Adrian Boyle

Reductions in hospital admissions and mortality rates observed after integrating emergency care: a natural experiment

Objectives Reducing emergency admissions is a priority for the NHS. A single hospitals emergency care system was reorganised with the principles of front-loaded investigations, integration of specialties, reduced duplication, earlier decision making by senior clinicians and a combined emergency assessment area. The authors relocated our Medical Assessment Unit into our emergency department in 2006. The authors evaluated changes in admissions and mortality before and after 2006, compared with other similar hospitals. Design Quasi-experimental before and after study using routinely collected data. Setting and participants 1 acute hospital in England, the intervention site, was compared with 23 other English hospitals between 2001 and 2009. Outcome measures Our outcome measures were hospital standardised mortality ratios (HSMRs) for non-elective admissions and standardised admission ratios (SARs). Results The authors observed a statistically and clinically significant decrease in HSMR and SAR. The intervention hospital had the lowest HSMR and SAR of all the hospitals in our sample. This was statistically significant, p=0.0149 and p=0.0002, respectively. Conclusion Integrating emergency care in one location is associated with a meaningful reduction in mortality and emergency admissions to hospital.

Comparison of the International Crowding Measure in Emergency Departments (ICMED) and the National Emergency Department Overcrowding Score (NEDOCS) to measure emergency department crowding: pilot study.

Introduction There is uncertainty about the best way to measure emergency department crowding. We have previously developed a consensus-based measure of crowding, the International Crowding Measure in Emergency Departments (ICMED). We aimed to obtain pilot data to evaluate the ability of a shortened form of the ICMED, the sICMED, to predict senior emergency department clinicians’ concerns about crowding and danger compared with a very well-studied measure of emergency department crowding, the National Emergency Department Overcrowding Score (NEDOCS). Methods We collected real-time observations of the sICMED and NEDOCS and compared these with clinicians’ perceptions of crowding and danger on a visual analogue scale. Data were collected in four emergency departments in the East of England. Associations were explored using simple regression, random intercept models and models accounting for correlation between adjacent time points. Results We conducted 82u2005h of observation in 10 observation sets. Naive modelling suggested strong associations between sICMED and NEDOCS and clinician perceptions of crowding and danger. Further modelling showed that, due to clustering, the association between sICMED and danger persisted, but the association between these two measures and perception of crowding was no longer statistically significant. Conclusions Both sICMED and NEDOCS can be collected easily in a variety of English hospitals. Further studies are required but initial results suggest both scores may have potential use for assessing crowding variation at long timescales, but are less sensitive to hour-by-hour variation. Correlation in time is an important methodological consideration which, if ignored, may lead to erroneous conclusions. Future studies should account for such correlation in both design and analysis.

Is “boarding” appropriate to help reduce crowding in emergency departments?

Moving patients from full emergency departments to corridors outside full wards is safe and necessary when accommodating new emergencies, say Adrian Boyle and Peter Viccellio. But Chris Whale warns of the danger in simply displacing the problem and wants a more comprehensive response to inefficient patient flow

Emergency physician performed rapid sequence induction and system changes reduce time to intubation in critically ill emergency medicine patients

control in a fasted patient with drug-induced agitation, that was not able to be controlled with relatively large doses (for weight) of i.v. diazepam, chlorpromazine, and droperidol. This has not previously been reported. A ‘carefully titrated’ sedating dose of propofol averted the need for intubation and mechanical ventilation, with its greater length of admission and hospital cost, but imposes a risk of aspiration and iatrogenic hypoventilation. Advanced airway management skills are therefore required whenever propofol is used [8].

Should we scrap the target of a maximum four hour wait in emergency departments

Pressure to achieve arbitrary targets is not a valid improvement strategy and leads to perverse incentives and use of resources, claims Peter Campbell, but Adrian Boyle and Ian Higginson say no alternative exists to keep emergency departments working

VALIDATION OF THE SHORT FORM OF THE INTERNATIONAL CROWDING MEASURE IN EMERGENCY DEPARTMENTS (ICMED): INTERNATIONAL STUDY

Objectives & Background There is little consensus on the best way to measure emergency department crowding. We have previously developed a consensus based measure, the International Crowding Measure in Emergency Departments (ICMED). This measure has both flow and non-flow items, and also contains items which measure Input, Throughput and Output. We aimed to externally validate a short form of the ICMED against emergency physicians perceptions of crowding and danger across a wide variety of Emergency Departments. Face validity is important to support implementation of any measure Methods We performed an observational validation study in seven emergency departments in five different countries. We recorded sICMED observations and the most senior available emergency physicians perceptions of crowding and danger at the same time. We performed a times series regression model to account for clustering and correlation. Results 397 data points were analysed. The sICMED showed moderate positive correlations with emergency physicians perceptions of crowding r=0.4110, p<0.05) and danger (r=0.4566, p<0.05.) There was considerable variation in the performance of the sICMED between different emergency departments. The sICMED was only slightly better than measuring occupancy or emergency department boarding time. Conclusion The short form of the ICMED has moderate face validity in measuring crowding. This is an important first step in validating this measure. The measure performs less well in Emergency Departments that are constantly crowded. Figure 1

Weather factors associated with paediatric croup presentations to an Australian emergency department.

We examined if croup presentations to the emergency department (ED) were associated with weather changes in a warm temperate climate. We collected data on all 729 cases with an ED discharge or admission diagnosis of croup over a 798 day time period. We obtained detailed climatic records from the New South Wales Meteorological Office for the same time period. Only one daily variable, ground temperature at 9:00, was significantly associated with the number of croup attendances (linear regression −0.2062; 95% CI −0.272 to −0.138). There was a stronger correlation (−0.426; 95% CI −0.684 to −0.072) between the calculated mean monthly temperature and the monthly number of croup admissions. Even in this milder climate, croup is associated with cooler weather. We are unable to conclude that hospital attendances for croup are caused by changes in temperature alone, as other factors such as the prevalence of viral illness also follow a seasonal, and therefore, temperature-related pattern.

Urgent care in England

Report proposes superficially attractive demand management strategies but fails to deal with fundamental problems

Incentives are needed to facilitate data sharing and reduce violence

Florence and colleagues present powerful evidence that sharing emergency department data with community safety partnerships can bring about meaningful reductions in community violence.1 Information sharing is a simple intervention that is almost entirely without harm or cost. The size of the benefit is …

Routinely asking women about domestic violence: inquiry may be acceptable in different healthcare environments and to different women

EDITOR—Taket et al debated the value of routinely asking about domestic violence1. Although no one would disagree that domestic violence is a major health problem and that health care offers opportunities to identify a largely hidden problem, …