The Australian public's preferences for emergency care alternatives and the influence of the presenting context: a discrete choice experiment

Objectives The current study seeks to quantify the Australian public's preferences for emergency care alternatives and determine if preferences differ depending on presenting circumstances. Setting Increasing presentations to emergency departments have led to overcrowding, long waiting times and suboptimal health system performance. Accordingly, new service models involving the provision of care in alternative settings and delivered by other practitioners continue to be developed. Participants A stratified sample of Australian adults (n=1838), 1382 from Queensland and 456 from South Australia, completed the survey. This included 951 females and 887 males from the 2045 people who met the screening criteria out of the 4354 people who accepted the survey invitation. Interventions A discrete choice experiment was used to elicit preferences in the context of one of four hypothetical scenarios: a possible concussion, a rash/asthma-related problem involving oneself or one's child and an anxiety-related presentation. Mixed logit regression was used to analyse the dependent variable choice and identify the relative importance of care attributes and the propensity to access care in each context. Results Results indicated a preference for treatment by an emergency physician in hospital for possible concussion and treatment by a doctor in ambulatory settings for rash/asthma-related and anxiety-related problems. Participants were consistently willing to wait longer before making trade-offs in the context of the rash/asthma-related scenario compared with when the same problem affected their child. Results suggest a clear preference for lower costs, shorter wait times and strong emphasis on quality care; however, significant preference heterogeneity was observed. Conclusions This study has increased awareness that the public's emergency care choices will differ depending on the presenting context. It has further demonstrated the importance of service quality as a determinant of healthcare choices. The findings have also provided insights into the Australian public's reactions to emergency care reforms

Evaluation of medical response in disaster preparedness : with special reference to full-scale exercises

Background: Disaster exercises and simulations serves as teaching and training tool for improving medical response in disaster preparedness. Rapid and effective medical response in major incidents is known as a “key phase” to optimise resources, and this requires that management systems have an “all hazards” approach. Decision-making at all levels of management is based on available information and involves allocation of medical resources and triage decisions. Aim: The overall aim of this thesis was to increase our knowledge of the impact of quantitative evaluation of medical response on disaster preparedness. The specific aims were: to increase the ability to learn from full-scale exercises by applying quality indicators at two levels of command and control (I, II); to identify key indicators essential for initial disaster medical response registration (III); to explore ambulance staff attitudes towards practising triage tagging (IV); and to increase our knowledge of the applicability of a technical support system and its potential to provide real-time, overall situation awareness available to those overseeing the medical management of the operation. Methods: Study I, II and V were observational studies based on data collections from full-scale exercises. Templates with measurable performance indicators for evaluation of command and control were used in Study I and II and the same performance indicators combined with outcome indicators was also included in Study II. A consensus method, the Delphi technique, with 30 experts was used in Study III. Study IV used mixed methods, a pre-and post web survey answered by ambulance nurses and physicians (n=57 respectively 57) before and after a time limited strategy with triage tags and three focus groups interviews comprising 21 ambulance nurses and emergency medical technicians. Study V used major two incidents simulations to test the applicability of Radio Frequency Identification (RFID tags) technology and compare it with traditionally paper-based triage tags (n= 20 respectively 20). The quantitative data were analysed using descriptive statistics, and content analysis was used for the qualitative data. Results: The evaluation model exposed several problems occurring in the initial decision-making process that were repeatedly observed (I, II). These results in study II also demonstrated to have a major impact on patient outcome.Out of 17 severely injured patients five respectively seven were at risk for preventable death. A total of 97 statements were generated, of these 77 statements reached experts consensus, and 20 did not (III). Ambulance staffs believe in the usefulness of standardised triage methods, but the sparse application of triage tags at the scene indicates that the tags are not used frequently. Infrequent use in daily practice prevents participants from feeling confident with the triage tool (IV).The Radio Frequency Identification system improved situational awareness in disaster management. Triage information was available at least one hour earlier compared to a paper-based triage system (V). Conclusions: The presented evaluation model can be used in an objective, systematic and reproducible way to evaluate complex medical responses, which is a prerequisite for quality assurance, identification of problems, and the development of disaster preparedness

Patient throughput times and inflow patterns in Swedish emergency departments. A basis for ANSWER, A National SWedish Emergency Registry

Objective: Quality improvement initiatives in emergency medicine (EM) often suffer from a lack of benchmarking data on the quality of care. The objectives of this study were twofold: 1. To assess the feasibility of collecting benchmarking data from different Swedish emergency departments (EDs) and 2. To evaluate patient throughput times and inflow patterns. Method: We compared patient inflow patterns, total lengths of patient stay (LOS) and times to first physician at six Swedish university hospital EDs in 2009. Study data were retrieved from the hospitals' computerized information systems during single on-site visits to each participating hospital. Results: All EDs provided throughput times and patient presentation data without significant problems. In all EDs, Monday was the busiest day and the fewest patients presented on Saturday. All EDs had a large increase in patient inflow before noon with a slow decline over the rest of the 24 h, and this peak and decline was especially pronounced in elderly patients. The average LOS was 4 h of which 2 h was spent waiting for the first physician. These throughput times showed a considerable diurnal variation in all EDs, with the longest times occurring 6-7 am and in the late afternoon. Conclusion: These results demonstrate the feasibility of collecting benchmarking data on quality of care targets within Swedish EM, and form the basis for ANSWER, A National SWedish Emergency Registry

The involvement of nurses and midwives in screening and brief interventions for hazardous and harmful use of alcohol and other psychoactive substances

This report provides details of a review of the literature on the involvement of nurses and midwives in screening and brief interventions for hazardous and harmful use of alcohol and other psychoactive substances

Redesigning an emergency department for interprofessional teamwork : a longitudinal evaluation of the impact on patient flow and team behaviour

Objective: Crowding in emergency departments (EDs) has negative effects on patients and staff, whereas effective teamwork in healthcare has positive effects. Triage interventions and streaming of specific patient categories are common strategies used by EDs to reduce the negative effects of crowding, but few studies have evaluated interprofessional teamwork as a strategy to reduce ED crowding. This thesis evaluated the redesign of an ED for interprofessional teamwork with the aim of studying the impact on patient flow and team behaviour. Methods: The project was conducted at an adult ED, where teamwork modules replaced the triage, fast track, and main ED sections in November 2014. Study I, II, and III were quantitative before- and-after studies using patient data, whereas study IV collected qualitative and quantitative data from health professionals for four years. Study I and II used registry data from May 2012 to November 2015. Study I included all patient arrivals on weekdays from 8 am to 9 pm for three one-year periods and compared the first year of teamwork to two previous triage processes, nurse-led triage and physician-led triage. Study II included patients who presented limb injuries or back pain to the ED, where the first year of teamwork was compared to a previous period, when ambulant low acuity patients were streamed to the fast track. An equal number of non-orthopaedic presentations were also included to control for the impact on other patient categories. The waiting time to physician assessment and ED length of stay were outcome measures in both studies. We used multiple linear regression analysis to adjust the ED length of stay for differences in patient and background characteristics between the periods. Study III included all patients 80 years or older arriving on weekdays during a pilot period in 2016, when a teamwork module was dedicated to older patients, and a corresponding period in 2015 with only regular teamwork modules for mixed age groups. The outcome measures were the ED length of stay and the total hospital admission rate within seven days. Study IV included triangulated data from three staff sources; structured observations of team behaviours in June 2016 and June 2018, semi-structured interviews in June 2018, and a questionnaire of the perceived workload, collaboration, and patient satisfaction repeated from October 2014 through June 2018. Results: Study I included 185 806 patient arrivals. The crude median ED length of stay was shortest for the teamwork period, 228 minutes (95% CI: 226.4 to 230.5) compared to 232 minutes (95% CI: 230.8 to 233.9) for the nurse-led triage period, and longest for the physician-led triage period, 250 minutes (95% CI: 248.5 to 252.6). The adjusted ED length of stay for the teamwork period was 16 minutes shorter than for the nurse-led triage period (p<0.001), and 23 min shorter than for the physician-led triage period (p<0.001). The median waiting time to physician assessment was 74 minutes (95% CI: 73 to 75) for the teamwork period, 116 minutes (95% CI: 114 to 118) for the nurse-led triage period, and 56 minutes (95% CI: 55 to 57) for the physician- led triage period. Study II included 22 551 orthopaedic patient presentations. In the fast track period, 70% were low acuity patients and 70% of these were dispositioned from the fast track. The crude median ED length of stay was shorter for the teamwork period compared to the fast track period, -13 minutes (95% CI: -18 to -8). The difference of the adjusted ED length of stay was -23 minutes (95% CI: -27 to -19). The mean waiting time to physician assessment was also shorter in the teamwork period, -57 minutes (95% CI: -60 to -54) compared to the fast track period. For the additional 21 780 non-orthopaedic presentations, the adjusted ED length of stay was also shorter in the teamwork period, -20 minutes (95% CI: -25 to -16), as was the mean waiting time to physician assessment, -30 minutes (95% CI: -33 to 26). Study III included 4 584 presentations by patients 80 years or older and there was no difference in patient characteristics between the periods. In the intervention period, 27% (n=634) of the patients received care in the geriatric module, and the remaining patients in standard teamwork modules. The total hospital admission rate within seven days was lower in the intervention period, compared to the control period. However, the ED length of stay was longer in the intervention period. Study IV included 50.5 hours of structured observations in 2016, when fidelity was observed for four of five key team behaviours. In 2018, fidelity remained only for one team behaviour and observation saturation was reached after 37.5 hours. Qualitative content analysis of 18 interviews in 2018 exposed several issues of the staff and context fidelity, for instance, team training and feedback were discontinued. In the questionnaire, positive ratings approximately doubled for items relating to the work experience when teamwork was introduced. However, in 2018 the ratings had deteriorated to pre-implementation levels. Conclusions: Effective interprofessional teamwork reduced the waiting time to physician assessment and the ED length of stay for the patients. However, the fidelity to the teamwork process decayed over time and the positive outcomes were not sustained

Presentations of children to emergency departments across Europe and the COVID-19 pandemic: A multinational observational study

BACKGROUND: During the initial phase of the Coronavirus Disease 2019 (COVID-19) pandemic, reduced numbers of acutely ill or injured children presented to emergency departments (EDs). Concerns were raised about the potential for delayed and more severe presentations and an increase in diagnoses such as diabetic ketoacidosis and mental health issues. This multinational observational study aimed to study the number of children presenting to EDs across Europe during the early COVID-19 pandemic and factors influencing this and to investigate changes in severity of illness and diagnoses. METHODS AND FINDINGS: Routine health data were extracted retrospectively from electronic patient records of children aged 18 years and under, presenting to 38 EDs in 16 European countries for the period January 2018 to May 2020, using predefined and standardized data domains. Observed and predicted numbers of ED attendances were calculated for the period February 2020 to May 2020. Poisson models and incidence rate ratios (IRRs), using predicted counts for each site as offset to adjust for case-mix differences, were used to compare age groups, diagnoses, and outcomes. Reductions in pediatric ED attendances, hospital admissions, and high triage urgencies were seen in all participating sites. ED attendances were relatively higher in countries with lower SARS-CoV-2 prevalence (IRR 2.26, 95% CI 1.90 to 2.70, p < 0.001) and in children aged <12 months (12 to <24 months IRR 0.86, 95% CI 0.84 to 0.89; 2 to <5 years IRR 0.80, 95% CI 0.78 to 0.82; 5 to <12 years IRR 0.68, 95% CI 0.67 to 0.70; 12 to 18 years IRR 0.72, 95% CI 0.70 to 0.74; versus age <12 months as reference group, p < 0.001). The lowering of pediatric intensive care admissions was not as great as that of general admissions (IRR 1.30, 95% CI 1.16 to 1.45, p < 0.001). Lower triage urgencies were reduced more than higher triage urgencies (urgent triage IRR 1.10, 95% CI 1.08 to 1.12; emergent and very urgent triage IRR 1.53, 95% CI 1.49 to 1.57; versus nonurgent triage category, p < 0.001). Reductions were highest and sustained throughout the study period for children with communicable infectious diseases. The main limitation was the retrospective nature of the study, using routine clinical data from a wide range of European hospitals and health systems. CONCLUSIONS: Reductions in ED attendances were seen across Europe during the first COVID-19 lockdown period. More severely ill children continued to attend hospital more frequently compared to those with minor injuries and illnesses, although absolute numbers fell. TRIAL REGISTRATION: ISRCTN91495258 https://www.isrctn.com/ISRCTN91495258

Trauma-related dispatch criteria for Helicopter Emergency Medical Services in Europe

Introduction: Helicopter Emergency Medical Services (HEMS) are used worldwide in order to provide potentially life-saving pre-hospital medical support to trauma patients at the accident scene. It is currently unclear how much overlap exists regarding the number and type of dispatch criteria used by individual HEMS organisations. The aim of the current study was to provide an overview of dispatch criteria for trauma cases used by HEMS organisations within Europe, and search for similarities and differences, between countries and HEMS stations. Materials and methods: HEMS dispatch criteria related to trauma care were obtained from the literature and divided into four groups of criteria and processed in a questionnaire. HEMS providing organisations were identified and contacted by telephone and via email. Results: Fifty-five of the 65 organisations (85%) that were contacted completed the questionnaire. The criteria "Fall from height", "Lengthy extrication and significant injury" and "Multiple casualty incidents" were used most frequently. Criteria from the subgroup "Patient Characteristics - Co-morbidities and Age" were used the least. In 44 of the organisations the Central Dispatch Centre (CDC) was primarily responsible for HEMS dispatch. Conclusion: This overview demonstrates the lack of uniformity in the use of dispatch criteria for trauma assistance on a national and international level. Furthermore, the activation of HEMS is not only depending on dispatch criterion protocols, but is also influenced by organisational factors like the education of the dispatcher, the training of the EMS personnel, the familiarity with the dispatch criteria, and the responses of bystanders. Future research should aim to identify a general set of criteria with the highest discriminating potential

Presentations of children to emergency departments across Europe and the COVID-19 pandemic : A multinational observational study

Publisher Copyright: © 2022 Nijman et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Background During the initial phase of the Coronavirus Disease 2019 (COVID-19) pandemic, reduced numbers of acutely ill or injured children presented to emergency departments (EDs). Concerns were raised about the potential for delayed and more severe presentations and an increase in diagnoses such as diabetic ketoacidosis and mental health issues. This multinational observational study aimed to study the number of children presenting to EDs across Europe during the early COVID-19 pandemic and factors influencing this and to investigate changes in severity of illness and diagnoses. Methods and findings Routine health data were extracted retrospectively from electronic patient records of children aged 18 years and under, presenting to 38 EDs in 16 European countries for the period January 2018 to May 2020, using predefined and standardized data domains. Observed and predicted numbers of ED attendances were calculated for the period February 2020 to May 2020. Poisson models and incidence rate ratios (IRRs), using predicted counts for each site as offset to adjust for case-mix differences, were used to compare age groups, diagnoses, and outcomes. Reductions in pediatric ED attendances, hospital admissions, and high triage urgencies were seen in all participating sites. ED attendances were relatively higher in countries with lower SARS-CoV-2 prevalence (IRR 2.26, 95% CI 1.90 to 2.70, p < 0.001) and in children aged <12 months (12 to <24 months IRR 0.86, 95% CI 0.84 to 0.89; 2 to <5 years IRR 0.80, 95% CI 0.78 to 0.82; 5 to <12 years IRR 0.68, 95% CI 0.67 to 0.70; 12 to 18 years IRR 0.72, 95% CI 0.70 to 0.74; versus age <12 months as reference group, p < 0.001). The lowering of pediatric intensive care admissions was not as great as that of general admissions (IRR 1.30, 95% CI 1.16 to 1.45, p < 0.001). Lower triage urgencies were reduced more than higher triage urgencies (urgent triage IRR 1.10, 95% CI 1.08 to 1.12; emergent and very urgent triage IRR 1.53, 95% CI 1.49 to 1.57; versus nonurgent triage category, p < 0.001). Reductions were highest and sustained throughout the study period for children with communicable infectious diseases. The main limitation was the retrospective nature of the study, using routine clinical data from a wide range of European hospitals and health systems. Conclusions Reductions in ED attendances were seen across Europe during the first COVID-19 lockdown period. More severely ill children continued to attend hospital more frequently compared to those with minor injuries and illnesses, although absolute numbers fell.publishersversionPeer reviewe

A retrospective description of a 12 month caseload at four private emergency centres in South Africa

Introduction In South Africa, private emergency departments (ED) are often the first port of call for a substantial proportion of the population served by the private healthcare sector. This study aims to describe the number, acuity and chief complaint of patients that presented to a sample of urban private EDs within South Africa. Methods A retrospective review of patient data from January 2018 to December 2018 was performed for four private facilities from a large private healthcare group. Data collected include demographics, time of arrival, disposal, triage score and presenting complaint. Results A total of 71079 patients presented to the four facilities. The South African Triage Scale (SATS) scores were as follows: red (5%), orange (11%), yellow (65%) and green (19%). Patients arrived mostly during the day (08:00-17:00 (54%)), evening (17:00-22:00 (27%)) and night (22:00-08:00 (19%)). Disposal of patients included admission (14%), discharge (77%), transfer to another facility (2%) and those who left without being seen (3%). The most frequent presenting complaints included gastrointestinal complaints, falls, respiratory issues, fever, traffic accidents and chest pain. Conclusion This study is the first description of the caseload and case mix in private EDs in South Africa. The most common presenting complaints were gastrointestinal and respiratory, with chest pain being the commonest red triaged complaint. Such complaints are similar to international data. In contrast, trauma related to assault is ranked 20th in private as opposed to 1st in the public sector. Admission rates are in keeping with US data, but lower than SA public, UK and Australia. Lastly, many green patients are follow ups which likely relates to the fee-for-service nature of the private sector and continuum of care fulfilled by ED doctors

Emergency Department Triage Scales and Their Components: A Systematic Review of the Scientific Evidence

Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed