Mode Of Arrival Research Articles

Abstract TP1: Impact Of Patient Characteristics And Covid-19 On Last Known Well To Arrival

Introduction: Stroke is a medical emergency requiring prompt evaluation and treatment. COVID-19 disproportionally burdened certain socioeconomic groups and its impact on patient's hospital arrival and access to emergency services to treat stroke is unknown. This study examines whether there was an impact of patient characteristics and COVID-19 on last known well (LKW) to arrival. Methods: Data from our health system stroke registry comprised of 40 hospitals were used for the analysis. Patients with a diagnosis of Ischemic stroke (ISC) or Intracerebral Hemorrhage (ICH) discharged between Jan 1 2018 - Mar 15 2020 (pre-COVID) and Mar 16 2020 - Apr 10 2022 (pandemic period) were included in the analysis. Inpatient strokes were excluded. Multinomial logistic regression was used to determine the likelihood of presenting to the hospital in the hyperacute phase (<4.5 hours) and the acute phase (4.5 to 24 hours) compared to delayed phase (> 24 hours), adjusting for COVID-19 time period, race/ethnicity, mode of arrival, insurance type, stroke type, age, NIHSS at admit, and medical history. Results: A total of 25,102 patients were included in the analysis, of which 55.7% arrived in hyperacute phase, 37.7% acute phase, and 6.6% delayed phase. ICH patients (AOR 1.10, 95% CI 1.03, 1.18) were more likely than ISC patients to arrive in the hyperacute phase than delayed phase. Asian patients were less likely than white patients to arrive in the hyperacute phase (AOR 0.72, 95% CI 0.58, 0.88) than delayed phase. Patients with a history of dementia (AOR 1.69, 95% CI 1.05, 2.72), depression (AOR 1.19, 95% CI 1.02, 1.39), and afib/flutter (AOR 1.31, 95% CI 1.12, 1.53) were more likely to arrive in the hyperacute phase than delayed phase. Patients with history of diabetes (AOR 0.69, 95% CI 0.61, 0.77), smoking (AOR 0.71, 95% CI 0.60, 0.83) and drug/alcohol abuse (AOR 0.62, 95% CI 0.52, 0.75) were less likely to arrive in the hyperacute phase than delayed phase. COVID-19 time period, history of stroke, and insurance had no impact on time to arrival. Conclusions: While several patient characteristics and medical comorbidities were significantly associated with delay in arrival of stroke patients, the first two years into COVID-19 was not associated with delay in presentation.

ORTHOPAEDIC INJURIES AFTER ELECTRONIC SCOOTER TRAUMA IN A LEVEL 1 TRAUMA CENTRE BEFORE AND AFTER INTRODUCTION OF AN ESCOOTER RIDE-SHARING SCHEME

The Victorian state government introduced a trial electronic scooter sharing scheme on 1st February 2022 in inner city Melbourne. Despite epidemiological data from other jurisdictions that show these devices are associated with significant trauma. This is a descriptive study from the largest trauma centre in Victoria demonstrating the “scope of the problem” after introduction of this government-approved, ride sharing scheme.Retrospective case series. Our hospital orthopaedic department database was searched from 1/1/2021 to 30/6/22 to identify all presentations associated with electronic scooter trauma, the mechanism of injury and admission information was confirmed via chart review. Data collected included: mode of arrival, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, list of injuries, operations undertaken, surgical procedures, discharge destination, death.In the 12 months prior to and 5 months since introduction of the ride share scheme, 43 patients were identified. 18 patients (42% of our cohort) presented in the 5 months since ride sharing was introduced, and 25 patients in the preceding 12 months.58% were found to be alcohol or drug affected. All patients were admitted to hospital, 14% of which included ICU admission. 44% were polytrauma admissions. Median hospital length of stay was 2 days. The longest individual hospital stay was 69 days. No patients in this series died. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. Mean Injury Severity Score was 10.Despite data demonstrating their danger in other jurisdictions, the Victorian state government approved a trial of an electronic scooter ride share scheme in inner Melbourne in February 2022. These devices are associated with a significant trauma burden and the rate has increased since the introduction of the ride-sharing scheme. This data may be combined with other hospital data and could be used to inform policy makers.

Abstract WP143: Use Of CTP For Evaluation Of EVT Candidates In The Early Time Window (<6 Hours From Lkwt) Does Not Delay EVT T And Use Of CTP Beyond 6 Hours Improves Speed Of EVT

Introduction: Computerized Tomography Perfusion (CTP) improves detection of distal occlusion and aids in patient selection for endovascular therapy (EVT) for acute ischemic stroke (AIS). As EVT continues to evolve, it is important to assess if CTP continues to aid in the evaluation of AIS or if it adds unnecessary time. Here we assess whether the imaging approach used to evaluate EVT patients was associated with improved door to device times or clinical outcomes. Specifically, we assessed whether CTA alone vs CTA/CTP combined had an effect on door to device (DTD) for EVT, discharge disposition and 90-day mRS. Methods: Data from 1357 AIS EVT patients from 17 hospitals was obtained from a multi-state health system’s stroke registry between Jan 1, 2018, to Apr 11, 2022. Multivariable mixed-effect linear and logistic regression models were employed to identify the association of evaluation type with DTD, discharge disposition and mRS, adjusting for age, sex, race, mode of arrival, NIHSS, stroke mechanism, medical history, and TICI score. Multivariable ordinal regression model was used with mRS as ordinal variable. Each clinical outcome was assessed for last known well (LKW) to arrival below 6 hours and between 6 and 24 hours. Results: The median age was 74 years, 729 (47.7%) were male; 958 (70.6%) arrived in less than 6 hours from LKW and 399 (29.4%) in the interval between 6 and 24 hours. CTA and CTP evaluation was used for 829 (61.1%) patients. In the multivariable models, evaluation with both CTA and CTP was significantly associated with a decrease of the DTD when LKW to arrival was > 6 hours (n= 955, regression coefficient -16, 95% CI -27, -3.6, p = .01) and had no effect on DTD inside of 6 hours. No significant association was found between evaluation type and discharge disposition or 90-day mRs after adjustment for covariates. Conclusions: In EVT patients presenting inside of 6 hours, addition of CTP to CTA caused no delay in DTD and in those presenting from 6-24 hours adding CTP shortened DTD by 16 minutes. This may reflect that CTP allows for more confident and expeditious treatment. These results along with no effect of evaluation type on clinical outcome argue that there is no disadvantage to the use of CTP inside of 6 hours and a clear time advantage beyond 6 hours.

Abstract NS7: Time To Reversal Is Brain - A Retrospective Analysis Of Door To Needle Times Of Anticoagulation Reversal Agents In Intracranial Hemorrhage, A Single Center Retrospective Analysis

Objectives: Anticoagulant associated intracranial hemorrhage (AA-ICrH) accounts for 10-25% of all intracranial hemorrhages and anticoagulation (AC) at the time of the event more than doubles mortality risk. No guidelines for target times to treatment have been established for the administration of AC reversal agents despite their rapid onset of action. We evaluated AC reversal treatment times among patients with AA-ICrH presenting to a single large community hospital with institutional target times established in 2018. Methods: Retrospective chart review was performed for all AA-ICrH treated with reversal agents in Sarasota Memorial Hospital Comprehensive Stroke Center, Sarasota, Florida, between 2018-2021. Clinical and non-clinical variables were collected. Predictors with p<0.20 in the univariate analysis were investigated further in a multivariable model. Results: We identified 175 patients, 60% male, 94% Caucasian. FXa inhibitors were used among 67%, warfarin 29% and dabigatran 4%. Half the cohort was treated with andexanet, 46% PCCs and 4% idarucizumab. Arriving via EMS, 70%, transfers from other facilities 14%, walk-ins 10%, and inpatients 6%. Overall, 62% arrived ≤3 hours from symptom onset, 52% and 20% presented under trauma alert (TA) and stroke alert (SA) protocols, respectively. Overall median [IQR] DTN and CTN times (in minutes) were 103 [69-182] and 81 [55-126] respectively, and order-to-needle time, 38 [31-46]. DTN and CTN times among EMS arrival were 98 [69-160] and 70 [54- 110], respectively, for walk-ins, 204 [144-262] and 88 [66-130], respectively (p<0.05). DTN ≤90 and ≤60 minutes was seen in 69% and 38% of SA and 48% and 14% of TA, respectively. CTN ≤60 minutes was achieved in 58% of SA and 35% of TA. The only two significant independent predictors of faster DTN times were SA protocol on arrival and arrival mode (p<0.001). Conclusions: Similar to ischemic strokes, arrival by EMS or under SA protocol was associated with faster DTN and CTN times for AC reversal therapies in patients presenting with AA-ICrH. Our institution’s proposed time goals for DTN ≤90 and CTN ≤60 minutes for >75% of patients remained unmet. Nationally accepted target times for AC reversal therapies used in certified stroke centers could help achieve these goals.

Current situation of acute ST-segment elevation myocardial infarction in a county hospital chest pain center during an epidemic of novel coronavirus pneumonia.

Our object was to examine how the pre- and post-pandemic COVID-19 impacted the care of acute ST-segment elevation myocardial infarction (STEMI) patients in county hospitals. Using January 20, 2020, as the time point for the control of a unique coronavirus pneumonia epidemic in Jieshou, 272 acute STEMI patients were separated into pre-epidemic (group A, n = 130) and epidemic (group B, n = 142). There were no significant differences between the two groups in terms of mode of arrival, symptom onset-to-first medical contact time, door-to-needle time, door-to-balloon time, maximum hypersensitive cardiac troponin I levels, and in-hospital adverse events (P > 0.05). Emergency percutaneous coronary intervention (PCI) was much less common in group B (57.7%) compared to group A (72.3%) (P = 0.012), and the proportion of reperfusion treatment with thrombolysis was 30.3% in group B compared to 13.1% in group A (P < 0.001). Logistic regression analysis showed that age ≥76 years, admission NT-proBNP levels ≥3,018 pg/ml, and combined cardiogenic shock were independent risk factors for death. Compared with thrombolytic therapy, emergency PCI treatment further reduced the risk of death in STEMI. In conclusion, the county hospitals treated more acute STEMI with thrombolysis during the COVID-19 outbreak.

Early Intravenous Magnesium Sulfate Administration in the Emergency Department for Severe Asthma Exacerbations.

Severe asthma exacerbations in pediatric patients occur frequently and can require pediatric intensive care unit (PICU) admission. To determine if early administration of intravenous magnesium sulfate (IVMg) to pediatric patients experiencing severe asthma exacerbations, defined as a respiratory clinical score (RCS) of 9 to 12, resulted in fewer PICU admissions. Retrospective chart review of pediatric patients aged from 2 to 17 years presenting with a severe asthma exacerbation to a single tertiary care pediatric emergency department. Univariable and multivariable logistic regression analyses were used to determine if admission to the PICU was associated with early IVMg treatment, within 60 minutes of registration. A total of 1911 patients were included in the study, of which 1541 received IVMg. The average time to IVMg was 79 minutes, with 35% of the patients receiving it within 60 minutes of arrival. Two hundred forty-eight (13%) were admitted to the PICU, 641 (34%) were admitted to the general inpatient floor, and 1022 (53%) were discharged home. Factors associated with increased odds ratio (OR) of PICU admission were: early IVMg (OR, 1.63; 95% CI: 1.16-2.28), arrival mode to the emergency department via ambulance (OR, 2.23; 95% CI: 1.45-3.43), history of PICU admission for asthma (OR, 1.73; 95% CI: 1.22-2.44), and diagnosis of status asthmaticus (OR, 8.88; 95% CI: 3.49-30.07). Calculated OR of PICU admission subcategorized by RCS for early IVMg patients, after controlling for PICU risk factors, are as follows: RCS 9 (reference), RCS 10 (OR, 2.52; 95% CI: 0.89-2.23), RCS 11 (OR, 2.19; 95% CI: 1.3-3.70), and RCS 12 (OR, 4.12; 95% CI: 2.13-7.95). Early administration of IVMg to pediatric patients experiencing severe asthma exacerbations does not result in fewer PICU admissions.

Clinical Impact of Prolonged Helicopter Emergency Travel Times in a Rural Trauma System.

In the United States, healthcare organizations utilize helicopter emergency medical services (HEMS), which are well-established and integral to trauma and emergency medical transport. HEMS expedites critical resources to trauma patients at the initial scene of the accident, which typically falls outside of the effective service area of ground transportation. This is a single-center study of trauma registry data, inclusive years July 1, 2016, to September 26, 2021. The inclusion criteria were all adult ICU patients (≥18years) traveling by air. An initial bivariate analysis was used to describe differences in HEMS vs rendezvous (ground + HEMS) mode of arrival. A multivariate linear regression was calculated to predict elapsed transport times on predictor variables to determine the clinical impact of prolonged transport times. There were 242 patients identified in the analysis, with 87 (36%) traveling by HEMS and 155 (64%) traveling by rendezvous. A significant regression equation was found (F(29,198) = 2.39, P < .01), with an R2 of .26. As the transport time increased by 10.67 minutes, the shock index ratio (SIR) increased by one unit (P = .04). Conversely, for each unit increase in Glasgow Coma Scores (GCS), flight time decreased by 1.03 minutes (P < .01). Rendezvous transport times were on average eight minutes longer than HEMS alone (P < .01). Those with prolonged travel times were likely to travel by rendezvous with presentation of lower GCS and higher SIR upon arrival, despite equivocal injury patterns and severity. This research highlights the need for a helicopter auto-launch program to expedite helicopter travel times in distant locations to the only Level I trauma center in the region.

Fall rates by specialties and risk factors for falls in acute hospital: A retrospective study.

Falls are common adverse events in acute care hospitals, and about 25-50% of fallers suffer injuries. In acute care, fall rates range from 0.4-9 falls per 1000 patient days, varying among unit types, patient characteristics, and diseases. Several risk factors have been identified, including recent falls, age, reduced mobility, cognitive ability and polypharmacy. Several countries have become an aging society in which an increasing number of older patients need acute care. Therefore, the prevention of falls has become one of the most important aspects of patient safety. This retrospective study aimed to explore adults' inpatient falls in a Finnish university hospital with several specialties. The objectives were to draw an overall picture of fall rates in Finnish acute care, and to model risk factors for falls including secondary diagnoses. The study was conducted in a large university hospital in Finland. The data consisted of patients' electronic health records from 2014-2016 and included a total of 114,951 adult patients. Univariable and multivariable binary logistic regression model analysis was used to identify risk factors for falls and multiple imputation was used to missing data. The study reporting followed the STROBE guidelines. A total of 841 falls were recorded, totalling 1.5 falls per 1000 patient days, and the rate of falls with injury was 0.4 per 1000 patient days. The regression model included the following risk factors: increasing old age, prolonged hospital stays, specialty of neurology, mode of arrival (emergency care and hospital transfer), no operation during hospital stays and secondary diagnoses such as dementia, pneumonia and alcohol abuse. In acute care, falls occur most in patients with neurological diagnoses and least in surgical patients. Risk factors for falls include increasing age, emergency arrival, hospital transfer and prolonged hospital stay. Educational interventions to improve healthcare professionals' competence and preventive interventions to avoid inpatient falls need to be prioritized in medical specialties with high fall rates.

Derivation and validation of a clinical decision rule to risk-stratify COVID-19 patients discharged from the emergency department: The CCEDRRN COVID discharge score.

To risk-stratify COVID-19 patients being considered for discharge from the emergency department (ED). We conducted an observational study to derive and validate a clinical decision rule to identify COVID-19 patients at risk for hospital admission or death within 72hours of ED discharge. We used data from 49 sites in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) between March 1, 2020, and September 8, 2021. We randomly assigned hospitals to derivation or validation and prespecified clinical variables as candidate predictors. We used logistic regression to develop the score in a derivation cohort and examined its performance in predicting short-term adverse outcomes in a validation cohort. Of 15,305 eligible patient visits, 535 (3.6%) experienced the outcome. The score included age, sex, pregnancy status, temperature, arrival mode, respiratory rate, and respiratory distress. The area under the curve was 0.70 (95% confidence interval [CI] 0.68-0.73) in derivation and 0.71 (95% CI 0.68-0.73) in combined derivation and validation cohorts. Among those with a score of 3 or less, the risk for the primary outcome was 1.9% or less, and the sensitivity of using 3 as a rule-out score was 89.3% (95% CI 82.7-94.0). Among those with a score of≥9, the risk for the primary outcome was as high as 12.2% and the specificity of using 9 as a rule-in score was 95.6% (95% CI 94.9-96.2). The CCEDRRN COVID discharge score can identify patients at risk of short-term adverse outcomes after ED discharge with variables that are readily available on patient arrival.

UK Border Digitalisation – a Commentary on the Current State of Affairs

The commentary focuses on the current process of digitalisation of the British immigration procedures by 2025 as a part of a reform brought about by Brexit and broader digital strategies. The policy plan, its implementation and reception are analysed briefly. The British government aim is to digitise the immigration procedures by 2025, support eGates and eventually enforce a contactless mode arrival. The challenges already encountered are presented with the conclusion on the emphasis that is still missing in the practical employment of the policy.

Clinician assessment of blood alcohol levels among emergency department patients

IntroductionAlcohol intoxication is a significant public health concern and is commonly seen among emergency department (ED) patients. This study was undertaken to identify the accuracy of clinician assessment of blood alcohol levels among emergency department patients. MethodsThis prospective survey study was conducted at a Level 1 Trauma Center. Eligible study participants included physicians, nurses, and medical students involved in the care of patients who had BAC. Clinicians estimated the BAC prior to results availability. ResultsAmong 243 clinicians, the mean difference between the estimated BAC and actual BAC was 17.4 (95% CI: 4.7 to 30.1). Providers tended to overestimate the actual BAC level. The accuracy between roles (attendings, residents, RNs, students) was not significant (ANOVA p-value 0.90). Accuracy was not correlated with age of the patient (Pearson correlation 0.04, p-value 0.54). Accuracy was not associated with the patient's gender (Student's t-test two-tailed p-value 0.90), ethnicity (White versus all others, t-test p-value 0.31), nor insurance (government versus not government, t-test p-value 0.81). The average accuracy value was associated with mode of arrival (t-test p-value 0.003). The average accuracy for walk-in subjects was −14.9 (CI: −32.8 to 3.1) compared to ambulance arrivals 28.3 (CI: 12.7 to 44.0). Providers underestimated BAC for walk-ins and overestimated BAC for ambulance arrivals.Among 107 patients with a BAC of 0, clinician estimates ranged from 0 to 350. Clinicians estimated non-zero BAC levels in 17% of patients with BAC of 0 (N = 18). ConclusionsClinicians' estimates of BAC were often inaccurate, and often overestimated the BAC.

Emergency Department: Analysis of Patient Flow and Length of Stay Variations

Abstract Background Crowding in Emergency Departments(ED)is a severe public health issue.Length of stay(LOS)is not a direct measure of crowding,but it is an essential indicator for monitoring emergency care quality.LOS in ED can be associated with delays in treatment,decreased patient satisfaction and adverse outcomes.The aim of this study is to analyze ED LOS in the Teaching Hospital of Siena for further strategies. Methods A retrospective observational study was conducted between January 1,2019, and December 31,2021.To manage admissions and discharges, all patients’ data admitted to ED of the University Hospital of Siena were accessed by Aurora,the IT system.In addition,a descriptive analysis was performed, collecting the following variables:sex,age,arrival mode,ED visit reasons,triage code,discharge mode,hospital admission area and LOS(cut-off&amp;gt;8hours).The analysis was carried out using STATA 17:variables were analyzed with ANOVA test. Results Our sample consisted of 152.393 patients (F49.47% M50.53%),and the average age was 50.51(SD ± 26.07).During the years total ED visits decreased:65.426(2019);40.318(2020); 46.649(2021),and there was a significant increase (p &amp;lt; 0.001) of patients with LOS&amp;gt;8 hours:13.96%(2019); 21.51%(2020); 23.10%(2021).In the years 2019,2020 and 2021, admissions of patients with LOS&amp;gt;8 hours were respectively: 25.92%; 43.95% and 37.09%, with the following percentage in medical areas:69.96% in 2019;70.51% in 2020;64.55% in 2021.A progressive increase of admissions in COVID area resulted since 2020(2.23%-2020;6.07%-2021). Conclusions The spread of COVID-19 and the containment measures,such as lockdown,caused a significant decrease in ED access.The increase LOS&amp;gt;8h could be primarily due to the time needed to perform laboratory investigations for the search for SARS-CoV-2 but also to the overflow of SARS-CoV-2-infected patients rapidly saturating the ED boxes and hospital bed capacity,with the need sometimes to dedicate other medical areas to manage COVID patients. Key messages • ED-LOS is a proxy indicator to monitor emergency care quality. • Further investigations should be performed to analyze the leading causes of ED LOS increase during the pandemic period.

Socioeconomic status and waiting time in the emergency department for patients with chest pain

Abstract Introduction Acute coronary syndrome (ACS) is one of the leading causes of death in the world and timeliness of treatment and diagnosis is of utmost importance to reduce mortality and morbidity. Emergency department (ED) crowding results in longer waiting times and length of stay in the ED and is a globally growing phenomenon with clear negative consequences for patients. Low socioeconomic status (SES) has previously been associated with poor prognosis after ACS, but it remains unclear if treatment and diagnostics in the acute state is a contributing factor. ED length of stay has been linked to crowding and poor patient outcomes whereas mechanisms for generally worse prognosis in low SES remains poorly understood. Purpose To investigate whether SES, measured as disposable income, is associated with ED waiting times among patients with the most common chief complaint in ACS, chest pain. Methods A registry-based cohort study on all 140,388 patients arriving at 14 Swedish emergency departments between 2015 and 2019 with chest pain as their chief complaint registered in the Swedish Emergency Registry (SVAR). Individual-level sociodemographic and clinical data were linked from multiple national registries. The associations between disposable income quintiles and ED length of stay and time to doctor were assessed using multivariable regression models adjusting for age, sex, education, comorbidities (diabetes, hypertension, hyperlipidemia, obesity and cardiovascular disease) and ED-visit characteristics (arrival mode, triage level, arrival time (day, evening or night as well as weekday or weekend) and hospital type). Results Median length of stay was 11 minutes (4.4%) longer among patients in the lowest income quintile, 4:04 [hours:minutes] (95% confidence interval [CI] 4:02–4:05), compared to patients in the highest income quintile (3:53, 95% CI 3:52–3:55). Similarly, time to doctor was 6 min (8.7%) longer among patients in the lowest income quintile (1:15 min, 95% CI 1:14–1:16) than patients in the highest income quintile (1:09, 95% CI 1:08–1:10). The associations were independent of adjustment for studied confounders and mediators. Conclusions Among ED chest pain patients, low income was associated with longer length of stay and time to doctor which may impact negatively on patients with serious cardiovascular diagnosis such as ACS. Longer waiting times may delay diagnosis and timely treatment for the individual patient such as anti-ischemic and antithrombotic therapy. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported by grants provided by Region Stockholm (ALF-project)

75 Disparities in Emergency Department Wait Times for Female, Transgender Female, Black and Non-English-Speaking Patients

Prolonged emergency department (ED) wait time is a significant barrier in access to medical care and timely diagnosis and treatment. Prior research has established that ED wait time disparities exist for non-white, non-male, and non-English speaking patients. However, disparities have been analyzed only for particular conditions or without controlling for patient condition. We study the existence of disparities in wait times of patients of different genders, races, primary languages, as well as transgender patients, while accounting for acuity, chief complaint, time of arrival, mode of arrival, patient age and vital signs as well as ED flow variables at the time of patient arrival.

Investigation into the predictive capability for mortality and the trigger points of the National Early Warning Score 2 (NEWS2) in emergency department patients

IntroductionNational Early Warning Score 2 (NEWS2) is widely used to monitor and trigger assessment throughout a patient’s hospital journey. Since the development and role out of NEWS2, its ability to...

The Frequency of Infant-Feeding Presentations at English Emergency Departments During the SARS-CoV-2 Pandemic: A Nation-Wide Electronic Health Records Study.

Objectives: To examine the frequency and distribution of infant feeding-related presentations at emergency departments (EDs) before and during the SARS-CoV-2 pandemic.Setting: Attendances at 48 major EDs in England in two 50-week periods before and during the COVID-19 pandemic: period 1, April 2, 2019 to March 10, 2020 and period 2, April 1, 2020 to March 10, 2021.Methods: We estimated the change in frequency of ED presentations by age group and diagnosis before and after the start of the SARS-CoV-2 pandemic in England. We compared changes in the frequency of attendances of infant-feeding related presentations by infant age, sex, ethnicity, deprivation, rurality, arrival mode, arrival time, acuity, mother’s age, gravidity and mental health, birth length of stay, attendance duration, and disposal (i.e., admission or discharge).Results: While total ED attendances fell by 16.7% (95% CI -16.8% to -16.6%), infant attendances increased for feeding problems (+7.5% 95% CI 2.3% to 13.0%), neonatal jaundice (+12.8%, 95% CI 3.3% to 23.3%) and gastro-esophageal reflux (+9.7%, 95% CI 4.4% to 15.2%). These increases were more pronounced amongst first babies (+22.4%, 95% CI 13.1% to 32.5%), and where the stay in hospital after birth was brief (0-1 days, +20.1%, 95% CI 14.8% to 25.7%). Our analysis suggests that many of these attendances were of low acuity.Conclusions: While ED attendances reduced dramatically and systematically with the COVID-19 pandemic, presentations for infant feeding issues increased, implying growth in the unmet needs of new mothers and infants.

Incidence, Trends, and Seasonality of Paediatric Injury-Related Emergency Department Presentations at a Large Level 1 Paediatric Trauma Centre in Australia

This retrospective cohort study aimed to examine the characteristics, incidence, temporal trends, and seasonality of paediatric injury-related Emergency Department (ED) presentations at a large metropolitan paediatric hospital. It included children aged ≤15 years who presented to the ED at The Children’s Hospital at Westmead, Sydney Australia, with a principal diagnosis of injury during the ten-year period from 1 January 2010 to 31 December 2019. Descriptive statistics were used to describe the characteristics of the cohort and the distribution of ED presentations by mode of arrival, triage category, discharge status, injury diagnosis. Negative binomial regression was used to examine percentage change in annual incidence. Seasonality was examined with Seasonal and Trend decomposition using Loess (STL). There were 134,484 (59.7% male children) paediatric injury-related ED presentations during the ten-year period, of which 23,224 (17.3%) were admitted to hospital. Head injury accounted for more than one-quarter (26.8%) of ED presentations. The average annual increase in incidence was more pronounced during the first five years (5.6% [95%CI 4.1% to 7.1%]) than in the last five years (0.8% [95%CI 0.2% to 1.5%]). The monthly incidence of ED presentations had a bimodal distribution with peaks during autumn (March–May) and spring (October–November) seasons. The mean number of ED presentations per day was higher on weekends (40.8 ± 0.3) than weekdays (35.3 ± 0.8). During 2010 to 2019, there was a significant increase in the annual incidence of injury-related ED presentations for children aged ≤15 years, with head injury accounting for more than one-quarter of the ED presentations. The incidence of paediatric injury-related ED presentations was higher during autumn and spring seasons and at weekends. These data will inform health resource planning and priority-setting and advocacy for child injury prevention strategies in Australia.

Association between focused cardiac ultrasound and time to furosemide administration in acute heart failure

BackgroundHeart failure (HF) is a global health burden, and its management in the emergency department (ED) is important. This study aimed to evaluate the association between focused cardiac ultrasound (FoCUS) and early administration of diuretics in patients with acute HF admitted to the ED. MethodsThis retrospective observational study was conducted at a tertiary academic hospital. Patients with acute HF patients who were admitted to the ED and receiving intravenous medication between January 2018 and December 2019 were enrolled. The main exposure was a FoCUS examination performed within 2 h of ED triage. The primary outcome was the time to furosemide administration. ResultsOf 1154 patients with acute HF, 787 were included in the study, with 116 of them having undergone FoCUS. The time to furosemide was significantly shorter in the FoCUS group (median time (q1–q3), 112 min; range, 65–163 min) compared to the non-FoCUS group (median time, 131 min; range, 71–229 min). In the multivariable logistic regression analysis adjusting for age, sex, chief complaint, mode of arrival, triage level, shock status, and desaturation at triage, early administration of furosemide within 2 h from triage was significantly higher in the FoCUS group (adjusted odds ratio, 1.63; 95% confidence intervals, 1.04–2.55) than in the non-FoCUS group. ConclusionsEarly administration of intravenous furosemide was associated with FoCUS examination in patients with acute HF admitted to the ED. An early screening protocol could be useful for improving levels in clinical practice at EDs.

Patient profile and outcomes of traumatic injury: The impact of mode of arrival to the emergency department

BackgroundTraumatic injuries are of global health concern and significant contributors to Emergency Department (ED) and hospital workload. AimTo compare patterns of traumatic injuries among patient presentations to the ED across different modes of arrival (ambulance, police, or private transport) and to examine the predictors of an ED length of stay (LOS) exceeding 4 hours and hospital admission requirement. MethodsA retrospective observational study using 6 months of health data (8th October 2012–7th April 2013) of ED patient presentations made to one large, regional ED in Queensland, Australia, with a diagnosis code related to trauma. FindingsOver 6 months, 24.2% (n = 6,668) of adult patient presentations were trauma-related; most (60.9%) arrived via privately arranged transport (PAT); 38.7% were brought in by ambulance (BIBA) and 0.4% were brought in by police (BIBP). Demographics, clinical profile and patient outcomes differed based on mode of arrival. One in four patient presentations required hospital admission and 25% had an ED length of stay of >4 hours. Factors influencing hospital admission included older age, night shift, more emergent priority, and being BIBA. An ED length of stay of >4 hours was associated with older age, being BIBA, emergent nature of presentation, and hospital admission. ConclusionThe profile and outcomes of ED patient presentations with traumatic injury differs based on their mode of arrival to the ED. People BIBA were more likely to require hospital admission and have longer ED LOS, compared with those BIBP or PAT, even when controlling for covariates. Our findings may be used to inform nursing resource allocation when considering mode of arrival, especially for older people and people BIBA.

Universal elevator round trip time calculation for general traffic conditions with extension to batch arrivals

Recent studies have revealed that the dominant traffic pattern of a modern high-rise building is much more complicated than the conventional up-peak model, i.e. incoming traffic only, upon which the popular formula of round trip time (RTT) calculation is based. RTT calculation is still recommended by ISO 8100:32:2020 and CIBSE Guide D: 2020 to precede any computer simulation. Nowadays, the concern is more on the lunch peak with a mixture of incoming, outgoing and interfloor traffic patterns. Moreover, the independent one-passenger arrival model should be replaced by the more practical batch arrival model, in particular during lunch-time peak. This article first summarizes what were previously published on the universal RTT evaluation for mixed traffic conditions, highlights the main arguments, updates and supplements some previously introduced formulae such as that related to coincidental stops, uses more symmetrical and easily manipulated graphics, and, second in particular, brings in the concept of batch arrivals of any desirable probability distribution, where the conventional independent one-passenger arrival up-peak model now becomes a special case. A step-by-step presentation is adopted for convenient application of this universal calculation approach by designers and the detailed verification of the whole process by Monte Carlo simulation is also included. Practical applications: Round trip time calculation is still recommended the first step of traffic design by the industry but it should reasonably include the consideration of mixed traffic patterns, versus a pure incoming (i.e. up-peak) approach in the past. Such universal RTT calculation was described in several articles previously, but with some missing details. Here, the whole process is summarized, updated and presented in a more graphical way for convenient use by designers. Furthermore, the more contemporarily practical batch passenger arrival mode is included in this universal RTT model as an extension to the methodology so that what are discussed in this article include incoming, outgoing, interfloor traffic patterns with batch arrival consideration. It is hoped that this article could provide a comprehensive universal RTT methodology that can eventually be popularly applied globally by designers and consultants.