Emergency Health Care System Research Articles

Unscheduled early revisit to emergency department

Background: Unscheduled revisits to the emergency department may present a considerable additional workload. Objectives: This study investigated the risk factors contributing to adverse event during unscheduled early revisit to Emergency Department Hospital Universiti Sains Malaysia. Methods: A retrospective cohort study was conducted from January 2014 to January 2015 to character the nature of unscheduled early revisits to Emergency Department Hospital Universiti Sains Malaysia. It included all patients 18 years old and above, revisited emergency department within 9 days post discharge from emergency department. Results: Data were collected from 492 case records. The rate of emergency department unplanned revisits within 9 days of previous emergency department discharge was 0.66% for the study period. Risk factors for revisit included advance age, pre-existing co-morbidities, duration spent during first emergency department visit and health care system–related error. The independent predictors of morbidity were diabetes mellitus (odds ratio, 2.07; 95% confidential interval, 1.08–3.96), respiratory disease (odds ratio, 2.42; 95% confidential interval, 1.18–4.98), gastrointestinal disease (odds ratio, 5.93; 95% confidential interval: 1.29, 27.35), nervous system disease (odds ratio, 4.65; 95% confidential interval: 1.27, 17.02), duration spent more than 6 h during first emergency department visit (odds ratio, 3.05; 95% confidential interval: 1.53, 6.07), and medical error leading to admission (odds ratio, 8.85; 95% confidential interval: 4.43, 17.67). The overall mortality rate was 0.2% (1/492). Conclusion: Emergency department physicians need to be extra vigilant when managing patients with risk factors, particularly the modifiable risk factors, to curb emergency department revisit.

Legislative and Policy Developments and Imperatives for Advancing the Primary Care Behavioral Health (PCBH) Model.

The Primary Care Behavioral Health (PCBH) practice model continues to gain converts among primary care and behavioral health professionals as the evidence supporting its effectiveness continues to accumulate. Despite a growing number of practices and organizations using the model effectively, widespread implementation has been hampered by outmoded policies and regulatory barriers. As policymakers and legislators begin to recognize the contributions that PCBH model services make to the care of complex patients and the expansion of access to those in need of behavioral health interventions, some encouraging policy initiatives are emerging and the policy environment is becoming more favorable to implementation of the PCBH model. This article outlines the necessity for policy change, exposing the policy issues and barriers that serve to limit the practice of the PCBH model; highlights innovative approaches some states are taking to foster integrated practice; and discusses the compatibility of the PCBH model with the nation's health care reform agenda. Psychologists have emerged as leaders in the design and implementation of PCBH model integration and are encouraged to continue to advance the model through the demonstration of efficient and effective clinical practice, participation in the expansion of an appropriately trained workforce, and advocacy for the inclusion of this practice model in emerging healthcare systems and value-based payment methodologies.

The Critical Patients Localization Algorithm Using Sparse Representation for Mixed Signals in Emergency Healthcare System

In this paper, a new architecture for the emergency healthcare system based on mobile cloud computation (MCC) and fifth-generation (5G) wireless link is proposed. Based on the processing speed of MCC and the communication rate of 5G scheme, this system can monitor and locate patients in real time. Multiple base stations of the massive multiple input multiple output cooperate with each other to locate the patients using cross-location method. Then, a new direction-of-arrival (DOA) estimation algorithm is proposed in the presence of unknown mutual coupling. The uncorrelated signals are first estimated using the estimation of signal parameters via rotational invariance technique algorithm. Then, these estimators construct the manifold matrix of uncorrelated signals to estimate the mutual coupling coefficients. The information about uncorrelated signals and mutual coupling is eliminated based on oblique projection technique in order to estimate the DOAs of coherent signals using the original array. Finally, the DOAs of coherent signals are achieved based on sparse representation theory. Simulation results demonstrate the effectiveness and performance of the proposed algorithm.

A Novel Emergency Healthcare System for Elderly Community in Outdoor Environment

By exploiting the advanced information and communication technologies, the current community healthcare systems provide digital healthcare services. However, the current healthcare framework for senior citizen in outdoor environment faces new challenges. The traditional healthcare systems are not efficient, and they do not comprise user‐friendly devices and interfaces suitable for the elderly in outdoor environment. Hence, in this work, we develop an outdoor healthcare system for community senior citizens based on unmanned aerial vehicle (UAV) and Internet of things (IoT). Our system includes physical devices, wireless and wired networks, cloud and data center, and smart terminals. Further, the analysis of the proposed healthcare architecture is presented from the perspective of different layers, and an algorithm on UAV for creating high‐speed communication channel and delivering medicine is provided. In addition, the healthcare UAV, related devices, and friendly APPs are designed. The proposed framework is evaluated by comparison with the current healthcare architecture. The emulating and experimental results show that our proposed system can provide a high‐quality wireless communication link even at large communication distances, and in real testbed our proposal can reduce the response time by about 20% in comparison with the current methods.

Developing an emergency nursing short course in Tanzania.

Nurses are the largest group of healthcare workers in Africa. By adequately equipping nurses to identify, intervene and care for emergency conditions, emergency healthcare systems can be strengthened. To address this need, a nursing working group was formed within the African Federation for Emergency Medicine (AFEM). The aim of this international emergency nursing group was to develop a guiding document to help improve emergency nursing skills within Africa. Using this guiding document, a group of Tanzanian clinical nurse trainers was selected to develop a context specific short course. They used this guiding document as a foundation to improve skill development. The pilot course was well received and has since expanded to training in five regions within the United Republic of Tanzania. The clinical nurse trainers leading the course, are supported by a mentorship programme with competent educators within a global emergency nursing infrastructure. This course, a combination of local knowledge, formal mentorship programs, and international nursing support, demonstrates that investing in the improvement of emergency nursing skills can have high impact results with low-cost. This will ultimately improve emergency care on the continent.

The North Carolina Way: emerging healthcare system and faith community partnerships

ABSTRACTUnited States healthcare policy has promoted the development of healthcare systems and community partnerships designed to decrease costs and readmissions, particularly for under-served populations. Typically, these partnerships are “hospital-centric”, focused on following in-house clinical costs into the community. Two contrasting large-scale community system models show results from development practices, integrating faith community partnerships that affect healthcare utilisation. This “community to hospital” focus is key to several such initiatives in the US. This article describes local implementation efforts in North Carolina, known as “the North Carolina Way”, and tests assumptions on implementation practices for creating robust faith-community and healthcare partnerships.

Quality of life at work for nurses in the 112 and 061 emergency healthcare systems in Spain

Introduction: A high-quality professional life is associated with increased motivation and the ability to adapt to constant change. Objective: To enhance our knowledge concerning the quality of professional life as perceived by nurses in the emergency healthcare systems in Spain. Methods: The study population included 2,852 professionals, and we obtained 328 (11.5%) valid responses. The data indicate that 80% of respondents had been in their position for more than 10 years. The study used the specifically validated questionnaire CVP-35, which examines quality of life at work. Results: The global quality of life score was approximately 6.76 points. The highest scoring item was "My work is important for the lives of other people" (9.12), and the lowest score was "Possibility of promotion" (3.76). The evaluation of the various dimensions was heterogeneous. The most significant correlations were found for ‘management support’ with ‘intrinsic motivation’ and for ‘intrinsic motivation’ with ‘training’. The Spearman correlation coefficients were 0.521 and 0.439, respectively. There was a direct relationship between these score items. Conclusions: Nurses’ perception of the global quality of professional life tends to be good, and the best results are found for ‘intrinsic motivation’ and ‘training’. The worst areas were related to the items

The Challenge of Introducing New Public Management to Kosovo’s Healthcare Sector

The paper outlines the current healthcare sector reform process in Kosovo and the challenges to its implementation. The reform attempts to introduce modern public management principles into Kosovo’s healthcare sector, including a purchaser–provider split, performance incentives, and performance-based contracting, as well as a reorganisation of healthcare service delivery with a view to improving effectiveness and efficiency. This is the first major reform of the healthcare sector since Kosovo declared independence in 2008, and it intends to replace the healthcare system established by the United Nations between 1999 and 2008. Kosovo’s earlier healthcare system had been characterised by decentralised decision-making, but was re-established by the UN in the form of an emergency healthcare system after the UN was deployed to administer Kosovo in 1999. The reform envisages separating healthcare regulators from healthcare providers and healthcare purchasers. Kosovo Hospital and University Clinical Services is established as a new entity providing healthcare services, and a new Health Insurance Fund will become the healthcare purchaser. The Ministry of Health will be restricted to the functions of a regulator, divested of all administrative functions in favour of healthcare providers and purchasers. A major challenge lies in the limited capacities of the Kosovo Government to implement such an ambitious reform. This is also an attempt to introduce modern public management principles into a public administration which is dominated by traditional public administration principles. Lack of implementation capacities and contradictory public administration principles are the most important factors that may endanger the successful implementation of the reform.

Patient-Physician Relationship; A keystone of Care in Emerging Health Care System

Patient-Physician Relationship; A keystone of Care in Emerging Health Care System

The Transition of Care Between Emergency Department and Primary Care: A Scoping Study.

Patients with chronic diseases are often forced to seek emergency care for exacerbations. In the face of large predicted increases in the prevalence of chronic diseases, there is increased pressure to avoid hospitalizing these patients at the end of the ED visit, if they can obtain the care they need in the outpatient setting. We performed this scoping study to provide a broad overview of the published literature on the transition of care between ED and primary care following ED discharge. We performed a MEDLINE search of English-language articles published between 1990 and March 2015. We created a data-charting form a priori of the search. Papers were organized into themes, with new themes created when none of the existing themes matched the paper. Papers with multiple themes were assigned preferentially to the theme that was consistent with their primary objectives. We created a descriptive numerical summary of the included studies. Of 1,138 titles, there were 252 potentially relevant abstracts, and among those 122 met criteria for full paper review. An additional 11 papers were acquired from reference review. From the 133 papers, 85 were included in the study. The papers were categorized into seven themes. These included Follow-up compliance and its predictors (38 studies), Telephone calls to discharged ED patients (15 studies), ED navigators (14 studies), The current system (nine studies), Ways to alert primary care providers (PCPs) of the ED visit (seven studies), and Patient views and PCP information requirements (one each). In the Follow-up compliance and predictors theme, the two most frequently identified significant predictors for increasing the frequency of follow-up care were the provision of a follow-up appointment time prior to ED departure and thepresence of health insurance. Follow-up telephone calls to patients resulted in better follow-up rates, but increased ED return visits in some studies. In the current system patients themselves are the conduit, andthe barriers to follow-up care can be high. E-mail and/or electronic medical record alerts to the PCP are relatively new, and no studies limited the alerts to patients who had a defined need for follow-up care. A plethora of work has been published on the transition of care from ED to primary care. To decrease hospitalizations among the upcoming wave of patients with chronic diseases, it appears that the two most efficient areas to target are a primary care follow-up appointment system and health insurance. Further research is needed in particular to identify the patients who actually need follow-up care and to develop information technology solutions that can be effectively implemented within the current emergency healthcare system.

Clarifying Problems with Emergency Healthcare Systems in Japanese Long-Term Care Facilities for Older People

Background: Long-term care facilities for older people play an important role as alternatives to family care in an aging society. This study aimed to assess staffing problems linked to emergency healthcare for residents of these facilities, and to investigate the relationship between these problems and the characteristics of the facilities. Methods: The study surveyed managers of long-term care facilities for older people in a Japanese urban area between September and December 2014. The type of care facility, the number of staff and any problems providing or accessing emergency healthcare for the residents were evaluated. Multiple logistic regression analysis was used to explore the factors common to facilities reporting staffing problems linked to emergency healthcare of residents. Results: In total, 321 long-term care facilities were eligible for this study and 226 (70%) returned the questionnaire. We compared the characteristics of facilities reporting and not reporting staffing problems in emergency healthcare of residents. The type of care facility was significantly associated with staffing problems in emergency healthcare of residents both during the day (p < 0.01) and at night (p = 0.04). The facilities most likely to report problems were group homes for older people with dementia, because of staffing shortages. Conclusions: Problems in emergency healthcare systems in Japanese long-term care facilities for older people varied by type of care facility. Our data underscore the need for telemedicine and consideration of mergers between smaller facilities such as group homes for older people with dementia.

Quality of life at work for nurses in the healthcare system of emergencies, 112 and 061, in Spain

Introduction: A high-quality professional life is associated with increased motivation and the ability to adapt to constant change. Objective: To enhance our knowledge concerning the quality of professional life as perceived by nurses in the emergency healthcare systems in Spain. Methods: The study population included 2,852 professionals, and we obtained 328 (11.5%) valid responses. The data indicate that 80% of respondents had been in their position for more than 10 years. The study used the specifically validated questionnaire CVP-35, which examines quality of life at work. Results: The global quality of life score was approximately 6.76 points. The highest scoring item was ‚My work is important for the lives of other people‛ (9.12), and the lowest score was ‚Possibility of promotion‛ (3.76). The evaluation of the various dimensions was heterogeneous. The most significant correlations were found for ‘management support’ with ‘intrinsic motivation’ and for ‘intrinsic motivation’ with ‘training’. The Spearman correlation coefficients were 0.521 and 0.439, respectively. There was a direct relationship between these score items. Conclusions: Nurses’ perception of the global quality of professional life tends to be good, and the best results are found for ‘intrinsic motivation’ and ‘training’. The worst areas were related to the items ‚possibility of promotion‛ and ‚my company tries to improve the quality of life of my post‛.

Changing Challenges and Evolving Opportunities in Nursing Education

With more people having access to health care in the United States as a result of the Affordable Care Act, there is a greater need for nurses now than ever before. Generalist nurses will need to be educated, not just to care for people in hospitals, but also to promote health and help manage chronic conditions in a wide variety of health care settings. More advanced-practice nurses will be needed to provide primary care. Although the need for nurses educated at both the undergraduate and graduate levels in emerging health care systems is increasing, the number of nursing educators is decreasing. Nursing educators in the future will need to be nimble in addressing emerging health care needs while ensuring succession planning.

The physical health of people with schizophrenia in Asia: Baseline findings from a physical health check programme.

Introduction People with schizophrenia have worse physical health than the general population, and studies in developed countries demonstrate that their health behaviours are often undesirable. However, as no similar studies have been conducted in Asian countries with emerging healthcare systems, the physical health promotion challenges in these settings is unknown. Aim To identify and explore relationships between cardiometabolic health risks, lifestyle and treatment characteristics in people with schizophrenia in Thailand. Method This cross-sectional study reports the baseline findings from a physical health check programme using the Thai version of the Health Improvement Profile. Results Despite desirable levels of exercise and relatively good diets being reported by most of the 105 service users, unhealthy body mass index values were observed in 44% of participants. A BMI>23kg/m² and central obesity was found to be most likely in women. Being prescribed antipsychotic polypharmacy was significantly associated with a higher BMI than in people prescribed monotherapy. Implications for Practice Mental health professionals in Asiashould be aware of the additional risks of obesity that are associated with antipsychotic polypharmacy and may benefit from additional training in order that they may advocate for service users within medication reviews to minimize the potential iatrogenic effects of treatment.

The Future of Patient Engagement in the Governance of Shared Data.

Background:The emerging health care system increasingly values patient engagement and shared decision-making between patients and their providers. The practice of these values is gaining importance as the patient-centered medical home model and personalized medicine come into greater use.Opportunity for Improvement:Exploration of patient preferences about personal health data use for research and quality improvement is a fundamental element of the provider-patient relationship. Giving patients an explicit opportunity to discuss their options about use of their data and implementing a process that allows patients to receive desired communications about how their information is used can help build patient trust, a requirement for successful care partnerships.Practice Advancement:Working to change organizational cultures that exclude patients from participation in important decisions related to personal health information use promotes a strong patient-provider relationship and, ultimately, lays the foundation for improved health care through expanded use of patient data.

Utilizing Big Data for Public Health

Big data is usually defined as information assets characterized by such high volume, velocity, and variety that specific technology and analytical methods are required for its transformation into value.1 Analysis of big data may provide useful information in a variety of areas, including healthcare.2 Numbers of data sets obtained from routine operations in the area of healthcare have rapidly increased in recent years, due to cheap and advanced information collection systems, but challenges in extracting useful information from large and complex datasets remain. In this context, an accompanying article published in this issue of the Journal of Epidemiology investigated outcomes after out-of-hospital cardiac arrest using data from the All-Japan Utstein registry for the Fire and Disaster Management Agency, which is a nationwide population-based registry based on guidelines for uniform reporting of cardiac arrest.3 The proportion of patients in the registry with favorable neurological outcomes was 1.6% during the national meetings of the Japanese Society of Intensive Care Medicine, the Japanese Association for Acute Medicine, and the Japanese Circulation Society, while the proportion was 1.5% during the remaining days of the year. Likewise, 1-month survival rates were comparable between meeting days (3.8%) and non-meeting days (3.8%). The present analysis of big data from the nationwide registry of cardiac arrests supports the robustness of the emergency healthcare system in Japan and suggests that the quality of emergency care is maintained even when many professionals in emergency medicine are absent from their hospitals to attend medical conferences. As demonstrated in the accompanying article,3 big data may provide useful information enabling the public sector and healthcare providers to assess their healthcare systems and distribution of resources. Big healthcare data also has great potential to improve our understanding of the effectiveness of treatments in the real world, as well as of the incidence, management, and prognosis of various medical conditions, particularly for rare diseases. Useful information obtained from big data will allow health professionals to provide better medical care. Although the privacy of individuals’ information must be protected, considering the great potential of big data, healthcare data generated within governmental processes should be open to researchers who have unique ideas on providing useful information regarding public health.

Responding to mass burn casualties caused by corn powder at the Formosa Water Park in 2015.

On the night of June 27th, 2015, a tragedy occurred while young people were celebrating the start of their summer break at the Formosa Fun Water Park in New Taipei City, Taiwan. At 8:32 PM, a blast caused by flammable cornstarch- based powder injured 499 people, including nine interna- tional tourists from five countries. Among the injured, half suffered burns over 40% of their body surface area (BSA), and 75% suffered from second or third degree burns to >20% BSA. The Taiwan emergency health care system encountered a very difficult challenge, and high fatality rates were ex- pected based on the seriousness of the injuries. The explosion was accidentally ignited from an over- heated spotlight on the stage in a dry swimming pool when colored powders were sprayed over the crowd. The un- precedented number of burn casualties caused panic in the Taiwanese public, and also brought into question the appropriateness of how ambulances were dispatched and the care received in the hospitals. On the night of June 27th, 2015, a tragedy occurred while young people were celebrating the start of their summer break at the Formosa Fun Water Park in New Taipei City, Taiwan. Immediately after the blast, the Ministry of Health and Welfare (MOHW) activated its two Regional Emergency Medical Operation Centers, notifying all emergency-designated hospitals to recall their medical personnel and prepare for mass burn casualties, and to report individual patient information and the number of patients entering each hospital. Facing the geographical limitations of the water park and the tremendous numbers of the injured, New Taipei and Taipei City dispatched >70 ambulances to the scene, along with ambulances from the cities of Keelung and Taoyuan, with the hospitals in these four cities volunteering to support the rescue. For better on-site response, the Ministry assisted in collaboration with the hospitals to set up on-site medical stations, and urged local health departments in these four cities to ensure that all burn units and intensive care units under their jurisdictions were well-prepared for the injured. With the intense cooperation and collaboration of fire departments and health departments, almost all of the 499 injured were sent to hospitals within an incredibly short period within 4 hours after the blast. The surge capacity of emergency rooms handling the injured was triggered in a very efficient way. It allowed these emergency rooms to obtain adequate staff, supplies, and equipment, as well as structures and systems to provide sufficient care to meet the immediate needs of patients following such a large-scale incident. Suffering from severe burns combined with inhalation pulmonary injuries, patients were unstable, and further intensive care was required. Patients were transferred to several hospitals with better burn-unit facilities to ensure the best medical care. Initially, the injured were treated in six hospitals in three cities in northern Taiwan. After they were stabilized, patients were distributed to 38 hospitals in seven cities by the following morning, with this distribution widened to 54 hospitals in 13 cities nationwide after 1 week. By the end of the 1st week, due to the less severely injured patients being discharged, patient distribution dropped to 46 hospitals in 13 cities... Language: en

The lived experiences of patients and ambulance ramping in a regional Australian emergency department: An interpretive phenomenology study

Internationally, the workload of emergency departments (ED) has increased, resulting in overcrowding and frequent delays in the offloading of patients arriving via ambulance--referred to in Australia as 'ambulance ramping'. Using interpretive phenomenology, this study sought to understand the experience of ambulance ramping from the perspective of patients. Semi-structured interviews were undertaken with seven patients who presented to a regional Queensland ED via ambulance, and experienced an ambulance offload delay of >30 min. Ambulance ramping in the ED was described as 'Being a patient, patient', and three major themes emerged: Understanding the emergency healthcare system; Making do within the emergency healthcare system; and Being 'in the dark' during ambulance ramping. Most participants did not understand the antecedents to ambulance ramping, but understood some of the consequences. Most were happy to wait with paramedics for a bed and, although without privacy, felt safe. However, most participants felt 'in the dark' during ambulance ramping, due to communication difficulties regarding bed availability, and this led to frustration. In light of the Australian Charter of Healthcare Rights, service improvement opportunities exist for patients arriving to the ED by ambulance to ensure delays are minimised and quality care is delivered.

Should a Thoracic Surgeon Transfer a Complicated Case to a Competing Medical Center Against the Hospital’s Order?

Robert M. Sade, MD The Patient Protection and Affordable Care Act was signed into law several years ago, but the future of the emerging health care system remains unclear. The law is not popular and the political outlook for many of its key components is in doubt. Certain aspects of health care can be predicted with considerable confidence, however: an increasing role for bureaucracies and decreasing power of physicians. These trends pose dilemmas for surgeons, particularly when a conflict of loyalties is created when hospital administrators demand that physicians place the interests of the medical center before the interests of patients. The question of how to respond to such conflicts of loyalties was debated at the 61st Annual Meeting of the Southern Thoracic Surgical Association. The session focused on the case of a surgeon faced with a complex clinical situation that would require operative management, either in her own hospital, as demanded by an administrator, or in a competing hospital after referral to a surgeon more experienced in handling such cases. A Case of Divided Loyalties Dr. Elizabeth Black, a young cardiothoracic surgeon in a 400 bed community hospital, receives a call from the emergency department regarding a patient with a confirmed diagnosis of perforated esophagus, which occurred more than 24 hours ago. The patient is stable, but has early sepsis and multiple co-morbidities, including alcohol abuse. The hospital where the surgeon works has 2 groups of cardiothoracic surgeons in competition with one another, all of whom do cardiac surgery and most of whom also do some general thoracic surgery. None of the surgeons has special expertise with esophageal surgery — they generally refer elective esophageal cases to a large university hospital 50 miles away, which has an international reputation in the management of esophageal disease. Dr. Black feels it would be in the patient's best interest to be transferred to the university hospital instead of caring for him locally. When arrangements for transfer are begun, the hospital administrator informs the surgeon that she must accept the patient and care for him. The hospital is in the same market catchment area as the university and does not wish to lose patients to its competitor, especially a patient who has already been seen in its emergency department. Dr. Black feels uncomfortable in accepting this patient, and does not feel confident in her ability to optimize his chances of survival. Nonetheless, financial arrangements and competition with the other group of surgeons make it very difficult to refuse the hospital's demand – she is board-certified and through her education and training, she knows the correct care of the patient, and has done similar cases as a resident. The patient's social situation (no apparent family members) and current medical condition do not allow him to make an informed decision about his locus of care. In case of a bad outcome, legal repercussion are highly unlikely. Dr. Black asks two of her out-of-state surgical colleagues to advise her on what she should do.

Earthquake Aftermath-Myth or Reality?

DOI: http://dx.doi.org/10.3126/nje.v5i2.12827Nepal J Epidemiol. 2015;5(2); 465-467.