High Patient Flow Research Articles

Evaluation of urea breath test as a diagnostic tool for Helicobacter pylori infection in adult dyspeptic patients

In this editorial, we discuss the article in the World Journal of Gastroenterology . The article conducts a meta-analysis of the diagnostic accuracy of the urea breath test (UBT), a non-invasive method for detecting Helicobacter pylori (H. pylori) infection in humans. It is based on radionuclide-labeled urea. Various methods, both invasive and non-invasive, are available for diagnosing H. pylori infection, including endoscopy with biopsy, serology for immunoglobulin titers, stool antigen analysis, and UBT. Several guidelines recommend UBTs as the primary choice for diagnosing H. pylori infection and for reexamining after eradication therapy. It is used to be the first choice non-invasive test due to their high accuracy, specificity, rapid results, and simplicity. Moreover, its performance remains unaffected by the distribution of H. pylori in the stomach, allowing a high flow of patients to be tested. Despite its widespread use, the performance characteristics of UBT have been inconsistently described and remain incompletely defined. There are two UBTs available with Food and Drug Administration approval: The 13C and 14C tests. Both tests are affordable and can provide real-time results. Physicians may prefer the 13C test because it is non-radioactive, compared to 14C which uses a radioactive isotope, especially in young children and pregnant women. Although there was heterogeneity among the studies regarding the diagnostic accuracy of both UBTs, 13C-UBT consistently outperforms the 14C-UBT. This makes the 13C-UBT the preferred diagnostic approach. Furthermore, the provided findings of the meta-analysis emphasize the significance of precise considerations when choosing urea dosage, assessment timing, and measurement techniques for both the 13C-UBT and 14C-UBT, to enhance diagnostic precision.

Factors Affecting the Implementation of Nursing Care Plans in Patient Care

Abstract: Background: Nursing Care Plan (NCP) is used in practice as a systematic and scientific problem-solving method to determining the care needs of individuals. There is lack of research on factors affecting regarding utilization of nursing care plan in patient care. Objective: The objective of this study were to evaluate the implementation of the nursing process and to determine the factors that may influence the implementation of the nursing process. Materials and Methods: A cross-sectional survey was conducted at a private hospital during February to June, 2023. The study protocol was reviewed and approved. Permission from institutional heads was sought. Informed consent was obtained before data collection. Simple random sampling method was employed. The data were collected with structured questionnaires whose responses were rated on Likert scale. Data were coded and analyzed using SPSS v25.0. Result: A total 108 nurses participated in the study. Study findings revealed 89% of the nurses were female nurses and 82% possessed diploma in nursing. The knowledge 50.5%, confidence 50.9% and willingness 54.2%, were at borderline good level. Whereas, assessment and diagnosis, planning, implementation, evaluation, and nurses’ views about nursing care planning implementation were at < 50% as poor. There was a moderate positive correlation between knowledge and implementation R-Value 0.312 and confidence and evaluation R-Value 0.246. Barrier to implement nursing process included uncooperative patients, lack of awareness about nursing process, lack of preparedness, low satisfaction level, lack of in-service training, lack of time, and high patient flow. Conclusion: Study’s findings revealed knowledge, confidence and willingness of the nurses determine the use of nursing process in their nursing practice.

Risk factors for adverse outcomes of percutaneous endoscopic gastrostomy

Introduction. Presently, percutaneous endoscopic gastrostomy is considered to be the operation of choice when long-term enteral feeding in dysphagia syndrome is required. The technique is characterized by low incidence of early and long-term complications due to low traumatic access and operation time. Aim of the work was to assess the risk predictors of percutaneous endoscopic gastrostomy complications and their significance for the postoperative period. Materials and methods. We searched publications and analyzed literature sources using PubMed and MedLine databases and Cochrane Library and elibrary.ru scientific libraries mainly for the last ten years. The search was performed using a set of key words: percutaneous endoscopic gastrostomy, dysphagia syndrome, postoperative complications, risk factors. Results and discussion. The leading and most studied predictors of early and long-term postoperative period complications after gastrostomy are hypoalbuminemia, uncompensated diabetes mellitus, thrombocytopenia, elevated levels of C-reactive protein, Charlson's comorbidity index (4 points or higher), antiaggregant and anticoagulant therapy, morphoconstitutional features of patients. Conclusion. Data analysis has shown that percutaneous endoscopic gastrostomy at high patient flow and gastropectomy supplementation with gastropexy is practically safe and effective if the selection criteria for the operation are observed taking into account the general condition, risk factors and exclusion of absolute contraindications.

Spondylodiscitis Associated with Multiple Vascular Accesses for Hemodialysis

Introduction: Spondylodiscitis (also called vertebral osteomyelitis) is the most frequent form of bone involvement. The most frequently isolated pathogen is S. aureus (more than 50% of cases), which can lead to disabilities and even death [4]. The most common pathogenic route is hematogenous dissemination, favored by the irrigation system of the spinal column, mainly affecting the lumbar spine due to its greater vascularization [5]. Case Report: A 67-year-old female with a history of stage 5 chronic kidney disease secondary to nephroangiosclerosis due to arterial hypertension, on renal replacement therapy 13 years ago, initially with peritoneal dialysis for approximately 11 years, with subsequent admission to three-weekly hemodialysis 2 years ago. Presents sudden mild to moderate low back pain, increasing progressively for 2 weeks, becoming incapacitating; presented painful lumbar region with active movements; flexoextension of the lower limbs limited by pain, right lower limb: positive straight leg raise (SLR) test and Lasègue’s sign. A magnetic resonance of the spine showed signs of spondylodiscitis between L4/L5 vertebrae, conditioning spinal canal stenosis; disc protrusion between L3-L4 and L4-L5 vertebrae; a probable abscess in the left multifidus muscles and a fluid collection in the right iliac muscle. Conclusions: Early identification of high-risk patients could improve patients’ safety and care. Implementation of diagnostic scores should be evaluated in centers with high flow of hemodialysis patients. Pain relief should be assessed appropriately and warranted for patients who overcome spondylodiscitis to improve their quality of life. Adequate treatment, initialized by prompt intravenous broad-spectrum antibiotic administration should be given to diminish morbidity and mortality.

Utilization of pharmacological labour analgesia: a survey of obstetric care providers in eastern Ethiopia.

Despite a crucial role played by obstetric care providers (OCPs) in providing pain relief methods during labour, the evidence suggests that there is a large number of women in Ethiopia who did not have access to pain relief methods. Moreover, to the best of the investigators' knowledge, evidence is scarce regarding the utilization of pharmacological labour pain management methods in the study area. Thus this study was carried out to determine the practice of pharmacological labour pain management methods among OCPs in Harari regional state health facilities in Ethiopia. A facility-based cross-sectional study was conducted from 20 May to 10 June 2021 in Harari regional state health facilities. All (n=464) OCPs in Harari regional state health facilities were included in the study. Data were collected using a structured questionnaire adapted from previous studies. The data were entered into Epi-data version 3.1 statistical software. Statistical analysis was carried out using SPSS for Windows version 22. Bivariate and multivariate logistic regression analyses were employed to determine the association between independent variables and the outcome variable. A p-value <0.05 was used to establish statistical significance. In this study, 464 OCPs participated. The overall utilization of pharmacological labour pain relief methods was 50.9% (95% confidence interval [CI] 45.8 to 55.8). The main barriers to labouring mothers receiving pain relief include high patient flow (54.4%), the limited number of staff (51.9%) and a lack of knowledge and skill (32.9%). Being female (adjusted odds ratio [AOR] 2.07 [95% CI 1.31 to 3.26]), not having training (AOR 1.60 [95% CI 1.02 to 2.53]) and having an unfavourable attitude (AOR 9.1 [95% CI 5.34 to 15.35]) were the predictors of utilization of pharmacological labour pain management methods. The study revealed that half of the OCPs utilized the pharmacological labour pain management method. In general, this study identified that variables like sex, training and the attitude of OCPs were factors associated with the utilization of pharmacological labour pain management methods. The health facilities should provide training to enhance the skill of OCPs and equip themselves with sufficient analgesic drugs.

Assessed and discharged – diagnosis, mortality and revisits in short-term emergency department contacts

BackgroundEmergency departments (EDs) experience an increasing number of patients. High patient flow are incentives for short duration of ED stay which may pose a challenge for patient diagnostics and care implying risk of ED revisits or increased mortality. Four hours are often used as a target time to decide whether to admit or discharge a patient.ObjectiveTo investigate and compare the diagnostic pattern, risk of revisits and short-term mortality for ED patients with a length of stay of less than 4 h (visits) with 4–24 h stay (short stay visits).MethodsPopulation-based cohort study of patients contacting three EDs in the North Denmark Region during 2014–2016, excluding injured patients. Main diagnoses, number of revisits within 72 h of the initial contact and mortality were outcomes. Data on age, sex, mortality, time of admission and ICD-10 diagnostic chapter were obtained from the Danish Civil Registration System and the regional patient administrative system. Descriptive statistics were applied and Kaplan Meier mortality estimates with 95% CI were calculated.ResultsSeventy-nine thousand three hundred forty-one short-term ED contacts were included, visits constituted 60%. Non-specific diagnoses (i.e. symptoms and signs and other factors) were the most frequent diagnoses among both visits and short stay visits groups (67% vs 49%). Revisits were more frequent for visits compared to short stay visits (5.8% vs 4.2%). Circulatory diseases displayed the highest 0–48-h mortality within the visits and infections in the short stay visits (11.8% (95%CI: 10.4–13.5) and (3.5% (95%CI: 2.6–4.7)). 30-day mortality were 1.3% (95%CI: 1.2–1.5) for visits and 1.8% (95%CI: 1.7–2.0) for short stay visits. The 30-day mortality of the ED revisits with an initial visit was 1.0% (0.8–1.3), vs 0.7% (0.7–0.8) for no revisits, while 30-day mortality nearly doubled for ED revisits with an initial short stay visit (2.5% (1.9–3.2)).ConclusionsMost patients were within the visit group. Non-specific diagnoses constituted the majority of diagnoses given. Mortality was higher among patients with short stay visits but increased for both groups with ED revisits. This suggest that diagnostics are challenged by short time targets.

Difficulties in the Management of Placenta Accreta Spectrum in Hospitals with Limited Resources.

Placenta accreta spectrum (PAS) is a serious diseases, and the recommendation is that the treatment is conducted in centers of excellence. Such hospitals are not easy to find in low- and middle-income countries. We seek to describe the process of prenatal diagnosis, surgical management, and postnatal histological analysis in a low-income country referral hospital with limited resources. A descriptive, retrospective study was carried out including patients with a pre- or intraoperative diagnosis of PAS. The clinical results of the patients were studied as well as the results of the prenatal ultrasound and the correlation with the postnatal pathological diagnosis. In total, 129 patients were included. Forty-eight of them had a prenatal PAS ultrasound diagnosis (37.2%). In the remaining 81 (62.8%), the diagnosis was intraoperative.Although hysterectomy was performed in all cases, one-third of the patients (31%) did not have a histological study of the uterus. In 40% of the patients who had a histological study, PAS was not reported by the pathologist. The frequency of prenatal diagnosis and the availability of postnatal histological studies were very low in the studied population. Surgical skill, favored by a high flow of patients, is an important factor to avoid complications in settings with limited resources.

Paradoxical consequences of CBHI scheme in rural Ethiopia: Enrollees’ perceived preferential treatment to paying clients and concomitant problems

Though financial protection and improvement in health seeking behavior of rural societies is the intended role of health insurance schemes, empirical evidence indicated that the scheme faced multitude of implementation challenges. This paper examined insurance enrollees’ perceived preferential treatment for paying clients and other concomitant problems in Eastern Gojjam district of north western Ethiopia. Researchers conducted in-depth interviews with 53 enrollees, six FGDs (with a total of 48 discussants) and 7 key informants with professionals from public healthcare facilities and other health insurance administrators. The data encoding, transcription, and thematic analysis process was all conducted manually. Findings indicated that, despite the economic relief households gained, the thrust on the service delivery process seems to be far behind. Comparing them with paying patients combined with the presumed “free medical treatment” that they associated with the insurance, the perceived preferential treatment for paying patients by practitioners seems common. Due to this, most participants hold a belief that visiting private health facilities during critical illness appears preferable to get quality health service. The perceived preferential treatment is alleged to be happening during consultation with physicians, medicine prescription, referral service, patient flow management, and others. Shortage of drugs induced frequent stock out and thereby prolonged reimbursement process, high patient flow induced over load in public health facilities, unnecessary price increment by private pharmacies on insurance beneficiaries and confusion on annual renewal payment without using service are all concomitant problems. Necessary awareness creation interventions and also improvements of public health facilities are recommended.

Telemedicine facilitates surgical training in placenta accreta spectrum.

The training of groups responsible for managing patients with placenta accreta spectrum (PAS) is complex because of the lack of hospitals with a high flow of patients and absence of formal educational programs. We report here the results of a virtual training program (VTP) that implemented one-step conservative surgery (OSCS). A prospective observation study of OSCS VTP between three expert groups and PAS reference hospitals without experience in OSCS was performed. Accessible or cost-efficient web meeting platforms were used to implement the VTP components: baseline observation of the participant's prior knowledge; instructions about essential PAS surgery topics; case selection and joint planning of surgery; expert group "telepresence" during surgery and postoperative debriefing. One-step conservative surgery was performed successfully at six hospitals. All patients had increta/percreta with a median intraoperative bleeding of 1300ml (IQR 825-2325) and surgical time of 184min (IQR 113-240). All groups considered the VTP very useful (n=33, 97%) or useful (n=1, 3%), they would use it again (definitely: n=27, 81.8%; or probably: n=6, 18.2%), and they would recommend it to other colleagues. Tele education and telepresence during PAS surgery facilitates the implementation of OSCS in selected cases.

A Systematic Review on Lean Applications' in Emergency Departments.

This article presents the state of the art of Lean principles applied in Emergency Departments through a systematic literature review. Our article extends previous work found in the literature to respond to the following questions: (i) What research problems in emergency departments can Lean principles help overcome? (ii) What Lean approaches and tools are used most often in this environment? (iii) What are the results and benefits obtained by these practices? and (iv) What research opportunities appear as gaps in the current state of the art on the subject? A six-step systematic review was performed following the guidance of the PRISMA method. The review analysis identified six main research problems where Lean was applied in Emergency Departments: (i) High Waiting Time and High Length of Hospital Stay; (ii) Health Safety; (iii) Process redesign; (iv) Management and Lessons Learned; (v) High Patient Flow; (vi) Cost Analysis. The six research problems’ main approaches identified were Lean Thinking, Multidisciplinary, Statistics, and Six Sigma. The leading Lean tools and methodologies were VSM, Teamwork, DMAIC, and Kaizen. The main benefits of applying Lean Principles were (a) reductions in waiting time, costs, length of hospital stay, patient flow, and procedure times; and (b) improvements in patient satisfaction, efficiency, productivity, standardization, relationships, safety, quality, and cost savings. Multidisciplinary integration of managers and work teams often yields good results. Finally, this study identifies knowledge gaps and new opportunities to study Lean best practices in healthcare organizations.

Ultrasound assessment of optic nerve sheath diameter for evaluation of elevated intracranial pressure in patient with head trauma: A comparative study with CT head

Purpose: Increased intracranial pressure (ICP) is complication of traumatic brain injury. Early detection of raised ICP is helpful in timely treatment. Bed side ultrasound of optic nerve sheath is easier for detection of raised intracranial pressure by measuring its diameter. Our aim was to determine whether bedside ultrasound measurement of optic nerve sheath diameter (ONSD) can accurately predict raised intracranial pressure in head injury patients and to calculation of validity of test. Methods and Materials: Total 150 patients with head injury was first examined by ultrasound. The ONSD was measured 3 mm behind the globe perpendicular to long axis of globe in both eyes than mean binocular ONSD was calculated. Diameter more than 5 mm was considered abnormal. CT scan was performed in all patients and result was considered positive for elevated ICP if mid line shift, effacement of sulci, ventricles and cisterns are seen. Results: Out of total 150 patients 61 was female and 89 was male, age was ranging from 23-61 years. 30 patients showed mean binocular ONSD >5mm by ultrasound out of them 26 patients showed positive signs of raised intracranial pressure on CT. Sensitivity and negative predictive value of ultrasound to detect raised ICP was 100%, Specificity was 96.7 % and negative predictive value was 86.6 %. Conclusions: Ultrasound can be used as bed side screening tool to detect raised ICP in ICU patients and head trauma patients especially in hospital with high patient flow in emergency department.

Comparative analysis of hospital environments in Australia and China using the space syntax approach

PurposeSpatial arrangement of hospital environments has been proven to have impacts on hospital users such as wayfinding, privacy and operational efficiency. Many studies examined the spatial quality of hospitals, but there is a lack of comparative research between Chinese and Australian hospitals. Hospitals in both countries have salient features that are worth to learn and can inform hospital stakeholders internationally on design decisions. The purpose of this paper is to evaluate and compare the spatial quality of hospitals from both countries using space syntax approach and field observation.Design/methodology/approachThis study uses space syntax analysis and observation to provide qualitative and quantitative data. Illustrative case studies from both countries are selected for comparison. The main benchmarks involved in measuring the spatial qualities, such as step depth and visual connectivity, are analysed using Depthmap X before comparing with the results from observation.FindingsFor Chinese hospitals to be more human-centred, public space design and facility management need additional attention. Australian hospitals could learn from Hospital D on how to design highly centralised nursing stations that cope with a high patient flow. Global policy and decision-makers should consider the potential inconsistency between initial design intention and practical use.Originality/valuePractical implications were made based on the results for bettering hospital environments. It is hoped that the methodology presented in this research is of significance to the enhancement of global healthcare environment research.

Clinical and epidemiologic features of psoriasis patients in an Egyptian medical center

BackgroundIdentification of epidemiologic and phenotypic variations of psoriasis among different ethnic groups can further our understanding of this perplexing disease, aiming at better management of patients worldwide.ObjectiveTo provide a descriptive analysis of psoriasis patients registered at Kasr Al-Ainy Psoriasis Unit Disease Registry.MethodsThis retrospective single-center registry study included patient records between November 2015 and November 2018 (2534 patients). Sociodemographic and phenotypic data were analyzed.ResultsThe mean age of the registered patients was 39.3 years and 56.3% were men. Stress was the main precipitating factor (48.3%), whereas the most common symptom reported was itching (82.4%). The median body mass index was 27.5, and the median percentage of body surface area involved was 10.0. The mean Psoriasis Area Severity Index score was 8.7, and the mean Psoriasis Disability Index score was 13.0. Both parameters correlated positively, and both showed significantly higher means in smokers.LimitationsDespite that the study was performed at a highly specialized tertiary care center with a high flow of patients, this was still a single-center registry.ConclusionsThis work shows that the characteristics of Egyptian patients with psoriasis are comparable to those of other studied ethnic groups, with minor differences.

Georreferenciamento e políticas públicas de acesso à fisioterapia na atenção primária na cidade de Parnaíba-PI

INTRODUÇÃO: O Sistema Único de Saúde (SUS) é uma política pública construída em um contexto de dimensões políticas, tecnológicas e sociais. Embora muito se tenha avançado no SUS, a ampliação do acesso à fisioterapia na atenção primária ainda é um dos seus grandes desafios. A distribuição espacial dos usuários pode fornecer importantes informações sobre políticas públicas voltadas para atenção primária á saúde. OBJETIVO: Analisar a distribuição espacial de usuários do SUS em busca de tratamento no Serviço Escola de Fisioterapia da Universidade Federal do Piauí (SEF-UFPI). MATERIAIS E MÉTODOS: Trata-se de uma pesquisa descritiva documental, quantitativa e retrospectiva. Pacientes com queixas musculoesqueléticas que buscaram tratamento fisioterapêutico no SEF-UFPI nos anos de 2010 a 2017 foram mapeados por meio de georreferenciamento espacial. RESULTADOS: 1476 prontuários foram identificados em 32 bairros distintos. 63% dos pacientes atendidos foram provenientes dos sete bairros mais próximos do SEF-UFPI. A maioria (n=924) dos pacientes era do sexo feminino, com queixas de dores crônicas nos membros inferiores. A cidade de Parnaíba-PI possui aproximadamente 155.000 habitantes e apenas quatro fisioterapeutas cadastrados como membros do NASF. CONCLUSÃO: O elevado fluxo de pacientes que buscaram atendimento fisioterapêutico é proveniente de áreas cobertas pela estratégia de saúde da família. A ausência de fisioterapeutas nestas equipes indica a necessidade urgente de reformulação das políticas públicas de acesso à reabilitação física na atenção primária.

Barriers to infection prevention and control practice among Amhara region teaching hospitals in Ethiopia: Qualitative study

Healthcare workers have good perception towards infection prevention, but there has been a poor practice towards it. Therefore, the aim of this study was to explore barriers to practice of infection prevention and control practice in teaching hospitals in Amhara region. A phenomenological approach used to explore the lived experience of healthcare workers and management staffs towards infection prevention practice and control. The data was collected from ten in-depth interviews and 23 focus group discussion participants, by face to face interview using open ended interview performed in safe and quiet places. Data was managed using OpenCode software version 4.03 and contents were analyzed thematically. Totally ten different barriers were identified, such as availability of facilities, shortage of material supply, lack of maintenance of facilities and equipment, high patient flow, experience, emergency situation, healthcare worker behaviour and healthcare worker’s information about infection prevention, low awareness of patients and visitors and overflow of families and visitors to the hospital. For effective infection prevention practice implementation, barriers should be considered via identifying specific organizational, healthcare worker, patients and visitors as targets.

Man vs machine in emergency medicine \u2013 a study on the effects of manual and automatic vital sign documentation on data quality and perceived workload, using observational paired sample data and questionnaires

BackgroundEmergency medicine is characterized by a high patient flow where timely decisions are essential. Clinical decision support systems have the potential to assist in such decisions but will be dependent on the data quality in electronic health records which often is inadequate. This study explores the effect of automated documentation of vital signs on data quality and workload.MethodsAn observational study of 200 vital sign measurements was performed to evaluate the effects of manual vs automatic documentation on data quality. Data collection using questionnaires was performed to compare the workload on wards using manual or automatic documentation.ResultsIn the automated documentation time to documentation was reduced by 6.1 min (0.6 min vs 7.7 min, p < 0.05) and completeness increased (98% vs 95%, p < 0.05). Regarding workflow temporal demands were lower in the automatic documentation workflow compared to the manual group (50 vs 23, p < 0.05). The same was true for frustration level (64 vs 33, p < 0.05). The experienced reduction in temporal demands was in line with the anticipated, whereas the experienced reduction in frustration was lower than the anticipated (27 vs 54, p < 0.05).DiscussionThe study shows that automatic documentation will improve the currency and the completeness of vital sign data in the Electronic Health Record while reducing workload regarding temporal demands and experienced frustration. The study also shows that these findings are in line with staff anticipations but indicates that the anticipations on the reduction of frustration may be exaggerated among the staff. The open-ended answers indicate that frustration focus will change from double documentation of vital signs to technical aspects of the automatic documentation system.

2113. Process Change Implementation to Decrease Catheter-Associated Urinary Tract Infections

BackgroundMore than 50% of catheter-associated urinary tract infections (CAUTI) occur within 5 days of urinary catheter (UC) insertion suggesting poor insertion technique. Breaks in sterile technique and inappropriate UC kit use were observed resulting in increased insertion-associated CAUTI (iCAUTI, CAUTI occurring ≤5 days post-UC insertion). Specific challenges with UC insertion were identified in the emergency department (ED, high patient flow) and critical care units (CCU, high acuity). The objective of the study was to change the UC insertion process in the ED and CCU to reduce iCAUTI.MethodsThe study included pre-intervention (August 2016–May 2017), implementation (June–December 2017) and post-intervention (January–March 2018) periods. The interventions were use of a buddy system for UC insertions and the reduction of UC insertions in the ED. The buddy system involved critical care nurses inserting UC catheters with another healthcare worker present to ensure correct process and identify breaches in sterile technique. The ED was notified of the patients who (1) received a UC within 24 hours of admission and (2) received the UC in the ED resulting in raised awareness and joint effort between ED and CCU. An iCAUTI rate was calculated for each of the three periods. The proportion of UCs inserted using the buddy system and the proportion of admitted patients with UCs inserted in the ED were calculated.ResultsThe iCAUTI rate decreased by 75.8% between pre-intervention (0.33 iCAUTI/100 UCs inserted) and implementation period (0.08) and increased slightly in post-intervention period (0.16). The ED demonstrated the largest decrease in iCAUTI rate between pre-intervention (0.40) and post-intervention (0.0). Buddy system adherence was 47.3% for the implementation and 58.2% for the post-implementation period. Patients who had UCs inserted in the ED decreased from 59.8% in pre-intervention, to 42.4% in implementation to 35.1% in the post-intervention period.ConclusionA decrease in iCAUTI was observed with the implementation of a buddy system and reduction of UC insertions in the ED. Sustainability of the iCAUTI reduction program will be successful with the use of tools such as electronic medical records as well as culture change and staff buy in. Future directions will include expanding the program to acute care floors.Disclosures All authors: No reported disclosures.

Emergencies in Plastic Surgery: Analysis of Emergency Presentation within a University Department for Plastic and Hand Surgery

Interdisciplinary emergency departments in Germany are seeing an increasing inflow of patients for several reasons. Since the number of patients in the emergency room cannot be planned, there may be a lack of capacity with prolonged waiting periods and delays. In particular, a significant amount of capacities is consumed by hand injuries. Also it is suspected for the discipline of plastic surgery that the majority of emergency presentations are unjustified. We provide a collection of data followed by an analysis of emergencies to better understand the increased number of patients with the aim of identifying possible solutions for the relief of emergency care. We performed a retrospective analysis of documented patient cases seen in the interdisciplinary emergency room of the Department of Plastic, Aesthetic, Hand and Reconstructive Surgery of a university hospital. Over the span of one year, we evaluated the diagnosis, waiting time and distribution of patients over 24 hours at 7 weekdays. Furthermore, we evaluated the justification of emergency presentation and the necessity of inpatient admission. We assessed a total of 2768 patients with an average age of 40 years (median = 37 years, male 59 %/ female 41 %) within one year (2016-2017). Of 2450 patients, 69 % were legitimate emergencies, defined by severity of trauma or disease. Proportionally, the most common cause of presentation for 2768 cases was upper extremity injury with cut and saw injuries amounting to 25 % (n = 697), followed by lacerations/bite injuries with 22 % (n = 611) and burns with 17 % (n = 477). Most services were performed between 09:00 a.m. and 01:00 p.m. There were no significant differences regarding the distribution over different weekdays. In 24 % (n = 583) of these cases, the patient was hospitalised for inpatient treatment. In 45 % of cases, there was no indication for hospitalisation after treatment. The waiting time for 2450 patients averaged 2:23 h (median = 01:43 h) until treatment. In face of these results it may be argued, that a majority of emergency cases could be selected through filter structures to be distributed to suitable facilities. This could cover a large proportion of the 45 % legitimate, but ambulatory emergencies. Furthermore a concentration of emergency departments should take place with a simultaneous supply of financial resources to expanding emergency departments with high patient flow.

Using telephone call rates and nurse-to-patient ratios as measures of resilient performance under high patient flow conditions

Patient admissions, discharges, and transfers are high work demand activities that have been associated with 30-day readmissions and increased patient mortality. Most mitigation strategies target peak demand, but variable demand may be more significant. Self-organizing holarchic open systems (SOHOs) and resilience engineering frameworks may explain system behavior, but a few quantitative studies of resilient organizational performance have been published. We used three measures to explore SOHO and resilience engineering constructs. We collected hourly data over 2 years, from five inter-related units in a cardiovascular disease division of a metropolitan teaching hospital. Our results show that information flows (inbound, outbound, answered, and unanswered telephone calls) representing anticipatory management are related to patient flows (patient admissions discharges and transfers) and nurse-staffing levels (nurse-to-patient ratios). We also found overall system stability despite high patient flow effects in lower level units. Unexpectedly, the time to recovery from high patient flow events lasted up to 7 days. We conclude that constructs proposed by resilience engineering can be quantified using simple measures collated within routine operations. The application of nonlinear statistical analyses can uncover important insights about resilient performance that may assist managers in better preparing for managing and recovering from unexpected variation in patient flow.

The Impact of Triage Nurse-ordered Diagnostic Studies on Pediatric Emergency Department Length of Stay.

To identify the need to revise the program triage nurse-ordered diagnostic tests in the emergency department (ED) of pediatric hospital, and to evaluate implementation of this program with three laboratory routine tests, namely blood, urine and stool, which the triage nurses ordered as relevant to pediatric patients' symptoms. The authors retrospectively reviewed the data of patients who registered in their ED between December 2015 and April 2016, including the tests as per the orders by triage nurses, and the time they arrived and the time they had their final payments. A comparison was made of those, who stayed in the ED, with nurse-requested tests, to those without such tests. The review indicated the total number of subjects who presented in ED during the study period and were included in the study was 116,202; 65.4% with nurse-requested tests while 34.6% without such tests. On median, the length of their stay with nurse-requested tests was 229min and without such tests was 244min, which has significant difference (P = 0.000). The results of this program were associated with a reduction in ED treatment which achieved the purpose to improve high patient flow in the emergency department. However, this intervention needs further studies to develop the nurse-ordered diagnostic studies program with more different clinical conditions and tests including triage nurses training and guideline.