Emergency Department Attendances Research Articles

Impact of frailty in older people on health care demand: simulation modelling of population dynamics to inform service planning.

As populations age, frailty and the associated demand for health care increase. Evidence needed to inform planning and commissioning of services for older people living with frailty is scarce. Accurate information on incidence and prevalence of different levels of frailty and the consequences for health outcomes, service use and costs at population level is needed. To explore the incidence, prevalence, progression and impact of frailty within an ageing general practice population and model the dynamics of frailty-related healthcare demand, outcomes and costs, to inform the development of guidelines and tools to facilitate commissioning and service development. A retrospective observational study with statistical modelling to inform simulation (system dynamics) modelling using routine data from primary and secondary health care in England and Wales. Modelling was informed by stakeholder engagement events conducted in Hampshire, England. Data sources included the Royal College of General Practitioners Research and Surveillance Centre databank, and the Secure Anonymised Information Linkage Databank. Population prevalence, incidence and progression of frailty within an ageing cohort were estimated using the electronic Frailty Index tool, and associated service use and costs were calculated. Association of frailty with outcomes, service use and costs was explored with multistate and generalised linear models. Results informed development of a prototype system dynamics simulation model, exploring population impact of frailty and future scenarios over a 10-year time frame. Simulation model population projections were externally validated against retrospective data from Secure Anonymised Information Linkage. The Royal College of General Practitioners Research and Surveillance Centre sample comprised an open cohort of the primary care population aged 50 + between 2006 and 2017 (approx. 2.1 million people). Data were linked to Hospital Episode Statistics data and Office for National Statistics death data. A comparable validation data set from Secure Anonymised Information Linkage was generated. Electronic Frailty Index score calculated annually and stratified into Fit, Mild, Moderate and Severe frailty categories. Other variables included age, sex, Index of Multiple Deprivation score, ethnicity and Urban/rural. Frailty transitions, mortality, hospitalisations, emergency department attendances, general practitioner visits and costs. Frailty is already present in people aged 50-64. Frailty incidence was 47 cases per 1000 person-years. Frailty prevalence increased from 26.5% (2006) to 38.9% (2017). Older age, higher deprivation, female sex, Asian ethnicity and urban location independently predict frailty onset and progression; 4.8% of 'fit' people aged 50-64 years experienced a transition to a higher frailty state in a year, compared to 21.4% aged 75-84. Individual healthcare use rises with frailty severity, but Mild and Moderate frailty groups have higher overall costs due to larger population numbers. Simulation projections indicate frailty will increase by 7.1%, from 41.5% to 48.7% between 2017 and 2027, and associated costs will rise by £5.8 billion (in England) over an 11-year period. Simulation modelling indicates that frailty prevalence and associated service use and costs will continue to rise in the future. Scenario analysis indicates reduction of incidence and slowing of progression, particularly before the age of 65, has potential to substantially reduce future service use and costs, but reducing unplanned admissions in frail older people has a more modest impact. Study outputs will be collated into a commissioning toolkit, comprising guidance on drivers of frailty-related demand and simulation model outputs. This study is registered as NCT04139278 www.clinicaltrials.gov. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/116/43) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 44. See the NIHR Funding and Awards website for further award information.

Impact of community-based multidomain preventive health program on healthcare utilisation among elderly persons in Singapore: a propensity score matched and difference-in-differences study

ObjectivesAgeing populations present substantial challenges for healthcare systems. Community-based health worker (CHW) interventions for promoting healthy ageing and preventing/managing non-communicable diseases have gained considerable attention in recent years. This study...

414 Comparison of Emergency Department Management and Disposition Among Adolescents and Young Adults 12-25 Seen for Mental Health Presentations

414 Comparison of Emergency Department Management and Disposition Among Adolescents and Young Adults 12-25 Seen for Mental Health Presentations

122 Implicit Bias in the Patient Descriptor “Homeless,” and Its Association With Emergency Department Opioid Administration and Disposition

122 Implicit Bias in the Patient Descriptor “Homeless,” and Its Association With Emergency Department Opioid Administration and Disposition

448EMF Characterizing Emergency Department Disposition Conversations for Veterans With Dementia Using Direct Observations

448EMF Characterizing Emergency Department Disposition Conversations for Veterans With Dementia Using Direct Observations

Orthopaedic patients' emergency department attendance behavior in relation to weather conditions: temperature, rain, day and time, and regional thursday effect.

Great variation was noticed in emergency department (ED) afflux in relation to daily weather conditions, including difficulties in arranging the correct number of orthopaedic on-calls on the floor. This study aimed to quantify the association between the number of patients referred to the orthopaedic team from the ED and weather conditions, particularly daily temperature and rain. Data were obtained from a large state research hospital's ED attendance. Weather information for the local area for the year was obtained from the regional meteorological office. Data were evaluated using descriptive statistics, with one-way analysis of variance for the relationship between the day of the week and patient numbers, the Pearson test for correlations between daily ED patient flow and daily temperature and the Spearman correlation test for correlations between daily patient flow and daily rain status. A positive and meaningful correlation existed between daily patient influx and daily temperature, along with a negative correlation between daily patient flow and daily rain. Throughout the year, significantly more patients were referred to the orthopaedic team on Thursdays than on any other day of the week. Patients tended to visit the ED more on warm days and days without rain. These results may help in organising daily, monthly or seasonal on-call orthopaedic team requirements despite the challenges. Incorporating climate forecasts into planning the on-call service might help alleviate the stress on the team.

The long-run effect of COVID-19 on hospital emergency department attendances:evidence from statistical analysis of hospital data from England

During the COVID-19 pandemic, hospital emergency departments worldwide experienced a pronounced fall in utilisation of emergency care, with a decrease of up to 40% in many countries. Evidence suggests the cause of these changes include both population fear of COVID-19 and the effects of lockdowns and the interaction of these two effects. We analyse a sub-sample of national data on Accident and Emergency (A&E) attendances in England over an extended period from April 2019 to March 2022 for different patient groups, including by age, mental/physical health status, acuity, and common clinical groupings. Our results showed that all patient groups experienced substantial declines in attendances during the first two waves of the pandemic, including high acuity and cardiovascular patients. Mental health patients were the only exception, with a smaller decline in attendances. Our findings suggest that policymakers should recognise the potential harmful effects of lockdowns, public messaging, and changes in health care provision on all patients during health emergencies.

Preventing Emergency Department Visits: Success Of A Community Dementia Care Model

Abstract Background Advanced dementia care in the community is an extremely complex task. NICE guidelines 2021 suggested that a gap in care was evident bridging between clinic attendance and end of life care. Secondary to a required need- a new advanced dementia care model was created in 2021.This was co-developed by an ANP with a specialist interest in gerontology, an integrated care team for older persons (ICPOP) consultant and palliative care in the community. Joint governance remains to this day. My aim is to review unexpected emergency department (ED) attendances of patients accepted to this pathway. Methods Patient records were reviewed of all cases accepted for review and managed under this model of care, time frame Jan 2023- May-2024. All patients > 65. Outcomes of management interventions were assessed. Those found to have an ED attendance during their time engaging with this model of care had closer review of their notes to assess reason why. Results 81 patients. Of which 75% were female. Average age – 89. Of these 48% died at home and are 37% still alive. Of the 81 patients only 5 (6%) had ED attendances. Of these 5 patients - 3 had unexpected traumatic falls- 2 resulting in hip fracture and 1 in humeral fracture. 2 were admitted with worsening delirium. Conclusion The advanced dementia care model has proved very successful in preventing ED attendances prior to direct end of life care engagement. Of those who were admitted – fractures appropriately warrant admission and the remaining 2 cases, had families who were resistant to accepting overall aims of treatment. This interdisciplinary model of care saves bed days. Expanding this care model further to ensure appropriate management of complex dementia cases is maintained in the community would further reduce hospital overcrowding and grant many patient and family wishes.

Establishment of Registered Advanced Nurse Practitioners (RANP) Gerontology Clinics in Two Ambulatory Day Units

Abstract Background Ireland is experiencing substantial growth in the older population. Data from The Irish Longitudinal Study on Ageing (TILDA) suggests that up to 25% of older people in Ireland are living with frailty while a further 45% are at risk of being pre-frail (Roe L et al, 2017). Frailty in older adults can be a predictor to adverse health outcomes including hospitalization, falls, and increased mortality risk. Ambulatory day units proactively identify older adults at risk of frailty living in the community using a comprehensive geriatric assessment (CGA), potentially reducing adverse outcomes. Methods Plan-Do- Study-Act (PDSA) cycle was used. Waiting lists were reviewed with Consultant Geriatricians for the ambulatory units. Referral pathways for RANP Gerontology Clinics with inclusion and exclusion criteria were developed. RANP clinics were established in 2023 in the ambulatory day units utilising Slaíntecare’s strategy. Referrals were triaged by Consultants Geriatricians resulting in the RANP clinic caseload. Results During 2023, 844 older adults were reviewed in the RANP clinics. This contributed to a reduction in Consultant Geriatricians’ waiting lists and allowed reduced wait times for new Consultant Geriatricians’ referrals. This service also enhanced communication pathways between primary and secondary care settings and became a point of contact for families in crisis, with rapid access review and care planning to avoid unnecessary Emergency Department attendances. Patients attending the RANP clinics, if admitted to hospital, were seen by the RANP during their admission, ensuring continuity of care. Conclusion Overall, establishment of RANP Gerontology clinics resulted in a better streamlined service for the older adult. This service ensures continuity of patient care through a working knowledge of patient cohort and rapid access for those known to the service, potentially avoiding an Emergency Department attendance.

Community Flexible Endoscopic Evaluation Of Swallowing (FEES): A Prospective Cohort Study Of Clinical, Process And Patient-Reported Outcomes

Abstract Background Dysphagia prevalence increases with age, impacts on quality of life and increases healthcare utilisation and cost (Atrill 2018). Instrumental swallowing assessment is essential for accurate diagnosis and treatment of dysphagia but can be difficult to access in the community. FEES is a gold-standard instrumental assessment delivered by speech and language therapists (SLTs). The aim of this abstract is to report clinical, process and patient-reported outcomes of participants who had a community FEES over a 6-month period. Methods A prospective cohort study recruiting adults who accessed community FEES in Ireland's Mid-West. Baseline assessment data (demographics, a range of validated tools and process data) were recorded at index visit. A structured phone interview was completed at six months. The primary outcome was the rate of medical complications potentially caused by dysphagia at follow-up. Secondary outcomes included healthcare utilisation, dysphagia severity, functional status and quality of life. Results 62 participants were recruited: mean age: 70.98 (SD=15.01), 55.4% were female. At follow-up, 27.42% reported medical complications potentially attributable to dysphagia, 27.4% had attended general practice, 3.23% attended medical assessment units, 6.45% attended emergency departments. 82.26% were diagnosed with dysphagia or modified independence: Dysphagia Outcome Severity Scale (DOSS) ≤6, (M=5.2, SD=1.53). Changes to dysphagia care plans were recommended in 60.94% of cases. There was significant difference in Functional Oral Index Scale (FOIS) scores across time, F (1.75, 106.78) = 5.38, p = 0.008. FOIS scores at 6 months (M=5.92, SD=1.50) were significantly higher than pre-FEES (M=6.42, SD=1.37). Significant differences in quality of life (EQ5D5L-VAS) scores p<0.001 were detected: higher scores at 6-months (M=69.35; SD=20.42) compared to index visit (M=64.52; SD=19.44). Conclusion Access to community FEES for older persons may improve outcomes by reducing the frequency of dysphagia-related complications and healthcare utilisation, improving functional swallowing status, enhancing quality of life and contribute to evidence-based dysphagia diagnosis and care planning.

Preventing Hospitalisation- Providing Specialist Geriatric Services To Nursing Home Patients

Abstract Background Nursing home (NH) residents often require acute hospital care in unexpected deterioration and may have repeated Emergency Department (ED) attendances. Grunier et al (2018) reported 48% of NH residents reattend ED within 1 year. Our aim is to determine if those who require acute hospital admission are more likely to reattend ED or require NH outreach services. Methods Nursing home residents who attended Mater ED in March 2023 were identified through Electronic Patient Record. Their age, gender, reattendance of ED within 28 days and 6 months, visit by NH outreach team within 28 days then 6 months and 6-month mortality were recorded. The residents were categorised as admitted or discharged from their sentinel visit in March 2023. Chi-square test was used, and statistical significance was set at p<0.05. Results Sixty-three nursing home residents attended within 1-month, median age 85 years (range 67-95), 43 were women. Forty-five (71%) required admission, 6 (9.5%) and 24 (38.1%) reattended ED within 28 days and 6 months respectively. There was no difference in 28-day or 6-month ED reattendance between those who were admitted or discharged in the sentinel visit to ED. Those discharged from ED were more likely to receive NH outreach visit within 28 days (84% vs 6.8%) and 6 months (84% vs 11%) than those who were admitted, p<0.0001. There was no difference in 6 months mortality between the groups. Conclusion Our study found that 71% of NH residents who attend ED require admissions showing that the transfer was warranted. More than one-third of NH residents reattend ED within 6 months. Those discharged from ED were more likely to be reviewed by NH outreach team as per service delivery. Working closely with the resident’s General Practitioner, NH and ED staff may help to manage these complex patients to coordinate their treatment and prevent ED reattendance.

Answering an “SOS”: A 12-Month Review of An Urban Pathfinder Service

Abstract Background The Pathfinder service is a collaboration between the National Ambulance Service (NAS) and acute hospital Physiotherapists (PT) and Occupational Therapists (OT). The service aims to safely treat over-65s who have called 999 with low-acuity problems at home. It offers safe alternative care pathways to traditional Emergency Department (ED) attendance to older adults within our hospital catchment area (Bernard et al. 2021). Methods A retrospective review of the service database for 2023 was completed. A patient experience survey was conducted over a 4-week period in Quarter 4 of 2023. The survey consisted of both Likert scale and open-ended questions. Service statistics and Likert data were analysed in Microsoft Excel, while open-ended responses were analysed thematically. Results A total of 598 calls were received by our Pathfinder service in 2023: live 999 calls (n=407), and “Special Services” (SS) calls from Dublin Fire Brigade (n=191). 55% of live 999 call referrals attended by Pathfinder were safely kept at home. Of 191 SS referrals, 35% (n=66) had a review by the Pathfinder team. Of the 66 assessed, 94% (n=62) were safely kept at home. A total of 1,392 follow-up interventions (home visits, phone calls, onward referrals) were completed by PT and OT. Service user feedback was overwhelmingly positive, with 100% (n=20) of respondents stating they would be happy to see the Pathfinder team again if calling 999. General feedback highlighted the responsiveness, thorough assessment, and friendliness and professionalism of the team. Areas for development included increasing staffing and increasing to a 7-day service. Conclusion The Pathfinder service is effective in an urban setting. Over a 12-month period, 55% of patients assessed by Pathfinder were safely treated at home, with follow-up support from Pathfinder PT and OT. Service users report positive experiences and would be happy to see the team in the future when calling 999.

The Effectiveness of a Community Specialist Team for Older Persons in Preventing Emergency Department Attendances 30 and 90 Days Post-Intervention

Abstract Background Population ageing is prevalent throughout Ireland and its impact is evident particularly in acute hospitals with long Patient Experience Times (PETs) in the emergency department. A Community Specialist Team for Older Persons (CSTOP) was established in our area in 2018 with expansion under Sláintecare in 2022. The main goal is to improve access in the community to age attuned services, and thus prevent Emergency Department (ED) presentations and admissions and improving health outcomes for older people. The team provides a comprehensive geriatric assessment and resultant interventions required for each patient. The cohort of patients includes (Frail Intervention Team) FIT referrals from the ED, Geriatrician referrals from Outpatient clinics and GP referrals. Many of these patients have either presented to the Emergency Department or are at risk of same. Methods Data for all CSTOP patients is recorded including medical record numbers. All medical records for patient admitted in 2023 were analysed using the integrated patient management system (IPIMS) in our local hospital. ED presentations and admissions were reviewed at 30 and 90 days post intervention. Results 232 referrals were received in 2023. 42 (18%) had an ED presentation 30 days post discharge and 48 (21%) had a presentation 90 days post discharge. 11 RIPs. Conclusion This study shows the effectiveness of the CSTOP team at preventing ED presentations and resultant admissions. The number of bed days is estimated at 2000. One limitation to our study is data could only be analysed from our hospital system, patients could attend other public or private hospitals during the follow up period. Our results are found to be in keeping with reviews by similar services. Our team provide a rapid access interdisciplinary assessment and intervention to people who may otherwise experience fragmented care within primary care services.

Cultivating A Culture Of Continuous Improvement And Teamwork In An ICPOP Hub

Abstract Background The Integrated Care for Older Person’s (ICPOP) Hub is one 3 Hubs in the healthcare region. The success of the ICPOP Hub has been the adaptability, motivation, dedication of the multi-disciplinary team (MDT) using inter-disciplinary methods to achieve best outcomes for people with frailty and complex multi-morbidity in the Community. Referrals have increased - 406 in 2023. There were 2,754 direct patient MDT contacts in 2023. Medical capacity for new patients is limited. Alternative ways of working were needed to meet increasing demand. Methods Quality improvement methodologies were employed to enhance efficiency. Existing practices were mapped, deficits highlighted. New practices were trialled in plan-do-study-act format. Results The MDT collaborated to develop structured pathways for Falls and Memory. Criteria were established for triaging referrals, assessment standards, management, post diagnostic support using national/international guidelines (Model of Care for Dementia in Ireland, World Falls Guidelines). More patients were seen via direct-to-MDT pathways and discussed at bi-weekly meetings. Direct referral pathway was instituted from the acute hospital Emergency Department (ED) Frailty Front Door Team to the Hub MDT. ‘One-stop-shop’, multiple, consecutive assessments, while comprehensive, resulted in significant patient fatigue. Moving to parallel assessment reduced appointment frequency and time in the Hub. Staff learned from other disciplines and translated knowledge/skills to tailored patient plans. Case management has prevented ED attendance, particularly for patients with delirium and/or dementia with non-cognitive symptoms. Early integration with Community/Voluntary groups was crucial. Visits from these groups promoted education and relationship building. The Community Connector role has been instrumental in linking people with wellbeing activities in their community. Challenges: Blurring boundaries between roles. Insufficient medical cover represents a barrier to timely patient assessment/management, obstacle to early hospital discharge. Demands on MDT intensify daily. Conclusion Enthusiasm, flexibility, ownership, teamwork, distributed leadership were essential in developing pathways and overcoming difficulties.

Predictors of nursing home conveyances to emergency department

BackgroundWith increasing rates of patient conveyances from nursing homes to emergency departments worldwide, we aim to examine factors causing high rates of conveyances from nursing homes to the emergency department (ED) of an acute tertiary hospital.MethodsThis was a prospective study involving presentation of ED attendances from nursing home residents during out-of-hours over a 23-month period from April 2020 to February 2022. Data was collected from a standardized manual form used by the Emergency Department to document nursing home conveyances.ResultsA total of 338 pre-conveyance forms were reviewed. The most common reasons for conveyances to ED were neurological symptoms (16%), unstable hemodynamics (12%), fever (11%) and falls (10%). The peak conveyances occurred between 1600 and 1900 h on weekends. Respiratory rate, oxygenation requirements and high National Early Warning Score (NEWS) were significantly associated with increased conveyances to the emergency department. When the components of NEWS were analyzed individually, decision for ambulance conveyance to emergency department was significantly associated with respiratory rate (p < .001), oxygen saturation (p < .001), and the use of oxygen supplementation (p < .005).ConclusionsUnstable hemodynamics and falls were among the leading factors for nursing home conveyances to the emergency department, which highlights the need to implement better fall prevention strategies and standardized parameters monitoring in nursing homes. Future research should focus on outcomes of conveyances and the characteristics of nursing home with higher conveyance rates. This would aid to assess the appropriateness of conveyances and to identify strategies to decrease preventable conveyances.

Lean-Based Approach to Improve Emergency Department Throughput.

Objective:Lean methodology can be utilized to increase throughput in a fast-track care area without changing staffing in a busy, urban emergency department (ED). Methods: A retrospective before-and-after analysis was performed to an improvement process in a fast-track care area within an ED with a census of 100,000 patients. The intervention utilized Lean methodologies to identify inefficiencies in the throughput model set for patients triaged to fast-track. Multiple ED stakeholders were involved in formulating a more efficient framework for how patients would receive care when triaged to fast-track. Results: There was a decline in the patient's overall length of stay (-9%, p=0.08), arrival to the room (-10%, p=0.4418), and ED attending to disposition (-9%, p=0.003). Additionally, all aspects of patients leaving prior to treatment completion (against medical advice (-29.4%, p=0.006), elopement (-20.4%, p=0.049), and left without being seen (-5.3%, p=0.11)) declined. Discussion:Identifying wasted time and resources in a patient's stay in the ED allowed for a more efficient throughput model to be developed. This resulted in patients being able to be seen in a more methodical manner leading to decreased wait times and lower left without being seen rates. Conclusion: A Lean-based throughput model was implemented to improve efficiency, reducing the length of stay and increasing the volume of patients evaluated per shift without additional costs. This improvement led to fewer patients leaving before treatment and demonstrated the value of process improvement in healthcare.

Redirection of low-acuity emergency department patients to nearby medical clinics using an electronic medical support system: effects on emergency department performance indicators

BackgroundOvercrowded emergency departments (EDs) are associated with higher morbidity and mortality and suboptimal quality-of-care. Most ED flow management strategies focus on early identification and redirection of low-acuity patients to primary care settings. To assess the impact of redirecting low-acuity ED patients to medical clinics using an electronic clinical decision support system on four ED performance indicators.MethodsWe performed a retrospective observational study in the ED of a Canadian tertiary trauma center where a redirection process for low-acuity patients was implemented. The process was based on a clinical decision support system relying on an algorithm based on chief complaint, performed by nurses at triage and not involving physician assessment. All patients visiting the ED from 2013 to 2017 were included. We compared ED performance indicators before and after implementation of the redirection process (June 2015): length-of-triage, time-to-initial-physician-assessment, length-of-stay and rate of patients leaving without being seen. We performed an interrupted time series analysis adjusted for age, gender, time of visit, triage category and overcrowding.ResultsOf 242,972 ED attendees over the study period, 9546 (8% of 121,116 post-intervention patients) were redirected to a nearby primary medical clinic. After the redirection process was implemented, length-of-triage increased by 1 min [1;2], time-to-initial assessment decreased by 13 min [-16;-11], length-of-stay for non-redirected patients increased by 29 min [13;44] (p < 0.001), minus 20 min [-42;1] (p = 0.066) for patients assigned to triage 5 category. The rate of patients leaving without being seen decreased by 2% [-3;-2] (p < 0.001).ConclusionImplementing a redirection process for low-acuity ED patients based on a clinical support system was associated with improvements in two of four ED performance indicators.

Surveillance of violence through health service interactions in Wales: A longitudinal national data linkage study.

Objective and ApproachThe study aimed to utilise multiple population-wide linked administrative, health, and survey data sources to identify victims from violence across various sociodemographic groups using healthcare service interactions. We calculated violence rates for the population of Wales to identify groups of people that experience higher rates of violence compared to the general population. Our approach involved creating an observational population-wide e-cohort utilising data held in the Secure Anonymised Information Linkage (SAIL) Databank. General practice records, emergency department attendances, hospital admissions, and the Office of National Statistics (ONS) deaths register were linked to the Welsh Demographic Service dataset to include individuals living in Wales, UK between 2013-2022, allowing for a 10-year analysis. ResultsIn total, 3.3 million individuals were included in the study, with 80,079 individuals having interacted with health services or died due to violence over the 10-year period. On average, every 4 per 1000 of the study population had experienced violence (2013-2022) with the majority of these being captured through emergency department attendances. 55% were male, of which 71% were aged under 35. The majority of individuals lived in the more deprived areas of Wales (61%). Conclusions and ImplicationsIt is important to understand and quantify violence over time to produce insight into which sociodemographic groups of individuals are being disproportionately impacted by violence for designing disparity-reducing policy interventions. ONS Census 2021 data will be used to examine the impact of violence by protected characteristics (e.g. disability, race, sexual orientation) under the UK Equality Act 2010.

Transitions Between Home and Unscheduled Care in the Last Year of Life

Almost half of Scottish people who die currently die in hospital, which may represent a complex need or lack of alternative options. Nearly 95% of people use unscheduled care in their last year of life, which includes the Emergency Department (ED) – the outcome of ED attendance is often hospital admission. This increased use of unscheduled care services is associated with high costs and poor patient outcomes. This study analyses sequences of patient visits and describes patterns of ED attendance and inpatient admissions in the patients' final year of life to help understand their healthcare journeys. This work examines the use of ED attendance and hospital admissions in NHS Tayside and NHS Fife between 2000 and 2021 for people in the last year of life. The retrospective cohort consists of all patients 18+ who died and visited the ED or were admitted to the hospital at least once. From a study population of 981,879, 164,506 (17%) people died, with 148,734 (90%) people having an ED visit or hospital admission. Data was divided for the 52 weeks before death, with three possible states for each week: home, ED visit, and admission. A preliminary analysis shows high and significant variability in ED attendance and hospital admissions with distinct usage patterns. A better understanding of the patients' characteristics within each pattern may allow for potential interventions that improve patient care by reducing avoidable ED attendances or hospital admissions in the last year of life.

Measuring Overcrowding in a Large Academic Tertiary Care Pediatric Emergency Department.

Overcrowding scores have been studied extensively in adult emergency departments (EDs), but few studies have determined utility in the pediatric setting. The objective of this study was to determine the association between a modified National Emergency Department Overcrowding Score (mNEDOCS) and established ED metrics in a large academic tertiary care pediatric ED. NEDOCS was modified to increase applicability in the pediatric setting by including the number of patients in resuscitation rooms instead of a number of patients on ventilators. Patient characteristics, ED disposition, ED length of stay (LOS), rate of left without being seen (LWBS), hospital LOS (HLOS), ED returns within 72 hours, and mNEDOCS were acquired retrospectively for every ED encounter in 2016-2019 using the electronic health record. Descriptive statistics, Spearman correlation, and multivariate analyses were calculated to evaluate the association between specific ED metrics and mNEDOCS. Modified NEDOCS positively correlated with ED LOS, LWBS, and rate of 72-hour return visits. A negative correlation was found between mNEDOCS and HLOS. When controlling for select covariates, the odds of LWBS doubled with each increase in mNEDOCS category (odds ratio, 2.03; 95% confidence interval [CI], 2.00-2.06), ED LOS was associated with an increase of 27 minutes as mNEDOCS category increased (β = 26.80; 95% CI, 26.44-27.16), and the odds of 72-hour return visits increased by 6% when mNEDOCS increased by one category (odds ratio, 1.06; 95% CI, 1.05-1.07). Hospital LOS was associated with a 100-minute decrease per increase in mNEDOCS category (β = -99.85; 95% CI, -180.68 to -18.48) when controlling for covariates. Modified NEDOCS is positively associated with ED LOS, LWBS, and 72-hour return visits, consistent with adult data. Further investigation is needed to elucidate the association between mNEDOCS and HLOS. This study illustrates the utility of mNEDOCS as a measure of overcrowding in a pediatric ED.