Hospital Emergency Medicine Research Articles

Identifying Guideline-Practice Gaps to Optimize Evaluation and Management for Patients With Syncope

Syncope is a common and complex symptom that requires efficient evaluation to determine the cause. Recent guidelines focus on high-value testing, but a systematic evaluation of their implementation has not been performed. To this end, we used a mixed-methods approach of surveys, chart reviews, and focus groups to understand current practices relating to the diagnosis and management of patients with syncope and to identify barriers and facilitators to the implementation of guideline-supported recommendations. Surveys were distributed to 1500 providers in the specialties of hospital medicine, cardiology, emergency medicine, and family medicine, and 175 responses were received. Knowledge of class I and III guideline recommendations were assessed with the use of clinical vignettes, which were answered correctly 60%-80% of the time. Chart reviews focused on patient history and testing for syncope. Per the guidelines, < 50% of charts met criteria for bare minimum history and physical examination. Based on the documentation, 25% of echocardiograms and 90% of neurologic testing obtained would not have been appropriate per the guidelines. Self-reported and actual practice patterns were similar in rates of testing. Our results indicate that there remains a gap between guideline-directed management and actual practice for syncope. Focus groups revealed barriers across multiple levels of care that need to be addressed to improve care. Our findings emphasize the need for proactive strategies to improve syncope testing practices, potentially saving millions of dollars in the health care system.

About design medical databases and information systems for the organization and management of clinical processes

In article questions of development of automated, integrated information systems and databases (DB), created by the authors to ensure that the information and intellectual support of organizations and management of clinical processes in a general hospital. Analyze the schema information and intellectual support for the main stages of activity of the doctor in the organization of clinical processes and proved the effectiveness of the transition to electronic document management and management of patient records. The techniques and steps in the process of designing a database of such systems. Presented data models based on relational principles and taking into account the peculiarities of information provision of medical care in a clinical hospital emergency medicine. Sanctified issues for creating a database implemented taking into account the specifics of health care regulations, standards and related problems of formalization and standardization of information, the problem of choice of database management systems (DBMS), including for medical applications, the issues of intellectualization of the database and the formation of a knowledge base. Showing crucial modeling domain – automation object articles in this case – the diagnostic and treatment process. The main requirements to the database integrated health information systems. Questions of formalization entered into the database of medical and other information, the solution of which the authors carried out through the creation of special electronic templates for all aspects of medical practice hospital. Being developed by leading medical specialists clinic, they do not only facilitate the design, but also remind us that we should find out, to ask to examine and help select the best tactics. This kind of technology is human-computer interaction – an element of the programming actions of the doctor. This option is the task of formalizing entered into the database of medical information used to provide a single standard of medical information, standardize the order of the information entered into the database. The results of the analysis of the effectiveness of the developed information system and performance of its database in the course of their use in the clinical setting. In particular, we studied the performance, response time and server load when working with different categories of users – doctors, nurses, administrators, and etc., which have shown the applicability of the developed health information system and its database to optimize the organization of clinical processes in the conditions of the experiment.

Acil Serviste Kan Transfüzyonu Yapılan Hastaların Özellikleri

Bu çalışmanın amacı acil serviste kan ve kan ürünleri transfüzyonu yapılan hastaların transfüzyon sonrası değişim verilerin incelenmesi amacıyla prospektif olarak incelemektir. Bu çalışma Sağlık Bilimleri Üniversitesi Bursa Yüksek İhtisas Eğitim ve Araştırma Hastanesi acil servisine başvuran hastaların yaş ve cinsiyetleri, şikayetleri, muayene bulguları, kan grupları, verilen kan ürünleri ve ünitelerinin dağılımı, transfüzyon öncesi ve sonrası hemoglobin(Hb), hematokrit(Hct) değerleri incelenerek yapıldı. Çalışmaya 92 hasta alınmış olup hastaların %56,5’u 65 yaş ve üzerindeydi. %59,8’i kadındı. %44,6 ile en fazla “halsizlik”şikayeti vardı. Muayenede hastaların %17,4’inde melena %14,1’inde hematokezya vardı. Hastaların %40,2’si anemi ve %35,9’u Gastrointestinal Sistem(GİS) kanaması tanısı almıştı. Hastalar en fazla %45,7 ile A RH+ ve %29,3 ile 0 RH + kan gruplarına sahipti. Hastaların %94,6’sına eritrosit süspansiyonu (ES) ve %5,4’üne ES+ taze donmuş plazma(TDP) transfüzyonu yapıldı. Hastaların %46,7’sine iki ünite ES ve %40,2’sine bir ünite ES verildi. Yaş gruplarının transfüzyon öncesi Hb değerleri arasında istatistiksel olarak önemli bir fark yokken ( p=0,879), transfüzyon sonrası istatistiksel olarak önemli fark olduğu bulundu (p=0,003). ES transfüzyonu sonrası hastaların %58,2’si beklenen Hb değerine ve %50,0’si beklenen Hct değerlerine ulaşmıştı. Yaş, cinsiyet ve tanıya göre beklenen Hb ve Hct düzeylerine ulaşma durumları arasında istatistiksel olarak önemli fark yoktu (p&amp;gt;0,05). Transfüzyon öncesi ve sonrası hastaların nabız, tansiyon ve ateş gibi vital bulgularında istatistiksel olarak fark yoktu (p&amp;gt;0,05), ancak Hb, Hct, MCV ve MCH’de önemli artış vardı (p&amp;lt;0,05). Çalışma sonunda acil serviste yapılan kan ve kan ürünü transfüzyonları incelendiğinde düşünülenin aksine travmaya bağlı acil transfüzyon değil de en fazla GİS kanama ve anemiye bağlı transfüzyon yapıldığı tespit edilmiştir.

"Five-minute emergency life chain" centering on department of emergency and intensive care unit patients: experience in the integration of department of emergency and intensive care unit of Yichang Central People's Hospital in Hubei Province

Yichang Central People's Hospital is a large prefecture-level tertiary hospital in Hubei Province. Since the late foundation and interdisciplinary characteritics, the department of emergency and critical care medicine faced many difficulties during development. Based on the actual situation of the hospital, leaders of the hospital and two disciplines advocated their core values of "putting patients' interests first and building team spirit". In consideration of the timeliness, multidisciplinary collaboration and importance of critical care, the department of emergency and critical care medicine in Yichang Central People's Hospital of Hubei Province was set up, and an integrated first-aid platform was established. The concept of "5-minute emergency life chain" was proposed, which highlighted the status and role of the department of emergency and critical care medicine in modern medical rescue and modern general hospitals. In the past 5 years, the emergency department and intensive care unit have made rapid development, including successful establishment of national demonstration centers for chest pain and stroke. Quality of the discipline has also been greatly improved, and a new construction path of department of the emergency and critical care medicine has been created.

Dawn Elizabeth Hazlehurst

Dawn Elizabeth Hazlehurst was a very experienced, committed, and dedicated general practitioner. She grew up in Manchester, attended Manchester University Medical School, and carried out her training in hospitals throughout...

Evaluation of patients with dizziness who applied to emergency service

Purpose: The aim of this study was to evaluate the demographic characteristics of the patients presenting to the emergency room with dizziness, the etiologic causes leading to the complaints and the laboratory findings as well as the prognosis.Materials and methods: The file data of a total of 5,056 patients admitted to the Adana Numune Training and Research Hospital Emergency Medicine Clinic between January 2013 and January 2015 were reviewed retrospectively. Mean, standard deviation, median, lowest, highest, frequency and ratio values were used in the descriptive statistics of the data. Results: Two thousand nine hundred four of the patients were female (57.4%), 2,152 were male (42.6%) and the average age was 53.6 (± 18.2) years. It was determined that the complaints were common in the population between the ages of 51-70, and peripheric peripheral vertigo (n: 4.130, 81.6%), systemic causes (n: 664, 13.1%), and central vertigo (n: 249, 4.9%) were the most prevalent etiologies, respectively. It was determined that 83% of the patients were discharged following necessary procedures in the emergency room.Conclusion: Dizziness is one of the most important symptoms that bring patients to the emergency services. While many etiologies play a part, it is determined that neurological and cardiological evaluations must be done. Patients can mainly be managed in emergency services by simple maneuvering or medical treatment options.

Use of Advance Care Planning Billing Codes for Hospitalized Older Adults at High Risk of Dying: A National Observational Study.

We analyzed advance care planning (ACP) billing for adults aged 65 years or above and who were managed by a large national physician practice that employs acute care providers in hospital medicine, emergency medicine and critical care between January 1, 2017 and March 31, 2017. Prompting hospitalists to answer the validated "surprise question" (SQ; "Would you be surprised if the patient died in the next year?") for inpatient admissions served to prime hospitalists and triggered an icon next to the patient's name. Among 113,621 hospital-based encounters, only 6,146 (5.4%) involved a billed ACP conversation: 8.3% among SQ-prompted who answered "no" and 4.1% SQ-prompted who answered "yes" (for non-SQ prompted cases, the fraction was 3.5%; P < .0001). ACP conversations were associated with a comfort-focused care trajectory. Low ACP rates among even those with high hospitalist-predicted mortality risk underscore the need for quality improvement interventions to increase hospital-based ACP.

A Qualitative Study of Risks Related to Interhospital Transfer of Patients with Nontraumatic Intracranial Hemorrhage

Goal: Interhospital transfer (IHT) facilitates access to specialized neurocritical care but may also introduce unique risk. Our goal was to describe providers’ perceptions of safety threats during IHT for patients with nontraumatic intracranial hemorrhage. Materials and Methods: We employed qualitative, semi-structured interviews at an academic medical center receiving critically-ill neurologic transfers, and 5 referring hospitals. Interviewees included physicians, nurses, and allied health professionals with experience caring for patients transferred between hospitals for nontraumatic intracranial hemorrhage. Interviews continued until data saturation was reached. Coding occurred concurrently with interviews. Analysis was inductive, using the constant comparative method. Findings: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. Insufficient communication highlights the unique communication challenges specific to IHT, which overlay and compound known intrahospital communication barriers. Gaps in clinical practice revolve primarily around the provision of neurocritical care for this patient population, often subject to resource availability, by receiving hospital emergency medicine providers. Lack of structure outlines providers’ questions that emerge when institutions fail to identify process channels, expectations, and accountability during complex neurocritical care transitions. Conclusions: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. These themes serve as fundamental targets for quality improvement initiatives. To our knowledge, this is the first description of challenges to quality and safety in high-risk neurocritical care transitions through clinicians’ voices.

Point-of-Care Ultrasonography (POCUS) in a Community Emergency Department: An Analysis of Decision Making and Cost Savings Associated With POCUS.

Point-of-care ultrasonography (POCUS) is an increasingly integral part of emergency medicine. This study investigated community emergency department physicians' choices regarding ultrasonography as a branch point in clinical decision making. During shifts covering all days of the week and all time-spans over a 3-month period, emergency department physicians were interviewed whenever POCUS was used. Questions focused on the role of POCUS in clinical management and on tests avoided because of ultrasonography use. Cost savings attributable to POCUS were calculated using Center for Medicare and Medicaid Services and FairHealth data. Anonymization of data precluded follow-up testing to account for misdiagnosis. On average, POCUS use eliminated $1134.31 of additional testing for privately insured patients, $2826.31 for out-of-network or uninsured patients, and $181.63 for Center for Medicare and Medicaid Services patients. Differences were significant when the total cost of eliminated additional testing was compared to a baseline of no savings (p < .001). Aggregate cost savings remained significant when analyses were broadened to include POCUS encounters that did not yield changes in management (p < .001). When physicians' clinical expertise suggests that POCUS may be indicated, its use results in significant cost savings, even in encounters in which management is not directly impacted. POCUS, when incorporated earlier and more frequently into community hospital emergency medicine diagnostic protocols, can lower direct and indirect costs associated with diagnostic workups. Community emergency departments, in particular, would benefit from additional investigation informing specific guidelines for the integration of POCUS into clinical management and the role that this has in cost savings.

病院前診療から繋ぐdirect CTの有用性と適応についての検討(Examination of the availability and indication of direct CT system lead to pre–hospital emergency medicine)

要旨【目的】全身CTから得られる情報は，重症外傷の治療戦略の決定に重要である。我々は病院前での診療結果から，重症外傷例では搬入時に全身CTを撮影する（以下direct CT）工夫を行ってきた。本戦略の有用性と適応を明らかにする。【対象】2010年4月から2017年1月の間に，病院前診療を行い体幹部緊急手術and/or血管塞栓術を要した88例をdirect CTの適応および実施の有無に分け，予後，時間，重症度等について比較した。【結果】18例が蘇生優先や手術室直入のためdirect CT適応外であった。残り70例のうち45例にdirect CTを実施し，根治的治療までの時間は実施群の方が早く（実施群vs. 非実施群 = 62分vs. 78分，P&lt;0.01），標準化死亡比は0.30（95%CI 0.05–0.62）と0.61（95%CI 0.17–1.36）であった。direct CT適応外症例の標準化死亡比は0.37（95%CI 0.11–0.80）で，direct CT実施群と比較し病院前輸液量が多く血圧は低値で，カットオフ値は輸液量695mL/h，病院到着前の収縮期血圧94mmHgであった。【結語】direct CTは根治的治療までの時間を短縮し予後を改善する可能性があり，病院前診療で蘇生のための輸液を695mL/h以上要するが病院到着前血圧が95mmHg以上を満たす症例が適応となる。

An assessment of emotional intelligence in emergency medicine resident physicians.

ObjectivesTo define the emotional intelligence (EI) profile of emergency medicine (EM) residents, and identify resident EI strengths and weaknesses. MethodsFirst-, second-, and third-year residents (post-graduate years [PGY] 1, 2, and 3, respectively) of Thomas Jefferson University Hospital’s EM Program completed the Emotional Quotient Inventory (EQ-i 2.0), a validated instrument offered by Multi-Health Systems. Reported scores included total mean EI, 5 composite scores, and 15 subscales of EI. Scores are reported as means with 95% CIs. The unpaired, two-sample t-test was used to evaluate differences in means. ResultsThirty-five residents completed the assessment (response rate 97.2%). Scores were normed to the general population (mean 100, SD 15). Total mean EI for the cohort was 103 (95%CI,100-108). EI was higher in female (107) than male (101) residents. PGY-2s demonstrated the lowest mean EI (95) versus PGY-1s (104) and PGY-3s (110). The difference in PGY-3 EI (110; 95%CI,103-116) and PGY-1 EI (95, 95%CI,87-104) was statistically significant (unpaired t-test, p<0.01). Highest composite scores were in interpersonal skills (107; 95%CI,100-108) and stress management (105; 95%CI,101-109). Subscale cohort strengths included self-actualization (107); empathy (107); interpersonal relationships (106); impulse control (106); and stress tolerance (106). Lowest subscale score was in assertiveness (98). Self-regard (89), assertiveness (88), and independence (90) were areas in which PGY-2s attained relatively lower scores (unpaired t-test, p<0.05) compared to their peers and the general population. PGY-3’s scored highest in nearly all subscales. ConclusionsThe EQ-i offers insight into training that may assist in developing EM residents, specifically in self-regard, assertiveness, and self-expression. Further study is required to ascertain if patterns in level of training are idiosyncratic or relate to the natural maturation of residents.

Acute chest pain

Patients presenting with acute chest pain are a challenge for attending physicians in private practice and specialists for emergency and acute medicine in hospitals because awide spectrum of diagnoses may be the cause, ranging from acute myocardial infarction (AMI) to harmless muscular tension. The evaluation of patients with acute chest pain follows basic principles independent of the setting: Athorough clinical investigation by the responsible physician including medical history and physical examination, followed by a12-channel electrocardiogram (ECG) and further focused diagnostics. The decision about hospital admission, monitoring and further diagnostic steps depends on the estimation of vital risk, the tentative diagnosis and the available diagnostic tools. Besides the ECG, laboratory tests (cardiac troponin, copeptin) and cardiac imaging (primarily the echocardiography) play akey role. Patients who did not necessarily require hospital admission (e. g. after exclusion of AMI) should be offered an inpatient or outpatient concept which enables the timely diagnosis and potential treatment of all relevant diseases in question. The diagnostic strategies need to take into account the pretest probability and for patients with confirmed diagnosis of an acute coronary syndrome (ACS), continuous monitoring and transfer to an emergency department with integrated chest pain unit (CPU) is strongly recommended. In this context, close collaboration between the emergency department and the physicians in private practice should be established.

Online survey of the organizational structures of emergency neurology in Germany

In 2007, the first poll among neurologists provided some insight into the organizational structures of emergency neurology in Germany. Given that emergency neurology as well as emergency medicine in general have undergone substantial changes during the last decade, the subcommittee Neurological Emergency Medicine of the German Neurological Society conducted afollow-up study to explore current structures supporting neurological emergency medicine in German neurological hospitals. Between July and September 2016, an online questionnaire was e‑mailed to 675 neurologists in institutions participating in in-patient neurological care. Of these, some 32% (university hospitals 49%) answered. Neurological patients represent 12-16% and hence asignificant proportion of emergency patients. The fraction of in-patients admitted to hospitals via emergency departments amounted to 78% (median) in general hospitals and 52% in university hospitals. Most emergency departments are organized as an interdisciplinary structure combining conservative with surgical disciplines frequently led by an independent department head. Neurology departments employ rather diverse strategies to organize neurological emergency care. Also, the way emergency patients are assigned to different disciplines varied largely. Currently, neurological patients represent arather growing fraction of patients in emergency departments. An increasing proportion of neurology in-patients enter the hospital via emergency departments. Neurology departments in Germany face increasing challenges to cope with large numbers of neurological emergency patients. While most of the participating neurologists indicated suffering predominantly from scarce personal resources both in neurology and neuroradiology, an independent neurological emergency department was not considered an option.

An Evaluation of Risk Attitudes and Risk Tolerance in Emergency Medicine Residents.

IntroductionPrevious studies have shown that risk attitudes and tolerance for uncertainty are significant factors in clinical decision-making, particularly in the practice of defensive medicine. These attributes have also been linked with rates of physician burnout. To date, the risk profile of emergency medicine (EM) physicians has not yet been described. Our goal was to examine the risk profile of EM residents using a widely available risk tolerance and attitude assessment tool.MethodsFirst-, second-, and third-year residents of Thomas Jefferson University Hospital’s EM residency program completed the commercially available, unmodified Risk Type Compass, a validated instrument offered by Multi-Health Systems (MHS Inc, New York, USA). Scored reports included information on residents’ risk type (one of eight personality types that reflect their temperament and disposition); risk attitudes (domains where residents are more likely to engage in risky behaviors); and an overall risk tolerance indicator (RTi) (a numerical estimate of risk tolerance). RTi scores are reported as means with 95% confidence intervals (CIs).ResultsThere was no significant change in RTi scores in residents across different years of their post-graduate year (PGY) training. PGY-one residents trended towards risk aversion; PGY-two residents were more risk-taking; and PGY-three residents scored in the middle.ConclusionOur pilot assessment of risk types in EM residents highlighted shifts across the years of training. Variations between members of each PGY cohort outweighed any outright differences between classes with regards to absolute risk tolerance. There was an increase in the frequency of health and safety risk-taking attitude with higher PGY class, and this was also the risk attitude that was the prominent domain for resident risk tolerance. The study was limited by sample size and single cross-sectional evaluation.

Development of a Quality Improvement/Patient Safety Curriculum to Increase Emergency Medicine Resident Scholarly Activity.

CONTEXTThere currently is no standard method for teaching Quality Improvement/Patient Safety (QIPS) content to prepare resident physicians planning QIPS projects. As part of the 2015-2016 MSU Statewide Campus System Teach for Quality (Te4Q) learner cohort, the first two authors from the McLaren Oakland Hospital Emergency Medicine (EM) residency program developed a structured multi-phase QIPS curriculum. The curriculum was developed to help a cohort of seven second-year EM residents feel more confident to design and conduct their own QIPS projects.METHODSAfter institutional review board project approval was obtained, the first two authors evaluated both the pre and post-curriculum confidence survey scores of enrolled EM residents during May, 2016 as part of their Te4Q program participation.RESULTSResidents completed a 15-item QIPS confidence survey before and after completing the QIPS curriculum. The mean pre-curriculum score was 3.00 (SD 1.53) on a scale from 0 to 10, indicating that the average sample respondent felt a lower level of comfort concerning their ability to design and conduct a prospective QIPS project. The mean post-curriculum confidence score from residents increased to 6.71 (SD 1.25) on a 0 to 10 scale, over double an increase from the pre-workshop score on this item. Using a series of non-parametric Wilcoxon Matched Pairs Signed Rank Test procedures suitable for smaller samples, statistically significant increases in pre- to post-curriculum differences were shown for composite confidence scores (Z = 2.207, p = 0.027), as well as for five of the 12 individual confidence items (p-values ranged from 0.023 to 0.046).CONCLUSIONSThese initial results certainly indicate that a structured ongoing QIPS curriculum may have the potential to improve EM residents’ confidence levels to design and implement QIPS projects with faculty. The impact of these types of curricula for EM and other types of residents needs to be more rigorously examined in more tightly controlled GME settings with larger samples to gauge what types of resident learners will more likely benefit from such educational offerings across the nation.

Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the "Acute Care" Anesthesiologist?

Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the "Acute Care" Anesthesiologist?

Lactate Clearance Predicts Survival Among Patients in the Emergency Department with Severe Sepsis.

IntroductionLactate clearance has been implicated as a predictor of mortality among emergency department (ED) patients with severe sepsis or septic shock. We aimed to validate prior studies showing that lactate clearance during the ED stay is associated with decreased mortality.MethodsRetrospective dual-centered cross-sectional study using patients identified in the Yale-New Haven Hospital Emergency Medicine sepsis registry with severe sepsis or septic shock who had initial lactate levels measured in the ED and upon arrival (<24 hours) to the hospital floor. Lactate clearance was calculated as percent of serum lactate change from ED to floor measurement. We compared mortality and hospital interventions between patients who cleared lactate and those who did not.Results207 patients (110 male; 63.17±17.9 years) were included. Two reviewers extracted data with 95% agreement. One hundred thirty-six patients (65.7%) had severe sepsis and 71 patients (34.3%) had septic shock. There were 171 patients in the clearance group and 36 patients in the non-clearance group. The 28-day mortality rates were 15.2% in the lactate clearance group and 36.1% in the non-clearance group (p<0.01). Vasopressor support was initiated more often in the non-clearance group (61.1%) than in the clearance group (36.8%, p<0.01) and mechanical ventilation was used in 66.7% of the non-clearance group and 36.3% of the clearance group (p=0.001).ConclusionPatients who do not clear their lactate in the ED have significantly higher mortality than those with decreasing lactate levels. Our results are confirmatory of other literature supporting that lactate clearance may be used to stratify mortality-risk among patients with severe sepsis or septic shock.

Comparison of carbon monoxide poisonings originated from coal stove and natural gas and the evaluation of Neutrophil/Lymphocyte ratio

Objective: The aim of our study is to present the epidemiologic, clinical, laboratory and prognosis differences between the coal stove origin poisoning and natural gas leakages. We also aimed to investigate relationship between the severity of clinical picture, prognosis, complications develop in CO poisoning with neutrophil/lymphocyte ratio (NLR) at the initial admission. Methods: All the acute carbon monoxide cases who applied to Ankara Training and Research Hospital Emergency Medicine Clinic between October 2009 and April 2010 were included to this prospective study. CO poisoning diagnosis was made by the history of CO poisoning with carboxyl hemoglobin (COHb) concentration is over 10%. 100 patients were included to our study. Results: Of the patients, 55(55%) were poisoned from the coal-stove and 45(45%) from natural gas leakage. The mean COHb level of the natural gas group was significantly high (p=0.01). The mean value of GCS of the natural gas group was significantly lower (p=0.018). The number of patients with indication for HBO therapy were 17 and 6 in the natural gas group and coal-stove group, respectively, being significantly higher in the natural gas group(p=0.001). There was no statistically significant relationship between the value of NLR and values of COHb, troponin, and GCS (p=0.872, p=0.470, and p=0.896, respectively). Conclusions: Carbon monoxide poisoning from natural gas leakage is more toxic than that from the coal-stove. There is no relationship between NLR at the time of presentation and the severity of clinical findings, prognosis and complications. Key words: Carbon monoxide poisoning, coal-stove; natural gas, Neutrophil/lymphocyte ratio

The embeddedness of organizational performance: Multiple Membership Multiple Classification Models for the analysis of multilevel networks

We present a Multiple Membership Multiple Classification (MMMC) model for analysing variation in the performance of organizational sub-units embedded in a multilevel network. The model postulates that the performance of organizational sub-units varies across network levels defined in terms of: (i) direct relations between organizational sub-units; (ii) relations between organizations containing the sub-units, and (iii) cross-level relations between sub-units and organizations. We demonstrate the empirical merits of the model in an analysis of inter-hospital patient mobility within a regional community of health care organizations. In the empirical case study we develop, organizational sub-units are departments of emergency medicine (EDs) located within hospitals (organizations). Networks within and across levels are delineated in terms of patient transfer relations between EDs (lower-level, emergency transfers), hospitals (higher-level, elective transfers), and between EDs and hospitals (cross-level, non-emergency transfers). Our main analytical objective is to examine the association of these interdependent and partially nested levels of action with variation in waiting time among EDs – one of the most commonly adopted and accepted measures of ED performance. We find evidence that variation in ED waiting time is associated with various components of the multilevel network in which the EDs are embedded. Before allowing for various characteristics of EDs and the hospitals in which they are located, we find, for the null models, that most of the network variation is at the hospital level. After adding these characteristics to the model, we find that hospital capacity and ED uncertainty are significantly associated with ED waiting time. We also find that the overall variation in ED waiting time is reduced to less than a half of its estimated value from the null models, and that a greater share of the residual network variation for these models is at the ED level and cross level, rather than the hospital level. This suggests that the covariates explain some of the network variation, and shift the relative share of residual variation away from hospital networks. We discuss further extensions to the model for more general analyses of multilevel network dependencies in variables of interest for the lower level nodes of these social structures.

Key Factors in Hospital Crisis Response-An Example of Violence in Emergency Medicine

The medical personnel has to particularly pay attention to the treatment processes, including medication, attitudes, and interaction, as a lot of violence in emergency medicine shows no absolute relationship with medical profession. However, finding out the sign of violence in emergency medicine in advance to further reduce the occurrence of violence in emergency medicine is a favorable approach. The nurses, doctors, and the public in emergency rooms of Kaohsiung Veterans General Hospital are investigated in this study. Total 300 copies of questionnaires are distributed, and 176 valid copies are retrieved, with the retrieval rate 59y. The research results show the top five indicators, among 12 evaluation indicators, appear Judgment Competence, Afterward Disposal, Potential Crisis, Decisive Management, and Command and Dispatch. Some suggestions are proposed in the conclusion in this study, expecting to assist in the worry of violence in emergency medicine in hospitals.