Emergency Care Community Research Articles

MACCABI-RED, community emergency care at the press of a button: a descriptive study.

Maccabi-RED is a new service developed in Israel that allows primary care staff to direct urgent cases to specialists in the community for evaluation in their local clinics on the same day as an alternative to an emergency department (ED) visit. A primary care physician or a nurse can activate the service, and all nearby specialists receive "a call" and can decide if they are willing to accept it, thus allowing the patient to avoid an unnecessary visit to the ED. To quantify and characterize the medical care provided by this service in a large national healthcare system. Multicenter, community-based, retrospective cohort study. All Maccabi-RED visits recorded between September 2021 and August 2022 were included. Patient characteristics were compared to national demographics. Descriptive statistics were used to present data regarding recorded diagnoses, treating physicians, treatments or referrals provided, and subsequent emergency department admissions or hospitalizations. 31831 visits were recorded. Most frequent diagnoses were musculoskeletal pain (12.1%), otitis or otalgia (7.8%), contusions (7.6%), fractures (7.1%), foreign body (6.7%), pregnancy-related symptoms (6.3%), and upper-respiratory or unspecified viral infection (6.3%). The most common treatments reported were foreign body removal (5%) and cast application (3.5%). Only 7.8% of visits resulted in emergency department admission within seven days (any cause). The average time from patient request to physician treatment was 91 min. Maccabi-RED is being widely used by patients nationwide. Additional studies are needed to investigate whether Maccabi-RED reduces emergency department visits and costs.

Community Emergency Care Use by Veterans in an Era of Expanding Choice

Recently passed legislation aimed at improving access to care has considerably expanded options for veterans to receive emergency care in community, or non-Veterans Affairs (VA) settings. However, national trends in community emergency department (ED) use by veterans are unknown. To examine national, temporal trends in the frequencies and types of ED visits provided in community settings and explore the association between facilities' purchase of community care with facility and regional characteristics. Retrospective, observational cross-sectional study of ED visits over fiscal years (FY) 2016 to 2022. VA and community ED encounter data were obtained from the VA Corporate Data Warehouse and the Office of Integrated Veteran Care. Participants were veterans receiving ED care at VA facilities or paid for by the VA in the community. Data were analyzed from June to September 2023. The primary outcome measures included community ED visit volume, disposition, and payments over time. Also, the most common and costly ED visits were assessed. Negative binomial regression analysis examined associations between facility and regional characteristics and the rate of ED visits purchased in community settings relative to all ED visits. There were 19 787 056 ED visits, predominantly at VA facilities (14 532 261 visits [73.4%]), made by 3 972 503 unique veterans from FY 2016 to 2022. The majority of ED users were male (3 576 120 individuals [90.0%]), and the median (IQR) age was 63 (48-73) years. The proportion of community ED visits increased in absolute terms from 18% in FY 2016 to 37% in FY 2022. Total community ED payments, adjusted to 2021 dollars, were $1.18 billion in FY 2016 and over $6.14 billion in FY 2022. The most common reasons for ED visits in the community were for nonspecific chest pain (305 082 visits [6%]), abdominal pain (174 836 visits [3%]), and septicemia (149 968 visits [3%]). The average proportion of ED visits purchased by a VA facility increased from 14% in FY 2016 to 32% by FY 2022. In multivariable analyses, facilities with greater ED volume and low-complexity facilities had higher expected rates of community emergency care than lower volume and high-complexity facilities, respectively. As veterans increasingly use community EDs for acute, unscheduled needs, attention to factors associated with veterans' use of acute care services in different settings are important to identify access barriers and to ensure veterans' health care needs are met.

Community emergency nursing process optimization combined with psychological intervention on elderly patients with acute stress disorder

Background Acute stress disorder is a serious hazard in elderly patients. This disorder can cause physical and psychological discomfort, affecting the patient’s life quality of functioning. Psychological intervention can help patients relieve anxiety and fear, and improve patients’ acceptance and participation in emergency nursing.Optimization of community emergency care processes can provide faster, more efficient, professional care services through process optimization. If the two are combined, its efficacy can be further improved. Therefore, this study further explored the therapeutic effect of combining the two.Objects and Methods Elderly patients diagnosed with ASD were selected as samples from the community. The intervention group adopted the optimized community emergency nursing process combined with psychological intervention, and the control group adopted the standard nursing. The Stanford Acute Stress Response Questionnaire (SASRQ) and 3-minute Disorder Assessment Scale (3D-CAM) were used to measure stress levels and cognitive dysfunction, respectively. SPSS23.0 was used for statistical analysis.ResultsASD symptoms were significantly reduced in the intervention group compared with the control group (P≤0.05). SASRQ scores decreased by 35 percent, indicating decreased levels of acute stress. The 3D-CAM score showed a 25% improvement in cognitive function in the intervention group.ConclusionsOptimizing the community emergency nursing process combined with psychological intervention is an effective way to treat acute stress disorder in the elderly. This integrated care model contributes to improved mental health outcomes and should be considered in clinical practice.

Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study

Background NHS England’s 7-day services policy comprised 10 standards to improve access to quality health care across all days of the week. Six standards targeted hospital specialists on the assumption that their absence caused the higher mortality associated with weekend hospital admission: the ‘weekend effect’. The High-intensity Specialist-Led Acute Care (HiSLAC) collaboration investigated this using the implementation of 7-day services as a ‘natural experiment’. Objectives The objectives were to determine whether or not increasing specialist intensity at weekends improves outcomes for patients undergoing emergency hospital admission, and to explore mechanisms and cost-effectiveness. Design This was a two-phase mixed-methods observational study. Year 1 focused on developing the methodology. Years 2–5 included longitudinal research using quantitative and qualitative methods, and health economics. Methods A Bayesian systematic literature review from 2000 to 2017 quantified the weekend effect. Specialist intensity measured over 5 years used self-reported annual point prevalence surveys of all specialists in English acute hospital trusts, expressed as the weekend-to-weekday ratio of specialist hours per 10 emergency admissions. Hospital Episode Statistics from 2007 to 2018 provided trends in weekend-to-weekday mortality ratios. Mechanisms for the weekend effect were explored qualitatively through focus groups and on-site observations by qualitative researchers, and a two-epoch case record review across 20 trusts. Case-mix differences were examined in a single trust. Health economics modelling estimated costs and outcomes associated with increased specialist provision. Results Of 141 acute trusts, 115 submitted data to the survey, and 20 contributed 4000 case records for review and participated in qualitative research (involving interviews, and observations using elements of an ethnographic approach). Emergency department attendances and admissions have increased every year, outstripping the increase in specialist numbers; numbers of beds and lengths of stay have decreased. The reduction in mortality has plateaued; the proportion of patients dying after discharge from hospital has increased. Specialist hours increased between 2012/13 and 2017/18. Weekend specialist intensity is half that of weekdays, but there is no relationship with admission mortality. Patients admitted on weekends are sicker (they have more comorbid disease and more of them require palliative care); adjustment for severity of acute illness annuls the weekend effect. In-hospital care processes are slightly more efficient at weekends; care quality (errors, adverse events, global quality) is as good at weekends as on weekdays and has improved with time. Qualitative researcher assessments of hospital weekend quality concurred with case record reviewers at trust level. General practitioner referrals at weekends are one-third of those during weekdays and have declined further with time. Limitations Observational research, variable survey response rates and subjective assessments of care quality were compensated for by using a difference-in-difference analysis over time. Conclusions Hospital care is improving. The weekend effect is associated with factors in the community that precede hospital admission. Post-discharge mortality is increasing. Policy-makers should focus their efforts on improving acute and emergency care on a ‘whole-system’ 7-day approach that integrates social, community and secondary health care. Future work Future work should evaluate the role of doctors in hospital and community emergency care and investigate pathways to emergency admission and quality of care following hospital discharge. 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. 9, No. 13. See the NIHR Journals Library website for further project information.

Veterans' Experiences With Accessing Community Emergency Care.

Under current regulations, there are three separate authorities for which the Veterans Health Administration (VHA) can pay for emergency medical care received by Veterans in the community. The three VHA authorities have overlapping criteria and eligibility requirements that contribute to a complex and confusing landscape for Veterans when they obtain emergency care in the community. Given the intricacies in how VHA provides coverage for community emergency care and the desire to provide seamless Veteran-centric care, it is imperative to understand Veterans' experiences with navigating coverage for community emergency care. The purpose of this study was to elicit feedback from Veterans about their experiences with and perceptions of community emergency care coverage paid for by VHA. Veterans Health Administration data were used to identify geographically diverse Veterans who recently used emergency care. We conducted semi-structured, qualitative interviews with 50 Veterans to understand their VHA coverage and experiences with accessing community emergency care. Interviews were audio recorded and transcribed verbatim. We conducted directed content analysis of interview transcripts. Veterans emphasized three major concerns with navigating community emergency care: (1) they lack information about benefits and eligibility when they need it most, (2) they require assistance with medical billing to avoid financial hardship and future delays in care, and (3) they desire multimodal communication about VHA policies or updates in emergency coverage. Our results highlight the challenges Veterans experience in understanding VHA coverage for community emergency care. Feedback suggests that improving information, support, and communication may help Veterans make timely, informed decisions when experiencing unexpected illness or injury.

Pediatric Sepsis in Community Emergency Care Settings: Guideline Concordance and Outcomes.

Bundled pediatric sepsis care has been associated with improved outcomes in tertiary pediatric emergency departments. Sepsis care at nontertiary sites where most children seek emergency care is not well described. We sought to describe the rate of guideline-concordant care, and we hypothesized that guideline-concordant care in community pediatric emergency care settings would be associated with decreased hospital length of stay (LOS). This retrospective cohort study of children with severe sepsis presenting to pediatric community emergency and urgent care sites included children 60 days to 17 years with severe sepsis. The primary predictor was concordance with the American College of Critical Care Medicine 2017 pediatric sepsis resuscitation bundle, including timely recognition, vascular access, intravenous fluids, antibiotics, vasoactive agents as needed. From January 1, 2015, to December 31, 2017, 90 patients with severe sepsis met inclusion criteria; 22 (24%) received guideline-concordant care. Children receiving concordant care had a median hospital LOS of 95.3 hours (50.9-163.8 hours), with nonconcordant care, LOS was 88.3 hours (57.3-193.2 hours). In adjusted analysis, guideline-concordant care was not associated with hospital LOS (incident rate ratio, 0.99 [0.64-1.52]). The elements that drove overall concordance were timely recognition, achieved in only half of cases, vascular access, and timely antibiotics. Emergency care for pediatric sepsis in the community settings studied was concordant with guidelines in only 24% of the cases. Future study is needed to evaluate additional drivers of outcomes and ways to improve sepsis care in community emergency care settings.

Aeromedical Battlefield Evacuation Under Endogenous Uncertainty in Casualty Delivery Times

We propose a new medical evacuation (MEDEVAC) model with endogenous uncertainty in the casualty delivery times. The goal is to provide timely medical treatment to injured soldiers and a prompt evacuation via air ambulances. The model determines where to locate medical treatment facilities (MTF) and air ambulances, how to dispatch air ambulances to the point-of-injury, and to which MTF to channel the casualty. The model captures the effect of a delayed MEDEVAC response on the survivability of soldiers, enforces the Golden Hour evacuation doctrine, and represents the availability of air ambulances as an endogenous source of uncertainty since it is contingent on the locations of MTFs. The MEDEVAC model is an MINLP problem whose continuous relaxation is in general nonconvex and for which we develop a new algorithmic method articulated around two main components: i) new bounding techniques obtained through the solution of restriction and relaxation problems, and ii) a spatial branch-and-bound algorithm solving conic mixed-integer programs at each node of the tree. The computational study based on data from the Operation Enduring Freedom reveals that: the bounding problems can be quickly solved regardless of the problem size; the bounds are tight; and the spatial branch-and-bound dominates the Cplex and the Baron solvers in terms of both computational time and robustness. As compared to the standard MEDEVAC myopic policy, our approach increases the number of casualties treated timely and contributes to reducing the number of deaths on the battlefield. The benefits increase as the MEDEVAC resources become tighter and the combats intensify. The model can be used at the strategic level to design an efficient MEDEVAC system and at the tactical level for intelligent tasking and dispatching. Additionally, this study provides valuable contributions to the civilian emergency care community and to the MINLP discipline.

Does community emergency care initiative improve the knowledge and skill of healthcare workers and laypersons in basic emergency care in India?

Background:Due to lack of training in emergency care, basic emergency care in India is still in its infancy. We designed All India Institute of Medical Sciences basic emergency care course (AIIMS BECC) to address the issue.Aim:To improve the knowledge and skill of healthcare workers and laypersons in basic emergency care and to identify impact of the course.Materials and Methods:Prospective study conducted over a period of 4 years. The target groups were medical and nonmedical personnel. Provider AIIMS BECC is of 1 day duration including lectures on cardio-pulmonary resuscitation, choking, and special scenarios. Course was disseminated via lectures, audio-visual aids, and mannequin training. For analysis, the participants were categorized on the basis of their education and profession. A pre- and a post-course evaluation were done and individual scores were given out of 20 and compared among all the groups and P value was calculated.Results:A total of 1283 subjects were trained. 99.81% became providers and 2.0% were trained as instructors. There was a significant improvement in knowledge among all the participants irrespective of their education level including medicos/nonmedicos. However, participants who had higher education (graduates and postgraduates) and/or belonged to medical field had better knowledge gain as compared to those who had low level of education (≤12th standard) and were nonmedicos.Conclusion:BECC is an excellent community initiative to improve knowledge and skill of healthcare and laypersons in providing basic emergency care.

Perceptions of emergency care in Kenyan communities lacking access to formalised emergency medical systems: a qualitative study

ObjectivesWe undertook this study in Kenya to understand the community's emergency care needs and barriers they face when trying to access care, and to seek community members’ thoughts regarding high...

Patterns of Alcohol Use among Patients Who Visited Community Emergency Care Services in Southwestern Brazil

Alcohol is among the most frequently consumed drugs worldwide. However, identification and intervention measures for alcohol abuse have not yet been established. This article reports the results of applying the Alcohol Use Disorders Identification Test (AUDIT) in 463 patients from five centers for emergency care community in a large city in the interior of Sao Paulo. The relationship between the AUDIT risk-levels of alcohol use and the socio-demographic variables of individuals seeking treatment between August and November 2010 was also examined. The instrument was administered by seven nurses and six students nurses. Individuals with AUDIT scores ≥07 received brief counseling (BC). The main reasons for seeking emergency care were “headache”, “pain”, and “ill-being”. Among the individuals in the study, 95.9% lived in the municipality where the data was collected, 40.7% had an incomplete elementary school education, and the percentage of alcohol dependence was lower among employed individuals (11.9%). The sample was composed of 61.1%

Urban density, deprivation and road safety: A small area study in the eThekwini metropolitan area, South Africa

The aim of this policy brief is to provide an evidence-informed answer to the question: ‘What is the role and scope of pre-hospital emergency care providers to domestic violence (DV) intervention as a form of gender-based violence prevention?’ The answer is intended to determine the theoretical and clinical best practice to inform the emergency care community and policy development by critically appraising the evidence that considers the responsiveness of Emergency Medical Services to the health needs of DV victims. Evidence-informed Decision Making methods are employed. The evidence appraised was based on electronic searches using the Cape Peninsula University of Technology database. Research and non-research publications were considered with publication dates mostly from 1999 to 2011. Upon screening 164 articles for content relevance, 53 were critically appraised against predetermined criteria for relevance of the evidence, robust nature of the evidence and presence of bias. A thematic/narrative analysis ensued in terms of strength of evidence and frequency of findings. Early recognition and intervention is seen as one of the most effective methods of DV prevention. This finding is nuanced if it is male caregivers doing so. There is an ethical obligation to implement a comprehensive health approach to manage domestic violence victims. The strong, majority findings are that educational intervention/s increases the health care provider’s understanding of DV and improves screening for DV. The research supports the development and use of screening tools/guidelines/ procedures for DV as they are found to improve DV intervention. The evidence supports an integrated effort of the health system in achieving its goal of DV prevention by promoting the participation of pre-hospital emergency care providers as critical stakeholders. Key words : Domestic Violence (DV) management and prevention, Emergency Care Providers (ECP’s), Gender-based violence (GBV) prevention, Evidence-informed Decision Making (EiDM), Emergency Medical Service

063PS Challenges and Opportunities in Low-Resource Settings: Guideline Development, Adaptation, Implementation and Performance Measurement

BackgroundHealth care and health policy organisations seeking to improve medical care in low-resource settings with significant numbers of uninsured, medically underserved and/or low-income populations face significant challenges in developing, adapting,...

Nursing and Equipment Troubleshooting for Special Needs Children in the Emergency Department

As pediatric medicine continues to advance, a growing number of special needs children depend on medical devices for both survival and to lead a more functional life. With this dependence, it is imperative that the emergency care community understand how to best assess these patients and troubleshoot their devices. In this article, we discuss some of the common devices used to assist the special needs patient, their nursing implications, and optimal care. This review will also include guidance for troubleshooting these devices.

Practical Implications of Implementing Emergency Department Crowding Interventions: Summary of a Moderated Panel

Emergency department (ED) crowding continues to be a major public health problem in the United States and around the world. In June 2011, the Academic Emergency Medicine consensus conference focused on exploring interventions to alleviate ED crowding and to generate a series of research agendas on the topic. As part of the conference, a panel of leaders in the emergency care community shared their perspectives on emergency care, crowding, and some of the fundamental issues facing emergency care today. The panel participants included Drs. Bruce Siegel, Sandra Schneider, Peter Viccellio, and Randy Pilgrim. The panel was moderated by Dr. Jesse Pines. Dr. Siegel's comments focused on his work on Urgent Matters, which conducted two multihospital collaboratives related to improving ED crowding and disseminating results. Dr. Schneider focused on the future of ED crowding measures, the importance of improving our understanding of ED boarding and its implications, and the need for the specialty of emergency medicine (EM) to move beyond the discussion of unnecessary visits. Dr. Viccellio's comments focused on several areas, including the need for a clear message about unnecessary ED visits by the emergency care community and potential solutions to improve ED crowding. Finally, Dr. Pilgrim focused on the effect of effective leadership and management in crowding interventions and provided several examples of how these considerations directly affected the success or failure of well-constructed ED crowding interventions. This article describes each panelist's comments in detail.

(A24) Does Community Emergency Care Initiative Improves the Knowledge, Skill And Attitude of Healthcare Workers and Laypersons in Basic Emergency Care in India?

BackgroundBasic emergency care at primary, secondary and tertiary health care level in India is in its infancy. Lack of training in emergency care is an important factor. We designed AIIMS basic emergency care course (AIIMS BECC) to address the issue.ObjectiveTo improve the knowledge, skill and attitude of healthcare workers and laypersons in basic emergency care and to identify and train instructors.MethodsProspective study conducted over a period of one and half years. The target groups were medical, police, fire fighter, paramilitary forces, teachers, school children of India. Provider AIIMS BECC is of one day duration. The contents of the course are cardio-pulmonary resuscitation, chocking and special scenarios like trauma, electrocution, drowning, hypothermia, pregnancy, etc. Course was disseminated via lectures, audio-visual and hands on training. The participants were evaluated by pre and post test questions. Subjects had to score 80% to be successful and those who scored more than 90% were eligible for instructor course. The confidence levels at baseline and at the end of the course were evaluated in policecourses were evaluated on course clarity, course delivery and trainers quality on a likert scale (1 = worst, 5 = excellent).Results1614 subjects were trained. 99.81% became providers and 2.6% were trained as instructors. 83.1% were non-medical and16.9% were medical personals. 76.14% were police, paramilitary 0.8%, teachers 1.6%, students 2.1% and mixed groups were 2.6%. The average and modal increase in confidence level among police were 66.14% and 62.49%. Likert scale of ≥ 4 was observed in 90.7% in course clarity, 91.28% in course delivery and 95.26% in trainer quality.ConclusionKnowledge, skill and attitude of healthcare care and laypersons in providing basic emergency care improved by community emergency care initiative. Instructors were identified for further dissemination of the course. The confidence levels increased among police.

Executive Summary—2010 Consensus Conference

Executive Summary—2010 Consensus Conference

The Emergency Care Community of Practice: Working in partnership to implement best practice

The Emergency Care Community of Practice: Working in partnership to implement best practice

Linking Public Health and the Emergency Care Community: 7 Model Communities

Public health and the emergency care community must work together to effectively achieve a state of community-wide disaster preparedness. The identification of model communities with good working relationships between their emergency care community and public health agencies may provide useful information on establishing and strengthening relationships in other communities. Seven model communities were identified: Boston, Massachusetts; Clark County, Nevada; Eau Claire, Wisconsin; Erie County, New York; Louisville, Kentucky; Livingston County, New York; and Monroe County, New York. This article describes these communities and provides a summary of common findings. Specifically, we recommend that communities foster respectful working relationships between agency leaders, hold regular face-to-face meetings, educate each other on their expertise and roles during a disaster, develop response plans together, work together on a day-to-day basis, identify and encourage a leader to facilitate these relationships, and share resources.

Maryland tackles emergency care crisis

Emergency medical care is something few Americans think about until a person or a family member is severely injured or incurs a sudden critical illness, said Maryland emergency medicine physician Aisha T. Liferidge. However, she said, most emergency departments (EDs) are operating at or near full capacity and struggling to handle their daily load of patients. ED overcrowding results in patients sometimes sitting for hours in waiting rooms or admitted patients being held in hallways and other ED areas until inpatients beds become available, a practice known as boarding. Overcrowding impedes practitioners’ ability to provide the best possible care to patients, Liferidge said. But, she said, ED overcrowding is not a problem for the emergency care community to solve alone. “It is a systemwide problem,” she said, and ultimately, a national problem that must be tackled together by lawmakers, patients, and the health care community. “Because it is a systems issue, we all have to vow to work together” to fix the overcrowding problem and other issues that impede patient care, said Liferidge, who practices emergency medicine at Washington County Hospital in Hagerstown, Maryland.

Assuring community emergency care capacity with collaborative Internet tools: the Milwaukee experience.

Hospital overcrowding and diversion of ambulances from emergency departments are being recognized as increasing problems in the health care system. This article, a descriptive narrative, examines the various factors contributing to the problem and describes how collaborative approaches to public health issues can be applied. It describes Milwaukee's experience with a collaborative approach. The use of a technological tool to assist with tracking and reporting on ambulance diversion and emergency department overload is explained, and data are provided to show the impact of various methods to blunt the impact of the flu season on diversion frequency. The article encourages use of similar collaborative approaches and Internet-based technology to address other public health problems.