Emergency department crowding and hospital patient flow : influential factors and evidence-Informed solutions

Background: Internationally, one of the biggest challenges in emergency departments is crowding – when demand for emergency care exceeds its capacity in resources and timeliness. Crowding is associated with increased morbidity, mortality, cost and decreased patient and health-care worker satisfaction. Consequently, governments in the United Kingdom, Australia and some Canadian provinces have implemented time targets for emergency department length-of-stay, but have had difficulty achieving them. Although there is much literature on etiology and solutions for emergency department crowding, there is a lack of evidence-informed policy and cost-effectiveness analyses on solutions for reaching targets. Which are the most appropriate interventions for the individual hospital? What factors associated with failing targets should the hospital prioritize? Objectives: The objectives of this thesis were to find factors strongly associated with failing to meet emergency department (ED) length-of-stay (LOS) targets and rigorously evaluate ED crowding solutions. The first two objectives were to determine the effectiveness of a supplementary physician-nurse team at triage (MDRNSTAT) on EDLOS, quality of care and its cost-effectiveness from the hospital and patient perspective. The third objective was to determine predictors of target time failure for discharged high acuity patients and intensive care unit (ICU) admissions at Sunnybrook Health Sciences Center (Sunnybrook), an academic tertiary-level hospital in Ontario, Canada. Finally, we compared performance and factors predicting failure of government time targets between 2012 and 2013 at Sunnybrook and between Sunnybrook and Austin Health (Austin), an Australian academic tertiary level hospital. Methods: Study I was a pragmatic cluster randomized trial comparing shifts with and without the MDRNSTAT. The primary outcome was emergency department length-of-stay (EDLOS) for non-consulted discharges. Secondary outcomes included EDLOS for patients initially seen by the emergency department, and subsequently consulted and admitted, patients reaching government-mandated thresholds, time to initial physician assessment, left-without being seen rate, time to investigation, and measurement of harm. Study II was a cost-effectiveness evaluation of the MDRNSTAT. Study III was a retrospective, observational study of 2012 Sunnybrook Hospital (Canada) emergency department data using multivariable logistic regression. The main outcome measure was failure to reach government EDLOS targets for high acuity discharges and ICU emergency admissions. Study IV was a retrospective, observational study of 2012, 2013 Sunnybrook Hospital (Canada) and 2012 Austin Health (Australia) administrative data using descriptive statistics and multivariable logistic regression. The main outcome measure was reaching ED time targets by subgroup: admissions, low and high acuity discharges. Secondary outcomes for Study III and IV were predicting failure of government targets and a select group of hospital factors. Results: For Study I, the MDRNSTAT decreased discharged, non-consulted, high acuity patients EDLOS by 34 minutes [CI: 16 to 52]. For discharged, non-consulted, low acuity patients, EDLOS decreased by 52 minutes [CI: 38 to 65]. Physician initial assessment duration (PIAD) decreased by 53 minutes [CI: 48 to 57]. The MDRNSTAT-associated shifts’ leftwithout- being-seen rate was 1.5% versus 2.2% for the control (p=0.06). No patients returned to the emergency department after being discharged by the MDRNSTAT at triage. From Study II, the added cost of the MDRNSTAT was $3,597.27 [$1729.47 to ∞] per additional patient-seen, $75.37 [$67.99-$105.30] per physician-initial-assessment hour saved and$112.99 [$74.68 –$251.43] per EDLOS hour saved. From the hospital perspective, the costbenefit ratio was 38.63 [18.96 to ∞] and net present value of -$447,996 [-$435,646 to - $459,900]. For patients, the cost-benefit ratio for satisfaction was 2.8 [2.3-4.6]. For Study III, factors predicting EDLOS target failure for Sunnybrook’s discharged high acuity patients were: having PIAD>2hrs (OR 5.63 [5.22-6.06]), consultation request (OR 10.23 [9.38-11.14]), a MRI (OR 19.33 [12.94-28.87]), CT (OR 4.24 [3.92-4.59]), or US (OR 3.47 [3.13-3.83]). For ICU admissions, factors predicting EDLOS target failure were: bed request duration (BRD)>6hrs (OR 364.27 [43.20-3071.30]) and access block (AB)>1hr (OR 217.27 [30.62-1541.63]). For discharged low acuity patients, factors predicting failure for the 4hr target were: PIAD> 2hrs (OR 15.80 [13.35-18.71]), consultation (OR 20.98 [14.10- 31.22]), TnI (OR 13.37 [6.30-28.37]), MRI (OR 31.68 [6.03-166.54]), or CT (OR 16.48 [10.07-26.98]). Study IV found that the Australian hospital, Austin Health, succeeded for all targets except for low acuity discharges. Sunnybrook failed all time targets. For low acuity discharges, Austin factors for failing government targets were PIAD>2 hrs (OR 11.62 [10.40- 12.99]), consultation (OR 6.99 [5.83-8.38]) and CT (OR 7.16 [5.19-8.66]). For high acuity discharges, Austin factors were evening shift (OR 4.09 [3.40-4.93]), consultation (OR 8.82 [7.62-10.21) and MRI (OR 8.16 [3.07-21.70]). For admissions, Austin factors were AB>1hr (OR 57.35 [39.31-83.67]) and BRD>6hrs (OR 46.07 [33.23-63.88]). Comparing 2012 to 2013 at Sunnybrook, the factors for failing targets remained similar for admissions, low and high acuity discharges. Conclusions: The MDRNSTAT reduced delays and left-without-being-seen rate without increased return visits or jeopardizing urgent care of severely ill patients; however, it was not a cost-effective daytime strategy at Sunnybrook. The MDRNSTAT would be more feasible during time periods with higher access block, such as the afternoon to late evening. Sunnybrook factors predicting failure of government targets for high acuity discharges and ICU admissions were hospital-controlled. The Australian hospital out-performed the Canadian hospital on government time targets. Factors predicting failure of government targets remained consistent over time in the same hospital but were different between hospitals. Irrespective of time and location, factors most associated with target failure were hospital-controlled. Therefore, hospitals should individualize their approach to shortening EDLOS by analyzing its patient population and resource demands. Study I Trial registration number: NCT00991471 ClinicalTrials.go

Effects of pharmacological agents for neurogenic oropharyngeal dysphagia: A systematic review and meta‐analysis

From Wiley via Jisc Publications RouterHistory: received 2021-04-30, rev-recd 2021-06-09, accepted 2021-06-25, pub-electronic 2021-08-01Article version: VoRPublication status: PublishedAbstract: Background: This systematic review and meta‐analysis aimed to evaluate the effects of pharmacological agents for neurogenic oropharyngeal dysphagia based on evidence from randomized controlled trials (RCTs). Methods: Electronic databases were systematically searched between January 1970 and March 2021. Two reviewers independently extracted and synthesized the data. The outcome measure was changed in (any) relevant clinical swallowing‐related characteristics. Key results: Data from 2186 dysphagic patients were collected from 14 RCT studies across a range of pharmacotherapies. The pooled effect size of transient receptor potential (TRP) channel agonists was large compared to placebo interventions (SMD[95%CI] =1.27[0.74,1.80], p < 0.001; I2 = 79%). Data were limited for other pharmacological agents and the overall pooled effect size of these agents was non‐significant (SMD [95% CI] =0.25 [−0.24, 0.73]; p = 0.31; I2 = 85%). When analyzed separately, large effect sizes were observed with Nifedipine (SMD[95%CI] =1.13[0.09,2.18]; p = 0.03) and Metoclopramide (SMD[95%CI] =1.68[1.08,2.27]; p < 0.001). By contrast, the effects of angiotensin‐converting enzyme (ACE) inhibitors (SMD[95%CI] = −0.67[−2.32,0.99]; p = 0.43; I2 = 61%), Physostigmine (SMD[95%CI] = −0.05[−1.03,0.93]; p = 0.92) and Glyceryl Trinitrate (GTN) (SMD [95% CI] = −0.01 [−0.11, 0.08]; p = 0.78) were non‐significant. Within stroke patients, subgroup analysis showed that TRP channel agonists had a moderate pooled effect size (SMD[95%CI] =0.74[0.10,1.39]; p = 0.02; I2 = 82%) whereas the effects of other agents were non‐significant (SMD[95%CI] =0.40[−0.04,0.84]; p = 0.07; I2 = 87%). Conclusions & Inferences: Our results showed that TRP channel agonists, Nifedipine and Metoclopromide may be beneficial for neurogenic dysphagic patients. Large scale, multicenter clinical trials are warranted to fully explore their therapeutic effects on swallowing

STAT3 regulates proliferation and survival of CD8+ T cells : enhances effector responses to HSV-1 infection, and inhibits IL-10+ regulatory CD8+ T cells in autoimmune uveitis

Peer reviewedPublisher PD

Interleukin 27 induces the expression of complement factor H (CFH) in the retina

Acknowledgements We thank Dr. Li Zhang (NEI, National Institutes of Health) for critical reading of the manuscript.Peer reviewedPublisher PD

Singaporean mothers' perception of their three-year-old child's weight status: A cross-sectional study

Singapore National Research FoundationFull Author List as below: Cheng T.S.; Cheng T.; Loy S.; Cheung Y.; Chan J.; Tint M.; Godfrey K.; Gluckman P.; Kwek K.; Saw S.; Chong Y.; Lee Y.; Yap F.; Lek N.; Sheppard A.; Chinnadurai A.; Goh A.; Rifkin-Graboi A.; Qiu A.; Biswas A.; Lee B.; Broekman B.; Quah B.; Shuter B.; Chng C.; Ngo C.; Hsu S.; Bong C.; Henry C.; Chee C.; Fok D.; Yeo G.; Inskip H.; Chen H.; Van Bever H.; Magiati I.; Wong I.; Lau I.; Kapur J.; Richmond J.; Holbrook J.; Gooley J.; Tan K.; Niduvaje K.; Singh L.; Su L.; Daniel L.; Shek L.; Fortier M.; Hanson M.; Chong M.; Rauff M.; Chua M.; Meaney M.; Teoh O.; Wong P.; Agarwal P.; Van Dam R.; Rebello S.; Chong S.; Cai S.; Soh S.; Lim S.; Rajadurai V.; Stunkel W.; Han W.; Pang W.; Goh Y.; Chan Y.</p

Comparison of emergency department time performance between a Canadian and an Australian academic tertiary hospital

Objective To compare performance and factors predicting failure to reach Ontario and Australian government time targets between a Canadian (Sunnybrook Hospital) and an Australian (Austin Health) academic tertiary-level hospitals in 2012, and to assess for change of factors and performance in 2016 between the same hospitals. Methods This was a retrospective, observational study of patient administrative data in two calendar years. The main outcome measure was reaching Ontario and Australian ED time targets for admissions, high and low urgency discharges. Secondary outcomes were factors predicting failure to reach these targets. Results Between 2012 and 2016, Sunnybrook and Austin experienced increased patient volume of 10.2% and 19.2%, respectively. Bed capacity decreased at Sunnybrook (-10.8%) but increased at the Austin (+30.3%). For both years, Austin failed to achieve the Australian time target, but succeeded for all Ontario targets except for low urgency discharges. Sunnybrook failed all targets irrespective of year. The top factors for failing Ontario ED length-of-stay targets for both hospitals in 2012 and 2016 were bed request greater than 6 h, access block greater than 1 h, use of cross-sectional imaging, consultation and waiting for the emergency physician greater than 2 h. Conclusion Austin outperformed Sunnybrook for Ontario and Australian government time targets. Both hospitals failed the Australian targets. Factors predicting failure to achieve targets were different between hospitals, but were mainly clinical resources. Sunnybrook focussed on increasing human resources. Austin focussed on increasing human resources, observation unit and hospital beds. Intrinsic hospital characteristics and infrastructure influenced target success.Peer reviewe

Recycling in the management of solid waste : a study of the governance of Hong Kong's EcoPark

published_or_final_versionPolitics and Public AdministrationMasterMaster of Public Administratio

Exploring parameters of gamma transcranial alternating current stimulation (tACS) and full‐spectrum transcranial random noise stimulation (tRNS) on human pharyngeal cortical excitability

From Wiley via Jisc Publications RouterHistory: received 2020-12-21, rev-recd 2021-04-25, accepted 2021-04-28, pub-electronic 2021-06-03Article version: VoRPublication status: PublishedFunder: Sun Yat‐sen University; Id: http://dx.doi.org/10.13039/501100002402Funder: Salford Royal NHS Foundation TrustAbstract: Background: Transcranial alternating current stimulation (tACS) and transcranial random noise stimulation (tRNS) have been shown to have physiological and functional effects on brain excitability and motor behavior. Yet, little is known about their effects in the swallowing system. Aim: To examine the effects and optimal stimulation parameters of tACS and tRNS for modulating excitability of human pharyngeal motor cortex. Methods: 10 Hz (alpha), 20 Hz (beta), 70 Hz (gamma) tACS, 0.1–640 Hz (full‐spectrum) tRNS, and sham were applied over pharyngeal motor cortices at 1.5 mA current intensity for 10 min in 15 healthy participants. Pharyngeal motor–evoked and thenar motor–evoked potentials (PMEPs and TMEPs) were assessed before and up to 2 h after stimulation with single‐pulse transcranial magnetic stimulation. Averaged MEP amplitude and latency changes were analyzed using repeated measures ANOVA (rmANOVA). Key Results: Two‐way rmANOVA across all active interventions demonstrated a significant MEP interaction both in the stimulated pharyngeal cortex (F (4, 56) = 1.731, p = 0.038) and in the ipsilateral thenar cortex (F (4, 56) = 1.506, p = 0.048). Compared to sham, subsequent post hoc tests showed site‐specific and sustained (60–120 min) increases in PMEPs with gamma tACS and tRNS (p = 0.005, p = 0.027, respectively) and for TMEPs with beta tACS (p = 0.006). Conclusions and Inferences: Our findings suggest that the effects of tACS and tRNS are frequency‐dependent and cortical (representation) site‐specific with both gamma tACS and full‐spectrum tRNS enhancing human pharyngeal cortical excitability. These techniques hold promise as potential treatments for neurological dysphagia

Cleft lip and palate: recommendations for dental anesthetic procedure based on anatomic evidences

Patients with cleft lip and palate usually present dental anomalies of number, shape, structure and position in the cleft area and the general dentist is frequently asked to restore or extract those teeth. Considering that several anatomic variations are expected in teeth adjacent to cleft areas and that knowledge of these variations by general dentists is required for optimal treatment, the objectives of this paper are: 1) to describe changes in the innervation pattern of anterior teeth and soft tissue caused by the presence of a cleft, 2) to describe a local anesthetic procedure in unilateral and bilateral clefts, and 3) to provide recommendations to improve anesthetic procedures in patients with cleft lip and palate. The cases of 2 patients are presented: one with complete unilateral cleft lip and palate, and the other with complete bilateral cleft lip and palate. The patients underwent local anesthesia in the cleft area in order to extract teeth with poor bone support. The modified anesthetic procedure, respecting the altered course of nerves in the cleft maxilla and soft tissue alterations at the cleft site, was accomplished successfully and the tooth extraction was performed with no pain to the patients. General dentists should be aware of the anatomic variations in nerve courses in the cleft area to offer high quality treatment to patients with cleft lip and palate

A feasibility pilot study of the effects of neurostimulation on swallowing function in Parkinson’s Disease [version 2; peer review: 1 approved, 1 approved with reservations, 1 not approved]

Introduction: Dysphagia often occurs during Parkinson’s disease (PD) and can have severe consequences. Recently, neuromodulatory techniques have been used to treat neurogenic dysphagia. Here we aimed to compare the neurophysiological and swallowing effects of three different types of neurostimulation, 5 Hertz (Hz) repetitive transcranial magnetic stimulation (rTMS), 1 Hz rTMS and pharyngeal electrical stimulation (PES) in patients with PD. Method: 12 PD patients with dysphagia were randomised to receive either 5 Hz rTMS, 1 Hz rTMS, or PES. In a cross-over design, patients were assigned to one intervention and received both real and sham stimulation. Patients received a baseline videofluoroscopic (VFS) assessment of their swallowing, enabling penetration aspiration scores (PAS) to be calculated for: thin fluids, paste, solids and cup drinking. Swallowing timing measurements were also performed on thin fluid swallows only. They then had baseline recordings of motor evoked potentials (MEPs) from both pharyngeal and (as a control) abductor pollicis brevis (APB) cortical areas using single-pulse TMS. Subsequently, the intervention was administered and post interventional TMS recordings were taken at 0 and 30 minutes followed by a repeat VFS within 60 minutes of intervention. Results: All interventions were well tolerated. Due to lower than expected recruitment, statistical analysis of the data was not undertaken. However, with respect to PAS swallowing timings and MEP amplitudes, there was small but visible difference in the outcomes between active and sham. Conclusion: PES, 5 Hz rTMS and 1 Hz rTMS are tolerable interventions in PD related dysphagia. Due to small patient numbers no definitive conclusions could be drawn from the data with respect to individual interventions improving swallowing function and comparative effectiveness between interventions. Larger future studies are needed to further explore the efficacy of these neuromodulatory treatments in Parkinson’s Disease associated dysphagia