Care Hospital Emergency Department Research Articles

Patient satisfaction with nursing triage care in hospital emergency departments: Scoping review

IntroductionPerceived quality of patient care is essential in healthcare, particularly in hospital emergency departments (EDs), where the triage process, performed by nurses, is fundamental yet under-researched. The aim is to explore patient satisfaction in triage, identify improvement opportunities, and provide guidance for future research to enhance ED care. MethodologyA scoping review was conducted across databases including PubMed, CINAHL, Scopus, Cochrane, Joanna Briggs, Google, and Google Scholar. Empirical articles from January 2014 to December 2023 were selected, excluding non-face-to-face triage, pediatrics, and aspects not related to nursing care. ResultsSix studies were included, demonstrating a high level of patient satisfaction with triage, especially regarding nurses’ skills and professional competence, courtesy, respect, interest, and empathy. However, pain management and confidence in treatment scored lower. Patient satisfaction was related to age, gender, reason for consultation, and perception of nurses’ professional competence. DiscussionSimilar opinions were observed regarding areas for improvement in care and nurses’ skills in triage. The need for qualitative research and more rigorous sampling methods was highlighted. ConclusionsNurse training and education in triage are crucial for patient satisfaction. Further research is needed to evaluate the effectiveness of nursing interventions in triage and address remaining challenges.

Spanish experts consensus on emergency psychiatric care in hospital emergency departments

BackgroundThe demand for urgent psychiatric care is increasing, but in Spain there are no clear recommendations for emergency departments (ED) on how to optimize care for patients with psychiatric emergencies. We aimed to provide expert consensus recommendations on the requirements for general hospitals´ emergency departments to treat patients with urgent psychiatric symptoms.MethodsWe used a modified Delphi technique. A scientific committee compiled 36 statements based on literature search and clinical experience. The statements covered the organizational model, facilities, staffing, safety, patient interventions, and staff training. A panel of 38 psychiatry specialists with expertise in psychiatric emergencies evaluated the questionnaire in two rounds.ResultsAfter two rounds of voting, 30 out of 36 proposed items (83%) were agreed upon. The panel agreed that psychiatric emergencies should be managed in a general hospital, with dedicated facilities for patient assessment, direct supervision of patients at risk, and an observation unit run by the psychiatric service. In addition to the psychiatrist, the ED should have specialist nurses and security staff available 24/7. Social workers should also be readily available. ED and consulting rooms should be designed to ensure patient and staff safety. A triage system should be established for patients with psychiatric symptoms, with medical evaluation preceding psychiatric evaluation. Guidance on supplies, equipment, and staff training is also provided.ConclusionAll ED in general hospitals should have adequate resources to handle any psychiatric emergency. This paper provides recommendations on the minimum requirements to achieve this goal.

The HEARTRISK6 Scale: Predicting Short-Term Serious Outcomes in Emergency Department Acute Heart Failure Patients

BackgroundAcute heart failure (AHF) is a common emergency department (ED) presentation that may have poor outcomes but often does not require hospital admission. There is little evidence to guide dispositional decisions. ObjectivesThe authors sought to create a risk score for predicting short-term serious outcomes (SSO) in patients with AHF. MethodsWe pooled data from 3 prospective cohorts: 2 published studies and 1 new cohort. The 3 cohorts prospectively enrolled patients who required treatment for AHF at 10 tertiary care hospital EDs. The primary outcome was SSO, defined as death <30 days, intubation or noninvasive ventilation (NIV), myocardial infarction, or relapse to ED <14 days. The logistic regression model evaluated 13 predictors, used an AIC-based step-down procedure, and bootstrapped internal validation. ResultsOf the 2,246 patients in the 3 cohorts (N = 559; 1,100; 587), the mean age was 77.4 years, 54.5% were male, 3.1% received intravenous nitroglycerin, 5.2% received ED NIV, and 48.6% were admitted to the hospital. There were 281 (12.5%) SSOs including 70 deaths (3.1%) with many in discharged patients. The final HEARTRISK6 Scale included 6 variables: valvular heart disease, tachycardia, need for NIV, creatinine, troponin, and failed reassessment (walk test). Choosing HEARTRISK6 total-point admission thresholds of ≥1 or ≥2 would yield, respectively, sensitivities of 88.3% (95% CI: 83.9%-91.8%) and 71.5% (95% CI: 65.9%-76.7%) and specificities of 24.7% (95% CI: 22.8%-26.7%) and 50.1% (95% CI: 47.9%-52.4%) for SSO. ConclusionsUsing 3 large prospectively collected datasets, we created a concise and sensitive risk scale for patients with AHF in the ED. Implementation of the HEARTRISK6 scale could lead to safer and more efficient disposition decisions.

The analysis of variables affecting patient satisfaction and its level in a hospital emergency department based on a selected emergency unit

Introduction. Patient satisfaction is perceived as one of the major criterium while evaluating the quality in the field of medical services.Aim of the study. Analysing and evaluating the level of satisfaction with the services provided by medical and nursing staff among patients of a selected Emergency Department (ED).Material and methods. The observational study was conducted from September to December 2022. The research was based on the data collected from 122 patients of the ED. The Patient Satisfaction Questionnaire and self- prepared questionnaire were used.Results. Using an 11-grade scale from 0 – 10 (0 – the worst of all possible hospitals, 10 – the best of all possible hospitals), only 15.83% (19) evaluated the researched hospital as ‘the best’. Most of the respondents - 23.33% (28) gave the hospital an 8 or 9 - point rate - 18.33% (22). While patients’ asked how often they were treated with respect and kindness by the nursing staff, the respondents most frequently answered ‘always’ - 70.83% (85) or ‘usually’ - 27.50% (33). While asked how often the doctors treated them with respect and kindness, most frequently answered ‘always’ - 61.67% (74) or ‘usually’ - 26.67% (32). Age and gender of patients did not significantly affect the level of satisfaction with care (p&gt;0.005). However, the higher the level of education, the lower the willingness to recommend the hospital to family or friends (p=0.027). Conclusions. General satisfaction with hospitalization was at a high level. The more educated the patients were, the lower the readiness to recommend the hospital to family or friends. The ED staff should take into consideration this fact while planning care in hospital emergency departments.

What adult patients prefer for reporting their pain levels, and frequency of reassessment when in the emergency department

ObjectivesThis study interviewed adult patients presenting to the emergency department (ED) for various pain conditions enquiring about their preferred tool for reporting pain severity and preferred time interval between initial assessment and subsequent pain reassessments. MethodsA prospective observational (cross-sectional) study was conducted in adult patients with acute pain in a tertiary care hospital ED setting. Patients' initial pain score was recorded using NRS (numerical rating scale) pain scale, and appropriate analgesia offered. Once the patient had been evaluated by an attending physician, a research team member interviewed the patient regarding the pain reassessment time and preferred pain assessment tool. The pain assessment tools evaluated in this study were NRS, PS (picture scale or face pain scale), VRS (verbal rating scale), and VAS (visual analogue scale). The patients were presented with the four pain assessment tools (in their primary language) through an audio-visual on an electronic tablet display. Results200 (138 male, mean age 36.5 ± 11.17) patients participated in the study. With increasing age, pain reassessment interval increased by 0.19 min (95% CI 0.03–0.36 min). Males requested pain reassessment 6.7 min (95% CI 2.2–10.8) faster than females. In this study, the preferred interval for pain reassessment was reported as a mean of 22.8 (SD + −13.6) minutes. There was no relationship reported between time reassessment and pain severity (P = 0.22). Out of 200 subjects, irrespective of the initial pain scores, 100 preferred NRS. NRS was preferred by patients with mild to moderated pain due to the perception of being faster. However, patients with severe pain choose a non-NRS scale to prioritize accuracy. ConclusionThere was no influence found between the initial pain severity scores and the desired frequency of pain reassessment. However, associations were identified between the time for pain reassessment interval and age, sex, and geographical region. Patients with severe pain preferred PS or VRS while patients with mild/moderate pain preferred the NRS.

Development and validation of a parental competence questionnaire in the paediatric hospital emergency setting (ECP-U)

ObjectiveTo develop and validate a parental competence questionnaire for parents of children seeking care in hospital emergency departments. MethodsAn instrumental study of the development of an assessment questionnaire was carried out in three phases: 1) review of relevant measures and item generation, 2) content validity evaluation, 3) psychometric evaluation. Exploratory factor analysis was performed to examine the factorial structure. Internal consistency was evaluated using ordinal alpha. Hypothesis testing was determined between the resulting factors, the Parental Stress Scale and the State-Trait Anxiety Inventory. ResultsThe participants were 270 parents of children aged 0–14 years old from a referral hospital in Valencia (Spain). An 18-item questionnaire was developed, comprising five factors that explain 53.0% of the variance: 1) “emotional management and expression”, 2) “passive social support”, 3) “parental agency”, 4) “basic needs and care” and 5) “active social support”. The internal consistency for the different factors was modest (>0.70). A negative correlation between the Parental Stress Scale and the parental competence questionnaire was found for most of the factors. ConclusionsThis questionnaire on parental competence in the hospital emergency department (ECP-U) is a useful and simple self-report instrument for assessing the parental competence of parents with children in the emergency department. Practical implicationsThe resulting questionnaire is of practical value to both healthcare professionals and researchers in this field. It can be administered quickly in clinical practice and used to identify parents' levels of parental competence and refer those with difficulties to appropriate support services.

Home Blood Pressure Telemonitoring Technology for Patients With Asymptomatic Elevated Blood Pressure Discharged From the Emergency Department: Pilot Study.

Hypertension affects 1 in 5 Canadians and is the leading cause of morbidity and mortality globally. Hypertension control is declining due to multiple factors including lack of access to primary care. Consequently, patients with hypertension frequently visit the emergency department (ED) due to high blood pressure (BP). Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring Blood Pressure is a pilot project that implements and evaluates a comprehensive home blood pressure telemonitoring (HBPT) and physician case management protocol designed as a postdischarge management strategy to support patients with asymptomatic elevated BP as they transition from the ED to home. Our objective was to conduct a feasibility study of an HBPT program for patients with asymptomatic elevated BP discharged from the ED. Patients discharged from an urban, tertiary care hospital ED with asymptomatic elevated BP were recruited in Vancouver, British Columbia, Canada, and provided with HBPT technology for 3 months of monitoring post discharge and referred to specialist hypertension clinics. Participants monitored their BP twice in the morning and evenings and tele-transmitted readings via Bluetooth Sensor each day using an app. A monitoring clinician received these data and monitored the patient's condition daily and adjusted antihypertensive medications. Feasibility outcomes included eligibility, recruitment, adherence to monitoring, and retention rates. Secondary outcomes included proportion of those who were defined as having hypertension post-ED visits, changes in mean BP, overall BP control, medication adherence, changes to antihypertensive medications, quality of life, and end user experience at 3 months. A total of 46 multiethnic patients (mean age 63, SD 17 years, 69%, n=32 women) found to have severe hypertension (mean 191, SD 23/mean 100, SD 14 mm Hg) in the ED were recruited, initiated on HBPT with hypertension specialist physician referral and followed up for 3 months. Eligibility and recruitment rates were 40% (56/139) and 88% (49/56), respectively. The proportion of participants that completed ≥80% of home BP measurements at 1 and 3 months were 67% (31/46) and 41% (19/46), respectively. The proportion of individuals who achieved home systolic BP and diastolic BP control at 3 months was 71.4% (30/42) and 85.7% (36/42) respectively. Mean home systolic and diastolic BP improved by -13/-5 mm Hg after initiation of HBPT to the end of the study. Patients were prescribed 1 additional antihypertensive medication. No differences in medication adherence from enrollment to 3 months were noted. Most patients (76%, 25/33) were highly satisfied with the HBPT program and 76% (25/33) found digital health tools easy to use. HBPT intervention is a feasible postdischarge management strategy and can be beneficial in supporting patients with asymptomatic elevated BP from the ED. A randomized trial is underway to evaluate the efficacy of this intervention on BP control.

Modeling the value of an emergency department influenza vaccination program

BackgroundSeasonal influenza continues to present a significant annual burden as the vaccination rate in the United States is 51.8%. Emergency Department (ED) based influenza programs have been successfully implemented and improve vaccine uptake, reduce incidence and costs, and improve outcomes. ObjectiveTo develop a predictive model to assess preventable influenza cases, hospitalizations, fatalities, and incremental cost avoidance based on the unvaccinated population. MethodsA retrospective cohort of ED encounters limited to Medicare and Medicaid populations was performed across 14 tertiary care hospital EDs and six freestanding EDs for 2020. The total number of unvaccinated individuals was identified to determine the potential impact of an ED vaccination campaign. The average cost and loss per inpatient stay was identified from prior industry Medicare benchmark data and was utilized to extrapolate Medicaid losses. Results from published cost-effectiveness studies identified the vaccination thresholds to prevent one additional case of influenza, one additional hospitalization, and one additional fatality. ResultsA total of 39,463 unvaccinated individuals were identified, with 14,064 classified as Medicare, and 25,379 classified as Medicaid. Assuming a 95% target outreach, 90% medical eligibility, and 70% acceptance rate, 414 influenza cases would be prevented (266 Medicaid, 148 Medicare), 28 hospitalizations would be prevented (18 Medicaid, 10 Medicare), and eight deaths would be prevented (5 Medicaid, 3 Medicare). Accordingly, a reduction in admissions would prevent $409,360 in total inpatient medical costs and $36,232 in losses to healthcare systems. ConclusionAn ED-based influenza vaccination program would have a measurable impact on patient influenza disease burden and associated medical expenditures.

Safe Discharge Needs Following Emergency Care for Intimate Partner Violence, Sexual Assault, and Sex Trafficking.

For survivors of gender-based violence (GBV) seeking care in hospital emergency departments (ED) the need for medical care and safe discharge is acute. In this study we evaluated safe discharge needs of GBV survivors following hospital-based care at a public hospital in Atlanta, GA, in 2019 and between April 1, 2020-September 30, 2021, using both retrospective chart review and evaluation of a novel clinical observation protocol for safe discharge planning. Of 245 unique encounters, only 60% of patients experiencing intimate partner violence (IPV) were discharged with a safe plan and only 6% were discharged to shelters. This hospital instituted an ED observation unit (EDOU) to support GBV survivors with safe disposition. Then, through the EDOU protocol, 70.7% were able to achieve safe disposition, with 33% discharged to a family/friend and 31% discharged to a shelter. Safe disposition following experience or disclosure of IPV and GBV in the ED is difficult, and social work staff have limited bandwidth to assist with navigation of accessing community-based resources. Through an average 24.3 hours of an extended ED observation protocol, 70% of patients were able to achieve a safe disposition. The EDOU supportive protocol substantially increased the proportion of the GBV survivors who experienced a safe discharge.

Outcome of emergency obstetric cases in relation to the referral pattern at a tertiary hospital in Puducherry: A cross-sectional descriptive study.

Referral is a crucial aspect of emergency obstetric care in India. Adequate and timely referrals help to improve the quality of health-care services and maternal and child well-being. Studies are needed to assess the outcome of obstetric mothers' emergency admissions in relation to referral patterns. A hospital-based cross-sectional descriptive study was done among obstetric patients admitted to a tertiary care hospital's emergency department (emergency medical service [EMS]). A retrospective cohort was analyzed. The data were entered in Epicollect5 and imported to STATA software version 16 for analysis. A total of 685 mothers admitted to EMS were selected for the study, with a mean (standard deviation) age of 26.5 years (4.2). Among the study participants, 181 (26.4%) were referred from other institutions, 382 (55.8%) were nonreferral who received antenatal checkups in the tertiary hospital, and 122 (17.8%) were self-referral who had not received any antenatal checkup in the tertiary hospital. The adverse fetal outcome was 1.88 (1.21-2.95) times higher in the referred mothers compared to the self-referral. We observed that a higher percentage of referrals were from the primary health centers. This kind of direct referral to tertiary care hospitals can be avoided by availing the emergency obstetric services at secondary hospitals to prevent adverse fetal outcomes and unnecessary referrals to the tertiary hospital.

An evaluation of violence prevention education in healthcare

BackgroundAn issue of international concern, violence towards healthcare workers from patients and visitors negatively affects the safety and health of workers and the quality of care they deliver. The principal intervention to address violence has been violence prevention (VP) educational programs for healthcare workers. Evaluating the overall effectiveness of VP education has been difficult due to pervasive underreporting of incidents, the complexity of healthcare settings, and the varying reasons for violence. MethodsA theory-driven, realist evaluation was conducted to examine the conditions under which VP education is effectively learned and applied in emergency department (ED) settings. Nine research sites included three rural, three community and three urban, tertiary care hospital EDs. Data from individual and focus group interviews with 136 participants was used to test a program theory (PT) of why and how VP education works, for whom, under what circumstances. ResultsThe initial program theory of VP education was based on a realist literature review and input from content experts. Qualitative data from the evaluation refined the initial program theory, yielding 15 explanations for how and why educational and workplace contexts influence ED workers' learning and application of VP knowledge and skills—ultimately reducing the risk of violence. While the explanations result from individual worker’s perspectives of VP education, they are situated in a broader context of organizational safety climate including organizational leaders’ response to employees’ experiences with violence and feelings of physical and psychosocial safety. ConclusionsThis research provides practical evidence for healthcare stakeholders to inform education, policy and practice decisions to increase the VP education effectiveness.

Cocaethylene cardiotoxicity in emergency department patients with acute drug overdose.

Cocaine use results in over 500,000 emergency department (ED) visits annually across the United States and ethanol co-ingestion is reported in 34% of these. Commingling cocaine with ethanol results in the metabolite cocaethylene (CE), which is metabolically active for longer than cocaine alone. Current literature on the cardiotoxicity of CE compared to cocaine alone is limited and lacks consensus. This study aims to fill this gap in the literature and examine cardiovascular events in cocaine use as confirmed by urine toxicology versus CE exposure. This was a secondary data analysis of a prospective cohort study of adult patients with acute drug overdose at two urban tertiary care hospital EDs over 4 years. Patients with positive urinary cocaine metabolites were analyzed, and outcomes were compared between patients with overdose and confirmed presence of cocaine on urine toxicology (cocaine group) and patients with cocaine and ethanol use (CE group). The primary outcome was cardiac arrest. Secondary outcomes included myocardial injury and hyperlactatemia. Data were analyzed using multivariable regression models. We enrolled a total of 199 patients (150 cocaine, 49 CE). Rates of cardiac arrest were significantly higher in the CE group compared to cocaine (6.1% vs. 0.67%, p= 0.048). Cocaine was significantly associated with myocardial injury compared to CE exposure (mean initial troponin 0.01 ng/ml vs. 0.16 ng/ml, p= 0.021), while hyperlactatemia was associated with CE exposure (mean initial lactate 4.1 mmol/L vs. 2.9 mmol/L, p= 0.038). When compared to cocaine exposure alone, CE exposure in ED patients with acute drug overdose was significantly associated with higher occurrence of cardiac arrest, higher mean lactate concentrations, and lower occurrence of myocardial injury.

Mental Health-related Utilization of Emergency Departments During Pregnancy in the U.S., 2016-2019.

Mental health conditions are a leading comorbidity of pregnancy, but little is known about the use of emergency departments (EDs) for mental health-related care during pregnancy. This study aims to describe both the characteristics of pregnant women who receive mental health-related care in hospital EDs in the United States and the most common mental health diagnoses, types of medications, and mental health services that these women receive. Pooled, cross-sectional data from the National Hospital Ambulatory Medical Care Survey (2016-2019) were used. Pregnant patients were identified based on diagnosis and reason for visit codes. Weighted descriptive analyses were performed to describe characteristics of pregnant women, services offered, and medications received for mental health-related visits. Mental health-related visits comprised 6.2% of all ED visits during pregnancy. History of depression was significantly higher in pregnant patients with mental health-related visits compared to those pregnant patients presenting for other reasons. The most common diagnoses for pregnant patients with mental health-related visits were substance use disorders (30.7%), anxiety-related disorders (19.1%), and depressive disorders (14.6%). Anxiolytics and antidepressants were the most common pharmacotherapies given. Few women saw a mental health provider during their visit (6.7%), while most were referred to an outside clinic for follow-up (55.0%). Many pregnant women seek care from EDs for mental health-related reasons. It remains important to train health care professionals who treat pregnant women in EDs how to deliver effective treatments, particularly for substance use disorders and anxiety. Many pregnant patients receive care in emergency departments during pregnancy. Despite mental health conditions being a leading comorbidity of pregnancy, little is known about the use of emergency departments for mental health-related reasons during pregnancy. This study is the first to analyze a representative sample of emergency department visits by pregnant women in the United States between 2016 and 2019 and report on mental health-related visits. Among pregnant women seen in the ED for mental health-related reasons, the most common diagnoses were substance use disorders, anxiety-related disorders, and depressive disorders, but few saw a mental health provider during their visit.

Non-emergent care visits in a turkish tertiary care emergency department after 2008 health policy changes: review and analysis

BackgroundThe Turkish government liberalized national healthcare policies in 2008 enabling Turkish citizens to seek general care in hospital emergency departments (ED). The number of ED visits has exceeded the total population every year for the last ten years. To explain this phenomenon and to identify trends and risk factors for non-emergent visits, we retrospectively reviewed the ED records of a tertiary hospital and the Turkish Ministry of Health bulletin.MethodsThis retrospective record-based study was conducted at a tertiary hospital in Samsun province of Turkey. A total of 87,528 records of adult patients who visited the ED between January 1 and December 31, 2017, were included in this study. We evaluated the pattern of ED use for non-emergent patients by age, gender, nationality, time of visit, means of arrival, ICD (International Classification of Diseases) diagnostic codes, triage codes, number of repeated and out-of-hours visits. We used the Turkish Ministry of Health statistics bulletins to compare the number of ED visits across the country by year.ResultsThe non-emergent visit rate in ED was found 9.9%. The rate of non-emergent ED visits was significantly higher in the 18-44 age group, in the female gender, and in those who arrived at the ED without an ambulance. The number of non-emergent visits was very similar between weekends and weekdays but was significantly higher in working hours on weekdays than out-of-hours (p<0.001). The most frequent diagnostic code was “Pain, unspecified” (R52) and the rate of repeat visits was 14.8% of non-emergent ED visits. According to binary logistic analysis, non-emergency visits were associated with 18-44 age group (OR = 2.75), female gender (OR = 1.11) and non-ambulance transportation (OR = 9.86).ConclusionsOur results showed that the 18-44 age group and female gender seek care in the ED for non-emergent problems more than the other parts of the population. The numbers of ED visits in the last decade continued to increase regardless of population growth. The health policy changes may have facilitated access to rapid physical and laboratory examination but also an exacerbation of the free-rider problem in ED services.

Prognostication in Acute Neurological Emergencies

BackgroundFor patients with acute, serious neurological conditions presenting to the emergency department (ED), prognostication is typically based on clinical experience, scoring systems and patient co-morbidities. Because estimating a poor prognosis influences caregiver decisions to withdraw life-sustaining therapy, we investigated the consistency of prognostication across a spectrum of neurology physicians. MethodsFive acute neurological presentations (2 with large hemispheric infarction; 1 with brainstem infarction, 1 with lobar hemorrhage, and 1 with hypoxic-ischemic encephalopathy) were selected for a department-wide prognostication simulation exercise. All had presented to our tertiary care hospital's ED, where a poor outcome was predicted by the ED neurology team within 24 hours of onset. Relevant clinical, laboratory and imaging data available before ED prognostication were presented on a web-based platform to 120 providers blinded to the actual outcome. The provider was requested to rank-order, from most to least likely, the predicted 90-day modified Rankin Scale (mRS) score. To determine the accuracy of individual outcome predictions we compared the patient's the actual 90-day mRS score to highest ranked predicted mRS score. Additionally, the group's “weighted” outcomes, accounting for the entire spectrum of mRS scores ranked by all respondents, were compared to the actual outcome for each case. Consistency was compared between pre-specified provider roles: neurology trainees versus faculty; non-vascular versus vascular faculty. ResultsResponses ranged from 106-110 per case. Individual predictions were highly variable, with predictions matching the actual mRS scores in as low as 2% of respondents in one case and 95% in another case. However, as a group, the weighted outcome matched the actual mRS score in 3 of 5 cases (60%). There was no significant difference between subgroups based on expertise (stroke/neurocritical care versus other) or experience (faculty versus trainee) in 4 of 5 cases. ConclusionAcute neuro-prognostication is highly variable and often inaccurate among neurology providers. Significant differences are not attributable to experience or subspecialty expertise. The mean outcome prediction from group of providers (“the wisdom of the crowd”) may be superior to that of individual providers.

Health Equity Needs Teeth.

People who are poor or members of communities of color face inequitable oral disease burden. Continued separation of dental and oral health from general medical care exacerbates inequity and forces members of underserved communities to seek nontraumatic dental emergency care in hospital emergency departments. This trend is unnecessarily costly and results in antibiotic prescriptions and pain management that are neither restorative nor responsive to patients' primary complaints. Value-based approaches to health care need to unify mouth care with general medical care, motivate medical-dental interprofessional practice, promote oral disease prevention, and support restorative dental care. Value-based approaches to health care must also innovate fiscal structures (eg, payment models, data sharing) to improve health outcomes for everyone.

The impact of emergency department crowding on admission decisions and patient outcomes.

The objective of this study is to evaluate the impact of emergency department (ED) crowding levels on patient admission decisions and outcomes. A retrospective study was performed based on 2-year electronic health record data from a tertiary care hospital ED in Alberta, Canada. Using modified Poisson regression models, we studied the association of patient admission decisions and 7-day revisit probability with ED crowding levels measured by: 1) the total number of patients waiting and in treatment (ED census), 2) the number of boarding patients (boarder census), and 3) the average physician workload, calculated by the total number of ED patients divided by the number of physicians on duty (physician workload census). The control variables included age, gender, treatment area, triage level, and chief complaint. A subgroup analysis was performed to evaluate the heterogeneous effects among patients of different acuity levels. Our dataset included 141,035 patient visit records after cleaning from August 2013 to July 2015. The patient admission probability was positively correlated with ED census (relative risk [RR]=1.006, 95% confidence interval [CI]=1.005 to 1.007) and physician workload census (RR=1.029, 95% CI=1.027 to 1.032), but inversely correlated with boarder census (RR=0.991, 95% CI=0.989 to 0.993). We further found that the 7-day revisit probability of discharged patients was positively associated with boarder census (RR=1.009, 95% CI=1.004 to 1.014). Patient admission probability was found to be directly associated with ED census and physician workload census, but inversely associated with the boarder census. The effects of boarder census and physician workload census were stronger for patients of triage levels 3-5. Our results suggested that (i) insufficient physician staffing may lead to unnecessary patient admissions; (ii) too many boarding patients in ED leads to an increase in unsafe discharges, and as a result, an increase in 7-day revisit probability.

102 - IPA Guidelines on Dementia and Agitation: From Provisional to Final

Agitation is common across neuropsychiatric disorders and contributes to disability, institutionalization, and diminished quality of life for patients and their caregivers. In 2015 IPA convened a transparent process to build a consensus definition of agitation and agreement on what elements should be included in the syndrome that resulted in publication of provisional guidelines. (Cummings et al, 2015) In the 2020-2021 year, the two co-chairs of this symposium have led a new workgroup to make the provisional consensus definition of agitation in patients with cognitive disorders that can be applied in epidemiologic, non-interventional clinical, pharmacologic, non-pharmacologic interventional, and neurobiological studies and guide treatment final.Co-Chairs will discuss methods used in updating and findings and compare changes made to the provisional guidelines. Dr. Sano will present new findings on the biological basis of agitation in dementia and Dr. Mintzer will present on application of guidelines in the special circumstances of persons in palliative and hospice care. Dr. Rosenberg will discuss the special circumstance of agitation care in hospital emergency departments. Mr. Splaine will present findings about the utilization of the 2015 guidelines in the peer reviewed literature, professional and government dementia care guidance, and clinical trials.Cummings, J., Mintzer, J., Brodaty, H., Sano, M., Banerjee, S., Devanand, D., … Zhong, K. (2015). Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition. International Psychogeriatrics, 27(1), 7-17. doi:10.1017/S1041610214001963

Assessment of Acute Complications of Diabetes Mellitus Using Clinical Records of Diabetic Patients in Adama Hospital Medical College, Oromia Regional State, Ethiopia

Background: Diabetes mellitus (DM) is one of the emerging public health problems in developing countries. Patients with acute complications of the disease frequently seek care in hospital emergency departments. However, the magnitude of acute complications of DM has not been studied at facility levels. This study was aimed at assessing the prevalence and associated risks of acute complications of DM at health facilities. Materials and Methods: Hospital-based cross-sectional study design was used. The source of population was medical records of DM patients and the study population was medical records of DM patients admitted to Adama Hospital Medical College. A total of 200 medical records of patients in AHMC medical ward were used to extract patients’ medical information concerning DM and associated factors. Moreover, DM-related pretested semi-structured questionnaires were developed and administered to 200 active DM patients following their treatment during December 2018 of data collection. Results: The proportion of diagnosed acute complications of DM among patients in this study was 146(73%) while 54(27%) did not present acute complication of DM. The history of acute complication associated with diabetic ketoacidosis (DKA) accounted for 133(66.5%) while hyperglycemic hyperosmolar state (HHS) was 21(10.5%) but 46(23%) did show neither DKA nor HHS. From this study of clinical record, the proportion of acute complication of DM with DKA was higher among type I DM patients than type II patients. However, the proportion of HHS was relatively low in type I DM and high in type II DM patients. Conclusion: The prevalence of acute complications of DM was 146(73%) and 67(85.9%) and 79(64.8%) in type I and type II DM, respectively. Moreover, the proportion of acute complication of DM with DKA was higher among type I DM patients than type II patients. Strengthening of health education both at health facilities and general population is important.

A Comparison Between Computer-Assisted Self-Triage by Patients and Triage Performed by Nurses in the Emergency Department.

Background and objectiveEmergency departments (EDs) often find the number of arriving patients exceeding their capacity and find it difficult to triage them in a timely manner. The potential risk to the safety of patients awaiting assessment by a triage professional has led some hospitals to consider implementing patient self-triage, such as using kiosks. Published studies about patient self-triage are scarce and information about patients’ ability to accurately assess the acuity of their condition or predict their need to be hospitalized is limited. In this study, we aimed to compare computer-assisted patient self-triage scores versus the scores assigned by the dedicated ED triage nurse (TN).MethodsThis pilot study enrolled patients presenting to a tertiary care hospital ED without ambulance transport. They were asked a short series of simple questions based on an algorithm, which then generated a triage score. Patients were asked whether they were likely to be admitted to the hospital. Patients then entered the usual ED system of triage. The algorithm-generated triage score was then compared with the Canadian Triage and Acuity Scale (CTAS) score assigned by the TN. Whether the patients actually required hospital admission was determined by checking their medical records.ResultsAmong the 492 patients enrolled, agreement of triage scores was observed in 27%. Acuity was overestimated by 65% of patients. Underestimation of acuity occurred in 8%. Among patients predicting hospitalization, 17% were admitted, but the odds ratio (OR) for admission was 3.4. Half of the patients with cardiorespiratory complaints were correct in predicting the need for hospitalization.Conclusion The use of a short questionnaire by patients to self-triage showed limited accuracy, but sensitivity was high for some serious medical conditions. The prediction of hospitalization was more accurate with regard to cardiorespiratory complaints.