Same-day Emergency Research Articles

Establishing an acute rheumatology liaison service in same-day emergency care

Establishing an acute rheumatology liaison service in same-day emergency care

Increasing same-day emergency care activity in an existing ambulatory care unit using quality improvement methodology

This project aimed to increase same-day emergency care (SDEC)-suitable activity within an existing ambulatory medical unit, in line with the recommendations set out in the NHS Long Term Plan. Prior to the project, much of the unit's activity was non-urgent and focused on supporting early discharges. Scoping exercises were undertaken to better understand current activity and identify interventions to increasing same-day referrals from within the urgent and emergency care system. Quality improvement methodology was then used to implement and study a variety of interventions, including but not limited to the development of new condition-based referral pathways. Retrospective review of SDEC activity demonstrated a threefold increase.

A case-crossover analysis to quantify the impact of wildfire smoke on hospital respiratory admissions in the Rogue Valley, Oregon

BackgroundWith the increasing prevalence of wildfire smoke in the Pacific Northwest, it is important to quantify health impacts to plan for adequate health services. The Rogue Valley region has historically faced some of the greatest wildfire threats in the state. Health impacts from smoke have been estimated in several recent studies that include Oregon's Rogue Valley, but the results between studies are conflicting. ObjectiveThe objective is to critically examine impacts of wildfire smoke on health in the Rogue Valley area and translate the results to support hospital staffing decisions. Study designThe study adopts a case-crossover approach. MethodsApply a conditional Poisson regression to analyze time stratified counts while controlling for mean temperature. ResultsEvery 10 μ/m3 increase in PM2.5 is associated with a 2% increase in same-day hospital or emergency room admission rates for respiratory conditions during fire season after adjusting for temperature and time (OR = 1.020; 95% CI: 1.004–1.034); a 10 μ/m3 increase in PM2.5 lasting nine days is associated with a 4% increase in admission rates (OR = 1.041; 95% CI: 1.018–1.065). In other words, for each 10 μ/m3 single day increase in pollution from smoke, an additional 0.26 respiratory patients would be expected in the area hospitals. With a single day increase from 10 μ/m3 to 150 μ/m3, hospitals could expect an additional four patients. ConclusionsThere are small but significant health impacts in the Rogue Valley. These impacts are smaller than some statewide estimates. We need further research to understand these differences.

765 Enhancing the Quality of Referrals to Vascular Surgery at a District General Hospital: A Closed-Loop Quality Improvement Project

Abstract This quality improvement project aimed to improve the completeness of referrals to vascular surgery from in-patient wards and the Sameday Emergency Care unit at a UK district general hospital. We implemented a comprehensive vascular surgery proforma to enhance the quality of referrals to the department. Referrals made between 01/01/23 and 01/03/23 were assessed according to Professional Record Standards Body (PRSB) guidelines, which outlines the necessary information to be included in clinical referrals. The new proforma was introduced to all hospital clinicians, enabling them to email completed referrals to a dedicated vascular surgery inbox. To evaluate the impact of the new system, referrals were re-audited between 12/05/23 and 13/07/2023 using the same PRSB criteria. Significant improvements were observed in the completeness of referrals, as indicated by the percentage of fulfilled PRSB criteria: patient demographics (60% vs. 100%), referrer details (51% vs. 100%), reason for referral (93% vs. 100%), relevant clinical risk factors (60% vs. 95%), medication history (60% vs. 100%), family history (40% vs. 84%), social history (47% vs. 93%), patient ideas concerns and expectations (40% vs. 81%), examination findings (60% vs. 93%), and investigation findings (63% vs. 91%). The median number of fulfilled criteria per referral increased from 2.5 to 9 (out of 10), demonstrating a substantial improvement (p < 0.0001). Our dedicated vascular surgery referrals proforma had a significant positive impact on the completeness of referrals to the department. This change has the potential to enhance continuity of care, improve clinical prioritisation, promote patient safety, and enhance the overall efficiency of our service.

Enhancing quality in same-day emergency care: a service improvement perspective

Background: Same-day emergency care (SDEC) units were introduced in the UK in response to growing numbers of emergency department visits. Key quality indicators for their performance include timely assessment, diagnosis and treatment to reduce delays and optimise care delivery. Aims: This article presents the findings from a multi-cycle service improvement project undertaken at a regional SDEC unit from the perspective of the advanced clinical practitioner (ACP). Methods: The SI project adopted an array of SI methodologies, including the Plan, Do, Study, Act model, process mapping and audit data analytics to identify and reduce variance in patient care. Results: The project identified the importance of adopting a whole-system approach to clinical leadership to improve the care experience of patients and staff. Success is highly dependent on the availability of a confident and skilled workforce to provide high-quality patient care. Conclusions: As demands on emergency health services continue to grow, the ACP is in an ideal position to adapt to change and generate innovative solutions to address capacity issues.

A retrospective evaluation of a multidisciplinary management strategy implemented to optimize outpatient care, hospitalization rates and clinical outcomes in a single-centre cohort of COVID-19-positive pregnant women in Australia during the Omicron BA.1 surge

Abstract Background During the Omicron BA.1 surge between 12 January and 18 February 2022, 189 COVID-19-positive pregnant women were managed by the Peninsula Health Positive Pathways program, in the Mornington Peninsula, Victoria, Australia. A multidisciplinary specialist team was rapidly assembled to work in conjunction with the Pathways COVID-19 physicians and monitoring team, to optimize patient care. Objective The aim is to describe the processes utilized to care for the pregnancy cohort from the time of enrolment to the COVID Monitor until recovery including outpatient monitoring, treatment strategies, hospital review criteria, and clinical outcomes including rate of hospitalization, oxygen requirements, and maternal and foetal outcomes during the study period. Method Outpatients were monitored daily by the Pathways program, while COVID-19 physicians and obstetricians conducted early telehealth review of patients after diagnosis. Members of the multidisciplinary team met on a virtual platform twice daily, and institution-specific treatment guidelines and hospital review criteria were established. Enoxaparin prophylaxis was delivered to the homes of selected patients, and inhaled budesonide was utilized for patients who did not require oxygen, who were immunocompromised, and who had significant respiratory symptoms or risk factors for deterioration. Sotrovimab was offered to women as per the existing Australian National COVID-19 Clinical Evidence Taskforce eligibility criteria. A service evaluation was undertaken adopting a retrospective cohort approach. Results There was minimal maternal morbidity and no mortality with 24/189 (12.7%) women requiring hospitalization, 18/189 (9.5%) requiring same-day emergency department presentations only, and 4/189 (2.1%) requiring oxygen, with no requirement for non-invasive ventilation or intensive care unit admission. Sixteen patients delivered live newborns during the study period, and there were two pregnancy losses at 7 and 19 weeks gestation, respectively, in patients with prior pregnancy complications. Conclusion A multidisciplinary approach involving virtual communication twice daily between treating specialist physicians may be a broadly applicable model to optimize care of pregnant women with COVID-19.

Outcomes of a Hybrid Ophthalmology Telemedicine Model for Outpatient Eye Care During COVID-19

The hybrid ophthalmology telemedicine model asynchronously pairs an imaging appointment by a technician with a subsequent virtual appointment by a clinician. Although it has been mentioned in several studies as an alternative to standard in-person care during the COVID-19 pandemic, outcomes of this alternative clinical care model remain to be evaluated. To investigate the outcomes associated with the hybrid ophthalmology telemedicine model during the COVID-19 pandemic for nonurgent and nonprocedural ophthalmological care. Retrospective, cross-sectional study of all hybrid visits scheduled during the year 2020 in a single academic, hospital-based eye clinic in Boston, Massachusetts. All hybrid ophthalmology telemedicine visits completed in the year 2020 by opthalmologists and optometrists were included. Data were analyzed from January to December 2020. Hybrid telemedicine clinical encounters. Four outcome metrics were calculated: (1) need for subsequent procedure visit, (2) medication change, (3) nonurgent, and (4) urgent consultation with another eye clinician. Adverse outcomes were defined as irreversible vision loss and the need for additional in-person evaluation to reach a management decision. From April 9 to December 30, 2020, 889 patients (506 female patients [56.9%]; mean [SD] age, 62.1 [14.5] years; age range, 13-98 years) completed 940 hybrid visits. The most common visit indications were glaucoma (424 visits [45.1%]) and retinal diseases (499 visits [53.1%]). A total of 25 visits (2.7%) led to a procedure, 22 visits (2.3%) led to a change in medication, and 44 visits (4.7%) were referred for nonurgent consultation with another subspecialty with no instances of urgent referrals. Sixteen patients (1.7%) were referred to the on-call clinician for a same-day emergency in-person visit or recommended for a subsequent standard in-person visit to reach a management decision. There were no cases of irreversible vision loss following a hybrid visit. These findings suggest that with the appropriate patient selection and clinical setting, the hybrid ophthalmology telemedicine model may be a good alternative to standard in-person visits, particularly for patients with glaucoma and retinal diseases.

Improving the provision and quality of safety netting instructions for patients seen in same-day emergency care (SDEC)

Improving the provision and quality of safety netting instructions for patients seen in same-day emergency care (SDEC)

Undiagnosed malignancy presenting to same-day emergency care: a single unit experience

Routes to diagnosis of malignancy include 2-week wait referrals from primary care, secondary care referrals and emergency presentations.[1][1] Understanding the phenotypical presentations of malignancy to same-day emergency care (SDEC) units informs resource allocation and pathway development. We

Possible futures of acute medical care in the NHS: a multispecialty approach

Changing population demographics and needs are resulting in a continual rise in acute medical admissions. This review draws on the observations of the NHS GIRFT programme across England. Fundamental aspects of acute medical care are not universally provided, resulting in preventable hospitalisation and over-use of emergency departments. Such aspects include care outside hospitals; appropriately sized, staffed, located and configured acute medical units; multispeciality same-day emergency care (SDEC) pathways; multidisciplinary care on wards; and readmission prevention. 'Hospital at home' services are developing, and require local evaluation. SDEC is expanding. Digital technologies make it possible to provide acute care in and across more settings. Addressing the fundamentals of acute medical care, evaluating new service opportunities, strong clinical and managerial partnerships, better data for analytics, and a multispeciality, multiprofessional approach will enable a better level of care to be achieved.

A Cost Comparison of Holmium Laser Enucleation of the Prostate with and without Moses™.

Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the treatment of benign prostatic hyperplasia. HoLEP has been shown to have excellent improvements in prostate symptom scores and maximum flow rates that have been durable for 2 decades. However, the steep learning curve associated with HoLEP has prevented its widespread adoption. New advancements in lasers, specifically the Moses™ pulse-modulation technology, have resulted in improvements in hemostasis and achieving same-day discharges and catheter removals. We aimed to perform a cost-comparison to analyze if Moses-augmented HoLEP (m-HoLEP) resulted in cost-savings. A retrospective review was performed of a single expert surgeon's experience from May 2018 to November 2020, comparing m-HoLEP with HoLEP. Perioperative and postoperative variables were abstracted from the medical record. Univariate and multivariate analyses were performed using SAS® 9.4. Two-sided significance was set at p <0.05. A total of 312 men underwent HoLEP during the study period (192 in m-HoLEP group and 120 in HoLEP group). The m-HoLEP group had more same-day discharges (p <0.001) and emergency department visits (6.3% vs 1.7%, p=0.0071). m-HoLEP resulted in hospital cost savings of $840 for the initial surgical episode (p=0.0297). When factoring in emergency department visits/readmissions, the cost savings decreased to $747 per case (p=0.0574). m-HoLEP was associated with same-day discharge and hospital cost savings of $840 for the initial surgical episode. Further study in other institutions with surgeons of varying experience levels will need to be performed to see if these findings can be replicated.

Outpatient parathyroidectomy in the pediatric population: An 18-year experience

BackgroundParathyroidectomy for primary hyperparathyroidism (pHPT) is safely performed in the outpatient setting in the adult population. However, concern that children and adolescents have higher complication rates and are unable to recognize and communicate symptoms of hypocalcemia has limited same-day discharges in the pediatric population. MethodsNineteen patients aged 8–18 years (14.1 ± 0.7) underwent outpatient parathyroidectomy for pHPT by a single high-volume endocrine surgeon from 2002–2020. Patient demographics, disease, operations, and complications were reviewed. ResultsSixteen of 19 patients were symptomatic with fatigue (62.5%), joint pain (37.5%) and nephrolithiasis (18.7%) most common. Mean preoperative Ca and PTH were 11.7 ± 0.3 mg/dL and 102.3 ± 11.8pg/mL, respectively. Ten of 19 had a single adenoma and 9 had multigland hyperplasia including one MEN1 and one MEN2A patient. We performed 11 four-gland explorations, 8 unilateral parathyroidectomies; including 9 transcervical thymectomies, 1 total thyroidectomy, and 1 bilateral central neck dissection. Mean 6-month postoperative Ca and PTH levels were 9.5 ± 0.3 mg/dL (range 7.3–10.3) and 29±5.0pg/mL (range 6.3–77), respectively. One patient developed permanent hypoparathyroidism and 1 had temporary hypocalcemia. No temporary or permanent hoarseness, unplanned same-day admission, wound complications, or Emergency Department visits occurred. ConclusionOutpatient parathyroidectomy can be safely and effectively performed in pediatric patients with primary HPT. Level of EvidenceTreatment Study, Level III.

Outpatient Percutaneous Endovascular Abdominal Aortic Aneurysm Repair: A Single-Center Experience

PurposeTo evaluate the safety of outpatient percutaneous endovascular abdominal aortic repair (PEVAR) versus inpatient PEVAR without or with adjunct procedures. Materials and MethodsBetween January 2012 and June 2019, a cohort of 359 patients comprising 168 (46.8%) outpatients and 191 (53.2%) inpatients who had undergone PEVAR were enrolled. All the patients were asymptomatic but had indications for endovascular aortic repair, ie, fit for intravenous anesthesia and anatomically feasible with standard devices. Patient sex, age, comorbidities, smoking status, type of anesthesia, adjunct procedures, type of graft device, operative times, mortality, complications, and readmissions were analyzed. ResultsMedian follow-up period was 16.5 months (interquartile range, 9–31 months). Except for a higher percentage of tobacco use (42.6% vs 28.8%; P = .04), dyslipidemia (39.7% vs 19.2%; P < .01), and use of local anesthesia (99.4% vs 82.2%; P < .01) in the outpatients, there was no significant difference in the type of graft and adjunct procedures used. No outpatient mortality occurred. There was no difference in the number, severity, and onset of complications (all P > .05). Outpatient unexpected same-day admission, 30-day readmission, and emergency department visit rates were 4.8%, 2.4% (P = .13), and 10% (P < .01), respectively. Operative times for outpatient PEVAR without adjunct procedures were shorter (P < .01). ConclusionsOutpatient PEVAR can be performed with a safety profile similar to that of inpatient PEVAR. The unexpected same-day admission, 30-day readmission, and emergency department visit rates were low. The outpatient PEVARs without adjunct procedures took less time.

Process of care and activity in a clinically inclusive ambulatory emergency care unit: progressive effect over time on clinical outcomes and acute medical admissions

Clinically relevant outcomes for same-day emergency care provided by ambulatory emergency care units (AECs) are largely unknown. We report the activity and outcomes for a large UK adult AEC operating an ambulatory-care-by-default model without specific exclusion criteria. The AEC consultant triaged all acute medical referrals to either the AEC or the standard non-ambulatory 'take' pathway during AEC opening hours. The proportion of acute medical referrals seen in the AEC increased to 42% (mean 700 referrals seen per month) in the last 6 months of the study and numbers seen in the non-ambulatory pathway fell. The most common diagnoses were for chest pain, pneumonia, cellulitis, heart failure and urinary system disorders. Seventy-four point eight per cent of patients completed their care in a single visit. In the last calendar year, the conversion rate from AEC to inpatient admission was 12%, and the 30-day readmission rate was 6.9% and 18% for the AEC and non-ambulatory pathways, respectively. Across the whole study period, the 30-day mortality was 1.6% and 6.9% for the AEC and non-ambulatory pathway, respectively. This ambulatory approach is safe and effective.

Home Care Nursing Visits and Same-Day Emergency Department Use: Which Patients Are Most at Risk?

Home care patients are a growing group of community-dwelling older adults with complex care needs and high health service use. Adult home care patients are at high risk for emergency department (ED) visits, which is greater on the same day as a nursing visit. The purpose of this study was to examine whether common nursing indicators modified the association between nursing visits and same-day ED visits. A case-crossover design within a retrospective cohort of adult home care patients in Ontario. A total of 11,840 home care nursing patients were analyzed. Home care patients who received a home nursing visit were more likely to go the ED afterhours on the same day with a stronger association for visits not admitted to the hospital. Having a urinary catheter increased the risk of a same-day ED visit (OR: 1.78 (95% CI 1.15-1.60) vs. 1.21 (95% CI 1.15-1.28)). No other clinical indicator modified the association. The findings of this study can be used to inform care policies and practices for home care nurses in the management of indwelling urinary catheter complications. Further examination of system factors such as capacity and resources available to respond to catheter related complications in the community setting are recommended.

Direct referrals from emergency department streaming to ambulatory care: improving same-day emergency care

Same-day emergency care is one of the many ways the NHS is working to provide the right care, in the right place, at the right time for patients. It aims to benefit both patients and the healthcare system by reducing waiting times and unnecessary hospital admissions. In our organisation patients presenting to the emergency department (ED) with common medical conditions like chest pain / shortness of breath (SOB), palpitations, headache, chest infection or deep vein thrombosis / pulmonary …

Using the principles of ‘same day emergency care’ in our new acute medical unit

In January 2019, Barnet Hospital opened the new acute medical unit (AMU), which uses the objectives and aims set out by NHS Improvement ‘same-day emergency care’ (SDEC).1 The ambulatory emergency clinic (AEC) forms part of the new AMU, as a clinic for those patients ‘fit to sit’, to avoid unnecessary hospital admissions in clinically stable, ambulatory patients. The principles of SDEC were used to answer the question: ‘Why does it take so long for general practitioner (GP) expected patients to be discharged?’ The objective was to determine any factors that lead to a delay …

Acute frailty services aim to cut avoidable emergency admissions

NHS Long Term Plan calls for acceleration towards same-day emergency care for older people

The association between home care visits and same-day emergency department use: a case-crossover study.

The extent to which home care visits contribute to the delay or avoidance of emergency department use is poorly characterized. We examined the association between home care visits and same-day emergency department use among patients receiving publicly funded home care. We conducted a population-based case-crossover study among patients receiving publicly funded home care in the Hamilton-Niagara-Haldimand-Brant region of Ontario between January and December 2015. Within individuals, all days with emergency department visits after 5 pm were selected as cases and matched with control days from the previous week. The cohort was stratified according to whether patients had ongoing home care needs ("long stay") or short-term home care needs ("short stay"). We used conditional logistical regression to estimate the association between receiving a home care visit during the day and visiting the emergency department after 5 pm on the same day. A total of 4429 long-stay patients contributed 5893 emergency department visits, and 2836 short-stay patients contributed 3476 visits. Receiving a home care nursing visit was associated with an increased likelihood of visiting the emergency department after 5 pm on the same day in both long-stay (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.17-1.48) and short-stay patients (OR 1.22, 95% CI 1.07-1.39). Stronger associations were observed for less acute visits to the emergency department. No associations were observed for other types of home care visits. Patients receiving home care were more likely to visit the emergency department during the evening on days they received a nursing visit. The mechanism of the association between home care visits and same-day emergency department use and the extent to which same-day emergency department visits could be prevented or diverted require additional investigation.

Gastrointestinal perforation during regorafenib administration in a case with hepatic metastases of colon cancer

Although common side effects of regorafenib include hand-and-foot syndrome and diarrhoea, the incidence of gastrointestinal perforation is reportedly unknown. We describe our experience with the case of a 65-year-old woman treated with regorafenib as a third-line therapy for progressive caecal cancer with multiple hepatic metastases after 4 and 6 courses of systemic mFOLFOX6 + bevacizumab (BV) and FOLFIRI + BV chemotherapy, respectively. The patient used regorafenib for 32 days but visited our hospital with abdominal pain during the second course. She was diagnosed with acute appendicitis and treated conservatively with antibiotics. The abdominal findings did not improve, and a computed tomography evaluation on day 4 of hospitalization revealed free air lateral to the caecal tumour, liver surface, and epigastric region. The patient underwent same-day emergency surgery based on a diagnosis of gastrointestinal perforation with generalized peritonitis. Upon observing digestive fluid leakage into the peri-ileocaecal area and a 5-mm perforation in the appendix, the patient was diagnosed with peritonitis due to gastrointestinal perforation. Ileocaecal resection with D2 debridement was performed, and a colostomy was opened into the ileum and ascending colon. We conclude that our patient developed gastrointestinal perforation during regorafenib therapy and note that clinicians should be aware of this possible complication in patients with a history of prior treatment with BV.