Return Visit Research Articles

Characteristics and patient impact of boarding in the pediatric emergency department, 2018–2022

ObjectivesBoarding admitted patients in the emergency department is an important cause of throughput delays and safety risks in adults, though has been less studied in children. We assessed changes in boarding in a pediatric ED (PED) from 2018 to 2022 and modeled associations between boarding and select quality metrics. MethodsWe performed a retrospective analysis of PED patients admitted to non-psychiatric services, broken into four periods: pre-COVID-19 (Period I, 01/2018–02/2020), early pandemic (II, 03/2020–06/2021), COVID-19 variants (III, 07/2021–06/2022), and non-COVID respiratory viruses (IV, 07/2022–12/2022). Patients were classified as critical (intensive care units (ICU)) or acute care (non-ICU inpatient services) based on their initial bed request. We compared median boarding times with Kruskal-Wallis tests. We assessed the relationship between boarding time and hospital length-of-stay (LOS) through hazard regression models, and the association between boarding time and PED return visit, readmission, and patient safety events through adjusted logistic regressions. ResultsMedian PED boarding time significantly increased from Period I (acute: 2.4 h; critical: 3.0 h) to Period II (acute: 3.0 h, critical: 4.0 h) to Period III (acute: 4.4 h, critical: 6.6 h) to Period IV (acute: 6.2 h; critical: 9.5 h). On survival analysis, as boarding time increased, hospital LOS increased for acute admissions and decreased for critical admissions. Increased acute care boarding time was associated with higher odds of a filed safety report. ConclusionsSince July 2021, PED boarding time increased for admitted children across acute and critical admissions. The relationship between acute care boarding and longer hospital LOS suggests a resource-inefficient, self-perpetuating cycle that demands multi-disciplinary solutions.

Flap Survival after Reconstructive Surgery for Pressure Ulcers: A Cohort Study

Background: Pressure ulcers are troublesome for patients and require considerable resources to resolve. Previous studies have focused on recurrence, whereas there are few studies on flap survival. The aim was to describe the group and to analyze possible factors for flap survival. Method: A descriptive retrospective analysis of all operations between 2008 and 2020 was carried out. Flap survival at 40 days was assessed. A flap was classified as a failure if a reoperation with removal or replacement was planned before, or in connection with, the first return visit. Variables of patient demographics, details of the pressure ulcers, and surgical treatment and care were analyzed with multivariable logistic regression for their effect on flap survival. Results: A total of 111 flaps were included [78 (70%) with random blood supply and 33 (30%) with axial or perforator-based blood supply]; 54 (49%) of the flaps were fasciocutaneous. Body mass index was 25 (IQR 22–28). Flap survival rate was 90%. Variables associated with flap failure were higher body mass index, congenital spinal cord injury, type of blood supply to the flap, and the use of methylene blue to guide debridement of the wound. Conclusions: The findings show factors that can be modified to improve future results, including a normalized body mass index and use of methylene blue in surgery to outline wound edges and depth, as this has been shown to protect against flap failure. Our data suggest that random flaps, such as V-Y, are preferable to axial flaps in the studied group.

Implementation of a digital tool for population management in Primary Health Care.

Describe the implementation of a digital diagnostic and territorial monitoring tool in primary healthcare. Quantitative and qualitative study, developed in 14 basic healthcare units in São Paulo, with community health workers, coordinators, nurses, and physicians. Data collection occurred in four phases: analysis of the instruments used by the team for territory management; development of the digital tool; training and implementation; and evaluation after 90 days using focus groups. Descriptive analyses were conducted by calculating absolute and relative frequencies to treat quantitative data. Qualitative data were subjected to content analysis. Three hundred thirty-four professionals participated in the study. In the first step, territory management's main challenges were filling out various instruments, system failures, data inconsistency, internet infrastructure/network, and lack of time. Therefore, a digital tool was developed consisting of 1) a spreadsheet recording the number of family members and markers of health conditions, date of visit, and number of return visits; 2) a spreadsheet with a summary of families visited, not visited, and refusals; and 3) a panel with a summary of the data generated instantly. In the evaluation, after the initial use of the tool, the themes that emerged were integration of the tool into daily work, evaluation of the digital tool implementation process, and improvement and opportunities for improvement. Faced with the challenges faced by family healthcare teams when filling out systems and managing the territory, the tool developed provided greater reliability and agility in data visualization, reduced the volume of instruments, and optimized the work process.

Association between Acute Pain Scores in Children with Sickle Cell Disease and Emergency Department Disposition and Return Visit Rates

Introduction Reducing pain through prompt administration of pain medication in the emergency department (ED) is a primary driver of national guidelines for sickle cell disease (SCD), yet there are few data on how pain scores and changes in pain scores are associated with both the disposition at the initial visit and the likelihood of a return visit. In this study, we analyzed acute pain scores from ED visits for children with uncomplicated SCD pain crisis to determine the relationships between pain scores and disposition (admission or discharge) or occurrence of a return ED visit. Objectives For children with uncomplicated SCD pain crises, we aimed to determine (1) the association between initial pain score, last pain score, change in pain scores and the disposition of index ED visits, and (2) the association between these pain score values, number of parenteral opioid doses in the ED, whether an opioid prescription was provided at discharge, and an ED return visit within 14 days. Methods This is a multicenter retrospective cohort study of acute pain scores of ED visits by children for uncomplicated SCD pain crises. It was conducted using electronic health care data from the Pediatric Emergency Care Applied Research Network (PECARN) Registry across 7 sites (Lurie Children's, Children's Hospital of Philadelphia, Cincinnati Children's Hospital, Children's National Medical Center, Children's Colorado, Children's Wisconsin, and Nationwide Children's). Index ED visits were defined as uncomplicated pain crises with no preceding ED visits within 14 days between 01/2017 - 11/2021. We collected the following ED pain scores: initial, last, and change in scores (initial minus last) as measured by a numeric rating scale (0-10). For analyses related to disposition, we modeled the relationship between the three pain scores and hospital disposition adjusting for age, sex and uncomplicated pain crisis visit admission rate. For analyses related to return visits, we utilized the same predictor variables and added both the number of parenteral opioid doses administered in the ED and whether or not a prescription for an opioid was given at discharge. For all analyses, adjustment for site was made using generalized estimating equations with an exchangeable correlation structure to account for clustering within site. Modified Poisson regression was used to identify associations. SAS software version 9.4 was used for all statistical analyses. Results A total of 4,985 index visits for uncomplicated SCD pain crisis were included; 52% resulted in hospitalization. Overall, 39% of the children were <12 years old, 54% were female, and 96% were Black. Eligible index ED visits per site varied from 157 to 1855. The overall ED median (IQR) initial pain score was 8.0 (6.0-10).The median last pain score was 5.0 (2.0-8.0); median change in ED pain score was 2.0 (0.0-5.0). In univariate analyses, higher initial and last pain scores and a smaller change in pain scores were all associated with higher hospitalization rates. Adjusted rate ratios (95% CI) from multivariable models showed last pain score was the best predictor of admission 1.16 (1.12, 1.19), with change in pain score no longer significant 0.98 (0.96, 1.00). Examining percent of children hospitalized by last pain score shows over 80% of children with a last pain score of 7 or higher were hospitalized, compared to less than 40% if 4 or lower (Figure 1). 29% of the 2,377 visits that were originally discharged to home had a return visit within 14 days. None of the included pain scores from the initial visit (initial, last, or change) were associated with having a return visit within 14 days. However, both an increased number of ED opioid doses and failure to receive a prescription for an opioid at discharge were associated with increased return visits. Figure 2 shows the ED opioid doses and prescription for opioid combination and their respective return visit rates, with a high of 36% for ≥ 3 doses of ED opioid doses and no prescription and a low of 22% if 1 opioid given and a prescription at discharge. Conclusions: We found that for a child with SCD presenting to the ED with an uncomplicated pain crisis, the last ED pain score was a better predictor of hospitalization than initial or change in pain score. None of those pain scores predicted a return visit after discharge; however, fewer opioid doses in the ED and receipt of an opioid prescription at discharge were associated with fewer return visits.

Minimally invasive endoscopic evacuation with the novel, portable Axonpen neuroendoscopic system for spontaneous intracerebral hemorrhage

Minimally invasive surgeries have shown potential to improve mortality and clinical outcomes of spontaneous intracerebral hemorrhage (ICH). The present study assessed the first-in-human outcomes of a novel, portable neuroendoscopic system for ICH evacuation at our single center. This neuroendoscopic system integrates real-time visualization into a handpiece which has controllable suction, irrigation, and coagulation to allow a neurosurgeon to conduct minimally invasive ICH evacuation independently with bimanual dexterity. Pre- and postoperative data of ten patients who had spontaneous basal ganglia hemorrhage (mean: 46.5 ± 12.2 mL) and underwent evacuation with the specified neuroendoscopic system were collected prospectively. The mean time to receive surgery was 12.1 ± 7.6 h. Mean operative time was 3.4 ± 0.9 h. The mean hematoma volume decreased to 6.0 ± 3.9 mL at postoperative 6 h, resulting in a mean volume reduction of 86.0 ± 11.2% (P = 0.005). The median length of intensive care unit stay was 3 days (IQR, 3–4 days). At discharge, the median Glasgow Coma Scale (GCS) score significantly improved to 11.5 (IQR, 11–15; P = 0.016), and the median modified Rankin Scale (mRS) score was 4 (IQR, 4–5). Six patients (60%) showed a favorable mRS score of ≤ 3 on their last return visit. Neither death nor rebleeding occurred during the follow-up periods. Integrated design of the innovative device is valuable to optimize minimally invasive endoscopic ICH evacuation procedure. Further studies are needed to clarify long-term benefits from such type of the innovative device to early intervention of ICH.

Slow on the Draw-ED Management of Elevated BP in Older Adults.

The purpose of this study is to review data surrounding the emergency department management of elevated blood pressure in older adults, including the management of hypertensive crisis andoutpatient management of markedly elevated blood pressure. Acute lowering of blood pressure in older adults with markedly elevated blood pressure may lead to serious complications without improvements in hospital length of stay, return visits, or mortality. Older adults presenting with elevated blood pressures without evidence of end-organ damage should be referred for outpatient management of their blood pressure. Treatment of hypertensive emergency should follow standard guidelines with additional considerations for aging physiology. Acute lowering of elevated blood pressure in older adults without evidence of end-organ damage has the potential for harm. If the emergency physician opts to acutely treat, they should consider the increased risk of side effects in older adults and avoid Beers list medications including short-acting nifedipine and clonidine.

Coming in Hot: A quality improvement approach to improving care of febrile infants.

Significant practice variation exists in managing young infants with fever. Quality improvement strategies can aid in risk stratification and standardization of best care practices, along with a reduction of unnecessary interventions. The aim of this initiative was to safely reduce unnecessary admissions, antibiotics, and lumbar punctures (LPs) by 10% in low-risk, febrile infants aged 29 to 90 days presenting to the emergency department (ED) over a 12-month period. Using the Model for Improvement, a multidisciplinary team developed a multipronged intervention: an updated clinical decision tool (CDT), procalcitonin (PCT) adoption, education, a feedback tool, and best practice advisory (BPA) banner. Outcome measures included the proportion of low-risk infants that were admitted, received antibiotics, and had LPs. Process measures were adherence to the CDT and percentage of PCT ordered. Missed bacterial infections and return visits were balancing measures. The analysis was completed using descriptive statistics and statistical process control methods. Five hundred and sixteen patients less than 90 days of age were included in the study, with 403 patients in the 29- to 90-day old subset of primary interest. In the low-risk group, a reduction in hospital admissions from a mean of 24.1% to 12.0% and a reduction in antibiotics from a mean of 15.2% to 1.3% was achieved. The mean proportion of LPs performed decreased in the intervention period from 7.5% to 1.8%, but special cause variation was not detected. Adherence to the CDT increased from 70.4% to 90.9% and PCT was ordered in 92.3% of cases. The proportion of missed bacterial infections was 0.3% at baseline and 0.5% in the intervention period while return visits were 6.7% at baseline and 5.0% in the intervention period. The implementation of a quality improvement strategy, including an updated evidence-based CDT for young infant fever incorporating PCT, safely reduced unnecessary care in low-risk, febrile infants aged 29 to 90 days in the ED. To develop and implement a multipronged improvement strategy including an evidence-based CDT utilizing PCT to maximize value of care delivered to well-appearing, febrile infants presenting to EDs.

Emergency Department Overcrowding: An Environmental Scan of Contributing Factors and a Summary of Systematic Review Evidence on Interventions


 Emergency department (ED) overcrowding occurs when the demand for health services in the ED exceeds the capacity of the ED, hospital, or community to deliver quality care in a reasonable amount of time. Overcrowding is worsening in jurisdictions across Canada and there is a need to address its many causes and identify potential solutions.
 This report uses a modified version of a conceptual model developed by Asplin et al. (2003) that organizes the emergency care system into 3 interdependent parts: input (arrival to the ED), throughput (flowing through the ED), and output (leaving the ED). We also examined an additional fourth part related to contextual factors and systems that affect overcrowding but lay outside of input, throughout, and output.
 
 Examples of factors include, but are not limited to, increased complexity of needs (input), diagnostic testing and procedures (throughput), boarding (output), and limited resources for mental health and substance use (outside the ED).
 Examples of interventions that were effective in some settings include, but are not limited to, prehospital decision-making by first responders, which reduced ED visits (input); short stay crisis units for people experiencing mental health challenges, which improved emergency department length of stay, wait times, boarding, and patient safety (throughput); ED-based discharge planning, which reduced ED return visits (output); and time-based policy reforms, which reduced ED length of stay (outside the ED).
 
 
 Most of the factors we identified in the published literature existed either outside of the ED or at the interface of the ED and other health care services (input and output), whereas most of the interventions we identified existed within the ED (throughput).
 We heard from participants (during multistakeholder dialogue sessions) and content experts that ED overcrowding is a complex health system issue for which the causes, impacts, and solutions extend beyond the ED. Specifically, the novel insights we heard included:
 
 ED overcrowding is better viewed as a problem of hospital overcrowding and strained resources in the broader social and health care systems. Contributing factors both within and outside the ED influence and interact with each other and are affected by economic, cultural, and institutional realities.
 Solving the issue requires addressing accountability and implementing multifaceted solutions in which several systems and voices work collaboratively.
 Existing technologies and data use and collection are not being used to their full potential; they can be better leveraged to alleviate this issue.
 
 
 In the identified literature, there was a lack of explicit reporting around equity and ethical considerations for factors contributing to, and interventions to alleviate, ED overcrowding. Future work should strive to deliberately and explicitly include ethical considerations inherent in research, planning, and policy-making; considerations of equity-deserving groups; and dedicate the time needed to consider the various facets of this issue.
 This CADTH report and our series of reports on ED overcrowding are a starting point to bridge the literature, stakeholder discussion, and expert opinion to help decision-makers understand the various parts of the issue and consult the relevant updated evidence to inform their work.

Workshop on Tourism Service Quality for Tourist Satisfaction and Return Visits to Cikadu Tourism Village, Tanjung Lesung Buffer Zone

In the light of COVID-19 outbreak, the tourism industry has affected the most with a loss in visitor both in local and foreign. The popularity of village tourism has increased as it can significantly boost the local and regional economies. This study is a explatorary research with descriptive analysis approach takes the form of community service activity program that based on a penta-helix structure and featured a strategic steering stakeholder with the representatives from academics, volunteers, businesspeople, and local resident from Cikadu, Tanjung Lesung. This paper intend to identify the stakeholders involved and increase their knowledge towards penta-helix model in village to rbuild restart tourism. This study found that not all tourism stakeholders in Cikadu village aware of the penta-helix model due to a lack of synergy in maximizing their roles. However, the workshop program giving a positive response from tourism village stakeholder and they are capable using a cooperative strategy between the community and stakeholders to manage tourism during a pandemic. The Penta helix instilled both knowledge and a fervor for tourist village development in participants.

Development of an Emergency Department Case Management Case-Finding Tool.

Identifying emergency department (ED) patients who are at high risk for return visits is an important goal for case management to improve patient care. This quality improvement study describes the development and evaluation of the Emergency Department Case Management Priority Score (EDCMPS), an electronic medical record (EMR)-based "case-finding" system, and its ability to identify these high-risk patients. In addition, the authors present data about its acceptability among emergency department case managers (ED CMs). Emergency departments with case management availability and staffing. A retrospective analysis at Duke University Hospital ED compared patient data pre- and postimplementation of the EDCMPS. The tool was developed using the LEAN and Plan-Do-Study-Act (PDSA) quality improvement methodologies, with ED CM participation. ED return and hospitalization rates within 7 and 30 days between both methods were compared, and a survey evaluated CM satisfaction with the EDCMPS. The 2-month preintervention period (July 1, 2022, to August 31, 2022) included 8,677 patients discharged from the ED, with 897 patients (10.3%) identified as at high risk for return based on the previous manual methodology. In the 3-month postintervention period (September 1, 2022, to November 30, 2022), there were 13,566 patients discharged, with 692 patients (5.1%) identified as at high risk for return using the EDCMPS. The EDCMPS outperformed the manual method, yielding a significantly higher odds ratio (OR) for 7- and 30-day ED return or hospitalization (e.g., 30-day any return OR = 4.21 vs. 1.69). The survey showed broad ED CM agreement on the tool's superior performance, especially in organizing outpatient resources and referring to support programs. However, challenges in securing primary care follow-up, housing, and health insurance applications were identified. The tool's collaborative development approach ensured its fit to ED CM needs, contributing to its success. The EDCMPS showcases promise in enhancing ED CM efficiency, with strong frontline staff endorsement. It pinpoints areas needing focus for patient support and has the potential to reduce ED revisits and therefore health care utilization. Its methodology offers insights for similar future implementations in health care institutions.

Potential delayed and/or missed STI diagnoses among outpatients presenting with lower genitourinary tract symptoms: a real-world database study

ABSTRACT Objectives Sexually transmitted infection (STI) diagnosis is complicated as these infections can present with lower genitourinary tract symptoms (LGUTS) that overlap with other disorders, i.e. urinary tract infections (UTIs). The study's objective was to determine potential missed STI diagnoses from patients presenting with LGUTS in the US between January 2010 and December 2019. Methods The de-identified insurance claims data from the IBM® MarketScan® Research Databases were collected from patients (14–64 years old) who presented with LGUTS, which could be caused by an STI. A ‘GAP’ cohort was created, consisting of episodes with potentially delayed STI (Chlamydia trachomatis [CT]/Neisseria gonorrhoeae [NG]) treatment. The intention was to capture episodes where an STI was not initially suspected. Four subgroups were defined depending on the treatment received (fluoroquinolone; azithromycin and/or doxycycline; cephalosporins; gentamicin and azithromycin). Results The GAP cohort consisted of 833,574 LGUTS episodes from the original cohort (23,537,812 episodes). Post-index CT/NG testing was carried out for 4.6% and 5.4% of the episodes from men and women, respectively. There were ≥2 return visits for 16.1% and 15.8% of the episodes from men and women, respectively. A substantial percentage of episodes from men (52.1%) and women (68.3%) were diagnosed with a UTI and/or acute cystitis at the index prior to receiving post-index STI treatment. Other top conditions diagnosed at index for men were dysuria (25.8% of the episodes), orchitis/epididymitis (14.3% of the episodes), and acute prostatitis (10.1% of the episodes), and for women were dysuria (24.2% of the episodes), vaginitis/vulvitis/vulvovaginitis (11.7% of the episodes), and cervicitis (3.3% of the episodes). Conclusion These findings highlight delayed STI antibiotic treatment and low rates of CT/NG testing, suggesting late STI consideration and suboptimal diagnosis. Additionally, our study illustrates the importance of accurately diagnosing and treating STIs in patients with LGUTS and associated conditions, to avoid antibiotic misuse and complications from delayed administration of appropriate treatment.

PENGARUH KUALITAS PELAYANAN TERHADAP KEPUASAN MASYARAKAT PADA PUSKESMAS MUNGKUR AGUNG KECAMATAN KELUA KABUPATEN TABALONG

Service quality is one of the factors that influence community satisfaction as service recipients. At the Mungkur Agung Health Center, Kelua District, Tabalong Regency, the quality of service is still not optimal, the length of service for medical records, the MCH poly and emergency room rooms are still relatively cramped, and the officers have not fully guaranteed timely service. with hope, and interest in a return visit which is still quite low. Based on the above, this study aims to determine the effect of service quality on community satisfaction at the Mungkur Agung Health Center and how much influence service quality has on community satisfaction at the Mungkur Agung Health Center. This research uses a quantitative approach with a descriptive quantitative research type. The date collection techniques used are questionnaires, observation and documentation. Sources of date were taken through accidental sampling with a total of 96 people. After the date was collected, it was analyzed using a simple linear regression test, T test and R2 test using the IMB SPSSv.25 program to prove the influence and how much influence the quality of service has on the satisfaction of people who seek treatment at the Mungkur Agung Health Center. The results showed that service quality had an influence on community satisfaction. It had a significant influence on community satisfaction at the Mungkur Agung Health Center, Kelua District, Tabalong Regency. It can be proven that the t count of 41.092 is greater than the t table (df-N-2) of 1.661 with a significance level of 0.000 with this number having a significant value of less than 0.05. The influence of service quality on community satisfaction is 95%, in other words, the influence of service quality on community satisfaction is said to be very strong. To increase community satisfaction at the Mungkur Agung Health Center, Kelua District, Tabalong Regency, the researchers suggested to the head and employees of the Mungkur Agung Health Center, Kelua District, Tabalong Regency to increase comfort in the infrastructure and services provided to the community

Fraser in Fearn: Migration, Diaspora, and the Ghosts of Empire in the Return Visits of Peter Fraser (New Zealand Prime Minister) to the Highlands, 1935–1949

Building on Eric Richards’ ideas about Scottish Highlanders as an ‘imperial people’, this article is about how diasporic movement and connection created significant bonds between Easter Ross and New Zealand in the twentieth century and beyond. It focuses on a microstudy of the village of Fearn, famed as the birthplace of Peter Fraser, who was Prime Minister of New Zealand from 1940 to 1949. Peter Fraser returned to the Scottish Highlands many times during the 1930s and 1940s, and these visits reveal the diasporic links between different parts of empire and ask questions about our understanding of enduring imperial legacies and memories. I argue that Peter Fraser’s return visits to Fearn can be interpreted as a form of ‘homecoming’, which tell us much about Fraser himself and how his own sense of identity continued to be shaped by a connection to the place of his birth. However, this article focuses less on Fraser and more on the effect his return visits to Fearn had on the village and its communities. Fraser and Fearn become, then, a case study of the diasporic ties of belonging between Scotland and New Zealand and how a shared belief in empire, especially during World War Two, connected folk in the Highlands with diasporic Scots, such as Fraser, on the other side of the world. Peter Fraser’s return visits to Fearn nurtured this sense of imperial connection and the way in which Fraser’s Highland homecomings are remembered in the region demonstrate the ongoing legacies of empire that continue to shape Scotland to this day.

Benefits of a novel automated digital platform to support cancer survivorship.

482 Background: Advances in treatment and early diagnosis have led to an increase in the 5-year relative survival rate for patients diagnosed with cancer. As of January 2022, there were 18.1 million cancer survivors in the United States, reflecting 5.4% of the total population. This number is projected to increase by 24.4%, to 22.5 million by 2032 (Cancer Facts and Figures 2023- American Cancer Society). Survivorship program needs include surveillance, member/ patient engagement, lifestyle changes and symptom management. Survivorship appointments make up >50% of the total return visits in oncology. There is a dire need for easy-to-use technology tools to help deliver high-quality survivorship care. Methods: We developed rules to automatically create a cohort of patients with Stage II and III colon cancer. The surveillance plan was developed by experts based on national guidelines. A separate set of rules drives the automatic generation of due dates for all elements of the care plan including laboratory tests, radiology examinations and clinical evaluations. A real-time dashboard clearly shows the care gaps. Tools were added to the dashboard to help with task completion. Results: The platform was successfully rolled out to 21 medical centers in Kaiser Permanente Northern California, an integrated healthcare system providing care for 4.4 million members. We experienced an increase in the completion for each of the surveillance elements needed for patients. Laboratory tests increased by 12.5%, radiology examinations by 8%, and clinical evaluations by 16%. Results have been sustained over the first year of use. Conclusions: We have successfully developed and operationalized a digital platform to sustainably support survivorship. This platform automatically identifies our survivorship cohort, informs the care team when care gaps exist and provides tools for task completion. Our care teams have used this platform successfully to outreach patients to ensure timely surveillance. This automatic platform reduces manual, redundant tasks previously performed by the care team. Further research is needed to explore the potential for this systems-based approach to reduce disparities in care. We plan to expand this to other cancers. Planned enhancements include automatic member reminders, lifestyle recommendations and symptom management.[Table: see text]

Characteristics of children hospitalized through the pediatric emergency department and effects of pediatric emergency ward hospitalization

Purpose: To evaluate the efficiency of the pediatric emergency ward (PEW) through the outcomes of children hospitalized to the ward by the department of pediatric emergency medicine (PEM).Methods: A chart review was completed for children (< 15 years) who were hospitalized to the PEW via the pediatric emergency center from March through May 2021. We compared the general characteristics and details regarding the outcomes depending on the departments they were hospitalized to, namely PEM, pediatrics (PED), and others.Results: We analyzed a total of 606 hospitalized children: PEM, 91; PED, 456; and others, 59. In the order listed above, their median ages were 2 years (interquartile range, 1-6), 1 year (0-4), and 9 years (7-14) (P < 0.001). The numbers of children with Korean Triage and Acuity Scale of 1-3 were 71 (78.0%), 400 (87.7%), and 33 (55.9%) (P < 0.001). Median length of stay (LOS) in the emergency department (ED) and hospital tended to be shorter in PEM (ED LOS: PEM, 4.3 hours vs. PED and others, 4.0-6.3 hours; hospital LOS: PEM, 19.0 hours vs. PED and others, 58.5-63.8 hours; all Ps < 0.001). The differences in the LOS were prominent between others and PEM (ED LOS, 1.538 [95% confidence interval, 1.353-1.749]; hospital LOS, 3.375 [2.741-4.157]). Transfers to other departments occurred only in PEM (4.4%) and PED (3.9%) whereas intensive care was performed only in others (27.1%). Return visits showed no difference among the 3 departments. Top 5 chief complaints and primary diagnoses of the children hospitalized to PEM were vomiting, fever, abdominal pain, head injury, and poisoning, and gastroenteritis, concussion, syncope, poisoning, and upper respiratory infection, respectively.Conclusion: Hospitalization to PEWs for short-term treatment or observation may relieve overcrowding in EDs or in hospitals, with comparable frequency of return visits.

Exploring the Impact of Supermarket Store Layout and Atmospheric Elements on Consumer Behavior: A Field Research Study in Greece

The highly competitive retail industry pushes retailers to seek strategies like creating atmospheric in-store experiences to boost consumer satisfaction and encourage return visits. Store atmosphere and layout design influence consumer decision-making, perception, and satisfaction. Factors such as building design, customer patterns, merchandise mix, and proximity requirements impact consumer perception and store layout. This article investigates the effect of supermarket chains’ layouts on consumer behavior, focusing on atmospheric elements. A Greek field study involving 205 participants assessed perceptions and attitudes toward supermarket layouts and design elements. Results suggest that retail environment characteristics impact emotional reactions, which in turn influence impulse buying behavior. Emphasizing the importance of a superior customer experience throughout the purchasing process, the study identifies key atmospheric elements affecting consumer behavior in supermarkets. The article concludes by discussing implications for retail marketers and suggesting future research directions.

Mpox in the Emergency Department: A Case Series.

We sought to describe the demographic characteristics, clinical features, and outcomes of a cohort of patients who presented to our emergency departments with mpox (formerly known as monkeypox) infection between May 1-August 1, 2022. We identified 145 patients tested for mpox, of whom 79 were positive. All positive cases were among cisgender men, and the majority (92%) were among men who have sex with men. A large number of patients (39%) were human immunodeficiency virus (HIV) positive. There was wide variation in emergency department (ED) length of stay (range 2-16 hours, median 4 hours) and test turnaround time (range 1-11 days, median 4 days). Most patients (95%) were discharged, although a substantial proportion (22%) had a return visit within 30 days, and 28% ultimately received tecrovirimat. Patients who presented to our ED with mpox had similar demographic characteristics and clinical features as those described in other clinical settings during the 2022 outbreak. While there were operational challenges to the evaluation and management of these patients, demonstrated by variable lengths of stay and frequent return visits, most were able to be discharged.

Research on Scheme Design and Decision of Multiple Unmanned Aerial Vehicle Cooperation Anti-Submarine Based on Knowledge-Driven Soft Actor-Critic

To enhance the anti-submarine and search capabilities of multiple Unmanned Aerial Vehicle (UAV) groups in complex marine environments, this paper proposes a flexible action-evaluation algorithm known as Knowledge-Driven Soft Actor-Critic (KD-SAC), which can effectively interact with real-time environmental information. KD-SAC is a reinforcement learning algorithm that consists of two main components: UAV Group Search Knowledge Base (UGSKB) and path planning strategy. Firstly, based on the UGSKB, we establish a cooperation search framework that comprises three layers of information models: the data layer provides prior information and fundamental search rules to the system, the knowledge layer enriches search rules and database in continuous searching processes, and the decision layer utilizes above two layers of information models to enable autonomous decision-making by UAVs. Secondly, we propose a rule-based deductive inference return visit (RDIRV) strategy to enhance the knowledge base of search. The core concept of this strategy is to enable UAVs to learn from both successful and unsuccessful experiences, thereby enriching the search rules based on optimal decisions as exemplary cases. This approach can significantly enhance the learning performance of KD-SAC. The subsequent step involves designing an event-based UGSKB calling mechanism at the decision-making level, which calls a template based on the target and current motion. Finally, it uses a punishment function, and is then employed to achieve optimal decision-making for UAV actions and states. The feasibility and superiority of our proposed algorithm are demonstrated through experimental comparisons with alternative methods. The final results demonstrate that the proposed method achieves a success rate of 73.63% in multi-UAV flight path planning within complex environments, surpassing the other three algorithms by 17.27%, 29.88%, and 33.51%, respectively. In addition, the KD-SAC algorithm outperforms the other three algorithms in terms of synergy and average search reward.

Is Ophthalmia Neonatorum Associated With Invasive Bacterial Infection? A Single-Center Retrospective Study.

Ophthalmia neonatorum (ON) is a conjunctivitis occurring in neonates and can be caused by multiple bacterial pathogens. The risk of invasive bacterial infection (IBI) in neonates with ON is poorly known. Our objectives were to document the association of ON with IBI in term neonates and to investigate practice variation. This was a retrospective observational study of all neonates who presented to a single emergency department (ED) between January 2018 and December 2019. Participants were all children with a final diagnosis of ON according to the treating physician as registered in the ED computerized database. Newborns with craniofacial malformations and premature infants were excluded. The primary outcome was IBI as defined by growth of any bacterial pathogen in the blood or cerebrospinal fluid. Perinatal risk factors, ED visit details (symptoms on presentation, management, and treatment plan) as well as complications (ocular morbidity, death, and unscheduled return visits) were collected. Data were analyzed using descriptive statistics. Fifty-two term neonates were included. There were no cases of IBI associated with ON (0%; 95% confidence interval [CI], 0%-6.9%). Six ocular bacterial infections were identified, one of which was Chlamydia trachomatis. Although there were no IBIs, ocular complications, deaths, or unscheduled return visits to the ED, there was a wide variation in physician's management of ON. Physicians ordered investigations in 49% (95% CI, 34%-62%) of neonates, prescribed antibiotics to 87% (95% CI, 74%-94%), and involved specialists in 39% (95% CI, 27%-52%) of cases. Emergency department presentations of term neonates with ON are associated with a low risk of IBI. A better understanding of the current practice variation is needed to inform clinical guidelines for the management of neonates with ON presenting to the ED.

Delays in treatment and disposition attributable to undertriage of pediatric emergency medicine patients

BackgroundTriage, the initial assessment and sorting of patients in the Emergency Department (ED), determines priority of evaluation and treatment. Little is known about the impact of undertriage, the underestimation of disease severity at triage, on clinical care in pediatric ED patients. We evaluate the impact of undertriage on time to disposition and treatment decisions in pediatric ED patients. MethodsThis was a case control study of ED visits for patients <22 years of age, with an assigned Emergency Severity Index (ESI) score of 4 or 5, and associated hospital admission, nebulized treatment, supplemental oxygen, and/or intravenous (IV) line placement, between January 1, 2018, to June 30, 2022. Controls were sampled from a pool of patient visits with an ESI score of 3, matched by intervention, disposition, and date and hour of arrival.Primary outcome measures were time to order of intervention (nebulized treatment, oxygen administration, or IV placement) and time to disposition decision. A secondary outcome measure was return visits requiring admission or emergency intervention within 14 days of the index visit. Continuous variables (time to orders) were analyzed using Wilcoxon rank sum test and dichotomous outcomes (return visits) were compared using odds ratios with 95% confidence intervals. Analysis was performed with Python v3.10. ResultsThe final analysis included 7245 undertriaged patients. Undertriaged patients had longer times to orders for nebulized treatments, (p < 0.001) IV placement, (p < 0.001) and admission (p < 0.001) when compared to controls. There were no significant differences in time to supplemental oxygen delivery and time to discharge compared to controls. Undertriaged patients were more likely to experience a return visit requiring admission or emergency intervention (OR 3.74, 95% CI 3.32,4.22). ConclusionsUndertriage in the pediatric ED is associated with delays in care and disposition decisions and increases likelihood of return visits.