Emergency Beds Research Articles

A Comparative Study of Hospitalization Mortality Rates between General and Emergency Hospitalized Patients Using Survival Analysis

Background/Objectives: In Korea’s emergency medical system, when an emergency patient arises, patients receive on-site treatment and care during transport at the pre-hospital stage, followed by inpatient treatment upon hospitalization. From the perspective of emergency patient management, it is critical to identify the high death rate of patients with certain conditions in the emergency room. Therefore, it is necessary to compare and analyze the determinants of the death rate of patients admitted via the emergency room and generally hospitalized patients. In fact, previous studies investigating determinants of survival periods or length of stay (LOS) primarily used multiple or logistic regression analyses as their main research methodology. Although medical data often exhibit censored characteristics, which are crucial for analyzing survival periods, the aforementioned methods of analysis fail to accommodate these characteristics, presenting a significant limitation. Methods:Therefore, in this study, survival analyses were performed to investigate factors affecting the dying risk of general inpatients as well as patients admitted through the emergency room. For this purpose, this study collected and analyzed the sample cohort DB for a total of four years from 2016 to 2019 provided by the Korean National Health Insurance Services (NHIS). After data preprocessing, the survival probability was estimated according to sociodemographic, patient, health checkup records, and institutional features through the Kaplan–Meier survival estimation. Then, the Cox proportional hazards models were additionally utilized for further econometric validation. Results: As a result of the analysis, in terms of the ‘city’ feature among the sociodemographic characteristics, the small and medium-sized cities exert the most influence on the death rate of general inpatients, whereas the metropolitan cities exert the most influence on the death rate of inpatients admitted through the emergency room. In terms of institution characteristics, it was found that there is a difference in determinants affecting the death rate of the two groups of study, such as the number of doctors per 100 hospital beds, the number of nurses per 100 hospital beds, the number of hospital beds, the number of surgical beds, and the number of emergency beds. Conclusions: Based on the study results, it is expected that an efficient plan for distributing limited medical resources can be established based on inpatients’ LOS.

IMMEDIATE BED AVAILABILITY IN CASE OF A DISASTER

Introduction: During a disaster, an increase in the number of casualties requiring hospital admission is recorded. This challenge the hospitals' management - there is a need for beds, rooms, consumables, drugs, and medical teams to support the increased number of patients arriving. Purpose: This study aims to analyze the awareness of hospital medical professionals about the required procedures described in the hospital contingency plan for increased bed availability in case of disaster. Materials and methods: 295 hospital medical professionals in the Plovdiv region, Bulgaria, participated in an anonymous survey that contained 55 questions. Results: Most of the respondents are not familiar with the approved procedures to optimize the availability of emergency beds after the disaster that impacts the hospital disaster resilience. Conclusions: Optimization of activities related to operational hospital disaster resilience must include training of medical specialists in immediate bed availability procedures.

Emergency Beds

Emergency Beds

Prediction of ICU Admission Analysis for Covid-19 Patients

Abstract: A rapid spread of SARS COVID-19 disease was first observed in China since early January 2020 and then in Italy. Covid 19 spread rapidly spread amongst many countries from one person to another person the deaths due to the pandemic continued to increase as all the countries faced many problems due to rapid spread of Coronavirus the health department was also clueless on how to provide facilities to the patients who needed ICU emergency beds in the hospitals as the cases increased all over the world. The SARS coronavirus has infected more than 100 million people and has resulted in almost three million deaths worldwide. In this project, the development of Machine Learning (ML) models for COVID-19 progression is discussed. As the pandemic situation was increased this Machine Learning model builds a web application framework where using the previous datasets we can create a complete blood count data based on which we will be able to the analysis of the ICU admitted patients. The proposed system is a Machine Learning approach which predicts the analysis of ICU and non ICU Patients. The analysis is made by uploaded details of patient which is based on CBC data only. The details of the patient data are data preprocessed and trained so that the system can predict the analysis of the entered data and gives the graphical representation through graphs. The proposed approach is a web application framework using Html, CSS, JavaScript as front end technology and for the validations. Python is an object oriented programming language which is the sever side language in this project. The data visualization is given by considering the analysis of the prediction in ICU

Chemical, Biological, Radiological, or Nuclear Response in Queensland Emergency Services: A Multisite Study.

A disaster overwhelms the normal operating capacity of a health service. Minimal research exists regarding Australian hospitals' capacity to respond to chemical, biological, radiological, or nuclear (CBRN) disasters. This article, and the research supporting it, begins to fill that research gap. We conducted a descriptive quantitative study with 5 tertiary hospitals and 1 rural hospital in Queensland, Australia. The study population was the hospitals' clinical leaders for disaster preparedness. The 25-item survey consisted of questions relating to each hospital's current response capacity, physical surge capacity, and human surge capacity in response to a CBRN disaster. Data were analyzed using descriptive statistics. The survey data indicated that over the previous 12 months, each site reached operational capacity on average 66 times and that capacity to respond and create additional emergency, intensive care, or surgical beds varied greatly across the sites. In the previous 12 months, only 2 sites reported undertaking specific hospital-wide training to manage a CBRN disaster, and 3 sites reported having suitable personal protective equipment required for hazardous materials. There was a noted shortfall in all the hospitals' capacity to respond to a radiological disaster in particular. Queensland hospitals are crucial to CBRN disaster response, and they have areas for improvement in their response and capacity to surge when compared with international preparedness benchmarks. CBRN-focused education and training must be prioritized using evidence-based training approaches to better prepare hospitals to respond following a disaster event.

Inequalities of visceral leishmaniasis case-fatality in Brazil: A multilevel modeling considering space, time, individual and contextual factors.

In Brazil, case-fatality from visceral leishmaniasis (VL) is high and characterized by wide differences between the various political-economic units, the federated units (FUs). This study was designed to investigate the association between factors at the both FU and individual levels with the risk of dying from VL, after analysing the temporal trend and the spatial dependency for VL case-fatality. The analysis was based on individual and aggregated data of the Reportable Disease Information System-SINAN (Brazilian Ministry of Health). The temporal and spatial distributions of the VL case-fatality between 2007 and 2017 (27 FUs as unit of analysis) were considered together with the individual characteristics and many other variables at the FU level (socioeconomic, demographic, access to health and epidemiological indicators) in a mixed effects models or multilevel modeling, assuming a binomial outcome distribution (death from VL). A linear increasing temporal tendency (4%/year) for VL case-fatality was observed between 2007 and 2017. There was no similarity between the case-fatality rates of neighboring FUs (non-significant spatial term), although these rates were heterogeneous in this spatial scale of analysis. In addition to the known individual risk factors age, female gender, disease's severity, bacterial co-infection and disease duration, low level schooling and unavailability of emergency beds and health professionals (the last two only in univariate analysis) were identified as possibly related to VL death risk. Lower VL incidence was also associated to VL case-fatality, suggesting that unfamiliarity with the disease may delay appropriate medical management: VL patients with fatal outcome were notified and had VL treatment started 6 and 3 days later, respectively, in relation to VL cured patients. Access to garbage collection, marker of social and economic development, seems to be protective against the risk of dying from VL. Part of the observed VL case-fatality variability in Brazil could not be explained by the studied variables, suggesting that factors linked to the intra FU environment may be involved. This study aimed to identify epidemiological conditions and others related to access to the health system possibly linked to VL case-fatality, pointing out new prognostic determinants subject to intervention.

A fuzzy rule-based efficient hospital bed management approach for coronavirus disease-19 infected patients.

Coronavirus disease-19 (COVID-19) is a very dangerous infectious disease for the entire world in the current scenario. Coronavirus spreads from one person to another person very rapidly. It spreads exponentially throughout the globe. Everyone should be cautious to avoid the spreading of this novel disease. In this paper, a fuzzy rule-based approach using priority-based method is proposed for the management of hospital beds for COVID-19 infected patients in the worst-case scenario where the number of hospital beds is very less as compared to the number of COVID-19 infected patients. This approach mainly attempts to minimize the number of hospital beds as well as emergency beds requirement for the treatment of COVID-19 infected patients to handle such a critical situation. In this work, higher priority has given to severe COVID-19 infected patients as compared to mild COVID-19 infected patients to handle this critical situation so that the survival probability of the COVID-19 infected patients can be increased. The proposed method is compared with first-come first-serve (FCFS)-based method to analyze the practical problems that arise during the assignment of hospital beds and emergency beds for the treatment of COVID-19 patients. The simulation of this work is carried out using MATLAB R2015b.

Trends and challenges of emergency and acute care in Chinese mainland: 2005-2017.

Emergency medical service system (EMSS) is essential in providing acute care services for health conditions. However, trends of emergency and acute care in China haven't been studied systematically. Relevant literature was carefully reviewed, including original and review articles, letters, government reports, yearbooks, both in Chinese and in English. Data on the number of emergency visits, physicians and beds in emergency departments (EDs), and the workforce of pre-hospital emergency care were summarized and analyzed from China Health and Family Planning Statistical Yearbooks (2006-2018). Over the past decade, the number of ED visits tripled from 51.9 million to 166.5 million; and utilization of pre-hospital emergency care increased from 3.2 million to 6.8 million. In response to rapid increases in demand, the number of licensed emergency physicians raised from 20,058 to 59,409; the beds' number increased from 10,783 to 42,367. For pre-hospital emergency care, the volume of health workforce increased from 3,687 to 8,671, with a 109% increase in the number of physicians from 1,774 to 3,712. However, overcrowding, the long length of stay in EDs, poor work environment, and work exhaustion were still the critical challenges faced by China's EMSS. The number of emergency visits has grown with continual capability enhancement during the past decade. However, overcrowding, the long length of stay in EDs, poor work environment, and work exhaustion still need to be solved by China's EMSS. These findings and comparison with the USA could offer experiences and lessons to EMSS development worldwide, especially for developing countries.

The Vital Role of a Full Continuum of Psychiatric Care Beyond Beds.

The authors make the case for expanding the national discussion of inpatient psychiatric beds to recognize and incorporate other vital components of the continuum of care in order to improve outcomes for individuals with serious mental illness. They review the varied terminology applied to psychiatric beds and describe how the location of these beds has changed from primarily state hospitals to the criminal justice system, emergency departments, inpatient units, and the community. The authors propose 10 recommendations related to beds or to contextual issues regarding them. The recommendations address issues of mental illness terminology, criminal and juvenile justice diversion, the Emergency Medical Treatment and Labor Act, mental health technology, and the mental health workforce, among others. Each recommendation is based on findings from publicly available data and clinical observation and is intended to reduce the human and economic costs associated with severe mental illness by promoting a robust, interconnected, and evidence-based system of care that goes beyond beds.

The investment Decision Making According to the Preliminary Feasibility Study for the 100-Bed Teaching Hospital - Service Sector in Diwaniya Governorate (Case Study)

The research aims to prepare a preliminary feasibility study that shows the importance of preliminary feasibility study in investment decision making, carrying out of the local demand of service provided in accordance with international standards and statement of investment opportunities available to the private sector in several investment methods. In order to reach the objectives of the study was adopted as a method of partial analysis at the level of economic unity through the study demand, supply, costs, economic and social profitability.
 The health sector in Iraq is one of the service sectors facing today a continuous deficiency due to the increase in population growth, diseases and injuries resulting from wars and conflicts, On the other hand, there is a deficit in government funding to complete health service projects, including the Diwaniya hospital with a capacity of 400 beds, Which completed part of its civil works by 19%.
 Accordingly, a preliminary feasibility study was prepared to ensure that there are no fundamental problems that hinder completion the project by investment of the private sector (national or foreign) based on the legislation in force and the market study, which showed the need to invest a 100 bed hospital distributed among 80 beds for care and 20 emergency beds, as well as Specialized clinics and advanced medical centers for all specialties with a medical university to treat lack of medical and nursing staff depend on approved standards, With providing excellent services and competitive prices leading to the development of the health sector in the Diwaniya province and neighboring provinces.

The effect of crowding in emergency department on precheck triage

Objective To explore the influence of crowding in emergency department on precheck triage. Methods Data of 126 078 patients admitted to the emergency department of the hospital from January 2017 to June 2017 were retrospectively analyzed. According to the occupancy rate of emergency beds, the patients were divided into crowded group and non-crowded group.The epidemiological data, number of patients waiting for triage, waiting time for triage, length of stay(LOS), delayed triage rate, missed triage rate, missed triage rate of critically ill patients, over triage rate of critically ill patients, disease level, years of service in triage of nurses and the flow of triage were compared between the two groups. Linear regression and Logstic regression were used to analyze patient wait triage, LOS, and factors influencing patient diversion to the clinic. Results The delayed rate of triage, missed rate and missed rate of critical patients in the crowded group were significantly higher than those in the non-crowded group, with statistically significant differences(P<0.01). There was no statistically significant difference in triage accuracy and overtest rate among critically ill patients. Waiting time for triage was significantly correlated with the number of waiting patients and the length of service of triage nurses (P<0.01). LOS was significantly positively correlated with the number of patients waiting for triage (P<0.001), and was negatively correlated with the triage nurse triage work year limit (P<0.001). They have nothing to do with the patient's age, disease level and gender.The working years of the triage nurse and the patients in the low age group were the influencing factors for the diversion to the outpatient service (P<0.001). The number of patients waiting for triage and gender were not the influencing factors. Conclusions Crowding in the emergency department causes many adverse effects on pre-diagnosis triage, leading to the extension of waiting time for triage and LOS, increasing the rate of missed tests in critically ill patients, which is not conducive to patient safety and brings hidden dangers to medical care. Therefore, it should be attached great importance to improve its negative effect on triage. Key words: Emergency department crowding; Pre-diagnosis triage; Missed rate; Triage accuracy

P071: A three-year analysis of adult protection patients in the emergency department

Introduction: While boarding of patients in the emergency department (ED) has been well documented and is carefully monitored, the time spent in emergency beds by patients waiting for Adult Protection (AP) placement is often relatively unnoticed, as they are not flagged as ‘admitted’. These patients have no emergency needs, yet consume considerable ED resources, often in excess of patients requiring emergency care. Staff familiarity with this issue may also bias them to premature diagnostic closure of patients as ‘placement problems’, risking misdiagnosis of active medical conditions. An observational study to retrospectively quantify the time spent in the ED by patients referred to AP services for urgent placement from the ED. Methods: A three-year audit of ED social work records of patients referred for AP. Results: For the period of October 1 2015-September 30, 2018, the ED social work service kept records of patients referred for AP from the ED. During this period, a total of 142 patients were referred to AP (40, 50, and 52 in each year respectively). There was an increase of 10 patients between 2015/16 and 2016/17 and two patients from 2016/17 to 2017/18. The overall length of stay for this subset of ED patients during this three-year period was alarmingly high, with an average length of stay of four days per patient (range 2.7 hours-18.5 days) compared to an average of all patients of 4.9 hours and admitted patients of 13.6 hours. Conclusion: Patients in the ED who are referred to AP services consume considerable ED resources, often requiring complete medical work-up, capacity assessments and close monitoring by multiple emergency personnel. This has been reported to cause considerable stress and friction between staff and consulting services. Furthermore, these patients are poorly served in a hectic, brightly lit, and noisy environment. The impact is often not fully appreciated due to ineffective capture by patient tracking systems.

Allocating Emergency Beds Improves the Emergency Admission Flow

The increasing number of admissions to hospital emergency departments (EDs) during the past decade has resulted in overcrowded EDs and decreased quality of care. The emergency admission flow that we discuss in this study relates to three types of hospital departments: EDs, acute medical unit (AMUs), and inpatient wards. This study has two objectives: (1) to evaluate the impact of allocating beds in inpatient wards to accommodate emergency admissions and (2) to analyze the impact of pooling the number of beds allocated for emergency admissions in inpatient wards. To analyze the impact of various allocations of emergency beds, we developed a discrete event simulation model. We evaluate the bed allocation scenarios using three performance indicators: (1) the length of stay in the AMU, (2) the fraction of patients refused admission, and (3) the utilization of allocated beds. We develop two heuristics to allocate beds to wards and show that pooling beds improves performance. The partnering hospital has embedded a decision support tool based on the simulation model into its planning and control cycle. The hospital uses it every quarter and updates it with data on a 1-year rolling horizon. This strategy has substantially reduced the number of patients who are refused emergency admission.

“Influencing without Power” Currency in Inspiration Labs—A Case Study of Hospital Emergency Beds

Most of literatures on currencies of “Influencing without Power” focus on skills, internal organisation command chain, convincing, indirect power, or what makes people do specific task and to have attitude to cooperate with others to reach gaols. In this case study paper currency of “influencing without power” is investigated in one of the inspiration labs carried out and then compared to current literature available on the concept of influencing without power or extra resources. The paper focuses on understanding how inspiration economy “influencing without power” currency has differentiated itself to leave an outcome not only results or improvement of enabler skills. A model of “Influencing without Power” used in inspiration labs was proposed followed by application on a complex case study about a regional hospital with a problem of scarcity beds limitations for emergency cases. The hospital was selected to experiment the concept of “influencing without power” and its currencies through inspiration lab. The research method consists of the analysis of the case-study specifically in its role in creating positive influence through approaches that shows how the waves of influence are triggered and what results or outcomes its creates. A discussion is done on the differentiation that inspiration labs offer to the knowledge community in comparison to current literature about influencing without power, or resources, or authority. The paper concludes about how currencies of inspiration economy focus on influencing the mindset and changing the way things are approached in dealing with problem solving, or overcoming challenges. The paper shows how effectiveness of “influencing without power” generate currencies that change the attitudes towards stages of synergy and opens new path for more research on both inspiration economy labs and the socio-economic value of influencing with minimal resources and limited or no power.

Bringing Cardiac Diagnostics to the Heart of the Community

Introduction & Context: Patients are at the heart of everything we do. Many elderly patients are asked to attend acute hospital for short duration appointments, when these can be performed closer to the patient, reducing stress, cost and anxiety. Sligo University Hospital’s (SUH) Cardiac Investigations Department serves a population of 213,000 . Activity has increased by 67% in the past 10yrs, with increased service demand / waiting lists. Practice Change Implemented: SUH identified a need for the introduction of diagnostic tests into the community away from the acute hospital setting with an overall aim of providing integrated, easily accessed care. Working with Sligo/Leitrim Community Services, this resulted in a jointly funded pilot project where this service was introduced for echocardiography, holter monitoring and pacemaker follow up across 3 separate sites within the community. An average of 30-40 Cardiac Ultrasounds per month, 15 holters and 5 pacemaker checks take place within the community setting. Aim and Theory of Change: The aim was to introduce a service to the community that would be patient focused, improve access /reduce waiting times. In addition, the aim was to improve patient flow in hospital whereby there would be a focus on enhanced decision making and early discharge. A key driver was demand for emergency beds - increase in numbers of patients on trolleys (by 26% from 2015). Targeted Population and Stakeholders: In addition to being wholly patient focused, GPs have easier access to diagnostic tests which facilitates earlier identification of patients, leading to enhanced patient outcomes and reduced hospital stays. Highlights: (innovation, impact and outcomes) Whilst this project originated as a relatively simple concept, outcomes to date have been extremely positive:- The patient experiences all the positives of a locally provided, timely service GPs benefit from better service access and earlier results The hospital benefits from capacity focus on complex investigations in-house,and reduced waiting times. Comments on sustainability: Due to successes, patient and GP feedback, it has been agreed to roll out the project across the region with a plan to extend further and to provide cross-border services in conjunction with CAWT. Comments on Transferability: This initiative delivers immeasurable benefits both to the acute and community sectors in bringing services closer to the patient. There are plans to roll this out further across the Western region. Conclusions: Whilst this initiative was originally established as a pilot study, results confirm its validity. A recent audit has shown saving of 250 beddays over a 6 week period. This is having a positive impact on the numbers of patients accommodated on trolleys - crucial coming into the winter period. Lessons Learned: This is a true example of what can be achieved through a shared vision, commitment and joint working involving both hospital and community staff working together to achieve a joint aim. It was necessary to embrace a different way of working which necessitated all members working together. This also involved setting up a monitoring process to demonstrate the outcomes of the initiative.

Patient trajectories in a Norwegian unit of municipal emergency beds

Objective: The Coordination reform was implemented in Norway from 2012, aiming at seamless patient trajectories. All municipalities are required to establish emergency care beds (MEBs) to avoid unnecessary hospital admissions. We aimed to examine occupancy rate, patient characteristics, diagnoses and discharge level of municipal care in a small MEB unit.Design: Cross-sectional, observational study.Setting: A two-bed emergency care unit.Subjects: All patients admitted to the unit during one year.Main outcome measures: Patients’ age and gender, comorbidity, main diagnoses and municipal care level on admission and discharge, diagnostic and therapeutic initiatives, occupancy rate.Results: Sixty admissions were registered, with total bed occupancy 194 days, and an occupancy rate of 0.27. The patients (median age 83 years, 57% women) had mostly infections, musculoskeletal symptoms or undefined conditions. Some 48% of the stays exceeded three days and 43% of the patients were subsequently transferred to nursing homes or hospitals.Conclusion: Occupancy rate was low. Patient selection was not according to national standards, and stays were longer. Many patients were transferred to nursing homes, indicating that the unit was an intermediate pathway or a short cut to institutional care. It is unclear whether the unit avoided hospital admissions.

ER型救急システム運用施設における職種別の業務実態に基づく室配置に関する調査研究(Study on room layout in emergency room based on work behaviors by occupational description)

【目的】近年，ER型救急システムを導入している医療施設が増えつつあり，診療体制に合わせた室配置を設計時にも検討する必要がある。救急部における医療従事者の諸室の使用実態および行動特性に関する調査研究を行った。【対象】ER型救急システムを運用している船橋市立医療センターで，超音波測位システムを用いて救急部内での医師，看護師，事務職員の業務行動を観測し，諸室の滞在時間や移動割合および動線を測定した。【結果】医師と看護師はスタッフステーション，事務職員は事務室での滞在時間が長かった。医師と看護師は，スタッフステーションを中心に初療室，診察室，観察ベッド室，患者待合などへの移動が確認されたが，その移動割合は職種により特徴がみられた。看護師は他の職種と比べて様々な場所での滞在が確認された。【結語】ER型救急システムを運用する施設を設計する際には，以下の事項を考慮した室配置が望まれる。①スタッフステーションは初療室と近接させ，スタッフステーションを中心に診察室，観察ベッド室，患者待合，事務室を配置して諸室へ容易に移動できるようにする。スタッフステーションは業務内容および人数などを考慮した面積を確保する。②トリアージ室は，自己来院患者出入口と待合およびスタッフステーションに近接する場所に配置し，使用人数や患者の状態，移動などに対応できる広さを確保する。③看護師の動線を主眼に置いて室配置を検討する。 Aims: We have investigated the circumstances and characteristics of medical staff in the US–style emergency room (ER), in order to consider the room layout. Methods: We monitored the work behaviors of physicians, nurses, and clerks in the ER at Funabashi Municipal Medical Center using an ultrasonic positioning system, and also measured their length of stay in each room as well as their movement ratios and traffic lines. Results: Ordinarily, physicians and nurses stay in the staff station when a patient is admitted. Medical staff move independently, but the movement ratio is different for each job. Nurses moved to every room in the ER. We confirmed that, compared with other occupations, nurses stay in a wider variety places. Conclusions: Therefore, when we design medical facilities that adopt the ER, the following conclusions can be drawn. (1) The staff station should be built near emergency beds, and examination rooms, observation bedroom, patient waiting room, and clerks’ office should be arranged around the staff station so that staff can easily move into every room. (2) The triage room should be arranged near the walk–in patient entrance, patient waiting room, and staff station, and it should be of appropriate size. (3) Consideration of room arrangements with a focus on the traffic lines of nurses should decrease work burden, and in turn, improve the efficiency of clinical activities among all medical staff. 本邦の救急医療体制は，傷病の重症度により初期救急から三次救急に選別され，該当する救急医療施設が診療する形態であり，医療圏ごとに救急医療施設が整備されている。近年，救急医を育成する教育的観点や救急医療施設が遍在する地域の事情から，または総合病院に併設した救命救急センターでは，初期から三次すべての救急患者を受け入れる北米のER（emergency room）を参考にしたER型救急システムを導入する医療施設が増えつつある 1。しかし，ER型救急システムを運用している施設の中には，重症度別に対応する診療を想定して設計された既存の建物をそのまま使用している施設も散見される。一方，救急医療施設では，救急車で来院した患者（以下，救急搬送患者），または自力や家族などに連れられて来院した患者（以下，自己来院患者）の様々な病状に対して，医師，看護師，検査技師，事務職員（以下，事務員）など多職種の医療従事者（以下，医療者）が，多様な行動を展開している 2。 これまでの建築学領域における救急部に関する研究においては，重症患者の診療を対象とした内容が多い。酒井ら 3は，患者の救急処置後の移送先や初療室内の作業領域，筧ら 4は，診療録などから重症患者の初療行為の特性などを明らかにしている。江川ら 5は，初療室にユビキタスステレオビジョンカメラを設置し，心肺停止患者の蘇生治療中に医療者が使用した床面積を算出している。島津ら 6は，近年の救命救急センターの運営体制と施設構成および利用実態の全国的な傾向を明らかにしている。一方で，医療・看護学領域では，本邦のER型診療の実施状況に関する研究が行われており，日比野ら 7は，米国の救急医療体制と本邦のER型診療を比較して，特徴や問題点を明示している。 しかし，医療者の行動特性や診療業務を対象とした研究は希少であり，このような救急診療の体制に合わせた室配置を含めた環境整備にも検討が必要と考えられる。このような行動特性を考慮した環境整備は，救急医療の質の向上に貢献すると考えられる。そこで，ER型救急システムを導入する救急医療施設の室配置に関する研究の端緒として，船橋市立医療センターを対象とした医療者における職種別の救急部門諸室の勤務実態および行動特性に関する調査研究を行った。 本研究は，船橋市立医療センター倫理委員会の承認を受けている。 船橋市立医療センター救急部は，1994年に竣工し，同年に救命救急センターの指定を受けて運用している。建物は，地上8階，地下1階，病床数は449床，26の診療科目で運営されている。救急患者の来院状況は，救急車は4,263台，自己来院患者は11,272人（いずれも2013年）である。自己来院患者においては，平日の午前8時30分から午前11時までは緊急性がない限り一般外来を受診する。同病院の救急部の平面図をFig. 1に示す。救急部は1階に配置されており，救急搬送患者と自己来院患者の入口は分離され，医療者および救急搬送患者と自己来院患者を含む一般来院者との動線は基本的に分離されている。救急搬送患者は，原則として救急車出入口から初療室に搬送され，初療室からは廊下1を経由してX線撮影室（以下，X線室）とCT検査室（以下，CT室）および血管造影室に移動することができる。自己来院患者は，一般出入口から入り，事務室窓口で受付を行い，患者待合または廊下2の座席に移動する。受付後，事務員は，廊下2を介して受付内容をスタッフステーションに連絡し，看護師が，電子カルテ端末とバイタルサイン測定機材を装備した記録カート（以下，カート）とともに待合に出向き，患者の重症度や緊急度から診療の優先状況を判断するトリアージを行う。脱衣等を伴う場合や問診の内容によりトリアージ室にてトリアージを行う。その際，重症または緊急度が高いと選別された自己来院患者は初療室に移動させる。その他の自己来院患者は，患者待合や廊下2に呼出しに来た医師と診察室に入室し，診療を受け，必要であればX線室とCT室を使用する。輸液治療や経過観察など，臥床が必要な患者は観察ベッド室（以下，観察室）を使用する。入院する場合は廊下1の自動ドアを通り，突き当たりにあるエレベーターを使用して，救急病棟（3階，35床），集中治療室（2階，8床），手術室（2階）に搬送される。診察終了後，入院が不要と判断された場合は事務室窓口にて会計し，一般出入口から離院する。なお，感染症の可能性のある患者は，隔離初療室（以下，隔離室）で診察を受ける。 Plan view of the ER at Funabashi Municipal Medical Center and locations of ultrasound measurement equipment. This diagram shows the various locations of ultrasonic measurement equipment in the emergency room. 救急部の勤務体制をTable 1に示す。医療者の主な診療活動は，救急搬送患者に対しては，救命救急センター医師（以下，救急医）が中心に初期診療を行い，各診療科の医師に連絡し連携して診療する。自己来院患者に対しては，原則として臨床研修医（以下，研修医）と各診療科の医師が対応し，必要に応じて救急医も介入する。看護師は救急部専属であり，スタッフステーションに常駐し，救急搬送患者と自己来院患者の両方に対応する。事務員は，駆けつけた患者家族を初療室や観察室へ案内すること，および一部電子化されていない診療記録や画像データなどを救急部外の保管庫へ取りに行く業務も担っている。 2014年2月17日から24日の8日間，対象施設の救急部が比較的混雑する午後5時より午後11時まで，対象施設の救急部内における滞在頻度が高いとされる救急医，研修医，小児科医，脳神経外科医（以下，脳外科医），看護師，事務員，カートを対象とし，各職種の主担当者を必要最小限の範囲で抽出したうえで，延べ87名とカート8台分の救急部内での移動状況を計測した。調査対象日の勤務者数と，調査対象人数をTable 2に示す。 計測手法は，超音波測位システム（古河産業株式会社製ZPS–3D）を採用した。超音波測位システムは，呼出ユニット（interface control unit: ICU）からの呼出しに対し，超音波発信機（echo beacon TAG: ETAG，以下，タグ）から発信した超音波（400kHz帯）を，複数の超音波受信器（echo receiver: REC，以下，受信器）で受信する。受信したデータを基に，演算ユニット（oustation processing unit: OPU）で，タグから受信器までの超音波の到達時間から距離を三辺測量でタグ（音源）の位置を特定し，算出する。算出されたデータはコントロールユニット（control unit: CU）に集約され，サーバーパソコン（front control unit: FCU）に送信され，蓄積する（Fig. 2）。 Ultrasonic positioning system components. This diagram shows the constituents of the ultrasonic positioning system. 受信器を天井面に設置することで配線が天井内となることから，医療者や患者の行動に影響を及ぼさずにデータの蓄積が可能であり，かつ同時に複数の行動データを正確に取得できる。また，超音波は光や電波と比較して伝播速度が著しく遅い（340m/s）特徴を利点として，電波を利用した測位よりも各受信器への到達時間差の計測が容易となり，測位精度が上がる。また，基本的に人体や医療機器に影響を及ぼさない。松下ら 8は病棟における看護師の動線測定を目的にこのシステムを開発し，本研究でもこのシステムおよびデータの解析手法を採用した。 本研究では，滞在位置を発信する名札型タグを医療者の肩部に付け（カートは上段に設置），受信器を建物天井面の各場所に設置することにより，医療者などの測位を行った。調査対象諸室および測定に用いた機器の設置状況をFig. 1に示す。 職種別医療者個人の移動状況のデータは日付，時刻，タグ番号，座標，測位条件パラメータのテキストデータで記録し，その内容をスタッフステーション内に設置したFCUに蓄積した。 はじめに，すべての測位データの位置座標を，初療室やスタッフステーションといった室名称に変換した。得られたデータは医療者ごとに分類し，時系列順の滞在場所の推移と室間の訪問回数を集計した。また時系列に並んだ室名称から，医療者が各室に入室した時刻と退室した時刻がわかるため，これらの差から，各室に滞在していた時間を算出した（Table 3）。但し，測位誤差を取り除くために，5秒以下の間隔で隣接室間の出入りを繰り返している場合は，室移動がないものとみなした。以上の作業から，得られた個人の各室での滞在時間と各室間の移動回数の合計を職種別に集計した後，各室間の移動回数を移動総数で除した移動回数割合を算出し，その平均値から各職種の施設利用状況の概要を把握した。 職種別にみた調査対象範囲内に滞在している時間内における各室の滞在時間の割合を算出した（Fig. 3）。 Proportion of time that medical staff spent in each room. The analysis results for the proportion of time spent by staff in each room are shown by occupational role. 救急医は，初療室（57.1%）（以下，括弧内に滞在時間割合を示す），次いでスタッフステーション（39.8%）の2室での滞在が多かった。研修医はスタッフステーション（53.4%）が約半数を占め，次いで診察室（25.3%），初療室（13.4%）の滞在が多かった。小児科医は初療室（36.7%），スタッフステーション（36.0%），診察室（18.8%）での滞在が，脳外科医は初療室（45.9%），スタッフステーション（35.5%），診察室（15.7%）での滞在が多かった。 一方，看護師はスタッフステーション（56.9%），初療室（30.8%）が多く，観察室（4.5%）や患者待合（4.1%）などと，様々な場所での滞在が確認された。事務員は事務室（96.8%）での滞在が9割以上を占めたが，患者待合（1.5%）やスタッフステーション（1.4%）での滞在も散見された。カートは設置場所であるスタッフステーション（85.3%）での滞在時間が最も長いが，使用時と思われる滞在時間の割合としては患者待合（9.5%），トリアージ室（3.4%）の滞在がみられた。 医療者の各室の移動状況をFig. 4に示す。Fig. 4は右上から救急部の診療の中心となる診察室，スタッフステーション，初療室を配置し，続いてその他診療関連諸室，左上に事務室，待合，トリアージ室と待合に関連する諸室を，すべての部屋間の移動を図示するために同心円状に配置した。枠外に向かう動線は救急部外への移動を示し，今回の調査では正確に把握していないが，日々の業務状況から，医師は常駐しているスタッフ室や当直室または担当する病棟への移動，看護師は病棟などへの搬送，事務員は，電子化されていない診療記録などを探しに保管庫へ移動していると推測される。各室間の移動回数割合は，救急医はスタッフステーションと初療室（20.5%）（以下，括弧内に移動回数割合を示す）が最多であった。研修医は，スタッフステーションを中心にスタッフステーションと初療室（15.0%），患者待合（12.5%），観察室（5.1%）の移動が多かった。一方，患者待合と診察室（8.4%）の移動も多く確認された。小児科医はスタッフステーションと初療室（20.3%），診察室と患者待合（10.0%），脳外科医はスタッフステーションと初療室（41.3%）間での移動が多かった。看護師は，スタッフステーションと初療室（32.7%）が約3割を占め，スタッフステーションと患者待合（4.5%）および観察室（5.1%）間での移動も確認された。事務員は，事務室と患者待合（8.1%）および事務室とスタッフステーション（8.3%），カートはスタッフステーションと患者待合（16.8%）の移動が多かった。 Medical staff movements between rooms. The movement of staff between rooms is shown by occupational role. 職種別の救急部内諸室での滞在時間では，救急医以外の医師は主に重症および緊急度の高い患者を診療する初療室と，その他の患者を診療する診察室の両方に滞在時間が長いことが判明した。このことから，ほとんどの医療者が救急搬送患者と自己来院患者の双方に柔軟に対応している様子が伺える。山下ら 1，鈴木ら 9はER型救急システムを運用している施設では，比較的少数の医療者による多数の患者の診療が行われている現状を示しており，今後も，少数の医療者で救急部内のすべての来院患者に対応せざるをえないと考えられる。対象施設においても三次救急の主体を担っているのは救急医であるが，その他の救急診療体制と医療者全体の業務内容を勘案し，初療室と診察室の近接性を設計時に考慮することは重要と考えられる。 移動回数は，事務員を除き，どの職種もスタッフステーションと初療室が最も多いことが判明した。さらに研修医と看護師は，スタッフステーションと観察室の移動も確認された。看護師は，スタッフステーションと患者待合の移動もみられ，事務員は，記入された受付内容の運搬および連絡と思われる事務室とスタッフステーションの移動がみられた。花木 10は，救急医療施設を設計する際には，スタッフステーションは診療活動の中枢になる場所であるため，どこからも容易に入ることができ，かつどのエリアにも目が行き届く中央に配置することが重要であると述べており，今回の結果とも合致した意見と言える。また，今回の調査では，看護師の診察室への移動がほとんどみられないことが判明した。対象施設では，異性の診察で配慮が必要な場合や対応でトラブルを生じている場合などを除き，診察室での医師の診療に看護師は原則として立ち会わない。Fig. 1の平面図をみると，診察室は廊下2を隔ててスタッフステーションの反対側に配置されている。対象施設における医師の診察に看護師が立ち会わない慣習が生じたのは，この室配置が一因であると推測される。診察室がスタッフステーション側に配置され，かつスタッフステーション側にも出入口を設ければ，看護師の介入も容易となり医療者の移動負担も減る。 以上から，ER型救急システムを運用する施設を設計する際には，スタッフステーションは，まず初療室と近接させ，さらにスタッフステーションを中心に診察室，観察室，患者待合，事務室を配置し，かつ諸室へ容易に移動できるようにすることで，業務の効率性と利便性が向上すると考えられる。なかでも，看護師のスタッフステーションからの移動が多くみられた観察室に関しては，対象施設では隣接するスタッフステーションの壁面に大きなガラス窓とスタッフステーション側にブラインドが設置されていて，医療者が観察室の様子をスタッフステーション側から確認することが可能となっている。このように，医療者側と患者側双方のプライバシーを配慮しつつ窓を設置するなど，視認性を高め，安全に監視できるようなしつらえを検討し，医療者の移動を減らし，業務負担を軽減させる工夫も必要と思われる。 スタッフステーションはカルテ入力や指示伝達，処置の準備，業務の引き継ぎやディスカッションなど，多くの医療者が多様な用途で使用する診療活動の中枢となる場所である。ERの設計に関する米国のガイドライン 11によると，情報の入力などの業務が電子化によりベッドサイドに分散化される可能性を示唆しつつも，ベッド数あたりのスタッフステーションの必要面積の目安が示されている。今回の調査においても，事務員を除くすべての職種の医療者がスタッフステーションを中心に業務を行っている。したがって，スタッフステーションは初療室全体を広く見渡すことが可能であること，かつ使用する職種の業務内容と同時に，使用する人数を想定すること，さらに災害など非常時対応も可能な十分な面積の確保が重要であると考えられる。しかし，米国ガイドラインでは，必要とされる面積の目安を定めているが，データに基づいた明確な根拠を示していないため，各職種における作業空間の測定などスタッフステーションの面積算定の基礎となる研究が今後必要と思われる。 職種別にみた滞在時間と移動回数の特徴からは，カートは，待機しているスタッフステーションを除き，使用時において患者待合での滞在時間が長く，本来トリアージを実施するための部屋であるトリアージ室の使用頻度が少ないことが明らかとなった。これは，建物竣工後に必要に迫られ，器材倉庫を改築して設置されたトリアージ室が，患者待合とスタッフステーションの両方から離れた場所に位置し，狭小かつ袋小路になっている間取りから，医療者，患者双方とも利便性が低いためと考えられる。 米国ガイドラインでは，トリアージ室はトリアージのための十分な広さ，および車いすを使用する患者と家族数名の椅子が置けるスペースが必要であると示されている。さらに個室でトリアージをするのであれば，エントランスや患者待合との視認性に配慮したガラス張りにする必要があり，プライバシー確保も考慮し，カーテンの設置も必要であると述べられている。また，梅田 12は，救急部においてトリアージ後の診療を待つ患者を見渡すことができる位置にトリアージカウンターを設置し看護師を配置することで，安全性を確保している事例を示している。以上から，トリアージ室の位置は自己来院患者の出入口近辺であること，また患者待合全体を視認できる場所やしつらえを検討することが望まれる。しかしながら，人員に余裕がない場合には，カウンターを設けて看護師にトリアージのみの業務を限定することは困難であり，トリアージを実施する看護師のスタッフステーションからのアクセスが容易なことも重要となる。したがって，トリアージ室は自己来院患者の出入口と患者待合およびスタッフステーションにも近接する場所に配置するのが適当と考えられる。また，事務カウンターを患者待合全体が視認できる場所に設置する，または警備員の立ち位置を工夫するなど，事務員と看護師の連携を図ることで，看護師の負担を抑えつつ安全性を確保することが可能となる。 また，今後のER型救急システムについて，鈴木 13は，多くの救急患者を診療できる体制ではあるが，米国では混雑が問題となっており，本邦でも救急外来の混雑は必至であると述べている。さらに，救急部は，災害時の傷病者受け入れでも使用されることが想定されるため 14，平常時と災害時の双方の混雑に対応できるように設計すべきと思われる。したがって，患者待合に関しても十分な広さを確保すること，視認性を確保すること，さらに必要時に区画が容易である平面形を検討すべきと考えられる。例えば，患者待合をL字型に設計することで広い矩形の平面形と比較し，用途別に区画することが容易となる。 今回の調査において，看護師は，他の職種と比べ，救急部内の様々な場所での滞在や移動が確認された。また看護師の業務内容は他の職種の業務と密接に関与し，他の職種の業務効率にも影響を及ぼす。そのことから室配置を設計する際には，看護師の動線に主眼を置いて検討することが重要と思われる。看護師の室間移動距離を短縮することで労働負担が軽減し，その効果が看護師に限らず診療業務全体の効率性を高めることが可能と思われる。 以上より，建物設計が救急診療業務における機能面の向上や労働負担の軽減を促すとともに，医療者と患者双方に安全かつ機能的な診療空間の実現に寄与できると考えられる。 最後に，本研究は1施設のみを対象とした調査研究であるため，診療体制，施設面積や室配置，人員など施設独自の事情が結果に影響していることは否めない。普遍性，多様性，客観性を高めるためには多施設での研究が必要である。 ER型救急システムを運用する施設において，職種別の諸室における使用実態および行動特性を調査した。ER型救急システムを運用する救急医療施設を設計する際には，機能性，効率性，安全性を向上させるために，以下の事項を考慮した室配置が望まれる。 ①スタッフステーションは，まず初療室と近接させ，さらにスタッフステーションを中心に診察室，観察室，患者待合，事務室を配置し，諸室へ容易に移動できるようにする。スタッフステーションは使用する医療者の業務内容および人数などを考慮した面積を確保する。 ②トリアージ室は，医療者と患者側双方の利便性にも配慮し，徒歩患者出入口と待合およびスタッフステーションに近接する場所に配置する。また，使用する人数や患者の状態，移動などに柔軟に対応できる広さを確保する。 ③看護師の動線を主眼に置いて室配置を検討する。 本研究は，公益財団法人日揮・実吉奨学会の助成を受けて実施した。

Correspondence and challenges as neurologists to Kumamoto Earthquakes in 2016.

Kumamoto Earthquakes in 2016 severely affected medical circumstances and condition of each patient with neuro-muscular diseases, in addition to having destroyed life circumstances of local residence. Number of neuro-muscular disease patients admitted to the Department of Neurology, Kumamoto University, the only university hospital in the prefecture, increased approximately twice compared to usual years. Most of the related facilities were able to admit emergency patients with neuro-muscular diseases although the hospital buildings were damaged in various degrees. A number of issues remained unsolved as to emergency contact system, securement of emergency beds for severe neuro-muscular diseases, and information system for these patients.

A Study of Cost incurred in providing Emergency Care Services in an Apex Tertiary Care Hospital

ABSTRACT Introduction An emergency department (ED), also known as accident and emergency (A8E), emergency room (ER), or casualty department, is a medical treatment facility specializing for acute care of patients who present without prior appointment, either by their own means or by ambulance. In spite of the emergency beds forming only a fraction of the hospital beds, they consume a relatively large proportion of the hospitals resources. There is a requirement to ascertain the cost incurred in providing emergency care treatment to the patients coming to an apex tertiary care center, whose principal mandate is to provide tertiary care treatment. The study will not only help in allocating funds to the ED in an apex tertiary care facility but will also be useful if the hospital authorities decide to outsource the emergency services to a third party. Aims and objectives To study the cost incurred in providing emergency care services in an apex tertiary care hospital. To identify the various cost centers pertaining to patient care in the emergency care department and to estimate the cost of rendering patient care in ED and the cost of running the emergency per day. Materials and methods Six months’ retrospective data were collected from the ED, accounts section, engineering section, stores department, radiology department, emergency lab, computer facility, etc. The cost was apportioned to per patient as well per hour in rendering emergency care services. Observations The total cost incurred in providing emergency care services in the hospital under study was Rs 2034 per patient, while Rs 31,000 are spent per hour in running the emergency care facility. Discussion Almost 40 to 50% of the total cost incurred on providing emergency care services goes to the salary head of the staff working in the ED. The next major sources of expenditure are the radiology and lab investigations. Conclusion The study suggests that a considerable amount of hospital funds are spent on providing emergency care services in the apex tertiary care facility, whose primary mandate is to provide tertiary care services. The possibility of complete outsourcing or partial outsourcing in the form of radiology investigations and hiring humanpower on a contract basis can be a viable solution, to reduce the cost on providing emergency care, which can better be utilized in providing high-end tertiary care facilities. How to cite this article Garg N, Gupta SK, Lathwal A, Garg R. A Study of Cost incurred in providing Emergency Care Services in an Apex Tertiary Care Hospital. Int J Res Foundation Hosp Healthc Adm 2016;4(1):45-50.

Development of key indicators of hospital resilience: a modified Delphi study.

Hospital resilience is an emerging concept, which can be defined as 'a hospital's ability to resist, absorb, and respond to the shock of disasters while maintaining its critical health care functions, and then recover to its original state or adapt to a new one'. Our aim was to develop a comprehensive framework of key indicators of hospital resilience. A panel of 33 Chinese experts was invited to participate in a three-round, modified Delphi study to develop a set of potential measures previously derived from a literature review. In the first round, these potential measures were modified to cover the comprehensive domains of hospital resilience. The importance of proposed measures was scored by experts on a five-point Likert scale. Subsequently, the experts reconsidered their voting in light of the previous aggregated results. Agreement on measures was defined as at least 70% of the responders agreeing or strongly agreeing to the inclusion of a measure. A large proportion of preliminary measures (89.5%) were identified as having good potential for assessing hospital resilience. These measures were categorized into eight domains, 17 subdomains, and 43 indicators. The highest rated indicators (mean score) were: equipment for on-site rescue (4.7), plan initiation (4.6), equipment for referral of patients with complex care needs (4.5), the plan execution (4.4), medication management strategies (4.4), emergency medical treatment conditions (4.4), disaster committee (4.4), stock types and quantities for essential medications (4.4), surge capacity of emergency beds (4.4), and mass-casualty triage protocols (4.4). This framework identifies a comprehensive set of indicators of hospital resilience. It can be used for hospital assessment, as well as informing priority practices to address future disasters better.