Regular Office Hours Research Articles

A Comparison of Voluntary and Involuntary Child and Adolescent Inpatient Psychiatry Admissions

ABSTRACTThe study compares voluntary and involuntary groups of patients and provides the first detailed description of involuntary admissions to a Canadian child and adolescent inpatient psychiatry setting. The involuntary group was found to have a higher percentage of adolescents, patients with suicide risk, patients living away from families, and patients presenting outside of regular office hours. Involuntary patients were more likely to be provided with secure transportation to inpatient care than voluntary patients. No differences were found between groups in terms of gender, culture, problem severity, global functioning, or medication. Inpatient psychiatry assessed lower prevalence of suicide risk relative to referral sources, kept involuntary patients for shorter stays than voluntary patients, and rapidly terminated involuntary status for the majority. Based upon the study findings, it appears that involuntary referrals may provide reassuring admission after emergency department screening identifies possible severe risk of suicide. But, this reassurance may come at the cost of admitting a significant proportion of individuals without serious mental illness, and who may not require involuntary status or who may not go on to profit from inpatient care. Research is required to evaluate the determinants, costs, and benefits of involuntary admissions for patients and the mental health system.

A New Method for the Prevention of Pre-Analytical Errors due to Hemolysis: Intensive Training.

Our aim was to compare the routine training (RT) method with the intensive training (IT) method, described for the first time by our group, for preventing pre-analytical errors in induced hemolysis. At two months, either RT or IT methods were introduced, and data collected in the second two months were compared with the initial two months to assess changes in the number of samples rejected. Working groups were formed according to the methods of training, clinics, and services. Group I contained only the emergency clinic and services. Group II included other polyclinics and services. In this study, Group I followed the IT method and Group II followed the RT method. Training and supervision were conducted during regular office hours every weekday. In this study, the percentage of errors in the different groups of the pre-analytical samples that underwent hemolysis was evaluated using the error correction ratio. The effectiveness of training in the groups was compared. The incidence of hemolysis in the samples showed a significant decline when the IT method was followed. The hemolysis frequency using the RT method had decreased compared to previous training. Both results were statistically significant. A further result of the study was a reduction in the incidence of the hemolysis ratio when comparing Groups I and II; the IT method was more effective than the RT method. The IT method is effective in preventing hemolysis-induced pre-analytical errors.

Homelessness and housing crises among individuals accessing services within a Canadian emergency department.

Studies have indicated that individuals who are homeless access hospital emergency departments more frequently and may have different needs than individuals who are housed. Successful interventions have been developed and tested to reduce discharge to homelessness for psychiatric inpatients but have not been similarly tested for discharge from emergency departments. This study was developed to provide baseline data on this issue to inform future emergency department interventions. Findings from the current study suggest that discharge from emergency departments to homelessness happens frequently in London, Canada. Participants are unlikely to spontaneously disclose their housing/homelessness issue when first entering the emergency department, which may result in services that do not adequately meet their complex needs. Screening for housing issues is necessary within emergency departments and psychiatric crisis teams as housing issues may be a reason for accessing care or contribute to the presenting condition. Nurses are in an ideal position to evaluate housing needs among emergency department patients. Services outside of the emergency department are also needed to address housing issues, particularly outside of regular office hours. Individuals who have mental health issues and are homeless or in housing crisis have been found to access emergency departments more frequently than individuals with stable housing. While emergency departments primarily focus on medical issues, homeless individuals may require psychosocial support as well. This study examined issues around housing crises and emergency department use for individuals with mental illness in Canada. Collecting baseline data about these issues is important to inform subsequent interventions. Administrative data from a hospital emergency department and psychiatric crisis service were collected, and five individuals accessing the emergency department for psychiatric reasons were interviewed. Results indicated that individuals with an identified housing crisis accessed the emergency department 930 times in 6 months. None of the interview participants identified housing as the primary reason for accessing the emergency department, but all noted that housing was a contributing stressor. Future research is needed to examine ways in which discharge to homelessness from emergency departments can be avoided and identify alternative services to address housing concerns, particularly for individuals with mental illness. Crisis service and emergency department staff, especially nurses, can play an important role in screening for housing issues and connecting individuals to outside services.

Water-drinking test and its importance in glaucoma management

Water-drinking test (WDT) was first described as a diagnostic tool for glaucoma; however, it was later abandoned because of its poor diagnostic accuracy. This test has gained significant attention in recent years because different studies have shown its use as a surrogate for detecting patients who have intraocular pressure (IOP) spikes not measured during regular office hours. According to the peer-reviewed literature, IOP peaks detected by the WDT positively correlate with the severity of visual field defects in glaucoma and may predict visual field progression. Furthermore, it was demonstrated that IOP peaks detected by the WDT were correlated and in agreement with the IOP peaks that normally occurred during the day. The WDT is also used to evaluate the quality of different clinical and surgical treatment options in glaucoma. The main objective of this review was to present and discuss the evidence and applicability of the WDT as an assessment tool for glaucoma.

Are Electronic Health Records Good for Health Care?

Are Electronic Health Records Good for Health Care?

The Development of a Hepatology Care Coordination Program: An Effort to Achieve Reductions in Hospital Readmissions

Introduction: Due to the progressive nature of cirrhosis, patients are prone to frequent hospital admissions and readmissions. The period immediately after discharge is a ‘high risk’ one. Patients often carry new diagnoses, are on new medications, have received changes in the dosages of existing medications, and are deconditioned from their hospital stay. The aim of this endeavor was to create a sustainable care coordination program that would improve patient outcomes and achieve reductions in cirrhosis-related re-admissions at our institution. Methods: Our hospital is an inner-city quaternary care medical center with a dedicated hepatology inpatient service and an active liver transplant program that performed 53 orthotopic liver transplants in 2013. Based on an over 30% patient 30-day readmission rate to the inpatient hepatology service for cirrhosis-related complications, a care coordination program was created in February 2014. Patients at high risk for readmission (i.e. recurrent encephalopathy, refractory ascites with frequent need for paracentesis, failure to thrive, poor social support systems) are enrolled on an ongoing basis. Once these patients are recognized by the attending hepatologist, the inpatient liver transplant coordinator is notified. When appropriate patients are identified, monitoring equipment is installed in the patient’s home and education/medication reconciliation is provided to the patient and family before discharge. On arrival home and on a daily basis, the patient’s daily weight, heart rate, blood pressure, and pulse oximetry are monitored by a home monitoring company call center. The program also includes frequent phone follow-up post-discharge by the inpatient coordinator for continued assessment. Any identified clinical issues are discussed real-time with attending hepatologist enabling medication adjustments and/or rapid clinic follow-up. After regular office hours, clinical abnormalities and concerns are discussed with the on-call doctor by the call center. Additionally, all enrolled patients are seen in the outpatient hepatology office within 1 week of hospital discharge. As of May 8, 2014, 11 patients have been enrolled in the program. Conclusion: In an effort to respond to the frequent and costly readmissions for management of complications due to cirrhosis, we created an intensive care coordination program. Although still in its early implementation, it may be a tool to avoid hospital readmissions in select cases. This model of patient discharge care coordination can be replicated at other institutions.

Adjuncts Committed to Their Students, Not Employers

Adjuncts Committed to Their Students, Not Employers

Association between Enhanced Access Services in Pediatric Primary Care and Utilization of Emergency Departments: A National Parent Survey

To measure the prevalence of enhanced access services in pediatric primary care and to assess whether enhanced access services are associated with lower emergency department (ED) utilization. Internet-based survey of a national sample of parents (n = 820, response rate 41%). We estimated the prevalence of reported enhanced access services and ED use in the prior 12 months. We then used multivariable negative binomial regression to assess associations between enhanced access services and ED use. The majority of parents reported access to advice by telephone during office hours (80%), same-day sick visits (79%), and advice by telephone outside office hours (54%). Less than one-half of parents reported access to their child's primary care office on weekends (47%), after 5:00 p.m. on any night (23%), or by email (13%). Substantial proportions of parents reported that they did not know if these services were available (7%-56%, depending on service). Office hours after 5:00 p.m. on ≥ 5 nights a week was the only service significantly associated with ED utilization in multivariable analysis (adjusted incidence rate ratio: 0.51 [95% CI 0.28-0.92]). The majority of parents report enhanced access to their child's primary care office during office hours, but many parents do not have access or do not know if they have access outside of regular office hours. Extended office hours may be the most effective practice change to reduce ED use. Primary care practices should prioritize the most effective enhanced access services and communicate existing services to families.

031 ADMISSION AT NIGHTS OR WEEKENDS HAS NO ADVERSE EFFECT ON MORTALITY FOR ST ELEVATION MYOCARDIAL INFARCTION PATIENTS TREATED BY PRIMARY PERCUTANEOUS CORONARY INTERVENTION

<h3>Introduction</h3> Mortality amongst emergency medical admissions has been reported to be higher when patients are admitted to hospital at nights and weekends. We studied the mortality for STEMI patients presenting at different times to a large cardiothoracic centre in the UK with a 24/7 primary PCI (PPCI) service delivered by senior medical staff. <h3>Methods</h3> We included all patients who underwent PPCI from September 2009 to November 2011. We divided them into three groups according to the time of admission to our unit as group 1: in-hours (08:00–18: weekdays), group 2: out-of-hours (18:00–08:00 week nights) and group 3: weekend (Saturday 08:00 to Monday 08:00) and bank holidays. <h3>Results</h3> Of the 1471 patients who were admitted and underwent PPCI in our unit during the study period, 605 (41.1%), 397 (27%) and 469 (31.9%) were included in group 1, 2 and 3 respectively. Pre-procedure cardiogenic shock was significantly higher in group 1 compared to group 2 (8.9% vs 5.5%, p 0.05), but no other significant difference was noted in the baseline and procedural characteristics between the groups (table&nbsp;1). When compared to group 1, door to balloon (DTB) time (median, IQR 29, 24–39 min) was significantly prolonged in group 2 (33, 24–36 min, p 0.004) and group 3 (36, 28–47 min, p&lt;0.0001). There was no difference in DTB time between groups 2 and 3 (p 0.15). However, there was no significant difference in in-hospital mortality (grp 1 vs grp 2 vs grp3: 4.6% vs 4.3% vs 5.3%, p NS), 30-day mortality (6.4% vs 6.3% vs 7%, p NS) or stent thrombosis (0.8% vs 0.8% vs 0.2%, p NS) between the groups (table&nbsp;2). <h3>Conclusions</h3> In this consecutive series of patients admitted to a high volume primary PCI centre, there was no difference in mortality when patients were admitted at night, at the weekend or during regular office hours. The involvement of senior medical staff early in the patients9 admission may have contributed to these consistent outcomes.

Dampening of Diurnal Intraocular Pressure Fluctuation by Combined Trabeculotomy and Sinusotomy in Eyes With Open-angle Glaucoma

Large diurnal intraocular pressure (IOP) fluctuation ([INCREMENT]IOP) is believed to be one of the causes of progression in glaucomatous changes. Some fully medicated glaucoma patients whose IOPs are controlled during the regular office hours (10:00 to 16:00 h) still have progression in glaucomatous changes and IOP elevation during off-office hours. The purpose of this study was to determine whether [INCREMENT]IOP is dampened after combined trabeculotomy and sinusotomy (LOT+SIN) in glaucoma patients with low IOPs during the regular office hours. Fourteen eyes of 8 open-angle glaucoma patients who had large [INCREMENT]IOP despite low IOPs during the office hours were studied. The IOP was measured every 3 hours for 24 hours before and >3 months after the operation. The IOPs were measured in the sitting position with a Goldmann applanation tonometer. All patients underwent LOT+SIN. All patients had IOP elevations >20 mm Hg between 0:00 and 3:00 hours before the operation, and none had an IOP peak after the operation. The postoperative mean IOP (16.5±1.7 to 13.9±2.0 mm Hg, P=0.00064), the maximum IOP (21.9±2.4 to 16.1±2.5 mm Hg, P=0.0020), and [INCREMENT]IOP (8.9±2.7 to 4.3±1.2 mm Hg, P=0.0032) were significantly lower than the preoperative values. However, the minimum IOP was not reduced significantly (13.0±1.9 to 11.7±1.7 mm Hg). The diurnal [INCREMENT]IOPs are dampened by LOT+SIN in glaucoma patients with controlled IOPs during regular office hours. These results indicate that these surgical procedures can be used for the treatment of open-angle glaucoma patients.

A Study on the Responsiveness of Local Health Departments that Use Facebook

Local health departments (LHDs), in concert with many other organizations, have begun to explore the potential of social media sites during emergencies. The most widely discussed and adapted social media site is Facebook. Apparently, once a decision to include Facebook is made, the Facebook logo is displayed on the organization’s homepage. The focus of this study was to assess the presence of Facebook on LHD websites and then determine whether LHDs actually used them as tools for communicating with the public or planned to do so during emergency or disaster situations. Secondary objectives were to test for the presence of two-way communications and to measure how quickly LHDs with two-way Facebook walls responded to a request for information received after regular office hours. We looked at 1970 LHD websites. Of those, 489 (24.6%) displayed the Facebook logo; 458 (93.7%) had a wall; 208 had walls with bi-directional (inbound and outbound) capability. A message was posted on each of the 208 bi-directional Facebook walls. Of the 208 LHDs receiving a message, 25 (12.0%) sent responses. The mean time for a response was 77.7±94.2 h.

The water-drinking test: a review

The water-drinking test (WDT) was first described as a diagnostic tool for glaucoma, which was later abandoned due to its poor diagnostic accuracy. This test has gained significant interest in recent years as different studies have shown its use as a surrogate for detecting patients who have intraocular pressure (IOP) spikes not detected during regular office hours. According to peer-reviewed literature, IOP peak detected by the WDT positively correlates with the severity of visual field defects in glaucoma and may be predictive of visual field progression. It was demonstrated that IOP peaks during the WDT are correlated and are in agreement with IOP peaks that normally occur during the day. The WDT has also been used to evaluate the quality of different clinical and surgical treatment options in glaucoma. The main objective of this article is to present and discuss these evidences and the applicability of the WDT as an assessment tool for glaucomatous disease.

The effect of insurance on emergency room visits: An analysis of the 2006 Massachusetts health reform

This paper analyzes the impact of a major health reform in Massachusetts on emergency room (ER) visits. I exploit the variation in pre-reform uninsurance rates across counties to identify the causal effect of the reform on ER visits. My estimates imply that the reform reduced ER usage by between 5 and 8%, nearly all of which is accounted for by a reduction in non-urgent visits that could be treated in alternative settings. The reduction in emergency room visits is most pronounced during regular office hours when physician's offices are likely to be open. In contrast, I find no effect for non-preventable emergencies such as heart attacks. These estimates are consistent with a large causal effect of insurance on ER visits and imply that expanding insurance coverage could have a substantial impact on the efficiency of health services.

Emergency department visits: Why adults choose the emergency room over a primary care physician visit during regular office hours?

It has been estimated that up to one third of all emergency department (ED) visits may be "inappropriate" or non-emergent. Factors that have been speculated to be associated with non-emergent use have been noted to include low socioeconomic status, lack of access to primary care, lack of insurance, convenience of "on demand care" and the patient's individual perception of their complaint urgency. The objective of this study is to identify the reasons contributing to self-perceived non-emergent adult emergency department visits during primary care physician office hours of operation. This study was a single-center, descriptive study with questionnaire. The questionnaire was collected from patients meeting exclusion/inclusion criteria who were triaged into an acute or fast track part of the emergency department during regular business hours on Monday through Friday, 8:00 am-5:00 pm during the months of July 2011 and August 2011. Questionnaire data were categorical and summarized using counts and percentages. Data collected included patient demographics, information about the patient's primary care provider, and information about the emergency department visit in question. All responses were compared among patients with visits considered to be non-emergent to those considered to be emergent by using individual chi-square tests. There were 262 patients available for the study. The patients were grouped according to their perception of the severity of their complaints. Roughly half of the patients placed themselves into the non-emergent category (n=129), whereas the other half of the patients categorized themselves into the emergent group (n=131). There were statistically significant differences in marital status and employment status between the two groups. It was found that 61.5% of the non-emergent patients were single, while 58.3% of the emergent patients were married. In the non-emergent group, 59.7% were unemployed, but in the emergent group 60.3% were employed (P<0.05). However, no other factors were significantly different. Our study did not identify a statistically significant factor to the reasoning behind why patients choose the emergency department over a primary care physician during regular office hours. The only significant demographic indicating who was more likely to make this choice during the specified time frame was being single and employed with perceived non-emergent complaint. Patients without insurance and/or without a primary care physician were no more likely to visit the emergency department with a self-perceived non-emergent issue than patients with insurance and/or with an established primary care physician.

The Effect of Insurance on Emergency Room Visits: An Analysis of the 2006 Massachusetts Health Reform

This paper analyzes the impact of a major health reform in Massachusetts on emergency room (ER) visits. I exploit the variation in pre-reform uninsurance rates across counties to identify the causal effect of the reform on ER visits. My estimates imply that the reform reduced ER usage by between 5 and 13 percent, nearly all of which is accounted for by a reduction in non-urgent visits that could be treated in alternative settings. The reduction in non-urgent and primary-care treatable visits is most pronounced during regular office hours when physician's offices are likely to be open. In contrast, I find no effect for non-preventable emergencies such as heart attacks. These estimates are consistent with a large causal effect of insurance on ER usage and imply that expanding insurance coverage could have a substantial impact on the efficiency of health services.

Parental Reasons for Utilization of an Urban Pediatric Emergency Department During the 2009 H1N1 Influenza Epidemic

The objective of the study was to understand the utilization of the pediatric emergency department (PED) of an academic hospital during regular primary care office hours during the 2009 H1N1 epidemic. Children with a usual source of care presenting for influenza-like illness (ILI) symptoms were compared with those presenting with other symptoms. During the 2009 H1N1 outbreak, parents visiting a PED in a low-income area in New York City in June 2009 were surveyed using open- and close-ended questions. Sociodemographic factors and reasons for seeking care in the PED rather than their usual source of care were compared between groups. There were no sociodemographic differences among children brought to the PED for ILI and those brought for other presenting symptoms. Those families with a child with ILI symptoms were less likely to report urgency as the primary reason they brought their child to the PED. A common reason reported for coming to the PED was limited access to care. In further exploration of limited access, parents with a child with ILI symptoms were more likely to report that their usual source of care did not have any evening and/or weekend hours, and they did not know how to reach their provider after hours. Enhancing access to primary care settings and encouraging parents to use their primary care providers might reduce the utilization of the PED for nonurgent problems during epidemics.

Women's well-being improves after missed miscarriage with more active support and application of Swanson's Caring Theory.

PurposeThe purpose of this study was to provide better organization and more efficient use of resources within the health care system in order to identify women with nonviable pregnancy earlier in their gestation terms and also to identify those women who experience severe grief reaction after the miscarriage. The proposed solution is to offer an appointment with a gynecologist during regular office hours after consultation with the patient’s midwife to women experiencing symptoms and who are concerned with the viability of their pregnancy. Unnecessary contact with the emergency room by the patients would be reduced as a result of this improvement in organization. The aim of the study was to give the women experiencing missed miscarriage an increased sense of well-being by applying Swanson’s Caring Theory to their recovery, in addition to the better organization and more efficient use of resources.MethodBoth the original study from 2002 to 2003 and the later study from 2004 to 2005 applied Swanson’s Caring Theory in the follow-up care management of the women, but only the later study was influenced by the changes made in the health care system. In the past, diagnosis of missed miscarriage was delayed because women experiencing minor symptoms were not highly prioritized in the health care system. More active support was introduced in order to get the proper information to the patient throughout the health care system. The size of the original study database was n = 43, compared with the later study database, which was n = 56. All of the women answered the Perinatal Grief Scale (PGS) questions twice, 1 month and 4 months after their diagnosis. Some additional questions about their circumstances unrelated to the PGS were also mailed to the women 4 months after their diagnosis.ResultsAs a result of the more active support, women felt that they received professional care when they needed it most. The patients were satisfied that they were treated as if they were suffering from normal grief. The group score above the limits for deep grief 4 months after diagnosis was significantly lowered. The chances of receiving their diagnosis at an appointment during office hours increased (odds ratio 3.38). Sick leave time of more than a week was reduced from 44% in the original study to 22% in the later study.

9: Why Do Parents Use Pediatric Emergency Department During Regular Office Hours?

9: Why Do Parents Use Pediatric Emergency Department During Regular Office Hours?

Change in Parental Reasons for Use of an Urban Pediatric Emergency Department in the Past Decade

To assess changes over the past decade in parental reasons associated with nonurgent visits to pediatric emergency departments (PEDs) during regular primary care office hours. Secondary analysis of cross-sectional surveys of families of children younger than 3 years visiting a PED in a low-socioeconomic area in New York City conducted in 1997 and 2006. We performed multivariable analyses to assess differences in parental reported reasons for PED use over the period, controlling for sociodemographic factors. Most children (95.6%) had a usual source of care across both periods. Compared with those seen in 1997, children seen in 2006 were far less likely to be brought to the PED during regular primary care office hours for parental perceived urgency (adjusted odds ratio [AOR], 0.076; 95% confidence interval [CI], 0.024-0.24; P < 0.001). At the same time, these children were more likely to be brought to the PED for limited access to their usual source of care (AOR, 3.35; 95% CI, 1.24-9.02; P < 0.05) and greater trust in the medical expertise of the PED (AOR, 5.95 95% CI, 1.20-29.45; P < 0.05). Over the last decade, despite the presence of a usual source of care, a greater number of parents report visiting this urban PED during regular office hours for reasons unrelated to parental perceived urgency. Limited access to care and greater trust in the medical expertise available in PEDs have played important roles. Approaches to decreasing nonurgent visits must take into account all of these factors.

Virtual office hours as cyberinfrastructure: the case study of instant messaging

Although out-of-class communication enhances students’ learning experience, students’ use of office hours has been limited. As the learning infrastructures of the social sciences and humanities have undergone a range of changes since the diffusion of digital networks, new opportunities emerge to increase out-of-class communication. Hence, it is important to investigate the role of cyberinfrastructures as valuable alternatives or supplements to existing infrastructures in the learning process. This paper proposes that virtual office hours can be a form of cyberinfrastructure that provides new possibilities for student–faculty interaction. We examine students’ perceptions of instant messaging as a tool for offering virtual office hours and enhancing student–faculty interaction. Students report that instant messaging is a useful tool for virtual office hours because of its convenience, interactivity, and ease of use. While students only made limited use of it when it was actually offered as an alternative to regular office hours, it represents an important new avenue for interaction. We outline reasons for students’ limited use of instant messaging for virtual office hours and discuss a series of barriers and potential solutions.