Hospital Emergency Services Research Articles

Stevens-Johnson syndrome and herpes simplex reactivation associated with paracetamol use. Case report

Introduction: Stevens-Johnson syndrome (SJS) is a rare disease that affects the skin, as well as the oral, ocular, and urogenital mucous membranes. This condition is caused by drug reactions in more than 50% of cases. Case presentation: A 20-year-old male visited the emergency service of a tertiary care hospital of Popayán due to a 10-day history of asthenia, adynamia, fever (without objective measurement records), cough with scarce whitish sputum, and headache that improved with paracetamol treatment. However, his condition worsened in the last two days, and he developed hyporexia, pharyngeal pruritus, vesicles, and blisters on the corners of the mouth, the oral mucosa, the trunk, and limbs, as well as breathing difficulty and odynophagia, prompting him to seek medical treatment at the ER. At first, disseminated herpes simplex, systemic lupus erythematosus and SJS were suspected, but based on clinical and laboratory findings, the patient was finally diagnosed with SJS with herpes simplex reactivation associated with the use paracetamol. Consequently, the administration of this drug was stopped and management with acyclovir and methylprednisolone was started. The patient progressed satisfactorily and was discharged 10 days after beginning the new treatment, and his general condition was optimal during follow-up appointments. Conclusion: The occurrence of SJS may be associated with the oral administration of paracetamol; nevertheless, its use is not discouraged due to its great overall benefits. In this sense, given that paracetamol is an over-the-counter drug widely used in Colombia, recognizing the clinical manifestations of SJS is essential to provide adequate management and avoid complications in cases such as the one reported here.

The impact of the COVID-19 pandemic on the dental-maxillofacial emergency service of a German university hospital in the year 2020

ObjectivesCOVID-19 is considered one of the most serious pandemic in history and has posed major challenges to the world’s health care. Dentistry and oral and maxillofacial surgery (CMFS) are particularly affected due to direct exposure to the respiratory tract, as the reservoir of SARS-CoV-2. In this study, the impact of the COVID-19-pandemic on a dental and CMFS emergency services in Germany in 2020 was first time investigated and correlated with governmental restriction measures in public life.Materials and methodsEpidemiological data of a German University Hospital were analysed from a total of 8386 patients in 2019 and 2020. Parameters included information on demographics, time, weekday and reason for presentation, as well as diagnosis and therapy performed. Data from 2020 were compared with those from 2019, taking into account the nationwide periods of public life restrictions.ResultsIn 2020, 22% fewer patients presented via dental and CMFS emergency service. In a monthly comparison, there were negative peaks of up to − 41% in November, but also a plus of 26% in July. The largest decreases were recorded during the lockdown periods in spring (− 33%) and winter (− 39%). Further, a threefold increase in actual emergencies and inpatient admissions revealed during these time periods (p < 0.001).ConclusionsCOVID-19 pandemic had a significant impact on the dental and CMFS emergency service in 2020 resulting in more severe cases.Clinical relevanceThis study underlines the importance of maintaining an emergency service system and basic outpatient care in these specialities, which requires uniform recommendations from the medical-dental societies and politics.

Work Climate Scale in Emergency Services: Abridged Version.

This study is based on a 40-item work climate scale in hospital emergency services (WCSHES). Teams working in these emergency services experience a heavy workload and have a limited amount of time with each patient. COVID-19 has further complicated these existing issues. Therefore, we believed it would be helpful to draft an abridged version of the 40-item WCSHES, considering both validity and reliability criteria, but giving greater weight to validity. One hundred and twenty-six workers between the ages of 20 to 64 (M = 32.45; standard deviation (SD = 9.73)) years old participated voluntarily in the study. The validity, reliability, and fit model were evaluated in an iterative process. The confirmatory factor analysis yielded appropriate global fit indices in the abridged 24-item version (Χ2(248) = 367.84; p < 0.01, RMSEA = 0.06 with an interval of 90% from 0.05 to 0.07, SRMR = 0.08, GFI = 0.9, AGFI = 0.96, CFI = 0.98, NFI = 0.95, and NNFI = 0.98), along with test criteria validity (ρXY = 0.68, p < 0.001) and excellent reliability (α = 0.94 and ω = 0.94), maintaining the same conceptualization and usefulness of the original scale. The abridged 24-item version was used to measure four work climate factors (work satisfaction, productivity/achievement of aims, interpersonal relations, and performance at work). Evidence of the usefulness of the new abridged scale is provided along with a description of our study limitations and future areas for development.

Endothelial Dysfunction and Neutrophil Degranulation as Central Events in Sepsis Physiopathology.

Sepsis is a major health problem worldwide. It is a time-dependent disease, with a high rate of morbidity and mortality. In this sense, an early diagnosis is essential to reduce these rates. The progressive increase of both the incidence and prevalence of sepsis has translated into a significant socioeconomic burden for health systems. Currently, it is the leading cause of noncoronary mortality worldwide and represents one of the most prevalent pathologies both in hospital emergency services and in intensive care units. In this article, we review the role of both endothelial dysfunction and neutrophil dysregulation in the physiopathology of this disease. The lack of a key symptom in sepsis makes it difficult to obtain a quick and accurate diagnosis of this condition. Thus, it is essential to have fast and reliable diagnostic tools. In this sense, the use of biomarkers can be a very important alternative when it comes to achieving these goals. Both new biomarkers and treatments related to endothelial dysfunction and neutrophil dysregulation deserve to be further investigated in order to open new venues for the diagnosis, treatment and prognosis of sepsis.

Impact of COVID-19 on a paediatric emergency service.

COVID-19 has significantly affected the use of health care worldwide and, consequently, admissions to hospital emergency services. The aim of this study is to describe the change of the activity of a Paediatric Emergency Service (PES) of a tertiary hospital during the pandemic. A retrospective cohort study with analysis of visits to the PES from March 30 to June 30, 2020, and comparison with homologous periods in the previous 3 years (2017–2019).A total of 53,883 episodes were analysed, with a median age of 5.8 years, and 53% were boys. In 2020, there was a 60% reduction in the number of admissions (p < 0.001). There was a significant increase in referral by the public medical advice phone line of the National Health Service (NHS) (18.5% vs 5.4%) and Emergency Medical Services (EMS) (5.1% vs 4.2%). Urgent patients decreased (31.2% vs 38.3%), and non-urgent patients increased (7.5% vs 1.7%). There was a significant reduction in school (0.4% vs 7.1%) and sports accidents (0.1% vs 1.2%) and an increase in other accidents (falls, wounds, burns, and dog bites) (12.2% vs 6.3%). Hospitalisation rate was higher (5.7% vs 3.1%, p < 0.001). The infection rate for SARS-CoV-2 was 1.1%, all with mild illness or asymptomatic.Conclusion: The pandemic brought a marked reduction in emergency admissions and a decrease in urgent situations but an increase in accidents, such as falls, wounds, burns, and dog bites. Despite the low infection rate for SARS-CoV-2, there were increased referrals by the phone line of NHS and EMS and a higher admission in the ward. What is Known: • The number of admissions to emergency services significantly decreased during the COVID-19 pandemic, particularly in the paediatric population, whom has a milder disease than adults. • Diseases that justify urgent/emergent hospital admission continue to exist and the eventual delay in seeking health care might lead to a worse prognosis.What is New: • Despite the low rate of SARS-CoV-2 infection in children, there was an increase in referrals by the phone line of the National Health Service and Emergency Medical Services. • The global admission rate to the ward increased but there were no admissions to intensive care or deaths.

The Horyzons project: a randomized controlled trial of a novel online social therapy to maintain treatment effects from specialist first-episode psychosis services.

This study aimed to determine whether, following two years of specialized support for first-episode psychosis, the addition of a new digital intervention (Horyzons) to treatment as usual (TAU) for 18 months was more effective than 18 months of TAU alone. We conducted a single-blind randomized controlled trial. Participants were people with first-episode psychosis (N=170), aged 16-27 years, in clinical remission and nearing discharge from a specialized service. They were randomly assigned (1:1) to receive Horyzons plus TAU (N=86) or TAU alone (N=84) between October 2013 and January 2017. Horyzons is a novel, comprehensive digital platform merging: peer-to-peer social networking; theory-driven and evidence-informed therapeutic interventions targeting social functioning, vocational recovery and relapse prevention; expert clinician and vocational support; and peer support and moderation. TAU involved transfer to primary or tertiary community mental health services. The primary outcome was social functioning at 18 months as measured by the Personal and Social Performance Scale (PSP). Forty-seven participants (55.5%) in the Horyzons plus TAU group logged on for at least 6 months, and 40 (47.0%) for at least 9 months. Social functioning remained high and stable in both groups from baseline to 18-month follow-up, with no evidence of significant between-group differences (PSP mean difference: -0.29, 95% CI: -4.20 to 3.63, p=0.77). Participants in the Horyzons group had a 5.5 times greater increase in their odds to find employment or enroll in education compared with those in TAU (odds ratio, OR=5.55, 95% CI: 1.09-28.23, p=0.04), with evidence of a dose-response effect. Moreover, participants in TAU were twice as likely to visit emergency services compared to those in the Horyzons group (39% vs. 19%; OR=0.31, 95% CI: 0.11-0.86, p=0.03, number needed to treat, NNT=5). There was a non-significant trend for lower hospitalizations due to psychosis in the Horyzons group vs. TAU (13% vs. 27%; OR=0.36, 95% CI: 0.11-1.08, p=0.07, NNT=7). So, although we did not find a significant effect of Horyzons on social functioning compared with TAU, the intervention was effective in improving vocational or educational attainment, a core component of social recovery, and in reducing usage of hospital emergency services, a key aim of specialized first-episode psychosis services. Horyzons holds significant promise as an engaging and sustainable intervention to provide effective vocational and relapse prevention support for young people with first-episode psychosis beyond specialist services.

Resilience Assessment Scale for the Prediction of Suicide Reattempt in Clinical Population.

The objective of this work was to construct and validate an instrument for assessing resilience to suicide attempts in a Spanish clinical population that has made a previous attempt, and to verify its efficacy for predicting future suicide reattempts at 6 months. For the construction of a Scale of Resilience to Suicide Attempts (SRSA) the theoretical-rational strategy was used. The constructed SRSA-18 consisted of 18 items and 3 subdimensions (internal and external protection and emotional stability), had high internal consistency (α = 0.88; ω = 0.89) and a high positive correlation with the Suicide Resilience Inventory-25, SRI-25 (r = 0.91; p < 0.01), and to a lesser extent with general resilience scales such as the Connor-Davidson Resilience Scale, CD-RISC (r = 0.79; p < 0.01) and the Resilience Scale of 14 items, RS-14 (r = 0.76; p < 0.01). Additionally, a specific SRSA-18 score predicted future suicide reattempts 6 months after the first attempt. This new scale (SRSA-18) assesses in a brief and rapid way, through protective factors rather than risk factors, the level of resilience to the suicide attempt in specific clinical subpopulations in hospital emergency services, being able to prevent suicide reattempts with higher lethality.

Direct health system costs for systemic lupus erythematosus patients in Alberta, Canada.

Systemic lupus Erythematosus (SLE) is a chronic multi-system autoimmune disease that can affect a person’s physical, mental, and social life. It imposes a substantial economic burden up on patients, carers, healthcare systems, and wider society. This is the first study to examine the direct health care costs of SLE in Alberta using real-world data. Alberta maintains a publicly funded, universally available health care system. Health service use and direct healthcare costs of SLE and non-SLE cases were determined from inpatient hospital services, fee-for-physician services, emergency services, and ambulatory care services. All costs were estimated for calendar year 2016. Data were analysed using central measures specifically the mean to determine the annual costs of SLE and non-SLE. A total number of 10,932 (Male = 2,546; Female = 8,386), and 41,851,36 (Male = 21,157,76; Female = 20,693,60) of SLE and non-SLE cases, respectively were included in this study. The mean annual costs of SLE, and non-SLE per case were $7,740.19 (Male = $7,986.59; Female = $7,665.38), and $2,479.53 (Male = $2,265.57; Female = $2,698.30), (p < 0.001) respectively. The mean annual costs of fee-for-physician services (SLE = $2,160.03; non-SLE = $840.00) (p < 0.001), inpatient hospital services (SLE = $3,462.86; non-SLE = $1,007.29), (p < 0.001) emergency services (SLE = $440.28; non-SLE = $176.65), (p < 0.001) and ambulatory care services (SLE = $1,677.03; non-SLE = $455.05) (p < 0.001) per case were estimated. The findings showed that the costs of SLE were considerably high for patients and healthcare system. This highlights the importance of appropriate treatment and management of SLE. Further studies are required to fully investigate both the direct and indirect economic burden of SLE including out-of-pocket expenses, costs to patients and caregivers and productivity loss.

Initial management of the patients with psychiatric involvement in hospital emergency departments: a systematic review

This article is a systematic review of studies that have investigated the initial management of patients with psychiatric conditions in hospital emergencies services in order to establish practical recommendations. A systematic review of the literature was carried out, consisting of studies published from 2010 to 2020, available in any language, consulting Cochrane Library Plus, PubMed, IBECS, LILACS and MEDLINE. The quality of the studies included in this review was assessed by the AMSTAR2 tool and the FCL 3.0 platform, together with the PRISMA statement. Results from the eleven papers selected showed that improvements in staff training, available resources, appropriate use of restraint and appropriate choice of medication can help to improve the care of patients with mental pathology in hospital emergency services. The same management for any other patient is recommended. However, if the patient is agitated or uncooperative, verbal, pharmacological and/or mechanical restraint (in this order) may be necessary. Keywords. Psychiatry. Psychomotor agitation. Crisis intervention. Hospital emergency service.

Current status of medical care of emerging infectious diseases at hospital emergency services in Spain

The aim of this study is to determine the current status of Spanish Hospital Emergency Services (HES) in diagnosing and treating the most prevalent tropical diseases (TD) in Spain. A cross-sectional descriptive study was carried out, using a questionnaire in Google Forms® sent to members of the INFURG-SEMES group. The following variables were analyzed: the size of the hospital in terms of number of beds, number of tropical disease emergencies, existence of tropical medicine protocols, urgent diagnostic tests or antimalarial treatment. The form was sent to 75 hospitals. Responses were obtained from 42 emergency services (55%) in 10 Autonomous Communities. Twenty-four (57.1%) had >500 beds. Only five hospitals (11.9%) have the facilities to diagnose malaria and dengue 24 hours a day. There was no tropical disease protocol in 19 (45.3%) hospitals. Seven (16.7%) hospitals had =?10 attendances/day. Larger hospitals were more likely to have an infectious disease unit independent from Internal Medicine service, along with a tropical medicine unit, and an on-call infectious disease specialist and microbiologist. There are no statistically significant differences between larger and smaller hospitals in terms of their capacity to carry out appropri-ate diagnoses or treatments in 24 hours. Care and treatment of emerging diseases are now a sizeable percentage of the consultations at an HES. Such units generally lack specific protocols, particularly for malaria. Urgent diagnostic testing for malaria is also needed.

Professional quality of life and perceptions of spirituality and spiritual care among nurses: Relationship and affecting factors.

This study aims to determine the relationship of nurses' perception of spirituality and spiritual care to the dimensions of professional quality of life, namely, nurses' compassion fatigue, burnout and compassion satisfaction, and identify the influencing factors, respectively. The population consisted of 316 nurses (response rate: 91.32%) working in various clinics of a Training and Research Hospital (gynecology, pediatrics, surgery, internal medicine and emergency service) between December 2018 and May 2019. Data was collected through the Socio-Demographic Form, The Professional Quality of Life Scale (ProQOL), and Spirituality and Spiritual Care Rating Scale (SSCRS). A meaningful relationship between SSCRS and ProQOL's "burnout" and "compassion fatigue" subscales was granted (p < 0.001). In particular, the comparison of ProQOL subscales to SSCRS's "spirituality/spiritual care" and "religiosity" subscales revealed a negative and strong relationship (p < 0.01) while SSCRS's "personalized care" subscale yielded a very strong positive relationship (p < 0.001). The nurses' professional quality of life was affected by variables such as "monthly number of shifts,""manner of work," and"average weekly working hours." It was determined that burnout was experienced at a higher level, whereas compassion fatigue at a moderate level. In terms of spirituality and spiritual care, the subscale mean scores for "spirituality/spiritual care,""personalized care," and "religiosity" were low. In light of the research findings, the charge nurses and nursing managers should oversee variables such as monthly income, monthly number of shifts, average weekly working hours at all times in the context of spiritual care and professional quality of life. Institution managers need to be competent in the prioritization of employee requests, planning the number of employees taking into account the ratio of nurse/patient/clinic capacity. Institution managers should familiarize themselves with notions such as compassion fatigue, burnout, and compassion satisfaction and spiritual care to plan and sustain the activities of the institution while overwatching the needs of her/his employees along the way. Nurses could also benefit from counseling services and in-service training programs contemplating sociodemographic and profession related variables that affect spiritual care and professional quality of life.

Factors Associated with Emergency Department Length of Stay in Critically Ill Patients: A Single-Center Retrospective Study.

BackgroundLength of stay (LOS) in the emergency department (ED) should be measured and evaluated comprehensively as an important indicator of hospital emergency service. In this study, we aimed to analyze clinical characteristics of critically ill patients admitted to the ED and identify the factors associated with LOS.Material/MethodsAll patients with level 1 and level 2 of the Emergency Severity Index who were admitted to the ED from January 2018 to December 2019 were included in this retrospective study. The patients were divided into 2 groups: LOS ≥4 h and LOS <4 h. Variables were comprehensively analyzed and compared between the 2 groups.ResultsA total of 19 616 patients, including 7269 patients in the LOS ≥4 h group and 12 347 patients in the LOS <4 group, were included. Advanced age, admission in winter and during the night shift, and diseases excluding nervous system diseases, cardiovascular diseases, and trauma were associated with higher risk of LOS. Nervous system diseases, cardiovascular diseases, trauma, and procedures including tracheal intubation, surgery, percutaneous coronary intervention, and thrombolysis were associated with lower risk of LOS.ConclusionsProlonged LOS in the ED was associated with increased age and admission in winter and during the night shift, while shortened LOS was associated with nervous system diseases, cardiovascular diseases, and trauma, as well as with procedures including tracheal intubation, surgery, percutaneous coronary intervention, and thrombolysis. Our findings can serve as a guide for ED physicians to individually evaluate patient condition and allocate medical resources more effectively.

Paraphrenia phantastica. A case report

IntroductionParaphrenia is a classic diagnostic entity characterized by an insidious development of a vivid and exuberant delusional system, more or less systematized, hallucinations and confabulations.ObjectivesIncrease knowledge about paraphrenia, a classic diagnosis that no longer appears on international classifications.MethodsExtensive research on the historical path of the paraphrenia diagnostic entity was carried out. Patient’s data is obtained from medical history and psychiatric interviews done during her hospitalizations.Results68 year-old patient attended the hospital emergency service due to a demonic possession delusion that emerged when she was 44 year-old, when she first consulted a psychiatrist because she believed someone introduced the demon inside her body. She described kinesthetic hallucinations as “movements of her brain” and an intense headache, both originated by the demon; as well as other types of hallucinations and confabulations. However, there was no deterioration in her personaliy or her intellectual capacity, as it could have been seen in a case of schizophrenia. This clinical case is considered a paraphrenia phantastica as it presents the typical features raised by the classic authors (mainly Henry Ey): paralogical thought dominance, megalomania, confabulation and integrity of relation with reality.ConclusionsCurrent internacional classifications do not consider paraphrenia as a differentiated diagnostic entity, as it also occurs with other classical entities. This causes a loss of important tools that would achieve a better approach to the patient’s condition.DisclosureNo significant relationships.

Resistencia antimicrobiana en infección del tracto urinario con bacteriuria en el servicio de urgencia de un hospital comunitario de la región de Ñuble, Chile

Introducción: la infección del tracto urinario es entre las enfermedades infecciosas una de gran incidencia en el adulto y la segunda con mayor incidencia en niños. Su tratamiento es inicialmente empírico y se sustenta fundamentalmente en la epidemiología y susceptibilidad local.

Nurse management of ischemic thoracic pain in hospital emergency services

Nurse management of ischemic thoracic pain in hospital emergency services

Exploring the potential for social prescribing in pre-hospital emergency and urgent care: A qualitative study.

There is a sustained increase in demand for emergency and urgent care services in England. The NHS Long Term Plan aims to reduce the burden on emergency hospital services through changing how pre-hospital care operates, including increased delivery of urgent care. Given the recognised potential of social prescribing to address wider determinants of health and reduce costs in other settings, this study aimed to understand the role that social prescribing can play in pre-hospital emergency and urgent care from the perspectives of staff. Semi-structured interviews (n=15) and a focus group (n=3) were conducted with clinical staff (n=14) and non-clinical health advisors (n=4) from an English Ambulance Service covering emergency (999) and non-emergency (111) calls. Data were analysed using a pre-defined framework: awareness of social prescribing; potential cohorts suitable for social prescribing; and determinants of social prescribing. Awareness and knowledge of social prescribing was limited, though when social prescribing was explained to participants they almost universally recognised its benefits for their role. Social prescribing was considered to be most beneficial to those calling for reasons relating to mental health, loneliness or social isolation, in particular older people and frequent users of 999 and 111 services. Determinants of social prescribing were identified across the micro (patient and staff acceptability of social prescribing), meso (triage and referral pathways) and macro (commissioning and funding) levels of analysis. This is the first empirical study to explore social prescribing in pre-hospital emergency and urgent care services, which suggests that it has potential to improve quality of care at the point of people accessing these services. There is a pressing need to address the micro, macro and meso level determinants identified within this study, in order to support staff within pre-hospital emergency and urgent care services to socially prescribe.

Correlation between the Glasgow Coma Scale Score and Tomographic Findings with in-Hospital Mortality in Patients Admitted in the Emergency Service of the General Hospital of Zone 50 of the IMSS of San Luis Potosi, with a Diagnosis of Traumatic Brain Injury

A Traumatic brain injury (TBI) is caused by sudden exchange of mechanical energy that causes cranial injury. It is a condition with high morbidity and mortality. A substantial number of survivors suffer disabling injuries. Management is aimed at avoiding secondary brain injury, thus improving the prognosis and reducing mortality. In the General Zone Hospital 50 of the Mexican Social Security Institute in San Luis Potosí, TBI is a frequent cause of visit in the emergency service; it represents 1.6% of all consultations.

COVID-19 and Other Viral Pneumonias

Objectıve: Distinguishing COVID-19 pneumonia, which shares common symptoms with other respiratory viruses, from other pneumonia types will be of utmost importance for maintaining the sustainability of health services, preventing long waiting times of patients at emergency services, and isolating. We compared patients with COVID-19 pneumonia and those with NONCOVID-19 pneumonia with a view to distinguishing COVID-19 pneumonia from other pneumonias.&#x0D; Methods: Our study retrospectively reviewed the medical records of patients who were admitted to the emergency service of training and research hospital in Ağrı, Turkey between April 1-July 1, 2020. In our study two groups: patients with COVID-19 pneumonia and those with other pneumonias (non COVID-19) were compared in terms of demographic characteristics, laboratory data, and thoracic computerized tomography (CT) findings.&#x0D; Results: Our study included 201 patients in the non COVID-19 group and 165 patients in the COVID-19 group. An analysis based on the CT findings showed that the rate of ground glass opacities (GGO) was significantly higher in the COVID-19 group (P &lt; 0.01). The rate of isolated lobar or segmental consolidation was significantly higher in the non COVID-19 group (P &lt; 0.01). The lesions had a significantly higher rate of bilateral distribution and peripheral location in the COVID-19 group (P &lt; 0.01). There was no significant difference between the two groups in terms of the mortality rate (P = 0.469).&#x0D; Conclusıon: We believe that in order to differentiate COVID-19 pneumonia from other pneumonias, a rapid thoracic computed tomography scan can be performed in the emergency department to be successfully patient management.

Understanding Components of Duration of Untreated Psychosis and Relevance for Early Intervention Services in the Canadian Context: Comprendre les Composantes de la Durée de la Psychose Non Traitée et la Pertinence de Services D'intervention Précoce Dans le Contexte Canadien.

Background:Clinical, functional, and cost-effectiveness outcomes from early intervention services (EIS) for psychosis are significantly associated with the duration of untreated psychosis (DUP) for the patients they serve. However, most EIS patients continue to report long DUP, while a reduction of DUP may improve outcomes. An understanding of different components of DUP and the factors associated with them may assist in targeting interventions toward specific sources of DUP.Objectives:To examine the components of DUP and their respective determinants in order to inform strategies for reducing delay in treatment in the context of an EIS.Methods:Help-seeking (DUP-H), Referral (DUP-R), and Administrative (DUP-A) components of DUP, pathways to care, and patient characteristics were assessed in first episode psychosis (N = 532) patients entering an EIS that focuses on systemic interventions to promote rapid access. Determinants of each component were identified in the present sample using multivariate analyses.Results:DUP-H (mean 25.64 ± 59.00) was longer than DUP-R (mean = 14.95 ± 45.67) and DUP-A (mean 1.48 ± 2.55). Multivariate analyses showed that DUP-H is modestly influenced by patient characteristics (diagnosis and premorbid adjustment; R 2 = 0.12) and DUP-R by a combination of personal characteristics (age of onset and education) and systemic factors (first health services contact and final source of referral; R 2 = 0.21). Comorbid substance abuse and referral from hospital emergency services have a modest influence on DUP-A (R 2 = 0.08). Patients with health care contact prior to onset of psychosis had a shorter DUP-H and DUP-R than those whose first contact was after psychosis onset (F(1, 498) = 4.85, P < 0.03 and F(1, 492) = 3.34, P < 0.07).Conclusions:Although much of the variance in DUP is unexplained, especially for help-seeking component, the systemic portion of DUP may be partially determined by relatively malleable factors. Interventions directed at altering pathways to care and promote rapid access may be important targets for reducing DUP. Simplifying administrative procedures may further assist in reducing DUP.

Prioritization and management of calls from older people to GP out-of-hours services.

Urgent out-of-hours medical care is necessary to ensure people can remain living at home into older age. However, older people experience multiple barriers to using out-of-hours services including poor awareness about the general practitioner (GP) out-of-hours (GPOOH) service and how to access it. In particular, older people are reluctant users of GPOOH services because they expect either their symptoms will not be taken seriously or they will simply be referred to hospital accident and emergency services. The aim of this study was to examine if this expectation was borne out in the manner of GPOOH service provision. The objective was to establish the urgency categorization and management of calls to GPOOH , for community dwelling older people in Ireland. An 8-week sample of 770 calls, for people over 65 years, to a GPOOH service in Ireland, was analysed using Excel and Nvivo software. Urgency categorization of older people shows 40% of calls categorized as urgent. Recognition of the severity of symptoms, prompting calls to the GPOOH service, is also reflected in a quarter of callers receiving a home visit by the GP and referral of a third of calls to emergency services. The findings also show widespread reliance on another person to negotiate the GPOOH system, with a third party making 70% of calls on behalf of the older person seeking care. Older people are in urgent need of medical services when they contact GPOOH service, which plays an effective and patient-centred gatekeeping role, particularly directing the oldest old to the appropriate level of care outside GP office hours. The promotion of GPOOH services should be enhanced to ensure older people understand their role in supporting community living.