Suzanne Mason

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.

Defining frequent use of an urban emergency department

Objective: This study aimed to develop a definition of frequent use of an emergency department (ED) by comparing differences in the observed frequency distribution with that of a theoretical frequency distribution. Methods: A retrospective analysis of attendance of ED and minor injury unit attendances in one city over 1 year was conducted. From these data, the expected frequency distribution was determined based upon a Poisson distribution. Results: During the period studied, 75 141 people attended on 98 908 occasions. The theoretical frequency distribution showed that there were 2764 (3.7%) “frequent users” presenting repeatedly due to non-random events. These patients made 12 316 (12.4%) attendances. Frequent users were older than chance users (mean age 49.7 vs 44.5 years). A greater proportion arrived by ambulance (55.3% vs 27.5%), presented with psychiatric problems (5.8% vs 1.1%) or alcohol intoxication (1.3% vs 0.5%), and were admitted to hospital (37.4% vs 19.6%). Conclusion: We have identified that there is a group of patients who present repeatedly due to non-random events, confirming the existence of “frequent users”. Their characteristics are clearly different to other patients in the ED. We propose that “frequent users” be defined as any patient who makes more than four attendances per year.

Outcomes after injury: a comparison of workplace and nonworkplace injury.

BACKGROUND Factors affecting recovery from injury are investigated comparing male emergency department patients involved in work-related and non-work-related accidents. METHODS This was a prospective cohort study of 154 injured employed male emergency department patients recording demographic and accident details, return to work information, and involvement in litigation. Standardized questionnaires measured psychological, physical, and social responses. Evaluations were at admission, and at 6 weeks, 6 months, and 18 months after injury. RESULTS Work-related injuries were less severe than non-work-related injuries (p = 0.006), and more patients became involved in litigation (p = 0.02) and suffered symptoms of posttraumatic stress disorder (p = 0.04). Psychosocial symptoms increased with nonreturn to work (p < 0.05). Factors predicting return to work include injury severity, blaming others, involvement in litigation, and subsequent physical and social functioning. CONCLUSION Patients injured at work are more likely to commence litigation and develop symptoms consistent with posttraumatic stress disorder. Nonreturn to work is associated with higher psychosocial morbidity. Return to work is predicted from event and recovery period variables.

A controlled evaluation of comprehensive geriatric assessment in the emergency department: the ‘Emergency Frailty Unit’

Background: the ageing demographic means that increasing numbers of older people will be attending emergency departments (EDs). Little previous research has focused on the needs of older people in ED and there have been no evaluations of comprehensive geriatric assessment (CGA) embedded within the ED setting. Methods: a pre-post cohort study of the impact of embedding CGA within a large ED in the East Midlands, UK. The primary outcome was admission avoidance from the ED, with readmissions, length of stay and bed-day use as secondary outcomes. Results: attendances to ED increased in older people over the study period, whereas the ED conversion rate fell from 69.6 to 61.2% in people aged 85+, and readmission rates in this group fell from 26.0% at 90 days to 19.9%. In-patient bed-day use increased slightly, as did the mean length of stay. Discussion: it is possible to embed CGA within EDs, which is associated with improvements in operational outcomes.

Effectiveness of emergency care practitioners working within existing emergency service models of care

Background: An emergency care practitioner (ECP) is a generic practitioner drawn mainly from paramedic and nursing backgrounds. ECPs receive formal training and extended clinical skills to equip them to work as an integral part of the healthcare team working within and across traditional boundaries of emergency and unplanned care. Currently, ECPs are working in different healthcare settings in the UK. Objectives: (1) To evaluate appropriateness, satisfaction and cost of ECPs compared with the usual service available in the same healthcare setting, (2) to increase understanding of what effect, if any, ECPs are having on delivery of health services locally and (3) to evaluate whether ECP working yields cost savings. Methods: Using a mixed-methods approach, data were collected quantitatively and qualitatively from three different types of health provider setting where ECPs are operational, in three areas of England. Data were collected by sending two questionnaires to each patient eligible to be seen by an ECP, at 3 and 28 days after presentation; telephone interviews were conducted with a sample of staff that included ECPs, other health professionals and stakeholders (eg, managers) in each of the three settings; and routine data were analysed to provide a perspective on costs. Results: After adjusting for age, sex, presenting complaint and service model, some differences in the processes of care between the ECPs and the usual providers in the three settings were observed. Overall, ECPs carried out fewer investigations, provided more treatments and were more likely to discharge patients home than the usual providers. Patients were satisfied with the care received from ECPs, and this was consistent across the three different settings. It was found that ECPs are working in different settings across traditional professional boundaries and are having an impact on reconfiguring how those services are delivered locally. Costs information (based on one site only) indicated that ECP care may be cost effective in that model of ECP working. Conclusion: Care provided by ECPs appears to reduce the need for subsequent referral to other emergency and unscheduled care services in a large proportion of cases. We found no evidence that the care provided by an ECP was less appropriate than the care by the usual providers for the same type of health problem.

The psychological burden of injury: an 18 month prospective cohort study.

Objectives: To determine the prevalence of post-trauma psychological problems among a cohort of male accident and emergency department patients admitted to hospital. To identify the changes in their psychological symptoms over an 18 month follow up period. Methods: A prospective cohort study of male accident and emergency department patients who were admitted for treatment of an injury. Baseline interview recorded demographic details and accident details. Standardised questionnaires measured baseline psychological state and personality type. Follow up at six weeks, six months, and 18 months after injury was by face to face interview or postal questionnaire and recorded progress since injury, and documented psychological status through the use of standardised questionnaires to detect psychiatric disorder and symptoms of post-traumatic stress disorder (PTSD). Results: 210 male patients were recruited into the study. Psychiatric disorder was identified in 47.6% of responders at six weeks, and 43.4% at six months after injury. This improved significantly at 18 months. PTSD symptoms were moderate in 25%–30% and severe in 5%–14% and did not change significantly over the study period. A significant relation was found between previous psychiatric history and psychological symptoms at 18 months after injury. No relation was identified between injury severity and psychological status after injury. Conclusion: This study finds a high prevalence of psychological distress in male accident and emergency department patients after injury. Although some symptoms resolve over the follow up period, a proportion remain and may be related to previous psychiatric history. There was no relation identified between severity of injury and psychological morbidity.

Supermodels: stick insects or hourglasses?

Supermodels have been criticised for being a bad role model for young women because of their unnatural thinness, and have even been linked to the increase in eating disorders, such as anorexia and bulimia. We compiled a biometric database of 300 fashion models, 300 glamour models, and 300 normal women (table). The information on fashion models was drawn from model cards, displayed on model agency World Wide Web pages. The model cards provide accurate biometric data (height, bust, waist, hip measurements) on the basis of which the models are hired. We obtained statistics for glamour models from Playboy, a source which has been used by previous researchers and which is judged reliable. The normal women were undergraduates and postgraduates with no clinical history of eating disorders, who scored within the normal range on a battery of seven questionnaires on eating disorders. For comparison, we included two smaller samples of 30 anorexic women and 30 bulimic women recruited from Newcastle City Healths Eating Disorder Service.

Analysis of the distribution of time that patients spend in emergency departments.

The NHS Plan stated: “By 2004 no one should be waiting more than four hours in Accident and Emergency from arrival to admission, transfer or discharge.”1 This target was changed to allow for certain clinical exceptions, and since January 2005, 98% of patients must spend less than four hours there.2 We analysed the distribution of time spent by patients in emergency departments in England. We invited major emergency departments (those providing 24 hour cover and most core services) in England to submit data for each new patient attending during April 2004. We determined the distribution of total time in each department for patients who were admitted to hospital and for those discharged from the department. To assess the generalisability of these findings, we used performance data from the Department of Health to compare trusts in which at least one department had submitted data or in which no department had.3 We received data from 83 …

International Survey of Emergency Physicians’ Awareness and Use of the Canadian Cervical-Spine Rule and the Canadian Computed Tomography Head Rule

OBJECTIVES The derivation and validation studies for the Canadian Cervical-Spine (C-Spine) Rule (CCR) and the Canadian Computed Tomography (CT) Head Rule (CCHR) have been published in major medical journals. The objectives were to determine: 1) physician awareness and use of these rules in Australasia, Canada, the United Kingdom, and the United States and 2) physician characteristics associated with awareness and use. METHODS A self-administered e-mail and postal survey was sent to members of four national emergency physician (EP) associations using a modified Dillman technique. Results were analyzed using repeated-measures logistic regression models. RESULTS The response rate was 54.8% (1,150/2,100). Reported awareness of the CCR ranged from 97% (Canada) to 65% (United States); for the CCHR it ranged from 86% (Canada) to 31% (United States). Reported use of the CCR ranged from 73% (Canada) to 30% (United States); for the CCHR, it was 57% (Canada) to 12% (United States). Predictors of awareness were country, type of rule, full-time employment, younger age, and teaching hospital (p < 0.05). Significant differences in use of the CCR by country were observed, but not for the CCHR. Teaching hospitals were more likely to use the CCR than nonteaching hospitals, but less likely to use the CCHR. CONCLUSIONS This large international study found notable differences among countries with regard to knowledge and use of the CCR and CCHR. Awareness and use of both rules were highest in Canada and lowest in the United States. While younger physicians, those employed full-time, and those working in teaching hospitals were more likely to be aware of a decision rule, age and employment status were not significant predictors of use. A better understanding of factors related to awareness and use of emergency medicine (EM) decision rules will enhance our understanding of knowledge translation and facilitate strategies to enhance dissemination and implementation of future rules.

The Utility of Clinical Features in Patients Presenting With Nontraumatic Headache: An Investigation of Adult Patients Attending an Emergency Department

Objective.—When patients present to an emergency department because of nontraumatic headache, they often present a diagnostic challenge. This study aimed to examine the utility of clinical features in detecting serious underlying causes of nontraumatic headache in adult patients presenting to an emergency department.