Emergency Department Referrals Research Articles

A Prepubertal Girl with Delusions of Pregnancy.

A Prepubertal Girl with Delusions of Pregnancy.

Reducing Unnecessary Treatments for Acute Bronchiolitis Through an Integrated Care Pathway.

To analyze the impact of an integrated care pathway on reducing unnecessary treatments for acute bronchiolitis. We implemented an evidence-based integrated care pathway in primary care (PC) centers and the referral emergency department (ED). This is the third quality improvement cycle in the management of acute bronchiolitis implemented by our research team. Family and provider experiences were incorporated by using design thinking methodology. A multifaceted plan that included several quality improvement initiatives was adopted to reduce unnecessary treatments. The primary outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were prescribing rates of other medications. The main control measures were hospitalization and unscheduled return rates. Salbutamol prescribing rate data were plotted on run charts. We included 1768 ED and 1092 PC visits, of which 913 (51.4%) ED visits and 558 (51.1%) PC visits occurred in the postintervention period. Salbutamol use decreased from 7.7% (interquartile range [IQR] 2.8-21.4) to 0% (IQR 0-1.9) in the ED and from 14.1% (IQR 5.8-21.6) to 5% (IQR 2.7-8) in PC centers. In the ED, the overall epinephrine use rate fell from 9% (95% confidence interval [CI], 7.2-11.1) to 4.6% (95% CI, 3.4-6.1) (P < .001). In PC centers, overall corticosteroid and antibiotic prescribing rates fell from 3.5% (95% CI, 2.2-5.4) to 1.1% (95% CI, 0.4-2.3) (P =.007) and from 9.5% (95% CI; 7.3-12.3) to 1.7% (95% CI, 0.9-7.3) (P <.001), respectively. No significant variations were noted in control measures. An integrated clinical pathway that incorporates the experiences of families and clinicians decreased the use of medications in the management of bronchiolitis.

Necrotising soft tissue infection in western Sydney: An 8-year experience.

This study aimed to assess the risk factors, management, imaging validity, Laboratory Risk Indicator for Necrotising infection (LRINEC) score and outcomes of necrotising soft tissue infection (NSTI) at a western Sydney tertiary hospital. A retrospective study was conducted of all patients with NSTI from 2012 to 2019 at our institution. Patient characteristics, imaging, microbiology and site, LRINEC score, surgical management and outcomes/disposition were collected. Thirty-six patients met the inclusion criteria with mean age of 52 years and body mass index of 38.1; 55.6% were male, 48% of Polynesian descent and 55.6% were diabetic. The most frequent sites of NSTI were perineal (30.6%), lower limb (30.6%), perianal (19.3%) and trunk (11.1%). A total of 64% of patients underwent computed tomography radiological imaging with diagnostic accuracy of 50%. The mean LRINEC score was 7 (1-20). A total of 52.8% were transferred from another facility or non-surgical teams which delayed surgical review by 11.4 h (P < 0.03) and operating time by 12.4 h (P < 0.04) compared with direct emergency department referrals to the on-call surgical team. There was no statistical difference in outcomes in both groups. The overall average time to surgical debridement was 16.2 h (standard deviation 19.6, range 3.4-105.1). The mean hospital length of stay was 20.9 days; 44.4% of patients were transferred for rehabilitation or plastic reconstruction with a single mortality from multi-organ failure. The optimal management of NSTI requires a high index of suspicion and LRINEC score is a useful adjunct in aiding a clinician's decision. Early surgical debridement within 24 h of diagnosis and a multidisciplinary approach is associated with a lower mortality rate.

Adhesive small bowel obstruction in elderly patients: a single-center analysis of treatment strategies and clinical outcomes

Introduction The incidence of adhesive bowel obstruction (ASBO) progressively increases with age. Strong evidences on the influencing role of age on ASBO clinical course and management are still lacking. Aim of this study is to retrospectively analyze the clinical outcomes of patients older than 65 years of age admitted to a tertiary referral Emergency Department with a diagnosis of ASBO. Materials and methods We reviewed the clinical records of patients admitted for ASBO in the period 2014–2019. Patients were divided in elderly (≥65 years) and non-elderly (<65 years). Primary endpoint was to compare the all-cause in-hospital mortality and the occurrence of major complications in the two groups. Secondary endpoint was a comparison of clinical presentation, clinical course and management. Results We enrolled 285 elderly and 492 non-elderly patients. Vomit was more frequent in the elderly (51.9% vs 34.6%; p < .001), while no difference was evidenced for the remaining symptoms of ASBO presentation. A higher rate of non-operative management (NOM) (26.3% vs 16.5%; p = .010), ICU admission (16% vs 0.6%; p < .001), mortality (2.1% vs 0.2%; p = .007) and cumulative major complications (8.8% vs 3.3%; p = .001), as well as a prolonged hospitalization (8.2 vs 5.4 days; p < .001) was evidenced in the ≥65 years group. Multivariate analysis identified increasing age (OR:2.8; 95%CI:1.09–7.2; p = .040) and Charlson comorbidity index ≥ 2 (OR:2.5; 95% CI:1.2–6.4; p = .050) as the only independent predictors of cumulative major complications. Conclusions Despite the similarity in terms of clinical presentation, elderly patient present higher mortality rate and occurrence of major complications. A comprehensive geriatric assessment is recommended to optimize the diagnostic and clinical strategies in case of ASBO.

P15 Admission avoidance in acute epistaxis: a prospective national audit during the initial peak of the COVID-19 pandemic

IntroductionIn March 2020, UK epistaxis guidelines were issued incorporating major shifts in standard practice, namely the recommended use of dissolvable products and discharge of patients with non-dissolvable packs.The aim of this audit was to assess patient outcomes following epistaxis care during the initial COVID-19 peak, exploring factors relating to unscheduled re-presentations.MethodsA UK-wide prospective multicentre national audit was performed over 12-weeks from 6th April 2020 at ENT departments treating adults with epistaxis. The primary outcome was re-presentation within 10-days. Univariable binary logistic regression analysis was used to identify significant determinants of the primary outcome measure.Results83 centres from all four UK nations submitted 2,631 cases, the majority of which were Emergency Department (ED) referrals (89.7%). ENT clinicians used a dissolvable intranasal product in 34.7% of patients overall (n = 816/2,351), and in 61.1% of those receiving an intranasal product (n = 816/1,336). 54.6% were discharged from the ED following ENT review. The overall re-presentation rate was 19.5% for ED discharges (n = 245/1,259) and 9.9% for ED admissions (n = 104/1,046). 6.8% of ED discharges and 5.7% of ED admissions were admitted following their re-presentations (n = 86 and 60 respectively). Not being packed by ED clinicians, antiplatelet medications, failed cautery and recent epistaxis treatment were predictors of re-presentation within 10-days.DiscussionRe-presentation data were similar to the 2016 UK Epistaxis Audit, however, there was a notable shift towards alternative packing techniques and reduced admission. This highlights that many patients who would previously have necessitated admission may be safely discharged from ED.

The impact of Covid-19 on patients with suspected cancer: An analysis of ED presentation and referrals to a quick diagnosis unit.

PurposePatients evaluated in the emergency department (ED) who have concerning symptoms suggestive of a cancer diagnosis are mostly referred to the quick diagnosis unit of our tertiary hospital. This study analyzed the impact of the Covid-19 pandemic on the volume, disease patterns, and accessibility to essential investigations of patients with suspected cancer referred by the ED to this unit.MethodsTrends in referrals were analyzed from January 1 to July 8, 2020 and the corresponding dates of 2019. Only non-Covid-19 conditions were evaluated. Three time-based cohorts were defined: prepandemic (January 1–February 19), pandemic (February 19–April 22), and postpandemic (April 22–July 8). Along with descriptive statistics, linear regression was used to test for time trends with weekly referrals as the dependent variable.ResultsThere were 384, 193, and 450 patients referred during the prepandemic, pandemic, and postpandemic periods, respectively. Following an increasing rate, referrals decreased to unprecedented levels in the pandemic period (average weekly slope: −2.1 cases), then increasing again until near normalization. Waiting times to most diagnostic procedures including radiology, endoscopic, nuclear medicine, and biopsy/cytology during the pandemic period were significantly delayed and time-to-diagnosis was considerably longer (19.72 ± 10.37 days vs. 8.33 ± 3.94 days in prepandemic and 13.49 ± 6.45 days in postpandemic period; P < 0.001 in both). Compared to other cohorts, pandemic cohort patients were more likely to have unintentional weight loss and fever of unknown origin as referral indications while anemia and lymphadenopathy were less common. Patients from the pandemic cohort had a significantly lower rate of malignancies and higher of benign gastrointestinal disorders (40.93% vs. 19.53% and 20.89% in prepandemic and postpandemic periods, respectively; P < 0.001 in both), most notably irritable bowel disease, and of mental and behavioral disorders (15.54% vs. 3.39% and 6.00% in prepandemic and postpandemic periods, respectively; P < 0.001 in both).ConclusionsAs our hospital switched its traditional care to one focused on Covid-19 patients, recognized indicators of healthcare quality of quick diagnosis units were severely disrupted. The clinical patterns of presentation and diagnosis of the pandemic period suggested that mass media-generated mental and behavioral responses with distressing symptoms played a significant role in most of these patients.

63 Risk Factors Associated with Lack of Patient Outpatient Follow Up at a Regional Burn Center

Abstract Introduction Burn patients are a vulnerable population at risk for poor follow up after injury. With few burn centers throughout the country, there is often limited access to specialized care. We investigated barriers to patient compliance with recommended outpatient burn care at a single ABA-verified burn center after presentation at referring Emergency Departments (ED). Methods A retrospective review was performed on patients who presented at two EDs located 60–75 miles from our burn center over a two-year period. Recommendation for follow up was made by a burn surgeon at our regional burn center after telephone consultation. Medical record review was performed to determine what specific follow up occurred. Data on patient demographics, burn size/location/etiology were also recorded. Results Out of 135 consults from the two EDs, a total of 60 patients were recommended for outpatient follow up (vs. transfer, local management, or no follow up). Median age was 35 years [IQR 27–38] and most patients were male (n=40, 66%). Most patients had burns measuring &amp;lt; 1% total body surface area (TBSA) (n=43, 72%). Half scheduled a follow up appointment (n=31, 52%) and fewer came to that appointment (n=26, 43%). Median time from initial presentation to burn clinic follow up was 2 days (range 1–8 days). Of patients who did not attend recommended follow up, 24% (n=8/34) presented for additional visits to the ED or another local provider. Patients who did not follow up were more likely to be male (79% vs. 50%, p=0.03), lack insurance (27% vs. 4%, p=0.05), be homeless/institutionalized (18% vs. 0%, p=0.03) and have facial burns as compared to other body regions (32% vs. 8%, p=0.05). Patients who followed up were more likely to have scald burns versus flash/flame/contact burns (69% vs. 18%, p&amp;lt; 0.001) and were more likely to have been injured at home/work as opposed to outdoors/other location (100% vs. 38% p&amp;lt; 0.001). Age, marital status, race/ethnicity, having a primary care physician, %TBSA, and other comorbidities were not associated with follow up. Although reasons for not following up were rarely noted in the medical record, anecdotal reasons included lack of transportation (n=4), incarceration (n=3), and feeling that burns were healing (n=1). Conclusions Less than half of patients followed up at the regional burn center as recommended, while nearly a quarter followed up at local EDs/clinics. Barriers to follow up include patient gender, insurance, and resources (transportation).

AB066. SOH21AS168. Remote delivery of the satellite virtual fracture clinic—a pilot report of the first 500 cases

Background: Presenting to the fracture clinic carries economic, social and societal consequences. The virtual fracture clinic (VFC) has proven to be a safe, patient-focused, cost-effective means of delivering trauma care, whilst reducing unnecessary clinic attendances. Within our institution, a Satellite VFC was established, so as to accommodate an offsite referring emergency department.

There is a low rate of major adverse cardiovascular events in chest pain patients with a moderate risk heart score referred from urgent care for expedited outpatient cardiology evaluation: a multi-center study

Background The HEART score is an effective method of risk stratifying emergency department (ED) patients with chest pain. The rate of major adverse cardiovascular events (MACE) in patients with moderate HEART score referred from an urgent care (UC) for an expedited outpatient cardiology evaluation for 11 months was described in 133 patients in a previous study. This is a follow-up study with 18 months of data and 206 patients.Aim. The primary outcome was to examine the rate of MACE when patients with moderate HEART score were referred for an expedited outpatient cardiology follow-up after evaluation in urgent care. The secondary outcome was to determine if there is a decrease in rate of ED transfer after this protocol was introduced.Methods. A cross-sectional study was conducted by a multispecialty group in Las Vegas, Nevada, which included 206 patients with a HEART score of 4 to 6 (i.e.: moderate risk) who presented to one of five UC centers with chest pain or an anginal equivalent. A streamlined evaluation protocol to assess each HEART score component was adopted by all UC providers to facilitate an expedited outpatient cardiology follow-up, as an alternative to referral to the emergency department. Data was collected from February 14, 2019 through August 13, 2020. The population was followed for 6 weeks with a primary endpoint of MACE determined by electronic medical record review and direct phone contact with patients. Outcomes were confirmed in 98% of patients. Chest pain transfer data was compared between 12 months prior to implementing HEART protocol and 18 months of data analysis while using the new protocol.Results. Over the course of 18 months, 206 patients with a moderate risk HEART score were referred to outpatient cardiology in an expedited manner. The average age was 65 with 53% female and 47% male patients. 150 patients (73% of the 206) were seen within 3 days, 114 (55%) underwent stress testing, 6 (3%) had coronary computed tomography angiogram, and 6 (3%) received an invasive coronary angiogram. Five patients were found to have MACE: one patient who had a non-ST-elevation myocardial infarction and subsequent coronary stent, two patients were found to have obstructive disease after coronary angiography with subsequent coronary artery bypass graft, one patient had an abnormal stress test and subsequent coronary stent, and one patient had critical mitral stenosis, multi-vessel coronary artery disease and underwent coronary artery bypass graft with mitral valve replacement with complications of renal failure and COVID-19 and expired. The emergency department referral rate declined by 21%.Conclusion. Patients with a moderate risk HEART score referred from UC for an expedited outpatient cardiology evaluation had a low rate of MACE and no deaths due to delay of care. There was also a significant decrease in the rate of ED referrals.

The 4-hour target in the emergency department, in-hospital mortality, and length of hospitalization: A single center-retrospective study.

The four-hour (4 h') rule in the emergency department (ED) is a performance-based measure introduced with the objective to improve the quality of care. We evaluated the association between time in the ED with in-hospital mortality and hospital length of stay (LOS). This was a retrospective study performed in one public hospital with over 100,000 ED referrals per year. Hospitalizations from the ED during 2017 were analyzed. We defined time in the ED as either: until a decision was made (DED); or total time in the ED (TED). In-hospital mortality and LOS were evaluated for patients with DED or TED within and beyond 4 h'. Compared to patients with TED or DED within 4 h', in-hospital mortality did not increase in patients with TED beyond 4 h' (2.8% vs. 3.1%, non-significant), or DED beyond 4 h' (2.1% vs. 3.2%, p < 0.001). LOS did increase in patients with either DED or TED beyond 4 h' (p < 0.001). In-hospital mortality increased with increasing DED-TED intervals for patients hospitalized in the internal medicine departments: 3.7% (0-1 h'), 5.1% (1-2 h'), 5.7% (2-3 h'), and 7.1% (>3 h') (p < 0.001). In-hospital mortality was not associated with time in the ED beyond 4 h'. LOS, however, was increased in this group of patients. Decreased LOS observed in patients with time in the ED within 4 h', does not support patients' risk as a contributing factor leading to higher trends in mortality observed in this patient group. In-hospital mortality was associated with an increase in DED-TED intervals in patients hospitalized in the internal medicine departments.

Pediatric Emergency Department Referrals to a Hospital-Based Violence Intervention Program

Pediatric Emergency Department Referrals to a Hospital-Based Violence Intervention Program

ENT Referral From Emergency Department During COVID-19: A Single-Center Experience.

COVID-19 pandemic transformed the health system response worldwide. The aim of this study is to report changes about numbers and reason for ENT consultations in emergency department (ED) during COVID-19 pandemic comparing with those occurred the previous year (2019). Data about patients admitted to adult and pediatric ED were collected from March 1 to May 31, 2019 and 2020. Patients referred for urgency from general practitioners were excluded from the study. Global ED admission (except for dyspnea or COVID-19-related symptoms) dramatically decreased during pandemic (-50.9% among adults and -71.4% among pediatrics). At the same time, ENT consultancy significantly reduced too, by 71.5% (P < .01) among adults and 45.1% (P < .01) for pediatrics. Among adults, it was reported a statistically significant decrease in consultation for ear problems (-88.5%, P = .0146). Reduction in ENT referral for bone fracture (-40%, P = .059), vertigo (-77.8%, P = .637), and tonsillitis (-87.5%, P = .688) was consistent, but not significant. Among pediatric patients, it was observed an increase by 25% about foreign bodies (12 vs 15, P < .01). A reduction in numbers of consults for ear problem (-90.8%; P = .045), epistaxis (-80%; P = .196), and nasal fracture (-70%; P = .36) was also observed. Fear of infection and the forced lock down caused a significant decrease in the number of ED accesses and in ENT consultancy. These data may suggest that some ED referral usually could be deferred, but on the other hand, pandemic will cause a great diagnostic delay.

Admission avoidance in acute epistaxis: A prospective national audit during the initial peak of the COVID-19 pandemic.

To report changes in practice brought about by COVID-19 and the implementation of new guidelines, and to explore factors relating to unscheduled re-presentations for patients discharged from the emergency department (ED). Prospective multicentre national audit over 12weeks from 6th April 2020. UK secondary care ENT departments. Adult patients with acute epistaxis. Re-presentation within 10days for patients discharged from the ED. Eighty three centres from all four UK nations submitted 2631 valid cases. The majority of cases were ED referrals (89.7%, n=2358/2631). 54.6% were discharged from the ED following ENT review (n=1267/2322), of whom 19.5% re-presented within 10days (n=245/1259) and 6.8% were ultimately admitted (n=86/1259). 46.7% of patients had a non-dissolvable pack inserted by ED prior to referral to ENT (n=1099/2355). The discharge rates for ED patients and their subsequent re-presentation rates were as follows: non-dissolvable packs, 29.5% discharged (n=332/1125), 18.2% re-presented (n=60/330); dissolvable products, 71.1% discharged (n=488/686), 21.8% re-presented (n=106/486); cautery only, 89.2% discharged (n=247/277), 20.0% re-presented (n=49/245); and no intranasal intervention, 85.5% discharged (n=200/234), 15.2% re-presented (n=30/198). Univariable logistic regression showed that not being packed by ED, antiplatelet medications, failed cautery and recent epistaxis treatment were significant predictors of re-presentation within 10days. Management of acute epistaxis was notably affected during the initial peak of the pandemic, with a shift towards reduced admissions. This national audit highlights that many patients who may previously have been admitted to hospital may be safely discharged from the ED following acute epistaxis.

The role of the school nurse in tackling serious youth violence: an analysis of healthcare provision

Background Incidents of serious youth violence have increased; however, the effectiveness of school nurse interventions in reducing these incidents lacks evidence. Aim To better understand the current role of the school nurse in relation to serious youth violence. Methods A mixed-method approach was taken, involving two key elements: a staff survey exploring school nurse experiences, interventions and confidence in delivering serious youth violence education and identifying vulnerable children and young people, and an audit of emergency department referrals and school nurse responses. Results The survey provided no evidence of interventions to reduce serious youth violence. Staff recognised their role in educating children and young people but lacked confidence and wanted further support. School nurse work with children and young people where serious youth violence had been identified mainly involved safeguarding. Only nine of the 62 emergency department referrals were followed up with a face-to-face contact. Conclusion School nurses recognise their role in serious youth violence but are not reflecting this in practice. Change is required to fulfil their public health role in helping to prevent or reduce serious youth violence.

Retrospective cohort study evaluating the efficacy and safety of an orthopaedic consultant‐led virtual fracture clinic in an Australian level 1 trauma centre

In Australian health care, the consistent rise in demand for orthopaedic outpatient clinic services is creating marked challenges in the provision of quality care. This study investigates the efficacy and safety of a virtual fracture clinic (VFC) as an alternative model of care for the management of acute injuries and musculoskeletal conditions in the Australian public hospital setting. A retrospective cohort study of consecutive emergency department (ED) referrals to the Department of Orthopaedic Surgery was conducted comparing outcomes prior to (November 2015-February 2017) and after (March 2017-June 2018) implementation of a VFC. The primary outcome measures assessed were the proportion of referrals virtually discharged and unplanned 30-day ED re-attendance rates. A total of 737 (36.4%) referrals managed by the VFC were discharged without requiring orthopaedic outpatient clinic attendance. The rate of unplanned ED re-attendances was 5.2% post-VFC implementation compared to 6.5% at baseline (P= 0.01). VFC implementation was also associated with reductions in the average number of orthopaedic outpatient clinic attendances per referral (1.1 versus 1.7, P< 0.01) and the number of referrals lost to follow-up (7.2% versus 14.7%, P< 0.01). In addition, patient wait times for first contact by the orthopaedic team were significantly reduced from a median of 7 (IQR 5, 9) days to 2 (IQR 1, 3) days post-intervention (P< 0.01). No complications or adverse events were reported. This study demonstrates that a VFC is applicable to the Australian healthcare system, and can lead to effective and safe provision of orthopaedic outpatient care.

Upper extremity high-pressure injection injuries with paint thinner: Case reports with review of the literature

<br><b>Introduction:</b> High-pressure injection injuries are rare traumas of upper extremity which can result in high morbidity incompatible with presentation. Clinical presentation right after the injury can be misleading and might cause underrating of the condition. This may lead to latencies in treatment and might worsen the final prognosis of the patients. Prognosis changes according to the material injected, pressure the material is injected, injection site, and time between the injury and the onset of treatment. Digit amputation rates are between 16% and 48% in literature series, and this seems to decrease with early debridement. <b>Materials and Methods:</b> Emergency department referrals are searched retrospectively for patients with high-pressure injection injuries. Four patients were found that were treated for injured with high-pressure injection gun with paint thinner or mixtures. Relevant literature was searched and discussed. <b>Results:</b> Three out of four patients needed amputations (75%). Two patients needed flap surgery for reconstruction: one interpolation and one free flap. The average time from hospitalization to definitive operation was 9.5 days (minimum 6, maximum 15 days). Fingertip injuries resulted in amputations, and amputation level was more proximal than the injury level which was connected to the dissemination of the injected material. <b>Discussion:</b> High-pressure injection injuries can cause devastating results if neglected, and can be overlooked with inexperienced eyes. Usually, there are minimal complaints from the patients on the onset of the injury, but symptoms exacerbate by time. Early debridement in the first 6 h is crucial for lowering amputation rates. Injected material has a great impact on the outcomes, and organic solvents such as paint thinner, paints, diesel, and engine oil have worse outcomes and higher amputation rates. <b>Conclusion:</b> High-pressure injection injuries need emergency surgical intervention and should not be neglected. Delay in treatment of these cases could cause detrimental outcomes.<br>

The Epidemiology of Co-Infections in Febrile Children Younger than 5-Years-Old in Emergency Department; A Cross-Sectional Hospital-Based Study

Background Fever is one of the most common causes of children’s referral to pediatric emergency department (ED), and almost 20% of General ED referrals relate to febrile children. When it comes to febrile pediatrics patients, co-infection is a very important issue to discuss. This topic has been considered in current literature so, we considered to examine the epidemiology of these co-infections in febrile children younger than 5 years in emergency department. Materials and Methods: This cross-sectional study was carried out retrospectively with the enrollment of children younger than 5-years-old (accessible sampling) in the emergency department of Mofid Hospital, Tehran, Iran, during November 2017 to December 2018. After designing and completing a check list. Results: Totally, 388 patients with the mean age of 25.4 ± 12.4 months were studied (51.5% Girl). The source of infection was unclear after using all of the diagnostic tools in 27.5% of cases. Based on the findings fever-associated diarrhea (132 patients, 46.9%), and cellulitis (1 patient, 0.4%) were the most and least frequent source of infections, respectively. The co-incidence of different source of infections showed that the most frequent co-infections were sepsis and UTI; otitis and UTI; pneumonia and UTI; pneumonia and URI; and sepsis and otitis. Conclusion It seems that co-infections have been significantly increased in girls and in theage range of 6-36 months. The most and least prevalent infections were fever-associated diarrhea and cellulitis among the patients with at least one type of infection. The co-incidence of different source of infection showed that the most frequent co-infections were sepsis and UTI; otitis and UTI; pneumonia and UTI; pneumonia and URI; and sepsis and otitis.

Effects of access to radiology in out-of-hours primary care on patient satisfaction and length of stay

Background Direct access to hospital radiology facilities by general practitioner (GP) cooperatives is known to decrease the number of emergency department referrals, but the effects on length of stay (LOS; time from patient arrival at GP cooperative till departure to home) and patient experiences are unclear. Objectives To provide insight into the LOS and experiences of trauma patients with an indication for radiology at GP cooperatives with and without access to radiology. Methods A multi-methods observational study in April 2014–October 2015 at six GP cooperatives in The Netherlands, covering three organisational models for access to radiology: no direct access, limited access and unlimited access. Patient experiences were measured with a questionnaire. Patient records were analysed for background characteristics, radiology outcomes, referral and LOS. Results In total 657 patients were included, 232 no direct access model, 307 limited access model and 118 unlimited access model. The mean LOS was 99 minutes, with a significant difference between GP cooperatives without access to radiology (121 minutes), with limited access (86 minutes), and with unlimited access (90 minutes). The differences were larger for patients without radiological abnormalities. On a ten-point scale, patients rated GP cooperatives with unlimited access to radiology higher (8.62) than those without access (8.36) or with limited access (8.39). Conclusion Access to radiology by GP cooperatives seems to reduce the length of stay and is slightly more appreciated by patients. GP cooperatives with unlimited access seem to provide the most efficient and best-valued care, contributing to more patient-centred care.

Impact of changes in community psychiatric service provision on mental health presentations to the emergency department.

BackgroundThe reconfiguration of many Irish stand-alone psychiatric units has led to many patients in acute mental health need now being assessed in emergency departments (EDs). This has implications for ED resources and raises questions about appropriate assessment location for this group.AimsThis report aims to examine the impact of removal of a direct community access point for patients in acute mental health need on ED presentations in a Dublin hospital.MethodsWe examined data on ED referrals to psychiatry over 5 years: 12 months before the service change, and four subsequent 12-month periods. We compared numbers referred, mode of referral, average ED length of stay, proportion with no physical issue requiring psychiatric assessment only, and numbers who did not wait for psychiatry assessment.ResultsIn the year directly after the service change, referrals to psychiatry from ED increased by 200%, remaining at this level for the subsequent 3 years. Of these, 32.5% were referred by a GP—more than a threefold increase in numbers from the previous year, with both numbers remaining similarly elevated over subsequent years. In the year after the service change, 52.1% of total ED to psychiatry presented solely for mental health reasons—nearly a fourfold increase in cases from the previous year, and remained high.ConclusionsRemoving a direct community access point for this group resulted in a substantial increase in ED presentations, many of which did not have physical needs. This study has implications for future policy to address the needs of this group, especially in light of the pandemic.

Remote Delivery of the Satellite Virtual Fracture Clinic - a Pilot Report of the First 500 Cases.

Presenting to the fracture clinic carries economic, social and societal consequences. The virtual fracture clinic (VFC) has proven to be a safe, patient-focused, cost-effective means of delivering trauma care, whilst reducing unnecessary clinic attendances. Within our institution, a Satellite VFC was established, so as to accommodate an offsite referring emergency department. The VFC database was accessed to identify the first 500 patients who were referred to the Satellite VFC. The decision made for each patient, the rate of returns to the clinic, and the rate of referrals requiring surgical intervention, following discussion at the VFC, ,were identified. A cost analysis and cost comparison was carried out between the Satellite VFC and the traditional "face to face" fracture clinic. There were 500 patients referred to the Satellite VFC within the study period. Of such patients, 288 (58%) were discharged directly following review at the Satellite VFC, 141 patients (28%) were referred to physiotherapy, 50 (10%) were redirected to the trauma clinic, 11 (2%) were sent directly to hand therapy, and 10 (2%) were sent to the ED review clinic. Patients who returned to the fracture clinic accounted for 3.8% of all referrals, and 0.2% of all referrals necessitated surgical intervention. This pilot initiative saved the Dublin Midlands Hospital Group over €50,000. The Satellite VFC is the first of its kind in the literature. Rural communities worldwide would benefit from remote orthopaedic management of suitable fracture patterns. The true value of the Satellite VFC process comes from its use of robust patient care pathways, rationalising resource use and minimising patient travel, whilst demonstrating reliable outcomes and promoting safety.