Hospital Emergency Department Research Articles

Hospital at home for elderly acute patients: a study protocol for a randomised controlled trial

IntroductionThe increasing elderly population has led to a growing demand for healthcare services. A hospital at home treatment model offers an alternative to standard hospital admission, with the potential to...

Delayed presentation and management approach of autonomic dysfunction associated with severe tetanus

Introduction: In 2019, there were over 73 000 estimated tetanus cases globally, including more than 27 000 cases of neonatal tetanus, and the worldwide deaths caused by tetanus were almost 34 684. The mortality rate of tetanus is greater than 50% in countries without ICUs and 10% in developed countries, mostly attributed to autonomic dysfunction. Countries with the greatest rates of post-neonatal tetanus mortality (greater than five fatalities per 100 000 people) were Somalia, South Sudan, and Kenya. Case presentation: A 66-year-old unvaccinated male patient came to our hospital emergency department with generalized rigidity, neck stiffness, lockjaw, and an altered level of consciousness for 5 days. His symptoms started with stiffness in his neck and back 4 days before. The patient was diagnosed with tetanus, as he was unimmunized, had a recent injury, and presented clinical findings. The authors started treatment by administering intramuscular human tetanus immunoglobulin and metronidazole. He was admitted to the ICU and placed in an isolation room with minimal auditory and visual stimuli. Following 2 weeks after admission his blood pressure began to fall, and his pulse rate started to fluctuate with alternating tachycardia and bradycardia. After 1 month in the ICU, he was discharged from the ICU and transferred to the ward. A catch-up immunization regimen was established. Clinical discussion: Tetanus is a rare condition in the Western world, primarily due to widespread vaccination programs from infancy to adulthood. There are crucial barriers that still exist to overcoming this disease in our country, including a lack of reliable immunization programs. In tetanus, the increase in survival is associated with the use of intensive care facilities for the management of tetanus, besides expanding the knowledge of the disease, which is a challenge for developing countries. Conclusion: It is essential to have enough immunization at an early stage of trauma since severe autonomic dysfunction linked to tetanus might be lethal.

Outcomes for Young Adults With Suicide Admitted to Adult Versus Pediatric Hospitals.

To evaluate differences in care and outcomes for young adults admitted with suicide ideation (SI) or attempt (SA) to medical units of an adult (AH) versus pediatric hospital (PH). Demographic and clinical characteristics were collected on patients aged 18 to 25 years admitted to either an AH or PH at an academic health system from September 2017 through June 2023 with a diagnosis of SI or SA. Outcomes measured were discharge location, length of stay (LOS), emergency department (ED) visit or hospital readmission, and inpatient consultations. Bivariate tests and multivariate regression were used to determine association of admission location and outcomes. Of 212 patients included, 54% were admitted to an AH and 46% to a PH. Admission to a PH compared with an AH was associated with shorter ED LOS (4.3 vs 7.3 hours, P < .01) and discharge to home (57% vs 42%, P = .028) on bivariate but not adjusted analysis. Admission location was not associated with hospital LOS, ED visit or medical readmission after discharge, or psychiatry consultation. Admission to a PH compared with an AH was associated with higher odds of psychology consultation (29 vs 3%, P < .01). Although young adults admitted to a PH for SI/SA had higher rates of psychology consultation, they otherwise had similar care and outcomes regardless of admission to an AH versus a PH. Further work is needed to determine if observed differences are generalizable and how they affect hospital throughput and long-term outcomes.

The situation of pre-hospital emergency care through traumatic patients have been admitted to emergency department of Viet Duc University Hospital in 2023

Introductions: Pre-hospital Emergency Care (PEC), especially for severe trauma is playing an important role. The study was conducted to provide an overview of the situation of PEC in Vietnam through traumatic patients at Viet Duc University Hospital. Materials and methods: A cross-sectional study enrolled all traumatic patients admitted to the Emergency Department of Hospital and had complete medical records, during the period from July to September, 2023, regardless of gender, age. Data were collected and processed using SPSS 20.0 software. Results: Characteristics of target population: 343 cases of traumatic patients were enrolled, male was majority accounted for 71.4%; The age group from 15 to 59 years old accounted for highest proportion (63%), ≥ 60 years old (32.6%). The sites of accident were mostly occurred on road (64.3%), at home (23.9%) and working place (10.2%). The brain injury accounted for the highest proportion (55.4%), multiple injuries (54.8%), extremities injury (38.5%), maxillofacial injury (25.1%) and spine injury (21.0%). Situation of PEC: First aid was mostly provided by first witness/accompanying person (64.5%), by community first aid provider (24.1%), only 11.4% provided by professional health worker. 8.7% patients were transported by taxi/car, 16.7% by unsafe ambulance, lacking official regulated medicine or equipment, or the health personnel did not know about the patient’s medical history. Some first aid were not provided on scene including: airway management 22.2%, wound care and dressing 33.0%, collar to cervical spine 14.5%, extremities splint 34.9%. Additionally, many extremities splint and wound care, 24.5% and 37.5% respectively, were done improperly. Conclusions and recommendations: The study showed some challenges such as improper first aid provision or unsafe transportation, which potentially cause unwanted risk for the patients. The author highly recommend the improvement of PEC according to the new law on this issue.

Pediatric torticollis: clinical report and predictors of urgency of 1409 cases

BackgroundTo date, the etiology and risk factors of torticollis are still poorly defined in the pediatric literature. Especially in the Emergency Department (ED) scenario, it is critical to reliably distinguish benign and transient conditions from (potentially) life-threatening disorders. This study describes the clinical characteristics of a large sample of children with torticollis. The aim of our study was to detect epidemiology, etiology and predictive variables associated with a higher risk of life-threatening conditions in acute torticollis.MethodsWe conducted a pediatric retrospective study of acute torticollis over a 13-year period referred to the ED of a tertiary pediatric Hospital. We reported the characteristics in the overall sample and in two subgroups divided according to urgency of the underlying condition. Furthermore, we developed a multivariate model aimed at identifying the main clinical predictors of the need for urgent care.Results1409 patients were analyzed (median age 5.7 years, IQR 5.8). A history of trauma was present in 393 patients (27.9%). The symptom most frequently associated with torticollis were pain (83.5%). At least one pathological finding was found in 5.4 to 7.9% of patients undergoing further imaging. Hospitalization was required in 11.1% of cases (median duration 4 days). The most frequent etiologies of torticollis were postural cause (43.1%), traumatic (29.5%), and infective/inflammatory (19.1%). A longer time from onset of torticollis and the presence of headache or vomiting were strongly correlated with an underlying urgent condition, after adjusting for the other clinically and statistically significant variables in the bivariate analysis.ConclusionOur study shows that an urgent condition most commonly occur in patients presenting with history of trauma or headache, vomiting and torticollis for more than 24 h should undergo further diagnostic evaluation and short-term follow-up, restricting invasive or expensive investigations to patients with clinical suspicion of an underlying harmful condition.

Piloting racial bias training for hospital emergency department providers treating opioid use disorder patients

Abstract Racial disparities in opioid overdose have increased in recent years. Several studies have linked these disparities to health care providers’ inequitable delivery of OUD services. In response, health care policymakers and systems have designed new programs to improve equitable OUD care delivery. Racial bias training has been one commonly utilized program. Racial bias training educates providers about the existence of racial disparities in the treatment of people who use drugs and the role of implicit bias. Our study evaluates a pilot racial bias training delivered to 25 hospital emergency providers treating patients with opioid use disorders in two hospitals in Detroit, Michigan. We conducted a three-part survey, including a baseline assessment, post-training assessment, and a 2-month follow-up to evaluate the acceptability and feasibility of scaling the racial bias training to larger audiences. We also investigate preliminary data on changes in self-awareness of implicit bias, knowledge of training content, and equity in care delivery to OUD patients. Using qualitative survey response data, we find training participants were satisfied with the content and quality of the training and especially valued the small group discussions, motivational interviewing, and historical context.

Pattern of admission, outcome and predictors of trauma patients visiting the surgical emergency department in comprehensive specialized hospital: a retrospective follow up study

Background: Traumatic injuries represent huge burden in the developing world, and significant proportion has found in low- and middle-income countries. However, the pattern, outcome and factors of injury varies from setup to setup and is less studied public health problems. Objective: To assess pattern of admission, outcome and its predictors among trauma patients visiting the surgical emergency department in comprehensive specialized hospital. Methods: A retrospective follow up study was conducted and data was taken from the medical records of patients from 2019 to 2021. Simple random sampling technique was used to get a sample size of 386 from injured patient charts. Data were entered into Epi-Data version 4.6 software and exported to STATA version 14.1 for analysis. The dependent variable was injured patient’s outcome that could be died or not died. The independent variables with P-value less than 0.25 in the bi-variable regression analysis were considered for the multivariable regression. Adjusted Odds Ratio with the 95% Confidence Interval were used to declare statistical significance. Result: About 13.99% of injured patients with (95% CI: 10, 17) had died during the study period. The leading cause of injury was assault (62.44%) followed by road traffic accident (26.17%). Severe Glasgow coma scale (AOR 6.6; 95% CI: 2.6-16.4), Length of hospital stay≥7days (AOR=2.8; 95% CI: 1.2-6.2), time of arrival in between 1-24 hours (AOR=0.15; 95% CI: (0.06-0.37), and upper trunk injury (AOR=6.3; 95% CI: 1.3-28.5) were significantly associated with mortality. Conclusion and Recommendation: Mortality after traumatic injury was considerably high. Severe Glasgow coma scale, Length of hospital stay≥7days, time of arrival in between 1-24 hours, and upper trunk injury were the associated factors for mortality. Priority should be given for injured patients with decreased level of consciousness and upper trunk injury. Establishment of organized pre-hospital emergency services and provision of timely arrival is recommended. We recommend prospective follow up study.

Validation of Difficult Airway Physiological Score (DAPS) in Critically Ill Adults Undergoing Endotracheal Intubation in the Emergency Department

Background. Critically ill patients have increased risk of cardiovascular collapse following endotracheal intubation due to physiological instability. This study aims to validate the Difficult Airway Physiological Score (DAPS) in adults to predict the risk of serious outcomes in the emergency department of a tertiary care private hospital. Methods. This is a cohort study conducted in the emergency department (ED) from 2021 to 2022. Difficult Airway Physiological Score (DAPS) was derived from a sample of 1021 patients through a retrospective study. The variables in the score were age, gender, time of intubation, vitals and vomiting at presentation, pH &lt;7.3, fever, physician’s anticipation for patient decline, and agitation. The model performance was assessed prospectively on a separate dataset (n = 326) using train-test split method. Postintubation desaturation, hypotension, cardiac arrest, and mortality postintubation were the serious outcomes. ROC analysis, sensitivity, specificity, PPV, and NPV were used to assess score validity. Results. Our study includes 326 patients, of which 123 (37.7%) were males and 203 (62.2%) were females. The sample was divided into high-risk (DAPS ≥10) group, n = 194 with mean age of 52 (SD = ±18) years, and low-risk (DAPS &lt;10) group, n = 132 with mean age of 47.7 (SD = ±17.4) years. The shock index ≥0.9 was in 128 (66%), while it was &lt;0.9 in low-risk n = 111 (84%), p value &lt;0.001. Similarly, pH &lt;7.3 was seen in 70 (36.1%) in high-risk group compared to 4 (3%) in low-risk group, p value &lt;0.001. Cardiac arrest was observed in 56 (17.2%) patients, of which 45 (23.2%) were in high-risk and 11 (8.3%) in low-risk groups (p&lt;0.001). Hypotension was the primary outcome in the high-risk group 100 (51.5%) versus 32 (24.2%) in low-risk group (p&lt;0.001). The DAPS of 10 had an area under the curve of 0.865 (0.71–0.84). The sensitivity of DAPS was 78.5%, specificity 77.9%, and accuracy 78.2%. Conclusion. The score can accurately predict serious outcomes in critically ill adult patients with physiologically difficult airway demonstrating good sensitivity and specificity.

Edpidemiology, Clinical Profile and Short- Term Outcome of Hypertensive Crisis in N'Djamena (Chad)

Objective Hypertensive crisis is an increasingly frequent medical condition in our context. Its management in medical emergencies is a real challenge for physicians. Few data on hypertensive crisis are available in Chad. The aim of this study was to investigate the epidemiological, clinical and prognostic characteristics of hypertensive crisis in the medical emergency department of Reference National Teaching Hospital in N'Djamena. Patient and methods This was a prospective cohort study running from 1er March 2020 to October 31 2020. Patients presenting with a sudden and severe rise in blood pressure (systolic ≥ 180 mmHg and/or diastolic ≥ 110 mmHg) with or without acute target-organs damage, had been consecutively included and followed up over a period of one (01) month. Epidemic and clinical characteristics on admission, and morbidity and mortality parameters during the course of the disease were collected. The Kaplan-Meier method and the Cox model were used to analyze survival and factors associated with death, with a significance level of p&lt;0.05. Results Of the 3978 hypertensive patients admitted to medical emergencies, 252 had a hypertensive crisis, i.e. a prevalence of 6.3%. Two hundred and seventeen (217) patients were included in the study, divided into 149 cases (69%) of hypertensive emergency and 67 cases (31%) of hypertensive hypertensive urgencies. The mean age of the patients was 55.2 ± 14 years (20 and 80 years) and 67% were male. Hypertension was known in 138 patients (64%). At least one complication was present on admission in 69% of patients. Complications were classified as cardiac (50.7%), neurological (38.2%), kidney impairment (46.5%) and ocular (46.1%). The average number of antihypertensive drugs used was 2 ± 0.83 1, 4. Calcium antagonists (86.5%), diuretics (35.5%), converting enzyme inhibitors or angiotensin II receptor antagonists (33.3%) and betablockers (18%) were the pharmacological classes prescribed. Good compliance during follow-up was observed in 124 patients. One-month survival was 84% for all patients, with a 16% mortality rate. Factors associated with death were the duration of hypertension, and the occurrence of cardiovascular, renal dysfunction and ocular disease (p &lt; 0.05). Conclusion Hypertensive crisis is a frequent pathology in sub-Saharan Africa, with high morbidity and mortality. Prevention requires early detection and effective management of hypertension.

Bedside critical care training: A quasi-experimental study in the paediatric emergency department of a referral hospital in Nigeria

Background. There is a need for critical care services outside intensive care units (ICUs), especially in emergency departments (EDs). However, there is a paucity of skilled manpower for ED critical care or emergency critical care (ECC) in resource-limited settings. Objective. To evaluate the impact of bedside training on emergency critical care practices of clinical staff. Methods. This was a quasi-experimental study using a pretest - post-test design in a paediatric ED. The intervention was a six-week structured bedside training on bubble continuous positive airway pressure (CPAP) high-flow nasal cannula (HFNC) and mechanical ventilation. Participants’ actual ECC practices pre and post training were evaluated, including their perceived proficiency on an uncalibrated 100 mm visual analogue scale (VAS). Descriptive and inferential analyses were done; p&lt;0.05 was considered significant. Results. A total of 35 clinical staff participated in the training, comprising 9 (24.3%) paediatric registrars, 12 (32.5%) senior registrars, 10 (27.0%) nurses, 4 (10.8%) house officers and 2 (5.4%) paediatric consultants. The male:female ratio of the participants was 1:1.6, and their mean (SD) age was 33.24 (6.30 years. Participants’ understanding of testing the CPAP circuit, connecting the patient and weaning significantly improved following training (p=0.004). Their capacity to select appropriate HFNC parameters improved (p=0.013). They performed more endotracheal intubations in the post-training period (p=0.001). Their pretest-post-test proficiency in mechanical ventilation increased on VAS (mean scores 45.26+31.99 v. 63.26+22.26; p=0.038). Also, there was a significant increase in their perceived proficiency in paediatric analgesia/sedation (30.83+29.86 v. 49.83+23.90; p=0.029). Conclusion. Short-term bedside critical care training enhanced the self-reported competency of paediatric ED staff. There is a need for on-the-job ECC training and retraining of clinical staff in our setting.

Barriers and Solutions to Comprehensive Care for Mental Health Patients in Hospital Emergency Departments

Hospital emergency departments in Ontario, have become a common place for patients with mental health problems to seek treatment. Studies report healthcare providers have limited knowledge and competency to provide optimal care for patients with mental health problems. As a result, these patients are at risk of poor hospital experiences and treatment outcomes. In addition, emergency staff report considering patients with mental health problems lower priority to other patients. This paper reviews the existing literature and examines the challenges surrounding patients with mental health problems seeking treatment in emergency rooms and how it leads to sub-optimal care. Strategies are then shared to overcome these challenges by changing emergency department experiences for mental health patients seeking treatment.

The Healthy Ageing/Vulnerable Environment (HAVEN) Index: Measuring neighbourhood age‐friendliness

AbstractThis study describes the development and testing of the Healthy Ageing/Vulnerable Environment (HAVEN) Index, a prototype composite spatial index for South Australia that reflects an area’s age‐friendliness. The index incorporates over 40 indicator variables across six variable themes: income and employment; education; health and housing; social connectedness; geographic access; and physical environment. Based on the deficit accumulation approach, the modelling uses area‐level rather than individual‐level data and is compiled through quantitative geospatial methods. Analysis using the HAVEN Index of state‐wide mortality data and hospital emergency department (ED) presentations for Central Adelaide found that vulnerable areas were associated with a higher risk of mortality and ED presentation. Comparisons between the HAVEN Index and a widely used national area‐level measure of socio‐economic differences found that the HAVEN Index compares favourably and provides additional information about local areas, which can inform needs‐based approaches to support the reduction of spatial inequalities and the development of age‐friendly neighbourhoods.

Emergency physician gender and head computed tomography orders for older adults who have fallen.

Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.

Incidence, predictors, and treatment outcomes of biphasic anaphylaxis in the emergency department of a tertiary hospital:A 5-year retrospective study.

Biphasic anaphylaxis despite successful treatment has an incidence of 4-5% based on NIAID/FAAN criteria. Our study aimed to investigate the frequency and predictive factors associated with biphasic reactions within the emergency department (ED) at Siriraj Hospital. This observational study assessed medical records of anaphylaxis and anaphylactic shock patients at Siriraj Hospital's ED from January 2015 to December 2019. Of these, a random sample was reviewed and validated by allergists. Telephone interviews were performed to collect more data. Uni- or biphasic response were analyzed descriptively. Prediction modeling was performed. Among 1888 ED anaphylaxis cases, 601 were randomly sampled; 239 patients completing interviews were analyzed. The incidence of biphasic reactions was 7.1% (17/239) of cases. Common triggers of biphasic responses were foods (57.7%), drugs (31%), other known allergens (5.9%). Shellfish, edible insects, and wheat were the leading food triggers. Biphasic responses were significantly associated with history of drug allergy, any allergic disease, allergic rhinitis, number of prior anaphylactic reactions, angioedema, less generalized erythema, less reaction to shellfish, reaction to NSAIDs, and no epinephrine giving at ED visit (all p < 0.1). From a 3-predictor prognostic model including drug/idiopathic reaction, duration from onset to first epinephrine > 60 minutes, and any cutaneous edema/angioedema with an area under the curve of 0.72 (95%CI 0.54, 0.90). The incidence of biphasic response was 7.1%. Predictors of biphasic response were drug/idiopathic reac- tion, any cutaneous edema/angioedema, and time from onset to first epinephrine > 60 minutes.

The Relationship between Neutrophil-Lymphocyte Ratios with Nutritional Status, Risk of Nutritional Indices, Prognostic Nutritional Indices and Morbidity in Patients with Ischemic Stroke.

Background: In recent years, whole blood parameters and derivatives have been used as prognostic criteria in the course of various diseases. The aim of this study was to evaluate the relationship between parameters such as the neutrophil-lymphocyte ratio (NLR), the systemic immune-inflammation index (SII), the prognostic nutritional index (PNI), controlling nutritional status (CONUT) score, nutritional risk index (NRI) and immunonutrition status and disease activity in patients with ischemic stroke of the small-vessel, large-vessel and other etiologies. Methods: We retrospectively evaluated the records of 1454 consecutive ischemic stroke patients hospitalized in the emergency department of Gaziosmanpasa Education and Research Hospital from 2019 to 2023. Results: Of the 1350 patients with ischemic stroke included in the study, 58.8% had small-vessel disease, 29.3% had large-vessel disease and 11.9% had other etiologies. There was a significant difference between the three etiology groups for PNI and CONUT. The mean of PNI was 47.30 ± 8.06 in the other etiology group, 37.25 ± 7.23 in the small-vessel group, and 34.78 ± 8.16 in the large-vessel disease group. The mean of CONUT was 5.49 ± 1.20 in the small-vessel group, 5.12 ± 1.46 in the large-vessel group and 4.22 ± 1.11 in the other etiology group. In addition, CONUT and PNI were also found to be independent risk factors for mortality. A negative significant correlation was observed between PNI and NLR (r: -0.692), SII (r: -0.591), and CONUT (r: -0.511). Significant correlations were observed between CONUT and NLR (r: 0.402), SII (r: 0.312). Conclusions: PNI, CONUT and NRI were found as more accurate prognostic indicators of nutritional status in patients with ischemic stroke. NLR and SII may be important predictive markers in the course and prognosis of stroke.

Effectiveness of antazoline versus amiodarone, flecainide and propafenone in restoring sinus rhythm at the emergency department

PurposeLittle is known about the effectiveness of pharmacological cardioversion (PCV) with antazoline in comparison to flecainide. The aim of this study was to compare the effectiveness of antazoline in restoring sinus rhythm (SR) versus amiodarone, flecainide and propafenone in a group of emergency department (ED) patients. Materials/methodsThis was a single-centre retrospective analysis of patient records from an ED in a large hospital in Poland. We analysed a total of 1878 patient records, divided based on the anti-arrhythmic drug (AAD) administered during PCV: antazoline (n ​= ​1080), antazoline ​+ ​β-blocker (n ​= ​479), amiodarone (n ​= ​129), flecainide (n ​= ​102), propafenone (n ​= ​88). Of the patients, 63.5 ​% were female (median 65 years, [19–100]). ResultsThe percentage of successful PCV was significantly higher in the antazoline group (84.3 ​%) than in the antazoline ​+ ​β-blocker (75.8 ​%, p ​= ​0.0001), propafenone (75.6 ​%, p ​= ​0.0364) and amiodarone (68.8 ​%, p ​< ​0.0001) groups. Post-hoc analysis revealed that patients who received PCV with antazoline, antazoline ​+ ​β-blocker, flecainide and propafenone had significantly shorter time to SR than those who received amiodarone (p ​< ​0.0001). Univariate regression analysis revealed that patients who underwent PCV with antazoline were almost twice as likely to return to SR compared to the other groups (p ​< ​0.0001, OR 1.81, 95 ​% CI 1.44–2.27). ConclusionsThis is the first study comparing the effectiveness of antazoline in PCV versus flecainide in addition to the previously studied amiodarone and propafenone. Our results indicate that antazoline is more effective in restoring SR than amiodarone, flecainide and propafenone. In addition, antazoline restored SR significantly faster than amiodarone or propafenone.

Redesigning Medication Management in the Emergency Department: The Impact of Partnered Pharmacist Medication Charting on the Time to Administer Pre-Admission Time-Critical Medicines, Medication Order Completeness, and Venous Thromboembolism Risk Assessment.

In order to enhance interdisciplinary collaboration and promote better medication management, a partnered pharmacist medication charting (PPMC) model was piloted in the emergency department (ED) of an Australian referral hospital. The primary objective of this study was to evaluate the impact of PPMC on the timeliness of time-critical medicines (TCMs), completeness of medication orders, and assessment of venous thromboembolism (VTE) risk. This concurrent controlled retrospective pragmatic trial involved individuals aged 18 years and older presenting to the ED from 1 June 2020 to 17 May 2021. The study compared the PPMC approach (PPMC group) with traditional medical officer-led medication charting approaches in the ED, either an early best-possible medication history (BPMH) group or the usual care group. In the PPMC group, a BPMH was documented promptly soon after arrival in the ED, subsequent to which a collaborative discussion, co-planning, and co-charting of medications were undertaken by both a PPMC-credentialled pharmacist and a medical officer. In the early BPMH group, the BPMH was initially obtained in the ED before proceeding with the traditional approach of medication charting. Conversely, in the usual care group, the BPMH was obtained in the inpatient ward subsequent to the traditional approach of medication charting. Three outcome measures were assessed -the duration from ED presentation to the TCM's first dose administration (e.g., anti-Parkinson's drugs, hypoglycaemics and anti-coagulants), the completeness of medication orders, and the conduct of VTE risk assessments. The analysis included 321 TCMs, with 107 per group, and 1048 patients, with 230, 230, and 588 in the PPMC, early BPMH, and usual care groups, respectively. In the PPMC group, the median time from ED presentation to the TCM's first dose administration was 8.8 h (interquartile range: 6.3 to 16.3), compared to 17.5 h (interquartile range: 7.8 to 22.9) in the early BPMH group and 15.1 h (interquartile range: 8.2 to 21.1) in the usual care group (p < 0.001). Additionally, PPMC was associated with a higher proportion of patients having complete medication orders and receiving VTE risk assessments in the ED (both p < 0.001). The implementation of the PPMC model not only expedited the administration of TCMs but also improved the completeness of medication orders and the conduct of VTE risk assessments in the ED.

A Granular Approach to Optimal and Fair Patient Placement in Hospital Emergency Departments

Prolonged emergency department (ED) length of stay (LOS) is associated with detrimental effects on patient care quality and outcomes. There is evidence that certain groups of patients experience longer LOS based on their gender or race, especially with regard to the part of LOS that is attributable to waiting to be seen by a clinician. This work tackles the patient prioritization and placement aspects of ED operations with the goal of improving throughput and wait time in a fair, equitable way. We present a novel Mixed Integer Linear Programming (MILP) predictive-prescriptive formulation that incorporates a breakdown of predicted patient ED LOS into actionable pieces. We incorporate considerations for fairness and reformulate the MILP formulation into a compact and computationally tractable formulation that can be solved efficiently in real time. To deal with uncertainty, we propose a sampling-based solution, and provide provable guarantees regarding its convergence, stability and sample complexity. The proposed solution increases the throughput of the ED by [Formula: see text] and decreases the average wait time by [Formula: see text] compared to current hospital practice. In addition, the method is near-optimal in terms of throughput, and produces high-quality solutions in terms of average wait time compared to a clairvoyant oracle. Our proposed approach demonstrates desirable properties when it comes to fairness in patient prioritization, illustrating a path for addressing hidden biases in patient ED wait times and hospital operations as a whole. This work was conducted in collaboration with a large US academic medical center. Data from more than 40,000 patient visits were used to shape and evaluate the predictive-prescriptive models. An important practical contribution is translating a complex algorithm’s output into recommendations that can be operationalized in the context of existing processes in the ED. Specifically, we develop an interpretable metamodel that is trained to mimic the predictive-prescriptive algorithm’s decisions and provides a transparent set of rules for patient placement. The method will be used by the hospital to improve patient flow and quality of care as well as to support more fair and consistent bed allocation decisions.

Rationale and protocol for a prospective cohort study of respiratory viral infections in patients admitted from emergency departments of community hospitals: Effect of respiratory Virus infection on EmeRgencY admission (EVERY) study

IntroductionRespiratory syncytial virus (RSV) is a causative virus for the common cold worldwide and can result in hospitalisations and even death in patients with high-risk conditions and older adults. However,...

A systematic review of reasons and risks for acute service use by older adult residents of long-term care.

To identify the reasons and/or risk factors for hospital admission and/or emergency department attendance for older (≥60 years) residents of long-term care facilities. Older adults' use of acute services is associated with significant financial and social costs. A global understanding of the reasons for the use of acute services may allow for early identification and intervention, avoid clinical deterioration, reduce the demand for health services and improve quality of life. Systematic review registered in PROSPERO (CRD42022326964) and reported following PRISMA guidelines. The search strategy was developed in consultation with an academic librarian. The strategy used MeSH terms and relevant keywords. Articles published since 2017 in English were eligible for inclusion. CINAHL, MEDLINE, Scopus and Web of Science Core Collection were searched (11/08/22). Title, abstract, and full texts were screened against the inclusion/exclusion criteria; data extraction was performed two blinded reviewers. Quality of evidence was assessed using the NewCastle Ottawa Scale (NOS). Thirty-nine articles were eligible and included in this review; included research was assessed as high-quality with a low risk of bias. Hospital admission was reported as most likely to occur during the first year of residence in long-term care. Respiratory and cardiovascular diagnoses were frequently associated with acute services use. Frailty, hypotensive medications, falls and inadequate nutrition were associated with unplanned service use. Modifiable risks have been identified that may act as a trigger for assessment and be amenable to early intervention. Coordinated intervention may have significant individual, social and economic benefits. This review has identified several modifiable reasons for acute service use by older adults. Early and coordinated intervention may reduce the risk of hospital admission and/or emergency department. This systematic review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. No patient or public contribution.