Decreased Emergency Department Research Articles

Management of Traumatic Wounds and a Novel Approach to Delivering Wound Care in Children

Significance: The costs and morbidity of pediatric traumatic wounds are not well known. The literature lacks a comprehensive review of the volume, management, and outcomes of children sustaining soft tissue injury. We briefly review the existing literature for traumatic wounds such as open fractures and burns. Such injuries require dedicated wound care and we propose a novel approach for more efficient and more effective delivery of dedicated pediatric wound care. Recent Advances: New pediatric literature is emerging regarding the long-term effects of wound care pain in traumatic injuries-especially burns. A variety of wound dressings and alternative management techniques exist and are geared toward reducing wound care pain. Our institution utilizes a unique model to provide adequate sedation and pain control through a dedicated pediatric wound care unit. We believe that this model reduces the cost of wound care by decreasing emergency department and operating room visits as well as hospital length of stay. Critical Issues: First, medical costs related to pediatric traumatic wound care are not insignificant. The need for adequate pain control and sedation in children with complex wounds is traditionally managed with operating room intervention. Afterward, added costs can be from a hospital stay for ongoing acute wound management. Second, morbidities of complex traumatic wounds are shown to be related to the acute wound care received. Future Directions: Further guidelines are needed to determine the most effective and efficient care of complex traumatic soft tissue injuries in the pediatric population.

Influence of In-House Attending Presence on Trauma Outcomes and Hospital Efficiency

The influence of in-house (IH) attendings on trauma patient survival and efficiency measures, such as emergency department length of stay (LOS), ICU LOS, and hospital LOS, has been debated for more than 20 years. No study has definitively shown improved outcomes with IH vs home-call attendings. This study examines trauma outcomes in a single, Level I trauma center before and after the institution of IH attending call. Patient data were collected from the University of Kentucky's trauma registry. Based on the Trauma-Related Injury Severity Score, survival rates were compared between the IH and home-call groups. To evaluate efficiency, emergency department LOS, ICU LOS, and hospital LOS were compared. A separate subanalysis for the most severely injured patients (trauma alert red) was also performed. The home-call group (n = 4,804) was younger (p = 0.018) and had a higher Injury Severity Score (p = 0.003) than the IH group (n = 5259), but there was no difference in Trauma-Related Injury Severity Score (p = 0.205) between groups. In-house attending presence did not reduce mortality. Emergency department LOS, ICU LOS, and hospital LOS were shorter during the IH period. Emergency department to operating room time was not different. There was no change in trauma alert red mortality with an attending present (20.7% vs 18.2%, p = 0.198). In-house attending presence does not improve trauma patient survival. For the most severely injured patients, attendings presence does not reduce mortality. In-house coverage can improve hospital efficiency by decreasing emergency department LOS, hospital LOS, and ICU LOS.

Caregiver-Support Program Decreased Dementia Emergencies

BOSTON – A pilot program that supports the caregivers of Alzheimer's disease patients decreased emergency admissions for those patients in San Francisco by more than 40% in 6 months, Elizabeth Edgerly, PhD, reported at the Alzheimer's Association International Conference 2013. The preliminary analysis also found that caregivers reported significant improvements in 7 out of 10 quality of life and quality of care measures, according to Dr. Edgerly, chief program officer of the Alzheimer's Association Northern California and Northern Nevada Chapter. The early results paint an encouraging picture of the future, she said in an interview. “We are very excited about the emergency utilization data. We're always confident about our capacity to impact efficacy, but affecting service utilization is a tough nut to crack. The beauty of this is, if we can improve quality of care while reducing utilization costs, it may actually be cost neutral to have this kind of a dementia support program.” The association created its Excellence in Dementia Care program in conjunction with Kaiser Permanente Northern California, the city and county of San Francisco, and the University of California, San Francisco. The Administration on Aging also provided funding. San Francisco was the perfect city for the pilot project, Dr. Edgerly said. “It's the only city in the United States with a strategic plan related to dementia. It also has an elderly, diverse population, and many of the residents live alone.” The pilot program is part of the city plan's goal of partnering with other institutions to improve quality of life and quality of care for people with dementia. It was designed to improve dementia care by both enhancing services and educating caregivers. “Kaiser hired a full-time social worker for just dementia support and who only worked with the caregivers,” Dr. Edgerly said. The social worker conducted initial evaluations and assessments and created an individualized dementia care program that was uploaded into the electronic medical record of each patient, making the individualized program available to everyone on the patient's care team. The social worker also called caregivers proactively to make sure the caregivers’ needs were being met and that they could access community services. The Alzheimer's Association provided dementia care support experts manning a 24-hour help line, a MedicAlert + Alzheimer's Association Safe Return bracelet for the patient, respite grants for day or evening supplemental care to give caregivers a break, and a support group where caregivers could meet to discusses their challenges. The association also administered the educational portion of the program. The first component provided a primer on Alzheimer's stage-by-stage effects on thinking, emotions, and behavior and noted resources that were available for help. Caregivers also were informed about legal and financial planning and ways to keep a positive, safe, and compassionate home environment for as long as the patient could stay at home. In surveys at baseline and after 6 months, caregivers rated their feelings about their abilities in 10 different areas: handling current patient problems in memory and behavior, handling future patient problems, dealing with their own frustrations, keeping the patient independent, caring for the patient as independently as possible, getting answers to patient problems, finding community organizations that provide answers, finding community organizations that provide services, getting answers to questions about services, independently arranging for services, and paying for services. Overall, 92 of the 105 patient-caregiver dyads have completed the 6-month assessments, Dr. Edgerly said. The surveys indicated significant improvements on seven of the caregiver measures. Caregivers said they felt better able to handle concerns, to get information, and to obtain and pay for services. Most importantly, the program led to about a 40% decrease in emergency department visits – a significant change, Dr. Edgerly said. There were also nonsignificant decreases in hospital length of stay, physician visits, and days spent in postacute or long-term care facilities. “Even the outcomes that didn't improve significantly were all going in the right direction,” Dr. Edgerly said, adding that she's hoping for even better results when the data are analyzed in their entirety. The program's positive impact on health care resources could be enough to attract the interest of other insurers, she said. “If this intervention reduced expenses associated with hospital or emergency department visits, an insurer might see that as good business sense.” The project was funded by the Alzheimer's Association of Northern California and Northern Nevada, Kaiser Permanente Northern California, and the National Institute on Aging.

Massachusetts General Physicians Organization’s Quality Incentive Program Produces Encouraging Results

Physicians are increasingly becoming salaried employees of hospitals or large physician groups. Yet few published reports have evaluated provider-driven quality incentive programs for salaried physicians. In 2006 the Massachusetts General Physicians Organization began a quality incentive program for its salaried physicians. Eligible physicians were given performance targets for three quality measures every six months. The incentive payments could be as much as 2 percent of a physician's annual income. Over thirteen six-month terms, the program used 130 different quality measures. Although quality-of-care improvements and cost reductions were difficult to calculate, anecdotal evidence points to multiple successes. For example, the program helped physicians meet many federal health information technology meaningful-use criteria and produced $15.5 million in incentive payments. The program also facilitated the adoption of an electronic health record, improved hand hygiene compliance, increased efficiency in radiology and the cancer center, and decreased emergency department use. The program demonstrated that even small incentives tied to carefully structured metrics, priority setting, and clear communication can help change salaried physicians' behavior in ways that improve the quality and safety of health care and ease the physicians' sense of administrative burden.

Impact of a diabetes control and management intervention on health care utilization in American Samoa

To examine the impact of a successful 12-month behavioral intervention to improve diabetes control on health care utilization in American Samoa. A cluster-randomized design was used to assign 268 diabetes patients to a nurse-community health worker intervention or usual care. Hospitalizations, emergency department, and primary care physician visits were collected retrospectively for 1 year prior to, and during, the intervention to assess changes in health care utilization. The association of utilization changes with change in HbA1c during the intervention was assessed. Adjusted incidence rate ratios (RR) for primary care physician visits were significantly higher in the community health worker relative to the usual care group (RR = 1.71; 95% CI, 1.25-2.33). There was no main intervention effect on emergency department utilization, but visits in the prior year modified the intervention effect on emergency department visits. Increased primary care physician utilization was associated with greater decreases in HbA1c (b = -0.10, SE = 0.04, p = 0.01). A culturally adapted community health worker diabetes intervention in American Samoa significantly increased primary care physician visits, and decreased emergency department visits among those with high emergency department usage in the prior year. These changes suggest important and beneficial impacts on health system utilization from the diabetes intervention in a low resource and high-risk population.

Postdischarge clinics: Hospitalist attitudes and experiences

Novel methods for improving transitions of care are needed. Hospitalist-run postdischarge clinics (PDCs) may improve access to postdischarge care, but require practice change from providers. We conducted a Web-based cross-sectional survey of hospitalists at 37 academic medical centers across the United States and a large private employer of hospitalists to assess the attitudes of hospitalists toward postdischarge care and PDCs. Two hundred twenty-eight of 814 hospitalists responded to the survey (28%). Responding hospitalists commonly (55%) experienced difficulty arranging outpatient follow-up, and felt that lack of access was responsible for most patient problems after discharge (61%). Despite this, 62% felt hospitalists should not provide postdischarge care in a clinic, and 77% felt they would require extra compensation for work in a PDC. However, 74% thought such a clinic would decrease emergency department visits. Practicing in a PDC was associated with a trend toward positive attitudes about providing postdischarge care (P = 0.054). Responding hospitalists expressed difficulty arranging appropriate postdischarge care, confidence that PDCs would reduce postdischarge utilization, and reservations about working in a PDC, perhaps because of practical or financial concerns. These results are important given the current emphasis on reducing hospital readmissions. Further work evaluating the experience of hospitalists in PDCs is needed.

A Case Series Using a Care Management Checklist to Decrease Emergency Department Visits and Hospitalizations in Children With Epilepsy

Each year, 1 million people are seen in an emergency department for seizures or epilepsy. We implemented a care management checklist for patients with frequent visits. A database was searched for patients with the highest number of emergency department visits and/or unplanned hospitalizations in 2011. Four patients were selected. A care management checklist was implemented in 2012. Compliance with the office visits, number of emergency department visits and/or hospitalizations, and the associated costs were tracked following implementation of the checklist for 2011 and 2012. These 4 epilepsy patients accounted for 46 visits in the year 2011 with associated health care costs of $380,209. Following a year using a care management checklist, the same patients accounted for 11 visits with a cost reduction of $188,130. Using a care management checklist was useful in these 4 epilepsy patients to decrease emergency department visits and/or unplanned hospitalizations. A limitation of this study is its small numbers.

Caregiver Asthma Knowledge, Aptitude, and Practice in High Healthcare Utilizing Children: Effect of an Educational Intervention

Factors underlying high healthcare utilization among Hispanic and African American (AA) children with asthma are not well known. We hypothesized that low parental knowledge and suboptimal practices are associated with high healthcare utlization and sought to elucidate these factors and identify ethnicity-specific differences. We also hypothesized that a targeted educational intervention will decrease emergency department (ED) visits and hospitalizations. A 57-item questionnaire investigating asthma knowledge, aptitude, and practice was administered during a hospitalization to 268 caregivers (158 Hispanic and 110 AA) of high healthcare utilizer children. Responses were compared between ethnicities. Participants were randomized into an education group and a control group to investigate the impact of an in-hospital educational intervention on future ED visits and hospitalizations. More than 80% of caregivers knew that asthma is associated with muscle constriction and mucus production. Overall, 66.7%-86.9% of caregivers found preventive steps including allergen avoidance, regular primary care physician (PCP) follow-up, and medication adherence helpful, but only 45.2% reported adherence to controller medications. Similarly, caregivers found management steps, including albuterol use, avoidance of ineffective medications, and need to contact PCP helpful but 33% Hispanic caregivers contacted their child's PCP at the time of the exacerbation leading the current hospitalization, compared with 17% AA caregivers (P=0.006). Moreover, 40% and 30% Hispanic and 27% and 18% AA caregivers felt stressed and helpless, respectively, about their child's asthma. Despite high baseline levels of knowledge, there were fewer ED visits in the education group (1.56±1.94) compared with the control group (2.05±2.32) (P=0.02) 2 years after the intervention. Although Hispanic and AA caregivers of children with high healthcare utilization were knowledgeable of asthma pathophysiology, and preventive and management steps, they reported being stressed and helpless and were unable to implement the steps at the time of an exacerbation, seeking care at the ED rather than contacting their PCP. The high health utilizers who underwent a targeted educational intervention had fewer ED visits 2 years following the intervention.

Cost‐effectiveness of asthma clinic approach in the management of chronic asthma in Australia

To compare cost-effectiveness of an asthma clinic that would provide education, promotion of self-monitoring of symptoms, regular review of treatment by a medical practitioner and a written asthma action plan to current practice in Australia. A decision tree model was used to compare treatment and improved management using asthma clinics under three scenarios: 1) intervention reduces only emergency department visits; 2) in addition, it leads to a reduction in days out of role; and 3) it also reduces unplanned general practitioner visits and hospitalisations. Evidence from existing published studies was used for asthma incidence, duration, treatment practices and health seeking behaviours. Costs for one year were estimated based on an asthma clinic trial in Australia. The estimated $274 million annual cost of asthma clinics is much greater than the potential cost savings of $11 million resulting from reduced emergency department visits, and an overall potential cost saving of $85 million resulting from decreased GP visits and hospitalisations. The incremental cost-effective ratio (ICER) is $24,000 if a reduction in days out of role is quantified as a health benefit in estimating disability-adjusted life years (DALY). If a potential $85 million in cost-savings from decreased emergency department visits, GP visits and hospitalisation is taken into account, the ICER drops to $17,000 per DALY averted. An asthma clinic as an intervention for improving self-management may be cost-effective in Australia if multiple benefits can be achieved. A large-scale asthma clinic trial and long-term evaluation of benefits are necessary to obtain stronger evidence on the benefit of asthma clinic approach in Australia.

The Promises and Perils of the MHS' Implementation of the Patient-Centered Medical Home

With increasing resource scarcity and rising costs of health care, the Military Health System (MHS) must transform from a chronically inefficient and costly health care system that is overly reliant on specialty care and large institutions into a cost-effective and outcome-based system of health. Over the past 2 decades, the United States has witnessed economically unsustainable rises in health care costs in both the civilian and the federal sectors. 1 During this period, however, the country has seen little improvement in access to and quality of health care. Multiple studies show primary care providers improve health care cost and quality, yet few initiatives have focused on reestablishing the primary care physician as the center of health care delivery. 2 The Patient-Centered Medical Home (PCMH) model rejuvenates the use of primary care providers as the central source of individual medical care. The PCMH is a commonly understood model; it is a modern adaptation of the classic, small town physician practice. Simply put, this is the patient’s home for all things medical. The PCMH uses a team of care providers to deliver continuous and comprehensive primary care and to ensure that the needs of the patient are met. In addition, specific focus is placed on preventive care and population health. Patients have increased access to providers on a continuous basis and can communicate with their care team via modern technology tools, such as secure messaging. Current research indicates improved patient experiences, better coordination of care, and decreased emergency department visits and inpatient admissions. 3 All these improvements are essential for sustainability in today’s economic environment.

Emergency Department Transport Rates of Children From the Scene of Motor Vehicle Collisions

Motor vehicle collisions (MVCs) are the leading cause of death and disability among children older than 1 year. Many states currently mandate all children between the ages of 4 and 8 years be restrained in booster seats. The implementation of a booster-seat law is generally thought to decrease the occurrence of injury to children. We hypothesized that appropriate restraint with booster seats would also cause a decrease in emergency department (ED) visits compared with children who were unrestrained. This is an important measure as ED visits are a surrogate marker for injury. The main purpose of this study was to look at the rate of ED visits between children in booster seats compared with those in other or no restraint systems involved in MVCs. Injury severity was compared across restraint types as a secondary outcome of booster-seat use after the implementation of a state law. A prospective observational study was performed including all children 4 to 8 years old involved in MVCs to which emergency medical services was dispatched. Ambulance services used a novel on-scene computer charting system for all MVC-related encounters to collect age, sex, child-restraint system, Glasgow Coma Scale score, injuries, and final disposition. One hundred fifty-nine children were studied with 58 children (35.6%) in booster seats, 73 children in seatbelts alone (45.2%), and 28 children (19.1%) in no restraint system. 76 children (47.7%), 74 by emergency medical services and 2 by private vehicle, were transported to the ED with no significant difference between restraint use (P = 0.534). Utilization of a restraint system did not significantly impact MVC injury severity. However, of those children who either died (n = 2) or had an on-scene decreased Glasgow Coma Scale score (n = 6), 75% (6/8) were not restrained in a booster seat. The use of booster-seat restraints does not appear to be associated with whether a child will be transported to the ED for trauma evaluation.

An Emergency Department-initiated, Web-based, Multidisciplinary Approach to Decreasing Emergency Department Visits by the Top Frequent Visitors Using Patient Care Plans

BackgroundMany patients present to the Emergency Department (ED) for multiple visits. Whatever the cause, assuring the highest quality of care is difficult in the ED. ObjectivesWe sought to implement a web-based, ED-initiated, multidisciplinary program to improve patient care and reduce frequent visits to the ED. MethodsThe top 50 ED frequent visitors were identified and care plans were constructed. Care plans consist primarily of a summary of the patient's pertinent history and any psychosocial issues that can contribute to frequent use of the ED, and recommend treatment plans for these patients. ResultsDuring the study period, ED visits by the top 50 chronic frequent visitors ranged from 88 to 98 visits/month and 28 to 31 admissions/month. As of January 2007, the top 50 frequent visitors had 94 ED visits/month (1,129 visits/year) for 2.2% of the total census, and 31 admissions/month (372 admissions per year) for approximately 3.3% of the total admissions. Each frequent visitor has approximately 22.6 visits/year (range from 11 to 41) and 7.3 admissions/year (range from 0 to 20). By May 2008, the top 50 frequent visitors had a decrease to 88 visits/month (1,059 visits/year) and 28 admissions/month (340 admissions/year), with each frequent visitor having 21.2 visits/year and 6.8 admissions/year. Social determinants included psychiatric disease (36%), substance abuse (22%), malingering (20%), medication noncompliance (16%), and unstable housing (10%). ConclusionsThere was a trend toward a decrease of monthly ED visits by the top 50 ED frequent visitors, but no effect on the rate of admissions. Based on these preliminary data and the relative ease of integration into the system, this project shows the potential to begin to address the problem of chronic ED use with patient care plans.

Community Asthma Initiative: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care

ER Woods, U Bhaumik, SJ Sommer. Pediatrics. 2012;129(3):465–472 To evaluate the cost-effectiveness of a quality improvement (QI) program in decreasing asthma emergency department (ED) visits, hospitalizations, limitation of physical activity, patient missed school, and parent lost work. Urban, low-income patients with asthma from 4 Boston-area zip codes were determined through records of ED visits or hospitalizations. The selected families were given the option of increased …

Early data from project engage: a program to identify and transition medically hospitalized patients into addictions treatment

BackgroundPatients with untreated substance use disorders (SUDs) are at risk for frequent emergency department visits and repeated hospitalizations. Project Engage, a US pilot program at Wilmington Hospital in Delaware, was conducted to facilitate entry of these patients to SUD treatment after discharge. Patients identified as having hazardous or harmful alcohol consumption based on results of the Alcohol Use Disorders Identification Test-Primary Care (AUDIT-PC), administered to all patients at admission, received bedside assessment with motivational interviewing and facilitated referral to treatment by a patient engagement specialist (PES). This program evaluation provides descriptive information on self-reported rates of SUD treatment initiation of all patients and health-care utilization and costs for a subset of patients.MethodsProgram-level data on treatment entry after discharge were examined retrospectively. Insurance claims data for two small cohorts who entered treatment after discharge (2009, n = 18, and 2010, n = 25) were reviewed over a six-month period in 2009 (three months pre- and post-Project Engage), or over a 12-month period in 2010 (six months pre- and post-Project Engage). These data provided descriptive information on health-care utilization and costs. (Data on those who participated in Project Engage but did not enter treatment were unavailable).ResultsBetween September 1, 2008, and December 30, 2010, 415 patients participated in Project Engage, and 180 (43%) were admitted for SUD treatment. For a small cohort who participated between June 1, 2009, and November 30, 2009 (n = 18), insurance claims demonstrated a 33% ($35,938) decrease in inpatient medical admissions, a 38% ($4,248) decrease in emergency department visits, a 42% ($1,579) increase in behavioral health/substance abuse (BH/SA) inpatient admissions, and a 33% ($847) increase in outpatient BH/SA admissions, for an overall decrease of $37,760. For a small cohort who participated between June 1, 2010, and November 30, 2010 (n = 25), claims demonstrated a 58% ($68,422) decrease in inpatient medical admissions; a 13% ($3,308) decrease in emergency department visits; a 32% ($18,119) decrease in BH/SA inpatient admissions, and a 32% ($963) increase in outpatient BH/SA admissions, for an overall decrease of $88,886.ConclusionsThese findings demonstrate that a large percentage of patients entered SUD treatment after participating in Project Engage, a novel intervention with facilitated referral to treatment. Although the findings are limited by the retrospective nature of the data and the small sample sizes, they do suggest a potentially cost-effective addition to existing hospital services if replicated in prospective studies with larger samples and controls.

Medical Home and Emergency Department Utilization Among Children With Special Health Care Needs

The purpose of this article was to determine whether medical home associated with reduction in emergency department utilization by children with special health care needs. The study comprised 40 723 children participating in the National Survey of Children with Special Health Care Needs. For whole sample, presence of medical home was not associated with a decrease in emergency department (ED) utilization. However, children aged 0 to 5 years and those with severe functional limitations derived the most benefit from a medical home. Presence of medical home for severely limited children was associated with fewer ED visits (odds ratio, 0.59; 95% confidence interval, 0.50-0.70). Additional studies are warranted to explore specific components of a medical home and ED use.

Laboratory-Confirmed Rotavirus Disease in Utah Children: Clinical and Economic Impact of Rotavirus Vaccination

Rotavirus is the most common cause of infectious diarrhea in children worldwide. Recent studies have described changes in the burden of all-cause gastroenteritis; however, there are limited data on the clinical and economic impact of rotavirus vaccine on cases of laboratory-confirmed rotavirus disease. We performed a retrospective study of laboratory-confirmed rotavirus disease from July 2003 through June 2010 at a children's hospital and a community hospital in Utah. Demographics and hospital costs for children <5 years with rotavirus symptoms and a positive rotavirus enzyme immunoassay test on a stool specimen were abstracted from electronic medical records. We compared the prevaccine period (2003-2007) with the postvaccine period (2008-2010). The overall incidence of rotavirus gastroenteritis declined in the postvaccine period, from 26.6 to 5.2 cases per 10 000 person-years for Salt Lake County residents. The largest decrease in the incidence of rotavirus gastroenteritis was among children <12 months (-87%; 95% confidence interval [CI], 79-93). Older children (12-23 months) also experienced significant decreases (-81%; 95% CI, 72-88), as did those 24-59 months (-61%; 95% CI, 51-71). In 2009, 3 years after rotavirus vaccine introduction, there was a 79% decrease in emergency department visits and a 78% decrease in hospitalizations across both hospitals. The cost of emergency department visits and hospitalizations for rotavirus gastroenteritis decreased by 79% and 72%, respectively, resulting in annual savings of $790 000 at a children's hospital and $140 000 at a community hospital. Rotavirus vaccination in infants has dramatically decreased the clinical burden and direct medical costs of rotavirus gastroenteritis in both infants and young children.

The Crimson Care Collaborative

The current shortage of primary care physicians (PCPs), particularly as more individuals obtain health insurance and seek primary care services, is a growing national concern. The Crimson Care Collaborative (CCC) is a joint student-faculty initiative in post-health-care-reform Massachusetts that was started with the explicit goal of attracting medical students to primary care careers. It fills a niche for student-run clinics, providing evening access to primary care services for patients without a PCP and urgent care services for patients of a Massachusetts General Hospital-affiliated internal medicine clinic, with the aim of decreasing emergency department use in both groups. Unlike other student-run clinics, CCC is integrated into the mainstream health care structure of an existing primary care clinic and, because of universal health insurance coverage in Massachusetts, can bill for its services. In addition to the clinical services offered, the student-run research team evaluates the quality of care and the patients' experiences at the clinic. This article describes the creation and development of CCC, including a brief overview of clinic operations, social services, research, laboratory services, student and patient education programs, and finance. In the wake of the Patient Protection and Affordable Care Act of 2010, CCC is an example of how students can aid the transition to universal health care in the United States and how medical schools can expose students early in their training to primary care and clinic operations.

Optimizing clinical operations as part of a global emergency medicine initiative in Kumasi, Ghana: application of Lean manufacturing principals to low-resource health systems.

Although many global health programs focus on providing clinical care or medical education, improving clinical operations can have a significant effect on patient care delivery, especially in developing health systems without high-level operations management. Lean manufacturing techniques have been effective in decreasing emergency department (ED) length of stay, patient waiting times, numbers of patients leaving without being seen, and door-to-balloon times for ST-elevation myocardial infarction in developed health systems, but use of Lean in low to middle income countries with developing emergency medicine (EM) systems has not been well characterized. To describe the application of Lean manufacturing techniques to improve clinical operations at Komfo Anokye Teaching Hospital (KATH) in Ghana and to identify key lessons learned to aid future global EM initiatives. A 3-week Lean improvement program focused on the hospital admissions process at KATH was completed by a 14-person team in six stages: problem definition, scope of project planning, value stream mapping, root cause analysis, future state planning, and implementation planning. The authors identified eight lessons learned during our use of Lean to optimize the operations of an ED in a global health setting: 1) the Lean process aided in building a partnership with Ghanaian colleagues; 2) obtaining and maintaining senior institutional support is necessary and challenging; 3) addressing power differences among the team to obtain feedback from all team members is critical to successful Lean analysis; 4) choosing a manageable initial project is critical to influence long-term Lean use in a new environment; 5) data intensive Lean tools can be adapted and are effective in a less resourced health system; 6) several Lean tools focused on team problem-solving techniques worked well in a low-resource system without modification; 7) using Lean highlighted that important changes do not require an influx of resources; and 8) despite different levels of resources, root causes of system inefficiencies are often similar across health care systems, but require unique solutions appropriate to the clinical setting. Lean manufacturing techniques can be successfully adapted for use in developing health systems. Lessons learned from this Lean project will aid future introduction of advanced operations management techniques in low- to middle-income countries.

The future of community-centred health services in Australia - an alternative view

Community-centred healthcare works in conjunction with hospital-centred healthcare. Both have strengths and limitations. Community-centred healthcare has been demonstrated to be a more cost-efficient and cost-effective alternative to hospital-centred care at best in a limited fashion. If hospital-centred services dominate healthcare services in Australia, as argued previously in this journal, then this has not extended to maintenance of inpatient bed provision. The author, as a hospital-based emergency specialist, has observed case load and models of care in hospitals and emergency departments for 30 years and is sceptical of promises to substantially further decrease emergency department demand and acute bed requirements. The real benefits of community, primary and preventive care should not be over sold.

The Value of the Medical Home for Children Without Special Health Care Needs

Although the medical home is promoted by the American Academy of Pediatrics and the Affordable Care Act, its impact on children without special health care needs is unknown. We examined whether the medical home is associated with beneficial health care utilization and health-promoting behaviors in this population. This study was a secondary data analysis of the 2003 National Survey of Children's Health. Data were available for 70 007 children without special health care needs. We operationalized the medical home according to the National Survey of Children's Health design. Logistic regression for complex sample surveys was used to model each outcome with the medical home, controlling for sociodemographic characteristics. Overall, 58.1% of children without special health care needs had a medical home. The medical home was significantly associated with increased preventive care visits (adjusted odds ratio [aOR]: 1.32 [95% confidence interval (CI): 1.22-1.43]), decreased outpatient sick visits (aOR: 0.71 [95% CI: 0.66-0.76), and decreased emergency department sick visits (aOR: 0.70 [95% CI: 0.65-0.76]). It was associated with increased odds of "excellent/very good" child health according to parental assessment (aOR: 1.29 [95% CI: 1.15-1.45) and health-promoting behaviors such as being read to daily (aOR: 1.46 [95% CI: 1.13-1.89]), reported helmet use (aOR: 1.18 [95% CI: 1.03-1.34]), and decreased screen time (aOR: 1.12 [95% CI: 1.02-1.22]). For children without special health care needs, the medical home is associated with improved health care utilization patterns, better parental assessment of child health, and increased adherence with health-promoting behaviors. These findings support the recommendations of the American Academy of Pediatrics and the Affordable Care Act to extend the medical home to all children.