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

Treatment of deep vein thrombosis and risk of recurrent venous thromboembolism

A cute deep vein thrombosis (DVT) and pulmonary embolism (PE) are different clinical presentations of the same underlying disease, namely venous thromboembolism (VTE), which is a common and potentially fatal condition. Risk factors associated with the first and probably also subsequent events of VTE are hereditary or acquired. Regarding recurrent VTE the risk persists for many years after the first episode and is increased approximately 50 times compared with the risk of the first event in the general population. The traditional treatment of VTE has for decades been unfractionated. heparin (UFH) given intravenously (i.v.) or subcutaneously (s.c.). Low-molecular-mass hepatitis (LMMHs) have been developed and are characterized by the following pharmacokinetic benefits compared with UFH: higher bioavailability; longer half-life in plasma and an improved dose response after s.c. administration. The aims of our studies (Paper I-III) were to investigate the efficacy and safety in the treatment of acute DVT with a LMMH (dalteparin) administered s.c. once daily in the dose of 200 U per kg bodyweight compared with UFH i.v., and secondly, whether this new regimen could be utilized in an outpatient setting. We have demonstrated that the efficacy, assessed as changes of venograms between inclusion, after initial treatment and 6 months later, were similar in dalteparin (n=101) and UFH (n=103) treated patients (Paper I and III). The safety defined as frequency of bleeding events was also comparable. In a safety assessment and health economy outpatient study (Paper II) using this dalteparin regimen the combined frequency of major bleeding and recurrent VTE was 0.92% (95% confidence interval 0.25-2.35%), which is lower than in in-hospital trials. Deficiencies of the coagulation inhibitors antithrombin, protein C and protein S, as well as the mutations G1691->A and G20210->A in the coagulation factor V (FV) and prothrombin (FII) genes, respectively, are important risk factors for the first episode of VTE. Impaired fibrinolysis and the presence of antibodies against cardiolipin have also been associated with VTE. In a prospective open study (Paper IV) we intervened with recommendations of a changed lifestyle (low-fat diet, weight reduction, physical exercise, cessation of smoking) in patients with VTE and impaired fibrinolysis, defined as increased level of plasminogen activator inhibitor-1 (PAI-1) in plasma. In 65% of 144 patients at least one of four life-style improvements was achieved and the more improvements the greater reduction in PAI-1 levels. However, the frequency of recurrent VTE episodes during 6 years of follow-up did not correlate with these improvements. In an open randomized multicenter trial (DURAC-1) 902 patients with objectively verified VTE received oral anti- vitamin K therapy for 6 weeks or for 6 months after the acute event. We followed 534 of these patients aged <70 years at inclusion, for 48 months after their index event and obtained blood samples retrospectively for analyses of the G1691A and G20210A allele in the FV and FII genes, respectively (Paper V). The aim was to investigate the risk of recurrent VIE in carriers of these mutations. This risk in heterozygotes for the G1691A allele was not different from that in non-carriers (15.4% vs 13.0%). Homozygotes had an increased risk (p=0.036) of recurrent VTE. The risk of recurrent VTE for G20210A carriers was not different from that in non-carriers. However, this risk was significantly increased in patients with an idiopathic cause or a proximal extension of DVT or with PE at the index event, independent of the mutations discussed here. Of the patients in DURAC-1 trial with a first episode of DVT initially (n=790) 175 and 43 experienced recurrent DVT and PE, respectively (Paper VI). A recurrent thrombosis in the contra- and ipsilateral leg was diagnosed in 95 and 80 patients, respectively. No variable was associated with the side of recurrent event, except that ipsilateral DVT was significantly more frequent within 6 months only among those randomized to 6 weeks of oral anti-vitamin K therapy. In conclusion, the dalteparin regimen used in our studies is well tolerated and effective in defined patient categories in an outpatient setting and allows for substantial cost savings. Our studies emphasize the persistent and continuous risk of recurrent VTE in a long-term perspective for many patients. An increased risk of recurrent VTE has been documented in patients with an idiopathic cause, proximal DVT or PE at the index event and for homozygotes of the G1691A mutation. The risk of recurrent ipsi- and contralateral DVT was similar

Emergency department crowding and mortality in 14 Swedish emergency departments, a cohort study leveraging the Swedish Emergency Registry (SVAR).

ObjectivesThere is evidence that emergency department (ED) crowding is associated with increased mortality, however large multicenter studies of high quality are scarce. In a prior study, we introduced a proxy-measure for crowding that was associated with increased mortality. The national registry SVAR enables us to study the association in a more heterogenous group of EDs with more recent data. The aim is to investigate the association between ED crowding and mortality.MethodsThis was an observational cohort study including visits from 14 EDs in Sweden 2015-2019. Crowding was defined as the mean ED-census divided with expected ED-census during the work-shift that the patient arrived. The crowding exposure was categorized in three groups: low, moderate and high. Hazard ratios (HR) for mortality within 7 and 30 days were estimated with a cox proportional hazards model. The model was adjusted for age, sex, triage priority, arrival hour, weekend, arrival mode and chief complaint. Subgroup analysis by county and for admitted patients by county were performed.Results2,440,392 visits from 1,142,631 unique patients were analysed. A significant association was found between crowding and 7-day mortality but not with 30-day mortality. Subgroup analysis also yielded mixed results with a clear association in only one of the three counties. The estimated HR (95% CI) for 30-day mortality for admitted patients in this county was 1.06 (1.01-1.12) in the moderate crowding category, and 1.11 (1.01-1.22) in the high category.ConclusionsThe association between crowding and mortality may not be universal. Factors that influence the association between crowding and mortality at different EDs are still unknown but a high hospital bed occupancy, impacting admitted patients may play a role

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

Abstract 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.</p