Major Depressive Disorder With Psychiatric Emergency in Hong Kong: A Review and Practice Recommendation of the Asian Association of Neuropsychopharmacology.

The Positive Impact of Establishing an Internal Transfer Center

For the purpose of evaluating the validity of the staff's overall needs assessment in terms of the 'appropriate level of care' as a measurement of resource needs--with particular emphasis on the need for institutional resources--an analysis was made concerning the relation of the assessment to various other factors. In the analysis, we used data collected in a survey undertaken in Solna municipality on November 1, 1991 according to the ASIM monitoring system. It was found by multiple regression analysis, that the 'appropriate level of care' was closely related to the client's degree of disability, age, and actual level of care. On the other hand, variables describing the client's social situation--marital status, single-living, informal social support, standard and accessibility of housing--bore no relation to the assessment of need for institutional care. Chiefly because of the close relation to the actual level of care it was concluded that the staff's overall assessment of 'appropriate level of care' should be used with a degree of caution as measure of the need for institutional resources, since it would tend to overrate that need. A more systematic needs assessment procedure is required in order to provide the municipal authorities with unbiased estimates of institutional resource needs.

ATA2020 Session Summaries (Abstracts)

Is Prehospital Advanced Life Support Harmful?

Public health care delivery in South Africa aims to provide equitable access at the most appropriate level of care. We studied to what extent the acute health care needs of adults admitted to public hospitals in the Cape Town Metropole were being appropriately met. A retrospective study was conducted of the hospital records of adults admitted to medical beds in public hospitals in Cape Town between August and November 2008. Intensive care unit patients were not included. Of 802 beds in use, the estimated occupancy was at least 95%. The average time elapsed since admission was 7.9 days; 94.3% of medical admissions were acute; 45% were severely to critically ill on admission; and co-morbid disease was present in 78.1%. Of all admissions, 31.9% were HIV-positive, and 17% had active tuberculosis. At least 396 (51.6%) patients were deemed to have required specialist or subspecialist consultation to expedite appropriate care; 386 (50.3%) accessed the appropriate level of medical care required; 339 (44.2%) accessed a more sophisticated level of care than required; and 42 (5.5%) did not access an adequate level of care. CT scan and ultrasound accounted for 59% of all restricted tests done. Our findings support the plan to provide more primary care hospital facilities in the metropolitan area. Most patients needing specialised care are accessing such care, and most patients accessing a higher level of care than needed can be addressed by ensuring that they first access primary care and are referred according to protocols.

Disparities in Timing of Trauma Consultation: A Trauma Registry Analysis of Patient and Injury Factors

Back to table of contents Previous article Next article CommunityFull AccessOregon Pilot Program Would Expand MH Crisis Services for YouthKatie O'ConnorKatie O'ConnorSearch for more papers by this authorPublished Online:23 Feb 2023https://doi.org/10.1176/appi.pn.2023.04.3.7AbstractThe implementation of 988 allowed many states to bolster their mental health crisis services, but quite often those efforts are focused on adults. A program in Oregon would set up a pilot to connect youth statewide with crisis services.In large states, the goal of establishing a robust, statewide mental health crisis system often runs into the same problem: distance. In Oregon, roughly 80% of the youth experiencing a psychiatric crisis present to three hospitals that are largely well equipped to treat them, explained Robin Henderson, Psy.D., chief executive of behavioral health with Providence Oregon. But what happens to the 20% of kids who present at the other dozens of rural hospitals across the state?The proposed pilot in Oregon will aim to empower hospitals and the communities around them to collaborate to create a range of local services and supports for youth in crisis, says Ajit Jetmalani, M.D.“Very often, children will need to travel to Portland for acute psychiatric emergencies, or they will sit in emergency rooms in a rural setting that has no services at all and just wait,” said Ajit Jetmalani, M.D., director of the Division of Child and Adolescent Psychiatry and the Joseph Professor of Child and Adolescent Psychiatry Education at Oregon Health & Science University.Jetmalani and Henderson are proposing a pilot program in Oregon that would harness the momentum created by the implementation of 988 to significantly improve access to care for youth in crisis statewide. The program would use Oregon’s existing regional trauma system for physical health crises, which assigns levels (between one and four) to the state’s more than 60 hospitals. The system allows hospitals to coordinate, ensuring patients are connected to the hospital with the most appropriate level of care. The proposed pilot would use that same system and apply it to youth mental health crises.“If you get in a motorcycle accident in Baker City, that little hospital in Baker City knows exactly what to do,” Henderson said. “They have a playbook. They know where to send you, how to stabilize you, and these things can happen very quickly. But if a child psychiatric crisis shows up, they would end up reinventing the wheel every time. What we are proposing is to take a page from the playbook of a successful, regionalized crisis system and apply that to mental health.”Under the pilot program, one hospital in each region would have a Regional Child Psychiatric Center within its emergency department (ED). The centers would have comprehensive mental health services including access to child/adolescent psychiatrists and other licensed mental health professionals, as well as family/peer support. Other hospitals in that region would have a memorandum of understanding with the Regional Child Psychiatric Center for remote consultation services, as well.“We’ve seen that if you can deliver high-quality assessments and interventions in the emergency room, you can oftentimes resolve crises and create a safe plan for care in the community,” Jetmalani said. “We’re hoping this program will make it easier for all kids to have access to those types of services, regardless of where a child presents.”Jetmalani and Henderson worked with Rep. Tawna Sanchez, a Democrat who represents parts of northern Portland, to introduce legislation into Oregon’s legislative session this year. The legislation includes funding for the next two years to get the pilot started, which would fund the development of three Regional Child Psychiatric Centers, including up to three Child/Adolescent Psychiatric Emergency (CAPE) units.The CAPE units are emergency evaluation areas with between four and eight beds. When the ED assessment determines there are no physical health issues, youth and their families can transition to a CAPE unit, where they can stay for up to three days for stabilization or observation. The CAPE units give patients, families, and professionals time to determine what the child needs and what may be driving the crisis in a safe environment, separate from a loud and busy ED.“The CAPE unit is a setting built specifically for supporting youth who are in crisis,” Jetmalani said. “We can implement trauma-informed practices and immediately work on pulling services together for the child and family, ensuring that they have support in the community and a safe place to go.”Henderson and Jetmalani are hoping that the funding included in the legislation will get the program up and running, allow them to show lawmakers that it works, and then allow them to expand so each region has a Regional Child Psychiatric Center. They aim to eventually make the program scalable so other states can implement it.The two-year period also allows more time to determine the best payment structure for the program, Henderson said. “There are schools of thought that say we should use a telecommunications tax to pay for these services,” she said. It could also potentially be paid through insurance.“First, we need to see what our experiences are. How many people are using these units? What kind of capacity issues do we have?” Henderson said. “This shouldn’t just be paid for by Medicaid. It should be paid for by all insurers. But we need to figure out what that’s going to look like.” ■ ISSUES NewArchived

BackgroundAlgorithm-based patient navigation is a key feature of the emergency and acute care reform being discussed in Germany. The software Structured Initial Medical Evaluation in Germany (SmED) is designed to assist in determining the appropriate time for medical complaints to be treated, as well as their most appropriate level of care. SmED is available in three different configurations, each of which is currently used in the German acute care sector and can be utilized by either a provider (SmED-Contact, SmED-Contact +) or a self-applicant (SmED-Patient). SmED-Patient is offered as a web-based self-assessment application that provides recommendations on the medical urgency and appropriate level of care for acute symptoms. This is the first study to explore and evaluate the accuracy, safety, utility and feasibility of using the self-assessment application SmED-Patient for self-referring patients and medical staff in the emergency department (ED) setting in Germany.MethodsThe study uses a mixed methods approach, including a prospective, multicenter cohort study combined with retrospective expert review of SmED-Patient recommendations for all cases by an expert panel as well as focus groups and a microsimulation. Expert reviews assess SmED-Patient recommendations on patients’ treatment urgency and the appropriate level of care based on routine clinical data. Adult patients (≥ 18 years) who self-refer at two inner-city emergency departments in Berlin (Germany) and able to provide written informed consent will be invited to participate. Target number of patients is n = 150. The primary endpoint is the accuracy of SmED-Patient’s recommended level of care, measured as the agreement with the expert review for all cases. Secondary endpoints include safety, utility and feasibility of use. Data sources include primary data, routine clinical data, and qualitative data from focus groups and a microsimulation.DiscussionThis study will provide insight into the accuracy, utility, safety and feasibility of using the self-assessment application SmED-Patient in the ED. By facilitating medical self-assessment for self-referring walk-in patients, SmED-Patient could contribute to re-directing patients to ambulatory care providers, improving the efficiency of ED operations and benefit providers’ as well as patients’ care experiences in the ED.Trial registrationGerman Clinical Trials Register: DRKS00036266. 25/02/2025.Supplementary InformationThe online version contains supplementary material available at 10.1186/s13063-025-09101-4.

Objectives. Influenza vaccination has long been recommended for health care workers, but vaccination rates among this group have been low. Data on emergency medical services (EMS) personnel's vaccination status have not been published. This study compared self-reported vaccination rates and barriers among EMS and emergency department (ED) personnel. Methods. We conducted a cross-sectional survey of full-time EMS providers servicing metropolitan Rochester, New York, and a convenience sample of ED personnel in an academic medical center in Rochester, New York. Surveys, completed during July and August 2006, focused on influenza vaccination status for the 2005–2006 season and opinions regarding the vaccination. Immunization rates of EMS providers and ED personnel were compared using the chi-square calculation. Results. Surveys were completed by 128 EMS providers (100% of eligible) and 128 ED personnel (100% of approached). Among EMS providers, 27 of 128 (21%; 95% confidence interval [CI] 14%–29%), and among ED personnel, 83 of 128 (65%; 95% CI 56%–73%) reported receiving an influenza vaccination in the preceding year (p < 0.001). Among interventions that could lead to an increase in influenza vaccination, the most commonly chosen by EMS providers and ED personnel alike were “no waiting” vaccination at work (71% and 62%, respectively) and free vaccination (59% and 50%, respectively). When asked about important factors in the decision whether to get an influenza vaccination the following season, the most common responses were frequency of exposure (71%, 69%) and concern about secondarily exposing family members (62%, 60%). Conclusion. EMS providers reported low influenza vaccination levels in 2005–2006, even as compared with ED personnel. This failure to receive vaccination poses potential risk to the workers themselves and their patients. Resolution of reported barriers could lead to higher vaccination rates.

How a community responds to behavioral health emergencies is both a public health issue and social justice issue. Individuals experiencing a behavioral health crisis often receive inadequate care in emergency departments (EDs), boarding for hours or days while waiting for treatment. Such crises also account for a quarter of police shootings and >2 million jail bookings per year. Racism and implicit bias magnify these problems for people of color. Growing support for reform provides an unprecedented opportunity for meaningful change, but solutions to this complex issue will require comprehensive systemic approaches. As communities grapple with behavioral health emergencies, the question is not just whether law enforcement should respond to behavioral health emergencies but how to reduce unnecessary law enforcement contact and, if law enforcement is responding, when, how, and with what support. This policy article reviews best practices for law enforcement crisis responses, outlines the components of a comprehensive continuum-of-crisis care model that provides alternatives to law enforcement involvement and ED use, and offers strategies for collaboration and alignment between law enforcement and clinicians toward common goals. Finally, policy considerations regarding stakeholder engagement, financing, data management, legal statutes, and health equity are presented to assist communities interested in taking steps to build these needed solutions.

IntroductionAcute bacterial skin and skin structure infections (ABSSSIs) represent a large burden to the US healthcare system. There is little evidence-based guidance regarding the appropriate level of care for ABSSSIs. This study aimed to develop a prediction model and risk-scoring tool to determine appropriate levels of care.MethodsThis was a single-center observational cohort study of adult patients treated for ABSSSIs from 2012 to 2015 at the Detroit Medical Center. The predictive model used to create a novel risk-scoring tool was derived using multinomial regression analysis. The overall accuracy of this tool was compared to the Clinical Resource Efficacy Support Team (CREST) Classification and Standardized Early Warning Score (SEWS) using area-under-the- receiver-operator-curve (AUROC) analysis and Z-statistic.ResultsFinal patient disposition was 230 (45.5%) home from the emergency department (ED), 65 (12.8%) observation unit (OU), and 211 (41.7%) initial inpatient. IV antibiotic therapy was used in 358 (70.8%) patients. CREST and SEWS were not accurate in the determination of ED versus OU disposition [AUROC CREST 0.0.682 (95% CI 0.640–0.724), AUROC SEWS 0.686 (95% CI 0.641–0.731)], but performed better in determining ED/OU versus inpatient [AUROC CREST = 0.678 (95% CI 0.630–0.725), AUROC SEWS 0.693 (95% CI 0.645–0.740)]. These scores were also not accurate in determining IV versus PO antibiotic therapy [AUROC CREST = 0.586 (95% CI 0.530–0.624), AUROC SEWS = 0.630 (95% CI 0.576–0.684)]. A risk-scoring tool ranging from 0 to 10 points was derived incorporating WBC, temperature, site of infection, and past medical history of diabetes, liver disease, PVD, AKI, and/or CKD. The AUROC of the new model was 0.675 (95% CI 0.611–0.739) ED versus OU, 0.789 (95% CI 0.748–0.829) ED/OU versus inpatient, and 0.742 (95% CI 0.694–0.789) IV versus oral antibiotics. The new score had a significantly higher AUROC compared to both the CREST and SEWS for determining ED/OU versus inpatient (p < 0.001).ConclusionPrediction models based on patient risk may be useful for determining appropriate level of care during for ABSSSIs. While the prediction model demonstrated moderate to high levels of correlation with patient level of care, further validation of a prospective cohort of patients is warranted.Electronic supplementary materialThe online version of this article (10.1007/s40121-018-0212-3) contains supplementary material, which is available to authorized users.

Regardless of their specialty, physicians encounter various potential clinical emergencies in their outpatients that may require referring patients for the appropriate level and urgency of care. One such situation is the outpatient who presents with suicidal or homicidal ideation. In this circumstance, the physician is faced with performing a rapid evaluation of the symptoms, determining the acuity of the situation, and safely referring the patient to an appropriate level of care. Using case vignettes, this article reviews some of the immediate critical factors to consider in evaluating and managing the outpatient who expresses thoughts of suicide or homicide.

In 2020, at the onset of the COVID-19 pandemic, the United States experienced surges in healthcare needs, which challenged capacity throughout the healthcare system. Stay-at-home orders in many jurisdictions, cancellation of elective procedures, and closures of outpatient medical offices disrupted patient access to care. To inform symptomatic persons about when to seek care and potentially help alleviate the burden on the healthcare system, Centers for Disease Control and Prevention (CDC) and partners developed the CDC Coronavirus Self-Checker ("Self-Checker"). This interactive tool assists individuals seeking information about COVID-19 to determine the appropriate level of care by asking demographic, clinical, and nonclinical questions during an online "conversation." This paper describes user characteristics, trends in use, and recommendations delivered by the Self-Checker between March 23, 2020, and April 19, 2021, for pursuing appropriate levels of medical care depending on the severity of user symptoms. User characteristics and trends in completed conversations that resulted in a care message were analyzed. Care messages delivered by the Self-Checker were manually classified into three overarching conversation themes: (1) seek care immediately; (2) take no action, or stay home and self-monitor; and (3) conversation redirected. Trends in 7-day averages of conversations and COVID-19 cases were examined with development and marketing milestones that potentially impacted Self-Checker user engagement. Among 16,718,667 completed conversations, the Self-Checker delivered recommendations for 69.27% (n=11,580,738) of all conversations to "take no action, or stay home and self-monitor"; 28.8% (n=4,822,138) of conversations to "seek care immediately"; and 1.89% (n=315,791) of conversations were redirected to other resources without providing any care advice. Among 6.8 million conversations initiated for self-reported sick individuals without life-threatening symptoms, 59.21% resulted in a recommendation to "take no action, or stay home and self-monitor." Nearly all individuals (99.8%) who were not sick were also advised to "take no action, or stay home and self-monitor." The majority of Self-Checker conversations resulted in advice to take no action, or stay home and self-monitor. This guidance may have reduced patient volume on the medical system; however, future studies evaluating patients' satisfaction, intention to follow the care advice received, course of action, and care modality pursued could clarify the impact of the Self-Checker and similar tools during future public health emergencies.

Early prehospital assessment of non-urgent patients and outcomes at the appropriate level of care: A prospective exploratory study

Envisioning the Post-COVID-19, Pre-Vaccine Emergency Department.