Drew Richardson

International perspectives on emergency department crowding.

The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes.

Access block and ED overcrowding.

Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20–30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998–1999) to 2.4 beds per 1000 (2002–2007) in 2002, and has remained steady at between 2.5–2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998–1999 rates, the number of available beds in 2006–2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.

Motorcycle protective clothing: protection from injury or just the weather?

BACKGROUND Apart from helmets, little is known about the effectiveness of motorcycle protective clothing in reducing injuries in crashes. The study aimed to quantify the association between usage of motorcycle clothing and injury in crashes. METHODS AND FINDINGS Cross-sectional analytic study. Crashed motorcyclists (n=212, 71% of identified eligible cases) were recruited through hospitals and motorcycle repair services. Data was obtained through structured face-to-face interviews. The main outcome was hospitalization and motorcycle crash-related injury. Poisson regression was used to estimate relative risk (RR) and 95% confidence intervals for injury adjusting for potential confounders. RESULTS Motorcyclists were significantly less likely to be admitted to hospital if they crashed wearing motorcycle jackets (RR=0.79, 95% CI: 0.69-0.91), pants (RR=0.49, 95% CI: 0.25-0.94), or gloves (RR=0.41, 95% CI: 0.26-0.66). When garments included fitted body armour there was a significantly reduced risk of injury to the upper body (RR=0.77, 95% CI: 0.66-0.89), hands and wrists (RR=0.55, 95% CI: 0.38-0.81), legs (RR=0.60, 95% CI: 0.40-0.90), feet and ankles (RR=0.54, 95% CI: 0.35-0.83). Non-motorcycle boots were also associated with a reduced risk of injury compared to shoes or joggers (RR=0.46, 95% CI: 0.28-0.75). No association between use of body armour and risk of fracture injuries was detected. A substantial proportion of motorcycle designed gloves (25.7%), jackets (29.7%) and pants (28.1%) were assessed to have failed due to material damage in the crash. CONCLUSIONS Motorcycle protective clothing is associated with reduced risk and severity of crash related injury and hospitalization, particularly when fitted with body armour. The proportion of clothing items that failed under crash conditions indicates a need for improved quality control. While mandating usage of protective clothing is not recommended, consideration could be given to providing incentives for usage of protective clothing, such as tax exemptions for safety gear, health insurance premium reductions and rebates.

Prevalence of access block in Australia 2004-2008.

Objective:  Access block is the inability of ED patients requiring admission to access appropriate inpatient beds in a timely fashion, defined in Australasia as more than 8 h in the ED. The present study describes changes in prevalence of access block in Australia over a 4 year period.

Bicycle Crashes in Different Riding Environments in the Australian Capital Territory

Introduction: Cyclists are increasingly overrepresented in traffic crash casualties in Australia. There is evidence that better cycling infrastructure increases participation, but whether it reduces the numbers of injured cyclists is less clear. This study examined injury outcomes of crashes in different cycling environments. Methods: Adult cyclists injured on- and off-road were recruited from emergency departments from November 2009 to May 2010 in the Australian Capital Territory. Eligible participants (n = 313/372, 84.1%) were interviewed and their injury self-reports were corroborated with medical records where available. Participants who had crashed in transport-related areas (n = 202, 64.5%) are the focus of this article. Results: Participants had crashed in traffic (39.1%), in cycle lanes (7.9%), on shared paths (36.1%), and on footpaths (16.8%). Based on average weekly traffic counts, the crash involvement rate per 1000 cyclists was 11.8 on shared paths compared to 5.8 on cycle lanes. Over half of the participants (52.0%) were injured in single-vehicle bicycle crashes. The remainder involved other road users, including motor vehicles (20.8%), other bicycles (18.8%), pedestrians (6.4%), and animals (2.0%). Pedestrians were involved in 16.4 percent of crashes on shared paths. Minor injuries (Abbreviated Injury Scale [AIS] 1) were sustained by 58.4 percent of cyclists, moderately severe injuries (AIS 2) were sustained by 36.1 percent of cyclists, and 5.4 percent of cyclists were seriously injured (AIS 3+). The average treatment required was 1.8 days with 7.5 days off work and cost to the cyclist of

Survey of alcohol-related presentations to Australasian emergency departments

869 excluding medical treatment. Cyclists who crashed on shared paths or in traffic had higher injury severity scores (ISS; 4.4, 4.0) compared to those in cycle lanes or on footpaths (3.3, 3.4) and required more treatment days (2.8, 1.7 versus 0.0, 0.2). Conclusions: Fewer cyclists were injured in on-road cycle lanes than in other cycling environments, and a high proportion of injuries were incurred on shared paths. This study highlights an urgent need to determine appropriate criteria and management strategies for paths classified as suitable for shared or segregated usage. Supplemental materials are available for this article. Go to the publishers online edition of Traffic Injury Prevention to view the supplemental files.

Emergency department access block occupancy predicts delay to surgery in patients with fractured neck of femur

Objective: To determine the proportion of alcohol‐related presentations to emergency departments (EDs) in Australia and New Zealand, at a single time point on a weekend night shift.

Perceptions of Australasian emergency department staff of the impact of alcohol-related presentations

Objective:  The present study aimed to identify any relationship between existing access block occupancy (ABO) at the time of patient presentation and delay to definitive procedure.

Emergency department targets: a watershed for outcomes research?

Objectives: To survey emergency department (ED) clinical staff about their perceptions of alcohol‐related presentations.

Effects of a hospital-wide intervention on emergency department crowding and quality: A prospective study

MJA 196 (2) · 6 February 2012 126 ational Emergency Access Targets (NEAT) are now in place and will progressively require a higher proportion of emergency department (ED) patients to be treated and to leave within a set time frame over the next 4 years. The stated aim of the NEAT is to improve patient safety and patient access; their implied aim is to reduce overcrowding. The funding model recognises that the causes of overcrowding often lie outside of the ED, providing states with upfront resources with which to reengineer hospital processes.1 From a researcher’s perspective, this “natural experiment” will provide an opportunity to address two major questions: what are the best hospital models of care for rapid and safe ED flow and what is the effect on patient outcomes? Overcrowding in the ED is strongly associated with excess patient mortality, both inside and outside of hospital.2-4 It is largely accepted that overcrowding contributes to dysfunction that might increase mortality, but demonstrating causality requires strength of association, consistency, specificity, temporality, a dose–response relationship, biological plausibility, coherence, reversibility and consideration of alternative explanations (the Bradford–Hill criteria5). Given the considerable difficulties that would be encountered in attempting a randomised trial, observers have been waiting for mortality reports from a setting where effort has been made to reduce overcrowding. The first such evidence of apparent reversibility is published in this issue of the Journal. Geelhoed and de Klerk6 describe the first year of Western Australia’s 4-hour rule in Perth hospitals, finding a 13% overall reduction in mortality in the three large hospitals where ED overcrowding also diminished. This certainly adds something to the evidence for a causal relationship between overcrowding and unnecessary patient deaths. The 80 fewer deaths recorded in the Emergency department targets: a watershed for outcomes research?