Who breaches the four-hour emergency department wait time target?:A retrospective analysis of 374,000 emergency department attendances between 2008 and 2013 at a type 1 emergency department in England

Background: The four-hour target is a key hospital emergency department performance indicator in England and one that drives the physical and organisational design of the ED. Some studies have identified time of presentation as a key factor affecting waiting times. Few studies have investigated other determinants of breaching the four-hour target. Therefore, our objective was to describe patterns of emergency department breaches of the four-hour wait time target and identify patients at highest risk of breaching. Methods: This was a retrospective cohort study of a large type 1 Emergency department at an NHS teaching hospital in Oxford, England. We analysed anonymised individual level patient data for 378,873 emergency department attendances, representing all attendances between April 2008 and April 2013. We examined patient characteristics and emergency department presentation circumstances associated with the highest likelihood of breaching the four-hour wait time target. Results: We used 374,459 complete cases for analysis. In total, 8.3% of all patients breached the four-hour wait time target. The main determinants of patients breaching the four-hour wait time target were hour of arrival to the ED, day of the week, patient age, ED referral source, and the types of investigations patients receive (p<0.01 for all associations). Patients most likely to breach the four- hour target were older, presented at night, presented on Monday, received multiple types of investigation in the emergency department, and were not self-referred (p<0.01 for all associations). Patients attending from October to February had a higher odds of breaching compared to those attending from March to September (OR 1.63, 95% CI 1.59 to 1.66). Conclusions: There are a number of independent patient and circumstantial factors associated with the probability of breaching the four-hour ED wait time target including patient age, ED referral source, the types of investigations patients receive, as well as the hour, day, and month of arrival to the ED. Efforts to reduce the number of breaches could explore late-evening/overnight staffing, access to diagnostic tests, rapid discharge facilities, and early assessment and input on diagnostic and management strategies from a senior practitioner

Heterogeneity in transmissibility and shedding SARS-CoV-2 via droplets and aerosols

Background: Which virological factors mediate overdispersion in the transmissibility of emerging viruses remains a longstanding question in infectious disease epidemiology. Methods: Here, we use systematic review to develop a comprehensive dataset of respiratory viral loads (rVLs) of SARS-CoV-2, SARS-CoV-1 and influenza A(H1N1)pdm09. We then comparatively meta-analyze the data and model individual infectiousness by shedding viable virus via respiratory droplets and aerosols. Results: The analyses indicate heterogeneity in rVL as an intrinsic virological factor facilitating greater overdispersion for SARS-CoV-2 in the COVID-19 pandemic than A(H1N1)pdm09 in the 2009 influenza pandemic. For COVID-19, case heterogeneity remains broad throughout the infectious period, including for pediatric and asymptomatic infections. Hence, many COVID-19 cases inherently present minimal transmission risk, whereas highly infectious individuals shed tens to thousands of SARS-CoV-2 virions/min via droplets and aerosols while breathing, talking and singing. Coughing increases the contagiousness, especially in close contact, of symptomatic cases relative to asymptomatic ones. Infectiousness tends to be elevated between 1-5 days post-symptom onset. Conclusions: Intrinsic case variation in rVL facilitates overdispersion in the transmissibility of emerging respiratory viruses. Our findings present considerations for disease control in the COVID-19 pandemic as well as future outbreaks of novel viruses.</p

Self-monitoring blood pressure in hypertension, patient and provider perspectives: A systematic review and thematic synthesis.

OBJECTIVE: To systematically review the qualitative evidence for patient and clinician perspectives on self-measurement of blood pressure (SMBP) in the management of hypertension focussing on: how SMBP was discussed in consultations; the motivation for patients to start self-monitoring; how both patients and clinicians used SMBP to promote behaviour change; perceived barriers and facilitators to SMBP use by patients and clinicians. METHODS: Medline, Embase, PsycINFO, Cinahl, Web of Science, SocAbs were searched for empirical qualitative studies that met the review objectives. Reporting of included studies was assessed using the COREQ framework. All relevant data from results/findings sections of included reports were extracted, coded inductively using thematic analysis, and overarching themes across studies were abstracted. RESULTS: Twelve studies were included in the synthesis involving 358 patients and 91 clinicians. Three major themes are presented: interpretation, attribution and action; convenience and reassurance v anxiety and uncertainty; and patient autonomy and empowerment improve patient-clinician alliance. CONCLUSIONS: SMBP was successful facilitating the interaction in consultations about hypertension, bridging a potential gap in the traditional patient-clinician relationship. PRACTICE IMPLICATIONS: Uncertainty could be reduced by providing information specifically about how to interpret SMBP, what variation is acceptable, adjustment for home-clinic difference, and for patients what they should be concerned about and how to act

SeroTracker-RoB: a decision rule-based algorithm for reproducible risk of bias assessment of seroprevalence studies

Risk of bias (RoB) assessments are a core element of evidence synthesis but can be time consuming and subjective. We aimed to develop a decision rule-based algorithm for RoB assessment of seroprevalence studies. We developed the SeroTracker-RoB algorithm. The algorithm derives seven objective and two subjective critical appraisal items from the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence studies and implements decision rules that determine study risk of bias based on the items. Decision rules were validated using the SeroTracker seroprevalence study database, which included non-algorithmic RoB judgments from two reviewers. We quantified efficiency as the mean difference in time for the algorithmic and non-algorithmic assessments of 80 randomly selected articles, coverage as the proportion of studies where the decision rules yielded an assessment, and reliability using intraclass correlations comparing algorithmic and non-algorithmic assessments for 2070 articles. A set of decision rules with 61 branches was developed using responses to the nine critical appraisal items. The algorithmic approach was faster than non-algorithmic assessment (mean reduction 2.32 min [SD 1.09] per article), classified 100% (n = 2070) of studies, and had good reliability compared to non-algorithmic assessment (ICC 0.77, 95% CI 0.74–0.80). We built the SeroTracker-RoB Excel Tool, which embeds this algorithm for use by other researchers. The SeroTracker-RoB decision-rule based algorithm was faster than non-algorithmic assessment with complete coverage and good reliability. This algorithm enabled rapid, transparent, and reproducible RoB evaluations of seroprevalence studies and may support evidence synthesis efforts during future disease outbreaks. This decision rule-based approach could be applied to other types of prevalence studies

Development and Validation of the Quality of Trauma Care Patient-Reported Experience Measure

To deliver patient-centered injury care, patient perspectives must be incorporated into quality measurement and improvement. Therefore, the purpose of this thesis was to develop and validate a measure of patient experience for use as a quality improvement tool in injury care. A draft survey measure of patient injury care experience was revised using cognitive interviews with 30 injury patients/surrogates. A multi-site prospective cohort study of 400 patients/surrogates was conducted and provided evidence of the measure's validity, reliability, and feasibility of implementation. Analysis of responses to the free-text items on the measure indicated that qualitative data obtained from open-ended items may be a valuable supplement to the quantitative component of the measure. The results of this thesis show that the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM) is valid and reliable and could be used as a tool to guide quality improvement efforts

Identifying and prioritising interventions to reduce emergency hospital admissions

The aim of this thesis was to identify and prioritise evidence-based interventions that reduce emergency hospital admissions and explore their implementation in clinical practice. To achieve its aim, this thesis first identified evidence-based interventions that reduce emergency admissions using a systematic review of systematic reviews. Second, it determined which of the evidence-based interventions had been recommended in national clinical guidelines, developed into quality of care indicators, and featured in national audits in England. Thirdly, it explored the extent to which evidence- and guideline-based interventions were being optimally utilised in primary care in the United Kingdom. Fourthly, it evaluated an innovative access to care initiative implemented in primary care to reduce hospital admissions. Fifthly, it explored the use of evidence by decision makers when designing and implementing local interventions as part of national campaigns to reduce admissions. Overall, the findings showed that there are a variety of evidence-based interventions that reduce emergency hospital admission rates. However, the thesis showed gaps in the promotion and use of these interventions in clinical practice in the United Kingdom. It also demonstrated that increasing access to primary care using innovative interventions may not be an effective or evidence-based approach to reducing hospitalisations. Stakeholders seeking to reduce admission rates may consider optimising use of the evidence- and guideline-based interventions prioritised in this thesis. This may be done using existing quality improvement infrastructure or by developing or expanding health care services that feature the interventions. Furthermore, efforts should be made to robustly evaluate novel interventions implemented in clinical practice to reduce hospital admissions. The results of such evaluations should be systematically disseminated to facilitate peer-peer learning, avoid duplicated efforts, and promote use of evidence-based interventions.</p

Consultative Emergency Medicine

Investigating the ways in which Emergency Physicians may play a consultant role in the healthcare system, and how this might expand their ability to provide emergency medical care beyond the physical emergency department

Prospective cohort study protocol to evaluate the validity and reliability of the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM)

BACKGROUND: Patient-centeredness is a key component of health care quality. However, patient-centered measures of quality have not been developed in injury care. In response to this challenge, we developed the Quality of Trauma Adult Care Patient-Reported Experience Measure (QTAC-PREM) to measure injured patient experiences with trauma care and pilot-tested the instrument at a single Level 1 trauma centre. The objective of this study is to test the reliability, validity, and feasibility of the QTAC-PREM in multiple Canadian trauma centers and to refine the measure based on the results. METHODS/DESIGN: This will be a prospective cohort study of consecutive adult (age ≥ 18 years) patients discharged from three trauma centres in Alberta, Canada with a primary diagnosis of injury. The target sample size is 400 participants to ensure precision for evaluating test-retest reliability. We will assess the psychometric properties of the measure (test-retest reliability, construct validity, internal consistency) and whether these properties vary by patient characteristics. We will also evaluate the predictive validity, convergent validity, and discriminant validity of the measure against other established tools (HCAHPS). DISCUSSION: A reliable and valid measure of patient reported experiences with injury care may be a valuable tool to evaluate quality of care and guide improvement efforts