Streamlining pathways for minor injuries in emergency departments through radiographer-led discharge

This is the author accepted manuscript. The final version is available from Elsevier via the DOI in this record.Diagnostic imaging services are essential to the diagnosis pathway for many patients arriving at hospital emergency departments with a suspected fracture. Commonly, these patients need to be seen again by a doctor or emergency nurse practitioner after an X-ray image has been taken in order to finalise the diagnosis and determine the next stage in the patients’ pathway. Here, significant waiting times can accrue for these follow-up consultations after radiographic imaging although the vast majority of patients are discharged. Research evidence from pilot studies suggests that patients with minor appendicular injuries could be safely discharged by a suitably qualified radiographer directly after imaging thereby avoiding queues for repeated consultation. In this study, we model patient pathways through an emergency department (ED) at a hospital in the South West of England using process mapping, interviews with ED staff and discrete event simulation (DES). The DES model allowed us to compare the current practice at the hospital with scenarios using radiographer-led discharge of patients directly after imaging and assess the reduction in patients’ length of stay in ED. We also quantified trade-offs between the provision of radiographer-led discharge and its effects, i.e. reduction in waiting times and ED workload. Finally, we discuss how this decision support tool can be used to support understanding for patients and members of staff.Part of this research, i.e. the work of Martin Pitt and Sebastian Rachuba, was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula (NIHR CLAHRC South West Peninsula)

Redesigning the diagnostic pathway for chest pain patients in emergency departments

This is the final version of the article. Available from Wiley via the DOI in this record.Patients presenting with chest pain at an emergency department in the United Kingdom receive troponin tests to assess the likelihood of an acute myocardial infarction (AMI). Until recently, serial testing with two blood samples separated by at least six hours was necessary in order to analyse the change in troponin levels over time. New high-sensitivity troponin tests, however, allow the inter-test time to be shortened from six to three hours. Recent evidence also suggests that the new generation of troponin tests can be used to rule out AMI on the basis of a single test if patients at low risk of AMI present with very low cardiac troponin levels more than three hours after onset of worst pain. This paper presents a discrete event simulation model to assess the likely impact on the number of hospital admissions if emergency departments adopt strategies for serial and single testing based on the use of high-sensitivity troponin. Data sets from acute trusts in the South West of England are used to quantify the resulting benefits.This publication is based on a project funded by the South West Academic Health Science Network (SW AHSN). The work of the authors is also funded by the National Institute for Health (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the SW AHSN or the Department of Health

A structured literature review of simulation modelling applied to Emergency Departments: Current patterns and emerging trends

This is the author accepted manuscript. The final version is available from Elsevier via the DOI in this recordThe public importance, wait-for-treatment ethos and clear geographic layout of Emergency Departments (EDs) has contributed to them being one of the most commonly modelled systems in healthcare Operational Research (OR). EDs are presently contending with higher than ever attendances, to which clinical research does not appear to have a comprehensive solution, whilst OR methodologies still need to command the trust of decision makers. With potentially greater acceptance of OR methodologies driven by heightened efforts to engage clinicians in evidence based approaches, we present a comprehensive review of the current literature. Whilst not the first in this area, our review is more broadly focused and thus able to serve both as a resource for modellers of methodology and study design, and as an introduction for decision makers. Our systematic literature search aimed to identify all English language papers from the year 2000 onward. We categorise papers using the defined dimensions of purpose, application area, method, scope and sponsor (originator). Of 254 retrievals, we find that new publications are currently appearing at approximately 25 per year, up seven fold since 2000. We find positive trends in terms of recent publications (75% since 2008) as well as a trend towards achieving publication in journals, including healthcare related journals, which may assist in bringing simulation to a clinical audience and facilitating future engagement. The majority of projects appear to be of academic origin, based on Discrete Event Simulation, and focused on capacity, process and workforce issues at an operational level. However, the use of hybrid modelling may be associated with a more strategic outlook, as do projects originated at the request of healthcare organisations. We present a selection of case studies to illustrate both our classification and findings, and suggest directions for further research.This research was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust

Violência e morte: diferenciais da mortalidade por causas externas no espaço urbano do Recife, 1991 Violence and death: differentials in mortality from external causes in Recife, Pernambuco, Brazil, 1991

Este estudo teve como objetivo descrever a tendência e a magnitude das mortes violentas na cidade do Recife, sua distribuição espacial no ano de 1991 e seus diferenciais quanto ao sexo, idade, local de ocorrência; objetivou, também, analisar a participação de algumas variáveis sócio-econômicas que expressam as condições de vida, nas possíveis explicações dessas diferenças. Utilizou-se como método o desenho de estudo ecológico do tipo exploratório e comparação de múltiplos grupos. Foram analisadas 1.181 declarações de óbitos de residentes em Recife, falecidos no ano de 1991. Verificou-se uma magnitude do coeficiente de mortalidade por causas externas na ordem de 90,9 por cem mil habitantes. Os grupos de dez a 39 anos e sessenta anos e mais constituíram os de maior risco, e o sexo masculino apresentou uma sobremortalidade em todas as faixas etárias. Os principais grupos de causas específicas foram os homicídios e os acidentes de trânsito, que representaram cerca de 51,3% e 23,4% do total de óbitos por essas causas, respectivamente. Discutiram-se alguns aspectos da desigualdade da mortalidade por causas externas nos espaços sociais, segundo condições de vida e sua relação com o processo histórico de formação da cidade do Recife.<br>This study aimed to describe the amount of (and trends in) violent deaths in the city of Recife, Pernambuco, Brazil, and to analyze their determinants. The article presents the spatial distribution of these deaths for the year 1991 and the differences regarding sex, age, and place of occurrence. It also analyzes the potential role of a series of socioeconomic factors, used as indicators of the population's living conditions. An exploratory ecological study was conducted to compare various groups. In 1991 there were a total of 1181 violent deaths in Recife. The study points to an overall mortality rate from external causes of 90.9/100,000 inhabitants. The two age groups 10-39 years and 60 years and over were those at highest risk of death. Males showed excess mortality in all age groups. The most important specific causes of death were homicides and traffic accidents, with 51.3% and 23.4%, respectively, of all violent deaths. The authors discuss the differences in the mortality rate from external causes in different social areas, defined according to living conditions and their relationship to the history of the development of Recife