Emergency Departments In England Research Articles

Psychometric validation of a patient-reported experience measure for older adults attending the emergency department: the PREM-ED 65 study

IntroductionOptimising emergency department (ED) patient experience is vital to ensure care quality. However, there are few validated instruments to measure the experiences of specific patient groups, including older adults. We...

Free-for-all: Does crowding impact outcomes because hospital emergency departments do not prioritise effectively?

Unexpected peaks in volumes of attendances at hospital emergency departments (EDs) have been found to affect waiting times, intensity of care and outcomes. We ask whether these effects of ED crowding on patients are caused by poor clinical prioritisation or a quality-quantity trade-off generated by a binding capacity constraint. We study the effects of crowding created by lower-severity patients on the outcomes of approximately 13 million higher-severity patients attending the 140 public EDs in England between April 2016 and March 2017. Our identification approach relies on high-dimensional fixed effects to account for planned capacity. Unexpected demand from low-severity patients has very limited effects on the care provided to higher-severity patients throughout their entire pathway in ED. Detrimental effects of crowding caused by low-severity patients materialise only at very high levels of unexpected demand, suggesting that binding resource constraints impact patient care only when demand greatly exceeds the ED's expectations. These effects are smaller than those caused by crowding induced by higher-severity patients, suggesting an efficient prioritisation of incoming patients in EDs.

Outcomes for university students following emergency care presentation for deliberate self-harm: a retrospective observational study of emergency departments in England for 2017/2018

ObjectivesIdentify university-aged students and contrast their healthcare provision and outcomes with other patients in the same age group attending emergency departments for deliberate self-harm.DesignRetrospective cross-sectional observational study.SettingPatients visiting 129 public...

Comparing physician associates and foundation year 1 doctors-in-training undertaking emergency medicine consultations in England: a quantitative study of outcomes

ObjectivesTo compare the contribution of physician associates (PAs) to the outcomes of emergency medicine consultations with that of foundation year 1 doctors-in-training (FY1s).DesignA quantitative study using retrospective chart review of...

Emergency Department Buprenorphine Quality Improvement and Emergency Physician Knowledge, Attitudes, and Self-Efficacy.

Buprenorphine is an evidence-based treatment for opioid use disorder that is underused in the emergency department (ED). In this study we evaluated changes in emergency physician knowledge, confidence, and self-efficacy regarding buprenorphine prescribing and working with patients who use drugs after implementation of an ED buprenorphine quality improvement (QI) initiative. An anonymous, online survey was administered to emergency physicians staffing four EDs in New England in 2019 and 2020 before and after an ED QI initiative. Survey questions included novel and previously validated questions to assess confidence, knowledge, self-efficacy, and attitudes about buprenorphine and working with patients who use drugs. Confidence, self-efficacy, and attitude responses were assessed on a Likert scale. Participants received a gift card for survey completion. We analyzed pre- and post- survey responses descriptively and compared them using t-tests. Using logistic regression we evaluated the factors associated with buprenorphine prescribing. Of 95 emergency physicians, 56 (58.9% response rate) completed the pre-intervention survey and 60 (63.2%) completed the post-survey. There was an increase in the number of X-waivered adult emergency physicians and ED buprenorphine prescribing after program implementation. Physician confidence increased from a mean of 3.4 (SD 0.8) to 3.9 (SD 0.7; scale 1-5, p < 0.01). Knowledge about buprenorphine increased from a mean score of 1.4 (SD 0.7) to 1.7 (SD 0.5, p < 0.01). Physician attitudes and self-efficacy did not change. Post-initiative, increased confidence was associated with higher odds of buprenorphine prescribing (odds ratio 4.4; 95% confidence interval 1.07-18.4). After an ED QI initiative, buprenorphine prescribing in the ED increased, as did both physician confidence in working with patients who use drugs and their knowledge of buprenorphine. Increased confidence was associated with higher odds of buprenorphine prescribing and should be a focus of future, buprenorphine implementation strategies in the ED.

Hospital-Level Implementation Barriers, Facilitators, and Willingness to Use a New Regional Disaster Teleconsultation System: Cross-Sectional Survey Study.

The Region 1 Disaster Health Response System project is developing new telehealth capabilities to provide rapid, temporary access to clinical experts across US jurisdictions to support regional disaster health response. To guide future implementation, we identified hospital-level barriers, facilitators, and willingness to use a novel regional peer-to-peer disaster teleconsultation system for disaster health response. We used the National Emergency Department Inventory-USA database to identify all 189 hospital-based and freestanding emergency departments (EDs) in New England states. We digitally or telephonically surveyed emergency managers regarding notification systems used for large-scale no-notice emergency events, access to consultants in 6 disaster-relevant specialties, disaster credentialing requirements before system use, reliability and redundancy of internet or cellular service, and willingness to use a disaster teleconsultation system. We examined state-wise hospital and ED disaster response capability. Overall, 164 (87%) hospitals and EDs responded-126 (77%) completed telephone surveys. Most (n=148, 90%) receive emergency notifications from state-based systems. Forty (24%) hospitals and EDs lacked access to burn specialists; toxicologists, 30 (18%); radiation specialists, 25 (15%); and trauma specialists, 20 (12%). Among critical access hospitals (CAHs) or EDs with <10,000 annual visits (n=36), 92% received routine nondisaster telehealth services but lacked toxicologist (25%), burn (22%), and radiation (17%) specialist access. Most hospitals and EDs (n=115, 70%) require disaster credentialing of teleconsultants before system use. Among 113 hospitals and EDs with written disaster credentialing procedures, 28% expected completing disaster credentialing within 24 hours, and 55% within 25-72 hours, which varied by state. Most (n=154, 94%) reported adequate internet or cellular service for video-streaming; 81% maintained cellular service despite internet disruption. Fewer rural hospitals and EDs reported reliable internet or cellular service (19/22, 86% vs 135/142, 95%) and ability to maintain cellular service with internet disruption (11/19, 58% vs 113/135, 84%) than urban hospitals and EDs. Overall, 133 (81%) were somewhat or very likely to use a regional disaster teleconsultation system. Large-volume EDs (annual visits ≥40,000) were less likely to use the service than smaller ones; all CAHs and nearly all rural hospitals or freestanding EDs were likely to use disaster consultation services. Among hospitals and EDs somewhat or very unlikely to use the system (n=26), sufficient consultant access (69%) and reluctance to use new technology or systems (27%) were common barriers. Potential delays (19%), liability (19%), privacy (15%), and hospital information system security restrictions (15%) were infrequent concerns. Most New England hospitals and EDs have access to state emergency notification systems, telecommunication infrastructure, and willingness to use a new regional disaster teleconsultation system. System developers should focus on ways to improve telecommunication redundancy in rural areas and use low-bandwidth technology to maintain service availability to CAHs and rural hospitals and EDs. Policies and procedures to accelerate and standardize disaster credentialing are needed for implementation across jurisdictions.

Characteristics of acute sexual assault care in New England emergency departments.

Interventions such as written protocols and sexual assault nurse examiner programs improve outcomes for patients who have experienced acute sexual assault. How widely and in what ways such interventions have been implemented is largely unknown. We sought to characterize the current state of acute sexual assault care in New England. We conducted a cross-sectional survey of individuals acute with knowledge of emergency department (ED) operations in relation tosexual assault care at New England adult EDs. Our primary outcomesincluded the availability and coverage of dedicated and non-dedicated sexual assault forensic examiners in EDs. Secondary outcomes included frequency of and reasons for patient transfer; treatment before transfer; availability of written sexual assault protocols; characteristics and scope of practice of dedicated and non-dedicated sexual assault forensic examiners (SAFEs), provision of care in SAFEs' absence; availability, coverage, and characteristics of victim advocacy and follow-up resources; and barriers to and facilitators of care. We approached all 186 distinct adult EDs in New England to recruit participants; 92 (49.5%) individuals participated, most commonly physician medical directors (n=34, 44.1%). Two thirds of participants reported they at times have access to a dedicated (n=52, 65%, 95% confidence interval [CI], 54.5%-75.5%) or non-dedicated (n=50, 64.1%; 95% CI, 53.5%-74.7%) SAFE, but fewer reported always having this access (n=9, 17.3%; 95% CI, 7%-27.6%; n=13, 26%; 95% CI, 13.8%-38.2%). We describe in detail findings related to our secondary outcomes. Although SAFEs are recognized as a strategy to provide high-quality acute sexual assault care, their availability and coverage is limited.

Evaluating the impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in patients with COVID-19 assessed in emergency departments in England: a retrospective matched cohort study

BackgroundTo identify the impact of enrolment onto a national pulse oximetry remote monitoring programme for COVID-19 (COVID-19 Oximetry @home; CO@h) on health service use and mortality in patients attending Emergency...

Evaluating the provision of paediatric liaison psychiatry services in England.

Liaison psychiatry provision for children and young people in England is poorly evaluated. We sought to evaluate paediatric liaison psychiatry provision and develop recommendations to improve practice. The liaison psychiatry surveys of England (LPSE) cross-sectional surveys engage all liaison psychiatry services in England. Services are systematically identified by contacting all acute hospitals with emergency departments in England. Questions are developed in consultation with NHS England and the Royal College of Psychiatrists' Faculty of Liaison Psychiatry, and updated based on feedback. Responses are submitted by email, post or telephone. Questions on paediatric services were included from 2015 (LPSE-2), and we analysed data from this and the subsequent four surveys. The number of acute hospitals with access to paediatric liaison psychiatry services increased from 29 (15.9%) in 2015 to 46 (26.6%) in 2019, compared with 100% provision for adults. For LPSE-4, only one site met the Core-24 criteria of 11 full-time equivalent mental health practitioners and 1.5 full-time equivalent consultants, and for LPSE-5, just two sites exceeded them. Acute hospitals with access to 24/7 paediatric liaison psychiatry services increased from 12 to 19% between LPSE-4 and LPSE-5. The proportion of paediatric liaison psychiatry services based offsite decreased from 30 to 24%. There is an unacceptable under-provision of paediatric liaison psychiatry services compared with provision for adults. Number of services, staffing levels and hours of operation have increased, but continued improvement is required, as few services meet the Core-24 criteria.

Suicidal Crisis among Children and Young People: Associations with Adverse Childhood Experiences and Socio-Demographic Factors.

Suicide is a major public health issue and a leading cause of death among children and young people (CYP) worldwide. There is strong evidence linking adverse childhood experiences (ACEs) to an increased risk of suicidal behaviours in adults, but there is limited understanding regarding ACEs and suicidal crises in CYP. This study aims to examine the ACEs associated with CYP presenting at Emergency Departments for suicidal crises, and specifically the factors associated with repeat attendances. This is a case series study of CYP (aged 8-16) experiencing suicidal crisis who presented in a paediatric Emergency Department in England between March 2019 and March 2021 (n = 240). The dataset was subjected to conditional independence graphical analysis. Results revealed a significant association between suicidal crisis and several ACEs. Specifically, evidence of clusters of ACE variables suggests two distinct groups of CYP associated with experiencing a suicidal crisis: those experiencing "household risk" and those experiencing "parental risk". Female sex, history of self-harm, mental health difficulties, and previous input from mental health services were also associated with repeat hospital attendances. Findings have implications for early identification of and intervention with children who may be at a heightened risk for ACEs and associated suicidal crises.

Cessation of smoking trial in the emergency department (CoSTED): protocol for a multicentre randomised controlled trial

IntroductionAttendees of emergency departments (EDs) have a higher than expected prevalence of smoking. ED attendance may be a good opportunity to prompt positive behaviour change, even for smokers not currently...

General practitioners working in or alongside the emergency department: the GPED mixed-methods study

BackgroundEmergency care is facing a steadily rising demand. In response, hospitals have implemented new models of care that locate general practitioners in or alongside the emergency department.ObjectivesWe aimed to explore the effects of general practitioners working in or alongside the emergency department on patient care, the primary care and acute hospital team, and the wider system, as well as to determine the differential effects of different service models.DesignThis was a mixed-methods study in three work packages. Work package A classified current models of general practitioners working in or alongside the emergency department in England. We interviewed national and local leaders, staff and patients to identify the hypotheses underpinning these services. Work package B used a retrospective analysis of routinely available data. Outcome measures included waiting times, admission rates, reattendances, mortality and the number of patient attendances. We explored potential cost savings. Work package C was a detailed mixed-methods case study in 10 sites. We collected and synthesised qualitative and quantitative data from non-participant observations, interviews and a workforce survey. Patients and the public were involved throughout the development, delivery and dissemination of the study.ResultsHigh-level goals were shared between national policy-makers and local leads; however, there was disagreement about the anticipated effects. We identified eight domains of influence: performance against the 4-hour target, use of investigations, hospital admissions, patient outcome and experience, service access, workforce recruitment and retention, workforce behaviour and experience, and resource use. General practitioners working in or alongside the emergency department were associated with a very slight reduction in the rate of reattendance within 7 days; however, the clinical significance of this was judged to be negligible. For all other indicators, there was no effect on performance or outcomes. However, there was a substantial degree of heterogeneity in these findings. This is explained by the considerable variation observed in our case study sites, and the sensitivity of service implementation to local factors. The effects on the workforce were complex; they were often positive for emergency department doctors and general practitioners, but less so for nursing staff. The patient-streaming process generated stress and conflict for emergency department nurses and general practitioners. Patients and carers were understanding of general practitioners working in or alongside the emergency department. We found no evidence that staff concerns regarding the potential to create additional demand were justified. Any possible cost savings associated with reduced reattendances were heavily outweighed by the cost of the service.LimitationsThe reliability of our data sources varied and we were unable to complete our quantitative analysis entirely as planned. Participation in interviews and at case study sites was voluntary.ConclusionsService implementation was highly subject to local context and micro-level influences. Key success factors were interprofessional working, staffing and training, streaming, and infrastructure and support.Future workFurther research should study the longer-term effects of these services, clinician attitudes to risk and the implementation of streaming. Additional work should also examine the system effects of national policy initiatives, develop methodologies to support rapid service evaluation and study the relationship between primary and secondary care.Trial registrationThis trial is registered as ISRCTN51780222.FundingThis project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full inHealth and Social Care Delivery Research; Vol. 10, No. 30. See the NIHR Journals Library website for further project information.

Realist analysis of whether emergency departments with primary care services generate ‘provider-induced demand’

BackgroundIt is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care (‘provider-induced demand’). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand.MethodsWe used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating ‘CMO’ configurations to develop and refine theories relating to drivers of demand.ResultsEDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients’ experiences of accessing primary care, community care capacity, service design and population characteristics.ConclusionsPatient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity.

Clinical features associated with ADB-BUTINACA exposure in patients attending emergency departments in England

Objective Synthetic cannabinoid receptor agonists (SCRA) are commonly encountered new psychoactive substances. Here we report the recent detection of ADB-BUTINACA in samples from patients attending United Kingdom emergency departments with toxicity after suspected drug misuse and describe the associated clinical features. Methods Consenting adults (≥16 y) presenting to participating hospitals with toxicity after suspected drug misuse have been included in the Identification Of Novel psychoActive substances (IONA) study since March 2015. Demographic and clinical features are recorded and blood and/or urine samples analysed using high-resolution accurate mass liquid chromatography-mass spectrometry. Results By December 2021, analytical data were available for 1279 IONA participants and ADB-BUTINACA was detected in at least one sample from 10 (9 males, age range 16–51 median 45 years), all presenting since February 2021. Smoking ‘spice’ was reported by four patients, two had ingested edible “cannabis” gums and four reported heroin use (2 intravenous, 1 smoked, 1 route not known). Co-use of pregabalin (oral) and crack cocaine (smoked) were also reported. In 3 cases ADB-BUTINACA was the only substance detected, while in seven other substances of misuse were also detected including other SCRA, opioids, benzodiazepines cocaine and pregabalin. Clinical features reported in these 2 groups respectively included reduced level of consciousness (3/3, 6/7), agitation (0/3, 4/7), tachycardia (0/3, 3/7), seizures (1/3, 1/7), hallucinations (1/3, 1/7), hypotension (1/3, 1/7). Metabolic acidosis (1/3, 0/7) and respiratory acidosis (1/3, 0/7), All 10 patients recovered with supportive care, including intubation and ventilation for one case. The median length of hospital stay was 19 h (range 2.6–131 h). Conclusions ADB-BUTINACA has recently emerged as a drug of misuse in England. Clinical features of toxicity are consistent with those of other SCRA and include reduced level of consciousness, respiratory and/or metabolic acidosis, seizures, confusion and hallucinations.

Socioeconomic inequality in access to timely and appropriate care in emergency departments

In publicly-funded healthcare systems, waiting times for care should be based on need rather than ability to pay. Studies have shown that individuals with lower socioeconomic status face longer waits for planned inpatient care, but there is little evidence on inequalities in waiting times for emergency care. We study waiting times in emergency departments (EDs) following arrival by ambulance, where health consequences of extended waits may be severe. Using data from all major EDs in England during the 2016/17 financial year, we find patients from more deprived areas face longer waits during some parts of the ED care pathway. Inequalities in waits are small, but more deprived individuals also receive less complex ED care, are less likely to be admitted for inpatient care, and are more likely to re-attend ED or die shortly after attendance. Patient-physician interactions and unconscious bias towards more deprived patients may be important sources of inequalities.

The Frequency of Infant-Feeding Presentations at English Emergency Departments During the SARS-CoV-2 Pandemic: A Nation-Wide Electronic Health Records Study.

Objectives: To examine the frequency and distribution of infant feeding-related presentations at emergency departments (EDs) before and during the SARS-CoV-2 pandemic.Setting: Attendances at 48 major EDs in England in two 50-week periods before and during the COVID-19 pandemic: period 1, April 2, 2019 to March 10, 2020 and period 2, April 1, 2020 to March 10, 2021.Methods: We estimated the change in frequency of ED presentations by age group and diagnosis before and after the start of the SARS-CoV-2 pandemic in England. We compared changes in the frequency of attendances of infant-feeding related presentations by infant age, sex, ethnicity, deprivation, rurality, arrival mode, arrival time, acuity, mother’s age, gravidity and mental health, birth length of stay, attendance duration, and disposal (i.e., admission or discharge).Results: While total ED attendances fell by 16.7% (95% CI -16.8% to -16.6%), infant attendances increased for feeding problems (+7.5% 95% CI 2.3% to 13.0%), neonatal jaundice (+12.8%, 95% CI 3.3% to 23.3%) and gastro-esophageal reflux (+9.7%, 95% CI 4.4% to 15.2%). These increases were more pronounced amongst first babies (+22.4%, 95% CI 13.1% to 32.5%), and where the stay in hospital after birth was brief (0-1 days, +20.1%, 95% CI 14.8% to 25.7%). Our analysis suggests that many of these attendances were of low acuity.Conclusions: While ED attendances reduced dramatically and systematically with the COVID-19 pandemic, presentations for infant feeding issues increased, implying growth in the unmet needs of new mothers and infants.

Perspectives of GPs working in or alongside emergency departments in England: qualitative findings from the GPs and Emergency Departments Study.

BackgroundAround 43% of emergency department (ED) attendances can be managed in general practice. Strategies to address this include directing appropriate patients to GPs working in or alongside EDs (GPED). Views of GPs choosing to work in GPED roles may inform planning and implementation of GPED services as well as wider general practice provision.AimTo explore the experiences and motivations of GPs choosing to work in GPED services in England, and to identify factors that may support or hinder GPs working in GPED roles.Design and settingThematic analysis of 42 semi-structured interviews of GPs working in 10 GPED case sites across England.MethodQualitative GP interviews from a mixed-methods study of GPs in GPED roles were thematically analysed in relation to research aims.ResultsFour themes were generated: the ‘pull’ of a portfolio career; the ‘push’ of disillusionment with general practice; professional reciprocity; sustainability of GPED services and core general practice. Flexible, favourable working conditions, collaboration, and professional development made GPED an attractive workplace, often as part of a portfolio career or after retiring from core general practice. Working in GPED services was largely driven by disillusionment with core general practice. Both GPED and core general practice were thought to benefit from GPED GPs’ skills. There were concerns about GPED sustainability and destabilisation of core general practice.ConclusionGPED may extend the clinical careers of experienced GPs and support recruitment and retention of more recently qualified GPs. Despite some benefits, GPED may destabilise core general practice and increase pressure on both environments.

Effectiveness and cost-effectiveness of face-to-face and electronic brief interventions versus screening alone to reduce alcohol consumption among high-risk adolescents presenting to emergency departments: three-arm pragmatic randomized trial (SIPS Junior high risk trial).

Background and aimsAlcohol use increases throughout adolescence. Emergency department (ED) attendance is an opportunity for alcohol screening and brief intervention (ASBI), which is effective for adults. This trial evaluated the effectiveness and cost‐effectiveness of ASBI compared with screening alone (SA) in high‐risk adolescents.Design, Setting and ParticipantsMulti‐centre, three‐group, single‐blind, individually randomized trial with follow‐ups after 6 and 12 months in 10 ED settings in England. From October 2014 to May 2015 we screened 3327 adolescents aged 14 to 18 years, of whom 756 (22.7%) scored at least 3 on the Alcohol Use Disorders Identification Test: consumption (AUDIT‐C) and consented to participate in this trial. Mean age was 16.1 years; 50.2% were female and 84.9% were white.InterventionsInterventions were personalized feedback and brief advice (PFBA), personalized feedback plus electronic brief intervention (eBI) and SA.MeasuresThe primary outcome was the weekly alcohol consumed in standard UK units (8 g ethanol) at 12 months post‐randomization, derived from extended AUDIT‐C. Economic outcomes included quality of life and service use, from perspectives of both the National Health Service and personal social services (NHS&PSS) and society.FindingsAt 12 months, mean weekly consumption was 2.99 [95% confidence interval (CI) = 2.38–3.70] standard units for the SA group, 3.56 (95% CI = 2.90, 4.32) for PFBA and 3.18 (95% CI = 2.50, 3.97) for eBI, showing no significant differences. The PFBA group consumed mean 0.57 (−0.36, 1.70) units more than SA; and eBIs consumed 0.19 (−0.71, 1.30) more. Bayes factors suggested lack of effectiveness explained non‐significance. From the NHS&PSS perspective, economic analysis showed that PFBA and eBI were not cost‐effective compared with SA: PFBA yielded incremental cost‐effectiveness ratio of £6213 (−£736 843, £812 884), with the intervention having 54% probability of being cost‐effective compared with SA at the £20 000 WTP threshold.ConclusionsIn emergency departments in England, neither personalized feedback and brief advice nor personalized feedback plus electronic brief intervention showed evidence of being effective or cost‐effective when compared with screening alone in reducing alcohol consumption among adolescents.

The effectiveness of primary care streaming in emergency departments on decision-making and patient flow and safety – A realist evaluation

Primary care streaming was implemented in UK Emergency Departments (EDs) to manage an increasing demand for urgent care. We aimed to explore its effectiveness in EDs with different primary care models and identify contexts and mechanisms that influenced outcomes: streaming patients to the most appropriate clinician or service, ED flow and patient safety. MethodWe observed streaming and interviewed ED and primary care staff during case study visits to 10 EDs in England. We used realist methodology, synthesising a middle-range theory with our qualitative data to refine and create a set of theories that explain relationships between contexts, mechanisms and outcomes. ResultsMechanisms contributing to the effectiveness of primary care streaming were: quality of decision-making, patient flow, redeploying staff, managing patients across streams, the implementation of governance protocols, guidance, training, service evaluation and quality improvement efforts. Experienced nurses and good teamworking and strategic and operational management were key contextual factors. ConclusionWe recommend service improvement strategies, operational management, monitoring, evaluation and training to ensure that ED nurses stream patients presenting at an ED seeking urgent care to the most appropriate clinicians for their needs in a safe and efficient manner.

Association between delays to patient admission from the emergency department and all-cause 30-day mortality

BackgroundDelays to timely admission from emergency departments (EDs) are known to harm patients.ObjectiveTo assess and quantify the increased risk of death resulting from delays to inpatient admission from EDs, using...