽

Monica Gentili ◽

Naoru Koizumi ◽

Andrew Rivard

Keyword(s):

United States ◽

Mortality Rate ◽

Waiting Time ◽

Average Distance ◽

The United States ◽

Allocation Model ◽

Geographic Disparity ◽

Transplant Candidates ◽

Geographic Equity ◽

The Impact

Organ allocation for transplantation across the United States is administered by the United Network for Organ Sharing (UNOS). UNOS recently approved a major policy change of the system used to allocate hearts for adult transplant candidates. The main objective of this study is to investigate the impact of the new policy on geographic disparity measured by four performance indicators (waiting time before a transplant, transplant rate, pre-transplant mortality rate, and average distance traveled by donated hearts). The current policy and the new policy were evaluated using the thoracic simulation allocation model. The results show that the new policy improves the median waiting time, transplant rate, and pre-transplant mortality rate. The overall predicted improvement in geographic equity is modest except in terms of waiting time. The findings highlight the need for a targeted approach for donor heart allocation to achieve equal access to heart transplantation in the US.

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First report of Klebsiella quasipneumoniae harboring blaKPC-2 in Saudi Arabia

Antimicrobial Resistance and Infection Control ◽

10.1186/s13756-019-0653-9 ◽

2019 ◽

Vol 8 (1) ◽

Cited By ~ 1

Author(s):

Sharif Hala ◽

Chakkiath Paul Antony ◽

Mohammed Alshehri ◽

Abdulhakeem O. Althaqafi ◽

Asim Alsaedi ◽

...

Keyword(s):

Public Health ◽

Saudi Arabia ◽

Tertiary Hospital ◽

Whole Genome ◽

Drug Resistant ◽

Global Public Health ◽

Gulf Region ◽

Carbapenem Resistant ◽

The Impact ◽

Klebsiella Spp

Abstract Background Nosocomial infections caused by multi-drug resistant Enterobacteriaceae are a global public health threat that ought to be promptly identified, reported, and addressed accurately. Many carbapenem-resistant Enterobacteriaceae-associated genes have been identified in Saudi Arabia but not the endemic Klebsiella pneumoniae carbapenemases (KPCs), which are encoded by blaKPC-type genes. KPCs are known for their exceptional spreading potential. Methods We collected n = 286 multi-drug resistant (MDR) Klebsiella spp. isolates as part of screening for resistant patterns from a tertiary hospital in Saudi Arabia between 2014 and 2018. Antimicrobial susceptibility testing was carried out using both VITEK II and the broth microdilution of all collected isolates. Detection of resistance-conferring genes was carried out using Illumina whole-genome shotgun sequencing and PacBio SMRT sequencing protocols. Results A Carbapenem-resistant Enterobacteriaceae (CRE) Klebsiella quasipneumoniae subsp. similipneumoniae strain was identified as a novel ST-3510 carrying a blaKPC-2 carbapenemase encoding gene. The isolate, designated as NGKPC-421, was obtained from shotgun Whole Genome Sequencing (WGS) surveillance of 286 MDR Klebsiella spp. clinical isolates. The NGKPC-421 isolate was collected from a septic patient in late 2017 and was initially misidentified as K. pneumoniae. The sequencing and assembly of the NGKPC-421 genome resulted in the identification of a putative ~ 39.4 kb IncX6 plasmid harboring a blaKPC-2 gene, flanked by transposable elements (ISKpn6-blaKPC-2–ISKpn27). Conclusion This is the first identification of a KPC-2-producing CRE in the Gulf region. The impact on this finding is of major concern to the public health in Saudi Arabia, considering that it is the religious epicenter with a continuous mass influx of pilgrims from across the world. Our study strongly highlights the importance of implementing rapid sequencing-based technologies in clinical microbiology for precise taxonomic classification and monitoring of antimicrobial resistance patterns.

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