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Background: Community-acquired pneumonia (CAP) poses a significant health threat to the elderly population, leading to high morbidity and mortality rates. Serum ferritin, a critical indicator of iron metabolism, plays a pivotal role in inflammation and immune regulation. Nevertheless, its specific prognostic relevance in elderly patients with CAP remains unclear. This study aimed to evaluate the predictive capacity of serum ferritin in determining the prognosis of elderly patients with CAP and to investigate its effectiveness when combined with the sequential organ failure assessment (SOFA) or CURB-65 (confusion, uremia, respiratory rate, blood pressure, aged ≥65 years) scores. Methods: This retrospective cohort study included 451 elderly patients (aged ≥65 years) diagnosed with CAP according to established criteria. Serum ferritin concentrations were measured upon admission and various prognostic indicators such as 28-day mortality, mechanical ventilation requirement, and vasopressor administration were analyzed in conjunction with white blood count (WBC), C-reactive protein (CRP), procalcitonin (PCT), lactate (Lac), SOFA scores, and CURB-65 scores. The independent predictive value of ferritin was assessed through receiver operating characteristic (ROC) curve analysis and multivariate logistic regression. Results: Among the 451 patients, 99 (22%) died within 28 days. The area under the curve (AUC) of serum ferritin for predicting 28-day mortality was 0.75 (95%CI: 0.695-0.805). Ferritin outperformed WBC, CRP, and PCT in predictive performance, and its performance was comparable to Lac. When combined with SOFA or CURB-65 scores, the AUC of ferritin for predicting 28-day mortality increased to 0.84 and 0.847, respectively (P <0.001). Moreover, the AUC of ferritin for predicting vasopressor administration was 0.707, which increased to 0.864 and 0.822 when combined with SOFA or CURB-65 scores, respectively (P <0.001). Ferritin could predict mechanical ventilation requirement with an AUC of 0.618, but it was not an independent risk factor, and its predictive ability was not significantly different from other indicators. Conclusion: Admission serum ferritin is an independent predictor for the prognosis of elderly patients with CAP, and it exhibits a strong ability to predict the 28-day mortality and vasopressor administration. The combination of ferritin with SOFA and CURB-65 scores significantly improves the prognostic predictive potency. [ABSTRACT FROM AUTHOR]

Introduction: Poisoning is a major public health issue and a leading cause of admission to the emergency department (ED). There is a paucity of data describing the epidemiology and cost of acute poisoning. Therefore, this study investigated the epidemiology, patterns, and associated costs of acute poisoning in emergency department of the largest tertiary care healthcare centre in Qatar. Method: This study was a retrospective review of the health records of patients admitted to the ED due to poisoning between January 2015 and December 2019. Incidence, clinical characteristics, and costs associated with acute poisoning were assessed. Frequency and percentages were calculated for categorical variables and mean and SD for continuous variables. The relationship between sociodemographic characteristics and poisoning profile was assessed using the chi-square test. A micro-costing approach using the cost of each resource was applied for cost calculations. Result: The incidence of acute poisoning was 178 cases per 100,000 patients. Females (56%) and children below 14 years (44.3%) accounted for the largest proportion. Most of the exposures were accidental involving therapeutic agents (64.2%). The mean length of hospital stay was found to be 1.84 ± 0.81 days, and most patients (76.6%) were discharged within the first 8 h. A statistically significant difference was found between age groups and type of toxin (χ2 = 23.3, p < 0.001), cause and route of exposure (χ2 = 42.2, p < 0.001), and length of hospital stay (χ2 = 113.16, p < 0.001). Admission to intensive care units had the highest cost expenditure (USD 326,008), while general wards accounted for the least (USD 57,709). Conclusion: Unintentional poisoning by pharmacological agents is common in infants and children. This study will assist in the development of educational and preventive programmes to minimise exposure to toxic agents. Further studies are required to explore the impact of medical toxicology services, and post discharge monitoring of poisoning. [ABSTRACT FROM AUTHOR]

Background: Influenza can be associated with nonrespiratory disease presentation, but these are less well documented due to the lack of routine testing for influenza in the healthcare system, especially if patients do not present with influenza‐like illness (ILI). We aimed to measure the proportion of influenza cases seeking care at emergency department (ED) for a nontraumatic cause, to describe their clinical presentation and their ED‐discharge diagnosis. Methods: The study was conducted at seven hospitals in France, Spain, Italy and Germany during the 2019–20 influenza season, for a period of 10 weeks. Patients (≥ 18 years) consulting for nontraumatic causes at the ED were invited to participate. Consenting patients provided upper respiratory swab samples for influenza testing by reverse transcription polymerase chain reaction. Clinical and demographic data were collected. Results: There were 8678 patients included, 50.7% were female and the median age was 57 years. Among them, 494 (5.7%) were laboratory‐confirmed influenza (LCI) cases. Nonetheless, only 24.3% of LCI cases had an ED‐discharge of influenza. Of all cases confirmed as influenza, 47.6% had a nonrespiratory discharge diagnosis, which frequency increased with age. ILI case definition from the European Centre for Disease Prevention and Control was the most frequently met among influenza cases (68.6%). Older patients (≥ 65 years) were less frequently identified based on any ILI signs/symptoms. Conclusion: Our findings indicate that the impact of influenza among patients seeking care at the ED cannot be easily assessed based on clinical presentation and medical records alone. Preventing influenza among adult population may reduce healthcare utilization. [ABSTRACT FROM AUTHOR]

Over 10 million ED visits occur each year across Australia and Aotearoa New Zealand. Outside basic administrative data focused on time‐based targets, there is minimal information about clinical performance, quality of care, patient outcomes, or equity in emergency care. The lack of a timely, accurate or clinically useful data collection represents a missed opportunity to improve the care we deliver each day. The present paper outlines a proposal for a National Acute Care Secure Health Data Environment, including design, possible applications, and the steps taken to date by the Australasian College for Emergency Medicine ED Epidemiology Network in collaboration with the College of Emergency Nursing Australasia. Optimal use of the existing information collected routinely during clinical care of emergency patients has the potential to enable data‐driven quality improvement and research, leading to better care and better outcomes for millions of patients and families each year. [ABSTRACT FROM AUTHOR]

Purpose: Lung Ultrasonography (LUS) have surface as an expensive tool in the analysis and monitoring of COVID-19, known its capability to offer realtime imaging and detect pulmonary abnormalities associated with the disease, the identification of the unique LUS findings of COVID-19 and the presentation of their correlation with the prognostic factors and early severity of the illness. Method: The PRISMA recommendations were followed when conducting the comprehensive analysis. Finding suggests utilizing the descriptions lung ultrasonography and corona virus disease-19, SARS-CoV-2 was done by a survey on PubMed. A total of 1400 publications were found in which 10 were included. The increasing number of COVID-19 necessitates analytical tools for therapeutic treatment. Results: LU is a non-invasive method used to diagnose interstitial lung syndrome, revealing a characteristic pattern in COVID-19 pneumonia patients. LU has shown promise in detect and correlated with CT scan outcome. It proved useful as a practical substitute for more intrusive treatments in both monitoring the development of the disease and detecting the original infection. Regular evaluations, which are essential for handling serious situations, were made easier by real-time imaging. The probability of negative outcomes (Intensive Care Unit (ICU) admission, or requirement for involuntary aeration, death,) was greater in patients in the Emergency Department (ED) with higher LUS scores. The diagnosis of COVID-19 was well-predicted by the LUS results and/or the LUS score. Conclusions: The development of negative consequences is correlated with high LUS scores. Pleural Effusion (PE) inclusion in the LUS score and imaging protocol standardization for COVID-19 LUS are still being discussed. Its practicality for medical professionals stems from its capacity to monitor the progression of diseases and offer quick feedback. To standardize techniques and maximize their application in diverse therapeutic situations even during lung cancer therapies, more research is required. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of NSTEMI (non- st elevation myocardial infarction) in acute coronary syndrome patients presenting with the chest pain in emergency department of tertiary care hospital. Study Design: Cross Sectional study. Setting: Jinnah Post graduate Medical College Hospital Karachi. Period: June 20, 2023. Methods: Enrolling 112 consecutive volunteers was carried out Interview questions focused on the participants’ smoking, blood pressure, diabetes, and type of chest pain. Whether or not the participants had ACS, their diagnosis was documented. NSTEMI frequency was computed. Results: We have 112 patients enrolled with mean age was 52.73±14.24 years. Sixty five (58%) were male while forty seven (41.9 %) were females. out of 112 patients 45 (40.1%) were hypertensive, 32(28.5%) were diabetes and 29 (25.8%) were smoker. Among the participants 21 (18.7%) had NSTEMI and showed positive correlation with age, gender, nature of chest pain, hypertension and smoking. Conclusion: Among the individuals, one of the most frequent causes of chest pain was acute coronary syndrome. High suspicion and additional testing are they key tools for early diagnosis and management. [ABSTRACT FROM AUTHOR]

Background: Chest pain is a prevalent reason for emergency room referrals and presents diagnostic challenges. The physician must carefully differentiate between cardiac and noncardiac causes, including various vascular and extracardiovascular conditions. However, it is crucial not to overlook serious conditions such as acute coronary syndrome (ACS). Diagnosis of acute myocardial infarction (AMI) and early discharge management become difficult when traditional clinical criteria, ECG, and troponin values are insufficient. Recently, the focus has shifted to a "multi-marker" approach to improve diagnostic accuracy and prognosis in patients with chest pain. Methods: This observational, prospective, single-center study involved, with informed consent, 360 patients presenting to the emergency department with typical chest pain and included a control group of 120 healthy subjects. In addition to routine examinations, including tests for hsTnI (Siemens TNIH kit), according to the 0–1 h algorithm, biochemical markers sST2 (tumorigenicity suppression-2) and suPAR (soluble urokinase plasminogen activator receptor) were also evaluated for each patient. A 12-month follow-up was conducted to monitor outcomes and adverse events. Results: We identified two groups of patients: a positive one (112 patients) with high levels of hsTnI, sST2 > 24.19 ng/mL, and suPAR > 2.9 ng/mL, diagnosed with ACS; and a negative one (136 patients) with low levels of hsTnI, suPAR < 2.9 ng/mL, and sST2 < 24.19 ng/mL. During the 12-month follow-up, no adverse events were observed in the negative group. In the intermediate group, patients with hsTnI between 6 ng/L and the ischemic limit, sST2 > 29.1 ng/mL and suPAR > 2.9 ng/mL, showed the highest probability of adverse events during follow-up, while those with sST2 < 24.19 ng/mL and suPAR < 2.9 ng/mL had a better outcome with no adverse events at 12 months. Conclusion: Our data suggest that sST2 and suPAR, together with hsTnI, may be useful in the prognosis of cardiovascular patients with ACS, providing additional information on endothelial damage. These biomarkers could guide the clinical decision on further diagnostic investigations. In addition, suPAR and sST2 emerge as promising for event prediction in patients with chest pain. Their integration into the standard approach in PS could facilitate more efficient patient management, allowing safe release or timely admission based on individual risk. [ABSTRACT FROM AUTHOR]

Background: Shortages of mechanical ventilation have become a constant problem in Emergency Departments (EDs), thereby affecting the timely deployment of medical interventions that counteract the severe health complications experienced during respiratory disease seasons. It is then necessary to count on agile and robust methodological approaches predicting the expected demand loads to EDs while supporting the timely allocation of ventilators. In this paper, we propose an integration of Artificial Intelligence (AI) and Discrete-event Simulation (DES) to design effective interventions ensuring the high availability of ventilators for patients needing these devices. Methods: First, we applied Random Forest (RF) to estimate the mechanical ventilation probability of respiratory-affected patients entering the emergency wards. Second, we introduced the RF predictions into a DES model to diagnose the response of EDs in terms of mechanical ventilator availability. Lately, we pretested two different interventions suggested by decision-makers to address the scarcity of this resource. A case study in a European hospital group was used to validate the proposed methodology. Results: The number of patients in the training cohort was 734, while the test group comprised 315. The sensitivity of the AI model was 93.08% (95% confidence interval, [88.46 − 96.26%]), whilst the specificity was 85.45% [77.45 − 91.45%]. On the other hand, the positive and negative predictive values were 91.62% (86.75 − 95.13%) and 87.85% (80.12 − 93.36%). Also, the Receiver Operator Characteristic (ROC) curve plot was 95.00% (89.25 − 100%). Finally, the median waiting time for mechanical ventilation was decreased by 17.48% after implementing a new resource capacity strategy. Conclusions: Combining AI and DES helps healthcare decision-makers to elucidate interventions shortening the waiting times for mechanical ventilators in EDs during respiratory disease epidemics and pandemics. [ABSTRACT FROM AUTHOR]

Background: People who use substances (PWUS) encounter significant barriers to accessing care for their complex health needs. As a result, emergency departments (EDs) often become the first point of healthcare access for many PWUS and are a crucial setting for the study of health inequities. This study aimed to understand the ED healthcare experiences of PWUS with the intent of informing ways of improving the delivery of equitable care. Methods: This qualitative study was part of a larger cross-sectional, mixed-methods study that examined ED experiences among diverse underserved and equity-deserving groups (EDGs) within Kingston, Ontario, Canada. Participants shared and self-interpreted a story about a memorable ED or UCC visit within the preceding 24 months. Data from participants who self-identified as having substance use experiences was analyzed through inductive thematic analysis. Results: Of the 1973 unique participants who completed the survey, 246 participants self-identified as PWUS and were included in the analysis. Most participants were < 45 years of age (61%), male (53%), and white/European (57%). 45% identified as a person with a disability and 39% frequently struggled to make ends meet. Themes were determined at the patient, provider, and system levels. Patient: history of substance use and experience of intersectionality negatively influenced participants' anticipation and perception of care. Provider: negative experiences were linked to assumption making, feelings of stigma and discrimination, and negative perceptions of provider care. Whereas positive experiences were linked to positive perceptions of provider care. System: timeliness of care and the perception of inadequate mental health resources negatively impacted participants' care experience. Overall, these themes shaped participants' trust of ED staff, their desire to seek care, and their perception of the care quality received. Conclusions: PWUS face significant challenges when seeking care in the ED. Given that EDs are a main site of healthcare utilization, there is an urgent need to better support staff in the ED to improve care experiences among PWUS. Based on the findings, three recommendations are proposed: (1) Integration of an equity-oriented approach into the ED, (2) Widespread training on substance use, and (3) Investment in expert resources and services to support PWUS. [ABSTRACT FROM AUTHOR]

Background: Rapid treatment is critical in managing acute ischemic stroke (AIS) to improve patient outcomes. Various strategies have been used to optimize this treatment process, including the Acute Stroke Protocol (ASP) activation, and minimizing the duration of key performance metrices, such as door-to-needle time (DNT), CT-to-needle time (CTNT), CT-to-groin puncture time (CTGP), and door-to-groin puncture time (DGPT). However, identifying the delay-causing sub-tasks within the ASP could yield novel insights, facilitating optimization strategies for the AIS treatment process. Methods: This two-phase prospective observational time and motion study aimed to identify sub-tasks and compare their respective durations involved in the treatment process for AIS patients within ASPs. The study compared sub-task durations between "routine working hours" and "evenings and weekends" (after-hours), as well as between stroke neurologists and non-stroke neurologists. Additionally, the established performance metrices of AIS were compared among the aforementioned groups. Results: Phase 1 identified and categorized 34 sub-tasks into five broad categories, while Phase 2 analyzed the ASP for 389 patients. Among the 185 patients included in the study, 57 received revascularization treatment, with 30 receiving intravenous (IV) thrombolysis only, 20 receiving endovascular thrombectomy (EVT) only, and 7 receiving both IV thrombolysis and EVT. Significant delays were observed in sub-tasks including triage, registration, patient history sharing, treatment decisions, preparation of patients, preparation of thrombolytic agents, and angiosuite preparation. The majority of these significant delays (P < 0.05) were observed when were performed by a non-stroke neurologist and during after-hours operations. Furthermore, certain sub-tasks were exclusively performed during after-hours or when the treatment was provided by a non-stroke neurologist. Consequently, DNT, CTNT, and CTGP were significantly prolonged for both non-stroke neurologists and off-hours treatment. DGPT was significantly longer only when the ASP was conducted by non-stroke neurologists. Conclusions: The study identified several sub-tasks that lead to significant delays during the execution of the ASP. These findings provide a premise to design targeted quality improvement interventions to optimize the ASP for these specific delay-causing sub-tasks, particularly for non-stroke neurologists and after-hours. This approach has the potential to significantly enhance the efficiency of the AIS treatment process. [ABSTRACT FROM AUTHOR]

The emergency department assessment of chest pain score‐accelerated diagnostic protocol (EDACS‐ADP) are commonly used for risk stratification in undifferentiated patients with acute chest pain. This systematic review aimed to investigate EDACS‐ADP for risk stratification of emergency department (ED) patients with chest pain. The PubMed, Web of Science, Medline, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases were searched for related studies without restrictions on the publication year. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess the risk of bias, and Stata 16.0 was used to determine the combined sensitivity, specificity, positive diagnostic likelihood ratio (DLR), and negative DLR. Twelve studies comprising 14 290 patients were identified. Of these, 7537 (52.74%) patients were considered low risk, and 67 (0.89%) had major adverse cardiovascular events (MACE), including myocardial infarction, stroke, and cardiovascular death within 30 days of the patients' ED presentation. EDACS‐ADP showed a combined sensitivity of 0.97 (95% confidence interval [CI]: 0.95−0.99); specificity, 0.58 (0.53−0.63); positive DLR, 2.34 (2.08−2.63); negative DLR, 0.04 (0.02−0.09); diagnostic odds ratio, 53.11 (26.45−106.63); and summary receiver operating characteristic area under the curve, 0.83 (0.79−0.86). Despite the large statistical heterogeneity of the results, EDACS‐ADP identified a considerable number of low‐risk patients for early discharge, with a specificity >50% and an incidence of MACE within 30‐days of patients' ED presentation <1%. Thus, it is a useful tool with a potential for clinical application. [ABSTRACT FROM AUTHOR]

Background: Patients seeking emergency care for self-harm and suicidality report varying experiences from being believed and taken seriously to not being believed and taken seriously. Epistemic injustice provides a conceptual framework to explore how peoples' experiences of self-harm and suicidality are believed or not. We use an empirical method -conversation analysis - to analyze epistemics in clinical communication, focusing on how knowledge is claimed, contested and negotiated. In courtroom, police and political interaction, conversation analysis has identified communication practices implying implausibility in a person's story to contest and recharacterize their accounts. Aims: To investigate communication practices in Emergency Department (ED) biopsychosocial assessments that may (1) undermine, imply implausibility and recharacterize or (2) accept peoples' experiences of suicidal ideation and selfharm. Methods: Using conversation analysis, we micro-analyzed verbal and nonverbal communication in five video-recorded biopsychosocial assessments with people presenting to the ED with self-harm or suicidal ideation, and conducted supplementary analysis of participants' medical records and postvisit interviews. We present three cases where experiences were not accepted and undermined/recharacterized and two cases where experiences were accepted and validated. Results: When peoples' experiences of suicidality and self-harm were not accepted or were undermined, questioners: did not acknowledge or accept the person's account; asked questions that implied inconsistency or implausibility ("Didn't you tell your GP that you were coping okay?"); juxtaposed contrasting information to undermine the person's account ("You said you were coping okay before, and now you're saying you feel suicidal"); asked questions asserting that, e.g., asking for help implied they were not intending to end their life ("So when you called 111 what were you expecting them to do"); and resistinged or directly questioned the person's account. Multiple practices across the assessment built on each other to assert that the person was not suicidal, did not look or act like they were suicidal; that the person's decision to attend the ED was not justified; that an overdose was impulsive and not intended to end life; asking why the person didn't take a more harmful medication to overdose; that selfharming behaviors were not that serious and should be in the person's control. Alternative characterizations were used to justify decisions not to provide further support or referrals to specialist services. At times, these practices were also delivered when speaking over the patient. When peoples' experiences were accepted, practitioners acknowledged, accepted, validated suicidality/self-harm and introduced a shared understanding of experiences that patients found helpful. Non-verbal feedback such as nodding and eye contact was central in acceptance of patients' accounts. Conclusion: These findings advance our understanding of how peoples' experiences of suicidality or self-harm are undermined or accepted in mental health encounters in the ED. They have important clinical implications: patients report that when their experiences are not accepted or undermined, this makes them more distressed, less hopeful about the future and discourages future help-seeking when in crisis. Conversely, acknowledging, accepting and validating suicidality/self-harm and introducing a new ways of understanding peoples' experiences may make people less suicidal and more hopeful, generates shared understanding and encourages future help-seeking. [ABSTRACT FROM AUTHOR]

Background: Sepsis, a life-threatening infection-induced inflammatory condition, has significant global health impacts. Timely detection is crucial for improving patient outcomes as sepsis can rapidly progress to severe forms. The application of machine learning (ML) and deep learning (DL) to predict sepsis using electronic health records (EHRs) has gained considerable attention for timely intervention. Methods: PubMed, IEEE Xplore, Google Scholar, and Scopus were searched for relevant studies. All studies that used ML/DL to detect or early-predict the onset of sepsis in the adult population using EHRs were considered. Data were extracted and analyzed from all studies that met the criteria and were also evaluated for their quality. Results: This systematic review examined 1942 articles, selecting 42 studies while adhering to strict criteria. The chosen studies were predominantly retrospective (n = 38) and spanned diverse geographic settings, with a focus on the United States. Different datasets, sepsis definitions, and prevalence rates were employed, necessitating data augmentation. Heterogeneous parameter utilization, diverse model distribution, and varying quality assessments were observed. Longitudinal data enabled early sepsis prediction, and quality criteria fulfillment varied, with inconsistent funding–article quality correlation. Conclusions: This systematic review underscores the significance of ML/DL methods for sepsis detection and early prediction through EHR data. [ABSTRACT FROM AUTHOR]

Introduction: Nystagmus is a valuable clinical finding. Although nystagmus is often described by the direction of its quick phases, it is the slow phase that reflects the underlying disorder. The aim of our study was to describe a new radiological diagnostic sign called "Vestibular Eye Sign"—VES. This sign is defined as an eye deviation that correlates with the slow phase of nystagmus (vestibule pathological side), which is seen in acute vestibular neuronitis and can be assessed on a CT head scan. Materials and methods: A total of 1250 patients were diagnosed with vertigo in the Emergency Department at Ziv Medical Center (ED) in Safed, Israel. The data of 315 patients who arrived at the ED between January 2010 and January 2022 were collected, with criteria eligible for the study. Patients were divided into 4 groups: Group A, "pure VN", Group B, "non-VN aetiology", Group C, BPPV patients, and Group D, patients who had a diagnosis of vertigo with unknown aetiology. All groups underwent head CT examination while in the ED. Results: In Group 1, pure vestibular neuritis was diagnosed in 70 (22.2%) patients. Regarding accuracy, VES (Vestibular Eye Sign) was found in 65 patients in group 1 and 8 patients in group 2 and had a sensitivity of 89%, specificity of 75% and a negative predictive value of 99.4% in group 1—pure vestibular neuronitis. Conclusion: VN is still a clinical diagnosis, but if the patient undergoes head CT, we suggest using the "Vestibular Eye Sign" as a complementary sign. As per our findings, this is a valuable sign on CT imaging for diagnosing the pathological side of isolated pure VN. It is sensitive to support a diagnosis with a high negative predictive value. [ABSTRACT FROM AUTHOR]

Background: Restraint and seclusion continue to be used with patients demonstrating aggressive and violent behaviors while in the emergency department and as inpatients in behavioral health (BH) units. The use of sensory interventions such as the weighted blanket (WB) is garnering interest as alternatives to aid in managing anxiety, anger, and aggressive behaviors. Reports of the effectiveness of the WB have primarily been anecdotal, and results of research with children have been mixed. Only one study has been conducted with the WB with adults on an inpatient psychiatric unit. Aims: The aim of this pilot study was to assess the effectiveness of the WB by determining whether it decreases anxiety and/or anger in adult emergency department patients with preexisting psychiatric diagnoses. Methods: The study used a quasi-experimental, nonequivalent control group design with pre- and posttests for anxiety and anger. The intervention was a 15-pound WB. Participants (N = 15) were in one of three groups, which included no weighted blanket (NWB), WB for 15 minutes, or WB for 30 minutes. Results: All three groups showed a decrease in anxiety and anger scores. However, participants in the WB groups had a greater decrease in anxiety and anger posttest scores. Conclusions: The small sample size in this study did not allow for the determination of any differences between groups on anxiety or anger scores that could be viewed as a significant finding. [ABSTRACT FROM AUTHOR]

Background: Telehealth can improve access to evidence-based care at a lower cost for patients, especially those living in underserved and remote areas. The barriers to the widespread adoption of telehealth have been well documented in the literature. However, the barriers may not be the same for pediatric patients, who must rely on their parents or guardians to make healthcare decisions. This paper presents some of the leading barriers parents or guardians of pediatric patients report in using telehealth to meet their children's healthcare needs. Methods: This cross-sectional survey was conducted in a tertiary care pediatric Emergency Department (ED) at a children's hospital in Alabama between September 2020 to December 2020. The parents or guardians of pediatric patients were asked about their reasons for not using telehealth despite having healthcare needs for their children, whether they canceled or rescheduled healthcare provider visits and facility visits, and whether the child's health conditions changed over the past three months. Descriptive analyses were conducted that explored the distribution of telehealth use across the variables listed above. Results: Five hundred ninety-seven parents or guardians of pediatric patients participated in the survey, and 578 answered the question of whether they used telehealth or not over the past three months. Of them, 33.1% used telehealth, 54.3% did not, and 12.6% did not have healthcare needs for their child. The leading reason for not using telehealth was that the doctor or health provider did not give them a telehealth option, the second main reason was that they did not know what telehealth is, and the third leading reason was that the parents did not think telehealth would help meet healthcare needs for their child. Conclusions: This study highlights the telehealth utilization barriers among underserved pediatric populations, including the need for physicians to proactively offer telehealth options to parents or guardians of pediatric patients. Improving health literacy is of paramount importance, given that a substantial proportion of parents were not familiar with telehealth. Policymakers and healthcare organizations should raise awareness about the benefits of telehealth which can improve healthcare access for underserved pediatric patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study aimed at investigating seven aspects, which are believed to be critical for healthcare customer satisfaction level, as well as determining underlying factors affecting them within the emergency department. DESIGN: A quantitative and cross-sectional study design, with deductive reasoning, was applied to undertake this study. Setting: The study site involves different tertiary care private and public hospitals in Karachi, Pakistan. MAIN OUTCOME MEASURES: General satisfaction perspective was measured involving satisfaction with technical quality, interpersonal manner, communication, financial aspects, time spent with the doctor, and accessibility and convenience. RESULTS: Respondents were 61.6% male and 38.4% female with mean age 34.65±10.27 years. Most of the healthcare customers (54.6%) commuted to the healthcare facility by ambulance. 72.2% of respondents were from private and 27.8% were from public healthcare facilities while the majority (55.4%) visits to healthcare emergency services were due to injury or intoxication. In our study mean general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with the doctor, and accessibility and convenience were 3.11±0.34, 3.42±0.37, 3.42±0.43, 3.45±0 .39, 3.31±0.42, 2.80±0.58 and 3.46±0.59 respectively. We found 52.6% of healthcare customers were satisfied with general aspects of service, 81.5% satisfied with technical quality, 80.50% satisfied with interpersonal manner, 82.5% satisfied with the communication, 66.3% satisfied with financial aspects, 20.4% satisfied with time spent with doctors and 75.7% satisfied with accessibility and convenience. CONCLUSION: General satisfaction with services was found to be at the lowest level, while the highest sati sfaction level was with the "time spent with the doctor". Healthcare institutes need to be more attentive to the service encounter time spent with doctors and on general issues for healthcare customers visiting the ED. [ABSTRACT FROM AUTHOR]

This paper presents the results concerning the evaluation of the processes of an Emergency Department (ED). Based on the analysis of both processes and data flow, a simulation model of patient throughput in the ED has been developed. Simulation results, obtained using the JaamSim software, pointed out the strengths and weaknesses of the departments' operations. Then, several alternative scenarios (hypothetical solutions) were created and tested, while the results were thoroughly analysed. In order to prioritise the several scenarios, two hierarchical processes were used. Firstly, a multicriteria table was developed based on decision makers' personal preference. Total length of stay was acknowledged as the factor with the higher importance. Consequently, the application of an analytical hierarchical process (AHP) managed to verify the primary ranking. A comparison of the proposed ideas was attempted, featuring the implementation of a fast track unit as the best practice. [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic has had profound effects on access to care, including outpatient sexually transmitted infection (STI) testing and treatment. Many vulnerable populations already relied on the emergency department (ED) for much of their care prior to the pandemic. This study examines trends in STI testing and positivity before and during the pandemic at a large urban medical center and evaluates the role of the ED in providing STI care. Methods: This is a retrospective review of all gonorrhea, chlamydia, and trichomonas tests from November 1, 2018, through July 31, 2021. Demographic information and location and results of STI testing were extracted from the electronic medical record. Trends in STI testing and positivity were examined for 16 month periods before and after the COVID-19 pandemic started (March 15, 2020), with the latter divided into the early pandemic period (EPP: March 15 -July 31, 2020) and late pandemic period (LPP: August 1, 2020 - July 31, 2021). Results: Tests per month decreased by 42.4% during the EPP, but rebounded by July 2020. During the EPP, the proportion of all STI testing originating in the ED increased from 21.4% pre-pandemic to 29.3%, and among pregnant women from 45.2% to 51.5%. Overall STI positivity rate increased from 4.4% pre-pandemic to 6.2% in the EPP. Parallel trends were observed for gonorrhea and chlamydia individually. The ED represented 50.5% of overall positive tests, and as much as 63.1% of positive testing during the EPP. The ED was the source of 73.4% of positive tests among pregnant women, which increased to 82.1% during the EPP. Conclusions: STI trends from this large urban medical center paralleled national trends, with an early decrease in positive cases followed by a rebound by the end of May 2020. The ED represented an important source of testing for all patients, and especially for pregnant patients, throughout the study period, but even more so early in the pandemic. This suggests that more resources should be directed towards STI testing, education, and prevention in the ED, as well as to support linkage to outpatient primary and obstetric care during the ED visit. [ABSTRACT FROM AUTHOR]

Purpose: COVID-19 pandemic transformed the health system response worldwide. The aim of this study is to report changes about numbers and reason for ENT consultations in emergency department (ED) during COVID-19 pandemic comparing with those occurred the previous year (2019). Methods: Data about patients admitted to adult and pediatric ED were collected from March 1 to May 31, 2019 and 2020. Patients referred for urgency from general practitioners were excluded from the study. Results: Global ED admission (except for dyspnea or COVID-19–related symptoms) dramatically decreased during pandemic (−50.9% among adults and −71.4% among pediatrics). At the same time, ENT consultancy significantly reduced too, by 71.5% (P <.01) among adults and 45.1% (P <.01) for pediatrics. Among adults, it was reported a statistically significant decrease in consultation for ear problems (−88.5%, P =.0146). Reduction in ENT referral for bone fracture (−40%, P =.059), vertigo (−77.8%, P =.637), and tonsillitis (−87.5%, P =.688) was consistent, but not significant. Among pediatric patients, it was observed an increase by 25% about foreign bodies (12 vs 15, P <.01). A reduction in numbers of consults for ear problem (−90.8%; P =.045), epistaxis (−80%; P =.196), and nasal fracture (−70%; P =.36) was also observed. Conclusion: Fear of infection and the forced lock down caused a significant decrease in the number of ED accesses and in ENT consultancy. These data may suggest that some ED referral usually could be deferred, but on the other hand, pandemic will cause a great diagnostic delay. [ABSTRACT FROM AUTHOR]

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The coronavirus disease (COVID-19) pandemic forced healthcare systems to quickly modify to swapping healthcare essentials. The emergency department (ED) decision-making condition is complex and particularly unstable order for care in a stated period conducts decision-makers to attempt to alter assets to touch the demand. ED managers are generally enforced to discover strategies and improving scenarios for decreasing transfer of patients. For this end, the proposed framework of this study is first developed to integrate the simulation model of the flow process of the COVID-19 patients with the Measurement of Alternatives and Ranking according to COmpromise Solution (MARCOS) methodology in Spherical fuzzy context to assess and prioritize scenarios based on desired performance measures. As a contribution, the proposed framework determined the importance of the performance measures based on Spherical fuzzy sets. The proposed SF-MARCOS approach takes the performance measures weights from the expert's team based on spherical fuzzy theory and the performance measures values from the simulation model, and rank the improving scenarios. Finally, a real-life study in a private hospital in Tehran, Iran, illustrates the effectiveness and feasibility of the proposed framework. The analysis of the results shows that the patients' transfer rate can be reduced by applying new strategies with sensible expenditure. [ABSTRACT FROM AUTHOR]

Hepatitis C virus (HCV) surveillance is a critical component of a comprehensive strategy to prevent and control HCV infection and HCV-related chronic liver disease. The emergency department (ED) has been increasingly recognized as a vital partner in HCV testing and linkage. We sought to consider active RNA HCV viremia over time in patients participating in an ED-based testing programme as a measure of local HCV surveillance and as a barometer of ED-testing programme impact. We performed a retrospective analysis of individuals participating in our ED-based HCV testing programme between 2015 and 2021. Chi-square tests were used to compare the demographic characteristics of HCV antibody positive tests with active viremia to those without active viremia. Cox proportional hazard models were used to estimate the trend in active viremia risk over time in the overall study population as well as in key subpopulations of interest. Of 5456 HCV antibody positive individuals, 3102 (56.8%) had active viremia. In the overall study population, we found that the risk of active viremia decreased by 4.8% per year during the study period (RR: 0.95, 95% CI: 0.93–0.97|p< .0001). Baby boomers experienced a 9% decrease in active viremia risk per year over the study period while non-baby boomers only had a 2% decrease in risk per year (p = .0009). Compared with insured patients, uninsured patients had a smaller decrease in risk of active HCV viremia per year (p = .003). No significant differences in the risk of active viremia over time were observed for gender (p = .4694) or by primary care provider status (p = .2208). In conclusion, this ED-based testing and linkage programme demonstrates significantly decreased active HCV viremia over time. It also highlights subpopulations, specifically non-baby boomers and uninsured patients, who may benefit from focused interventions to improve access to and adoption of definitive HCV care. [ABSTRACT FROM AUTHOR]

The Emergency Department (ED) is a highly stressful and fast-paced environment in which doctors are challenged to efficiently adapt and recall knowledge to make safe patient-care decisions. This commentary discusses the benefits of exclusively hiring pre-clerkship and clerkship medical students as medical scribes in the emergency department. A total of twenty-eight (28) articles and studies are explored and used to reflect upon the benefits of scribing implementation in medical education. These include, but are not limited to, increasing medical student exposure to the specialty of emergency medicine, enhancing their clinical skills, and assisting students to pay-down their medical school-related debt. Furthermore, appointing medical students as scribes is mutually beneficial to the ED by helping to cut down the lengthy wait times for patients and reduce the significantly high rates of emergency physician burnout. We conclude that hiring medical students as scribes in the ED is a potentially beneficial practice that merits further consideration and analysis. [ABSTRACT FROM AUTHOR]

This paper addresses the non-urgent use of the Emergency Department (ED) and the impact it has on both healthcare organizations and patient care. Emergency Departments are a vital part of the healthcare system seeing on average 27 million patients per year. Of those 27 million, 18 million visits are considered nonurgent. As costs associated with healthcare continue to rise, identifying ways to cut down on these non-urgent visits will benefit both healthcare systems and patients alike. This project seeks to offer solutions that can help healthcare organizations mitigate these factors in order to reduce inappropriate use of the emergency department as well as better serve the needs of their community. Overall, the goal of this project is to understand the needs of the patients within their community, reduce spending and offer solutions that are sustainable for generations to come. [ABSTRACT FROM AUTHOR]

Aim: The aim of the study was to analyze whether a patient's opinion is related to the effect of analgesic treatment. Methods: The study was conducted using a survey questionnaire among adult patients admitted to the hospital emergency department in March 2021. The Numerical Rating Scale (NRS) was used to assess pain. Patients were asked to rate the intensity of pain during their stay in the emergency department in three situations: (1) at admission; (2) during the stay; and (3) upon discharge. The relationships between qualitative variables were assessed by the chi-squared test. Significance was set at p < 0.05. Results: There was no statistical dependence between the patient's opinion about the medical institution and results of the effectiveness of analgesic treatments (p = 0.056). The highest percentage of patients satisfied with the received treatment were those who did not feel pain during ED discharge (94.12%), and the lowest were those who complained of severe pain during ED discharge (63.91%). The average mark for the functioning and organization of the emergency department was 7.44 (±2.04). Only 54 patients (29.83%) had taken pain medication before deciding to visit ED. Conclusions: No statistical dependency between the effect of the analgesic treatment and the patient's opinion has been observed. The majority of patients with pain discomfort visit emergency departments without looking for consultation in other locations or without taking analgesics. In the considered institution, patients were satisfied with the analgesic treatment, staff performance, and with the organization of the department. [ABSTRACT FROM AUTHOR]

Headaches are a frequent reason for presentation to the emergency department (ED) and can pose a great challenge for the attending physicians. First and foremost, the distinction between a primary and secondary headache with potentially life-threatening implications can be difficult. Moreover, it often occurs that no specific headache diagnosis is made at discharge from the ED. Therefore, in this present retrospective cross-sectional study, all patients who presented to the emergency department of the Department of Neurology at Rostock University Medical Centre with the main symptom of headache between November 2013 and November 2016 underwent a neurological examination and the extent to which warning symptoms ("red flags") for a secondary headache as well as symptoms necessary for a correct headache diagnosis according to the ICHD-3 classification were recorded and documented. We could show that documentation of red flags and clinical characteristics is inadequate and does not allow proper diagnostic categorization. To facilitate concise documentation and rapid decision making we suggest a structured and standardized form for documenting the headache history and red flags in the ED. [ABSTRACT FROM AUTHOR]

Background Studies investigating outcomes of delirium using large-scale routine data are rare. We performed a two-centre study using the 4 'A's Test (4AT) delirium detection tool to analyse relationships between delirium and 30-day mortality, length of stay and home time (days at home in the year following admission). Methods The 4AT was performed as part of usual care. Data from emergency admissions in patients ≥65 years in Lothian, UK (n  = 43,946) and Salford, UK (n  = 38,824) over a period of |$\sim$| 3 years were analysed using logistic regression models adjusted for age and sex. Results 4AT completion rates were 77% in Lothian and 49% in Salford. 4AT scores indicating delirium (≥4/12) were present in 18% of patients in Lothian, and 25% of patients in Salford. Thirty-day mortality with 4AT ≥4 was 5.5-fold greater than the 4AT 0/12 group in Lothian (adjusted odds ratio (aOR) 5.53, 95% confidence interval [CI] 4.99–6.13) and 3.4-fold greater in Salford (aOR 3.39, 95% CI 2.98–3.87). Length of stay was more than double in patients with 4AT scores of 1–3/12 (indicating cognitive impairment) or ≥ 4/12 compared with 4AT 0/12. Median home time at 1 year was reduced by 112 days (Lothian) and 61 days (Salford) in the 4AT ≥4 group (P  < 0.001). Conclusions Scores on the 4AT used at scale in practice are strongly linked with 30-day mortality, length of hospital stay and home time. The findings highlight the need for better understanding of why delirium is linked with poor outcomes and also the need to improve delirium detection and treatment. [ABSTRACT FROM AUTHOR]

This study examined emergency department (ED) utilization by adolescents and young adults, 12–30 years of age (AYA) with autism spectrum disorder (ASD) using the 2016 Healthcare Cost and Utilization Project/National Emergency Department Sample (HCUP/NEDS). We investigated the principal reason for an ED visit, presence of an ambulatory care sensitive condition (ACSC), and likelihood of hospital admission following ED encounter in ASD and Non-ASD cohorts. The ASD cohort had a higher proportion of ED visits for ACSC diagnoses as compared to the Non-ASD cohort. In addition, the likelihood of admission following an ED visit in the ASD cohort was 3.7 times greater than in the Non-ASD cohort. [ABSTRACT FROM AUTHOR]

Objectives Frailty is characterized by an increased vulnerability to stressors. Frail older patients are at increased risk of Emergency Department (ED) visits, hospitalization, and disability. The aim of this study was to determine the relationship between frailty syndrome and polypharmacy in the elderly referred to the emergency department of Ardabil teaching hospitals. Methods & Materials In this cross-sectional descriptive study, 505 elderly people referred to the hospital emergency department were selected by convenience sampling method. Frailty syndrome was measured using the five-item criteria of fried which include: 1) slow walking, 2) muscular weakness, 3) exhaustion, 4) low physical activity and 5) unintentional weight loss. Polypharmacy considered the use of 5 or more drugs. Data were analyzed using descriptive statistics including mean and standard deviation and inferential analysis including analysis of variance, independent t-test, correlation, and multiple regression using SPSS v. 22 statistical software. Results The mean age of participants was 70.91 ± 7.49 and 255 (50.5%) were male, 318 (63%) were married and 271 (53.7%) were illiterate. the results of the study showed that 204 (40.4%) of the elderly who referred to the emergency department had frailty and 177 (35%) had pre frailty. In this population, we identified a 42.2% (n=98) of frail with polypharmacy, 37.1% (n=86) of prefrail with polypharmacy. The correlation test showed that there is a significant relationship between fertility and polypharmacy (P˂0.001). Linear regression analysis showed the variables of age, education, living arrangement, hospitalization, and the number of medications used by the patient as predictors of frailty syndrome in the elderly referred to the emergency department. Conclusion Number of drugs used, age, education, living arrangement and number of hospitalizations were predictors of frailty syndrome in the elderly. Considering the living conditions of the elderly and the prevention of unnecessary hospitalizations can reduce polypharmacy and ultimately a preventive strategy to prevent and manage frailty. Of course, further research is needed to confirm the possible benefits of reducing polypharmacy in the development, reversion, or delay of frailty. [ABSTRACT FROM AUTHOR]

Background: Workplace violence (WPV) is a prevalent phenomenon in Egyptian emergency departments (EDs), an issue that threatens an already scarce resource of healthcare workers. Furthermore, changes and modifications are continuously taking place in hospitals, with no consideration to the important role those changes might play in reducing or encouraging WPV behaviors. Objective: This research serves as an initial step in offering answers on how the environmental design of an ED can be modified and manipulated to prevent and control WPV. Accordingly, the objective of this research is to identify the environmental features that potentially influence WPV in the ED. This could provide healthcare designers with the necessary tools to forecast the location of WPV and define the measures needed for a safer working environment. Method: The study comprised a hybrid method approach that evaluates the implementation of crime prevention through environmental design (CPTED) through field observation and combined with space syntax analyses (SSAs) of the spatial attributes. Results: The results showed a positive relationship between the spatial properties (high integration and connectivity values) and WPV locations. The results also demonstrated that situational factors as natural surveillance played an important role in displacing the WPV locations. Conclusions: The contribution of this research lies in elaborating the SSA and CPTED from a conceptual to an empirical level. Combining those tools will help identify the location of WPV in the ED and hence facilitates successful future environmental intervention strategies. [ABSTRACT FROM AUTHOR]

Purpose: Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition. Methods: We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients' ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition. Results: Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload. Conclusions: Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration. [ABSTRACT FROM AUTHOR]

Emergency department (ED) is known as the beating heart of a hospital which operates 24 hours, every day of a year. It provides services to a wide spectrum of patients with various medical conditions. Therefore, it is crucial to simulate and optimize the ED's processes for enhancement of services provided. Improving processes can be challenging, especially when a complex and unpredictable environment such as ED is under study. This research aims to identify an improved allocation of resources in different wards of an emergency department, with the goal of improving the patients and staff workflow. The research approach untaken is a case study at a state hospital in the Semnan province, Iran. The emergency department of this hospital is evaluated for a new layout design by which the average patients waiting time be reduced and the allocation of staff be optimized. The simulation technique, using Arena, is adopted to fulfil these goals. Recommendations are proposed for a layout design which could improve the average waiting time of the Internal-Emergent patients by 23.18% and the Surgical-Emergent patients by 81.7%. This means waiting time reduction of 3.31 minutes for the Internal-Emergent patients and 10.58 minutes for the Emergent patients. [ABSTRACT FROM AUTHOR]

Objective: The head impulse test (HIT) assesses the vestibulo-ocular reflex (VOR) and is used to differentiate vestibular neuritis (abnormal VOR) from stroke (normal VOR) in patients presenting with an acute vestibular syndrome (AVS). The video-oculography-based HIT (vHIT) quantifies VOR function and provides information imperceptible for the clinician during clinical bedside HIT. However, the vHIT—like an electrocardiogram—requires experienced interpretation, which is especially difficult in the emergency setting. This calls for a simple, reliable and rater-independent way of analysis. Methods: We retrospectively collected 171 vHITs performed in patients presenting with AVS to our emergency department. Three neuro-otological experts comprehensively assessed the vHITs including interpretability (artifacts), VOR gain (eye/head velocity ratio), velocity profile (abrupt decline) and corrective saccades (overt/covert). Their consensus rating (abnormal/peripheral vs. normal/central) was compared to a simple algorithm that automatically classified the vHITs based on a single VOR gain cutoff (0.7). Results: Inter-rater agreement between experts was high (Fleiss' kappa = 0.74). Five (2.9 %) vHITs were "uninterpretable" according to experts' consensus, 80 (46.8 %) were rated "normal" and 86 (50.3 %) "abnormal". The algorithm had substantial agreement with the experts' consensus (Cohen's kappa = 0.75). Importantly, it correctly classified all of the normal/central vHITs denoted by the experts (100% specificity) and at the same time it had sufficient sensitivity (75.6%) in detecting abnormal/peripheral vHITs. Conclusion: A simple, automated, gain-based evaluation of the vHIT reliably detects normal/central VOR and may be a feasible and effective tool to screen AVS patients for potentially underlying stroke in the emergency setting. [ABSTRACT FROM AUTHOR]

Introduction: The health benefits of entering methadone maintenance treatment (MMT) for opioid-dependent persons may not be merely limited to therapy of opioid use disorder. We aimed to compare the healthcare utilization of MMT patients before and after MMT. Methods: A retrospective analysis was performed using the Taiwan Illicit Drug Issue Database and the National Health Insurance Research Database (NHIRD) between 2014 and 2016. We included 1255 newly enrolled MMT patients in 2015 and randomly selected 5020 patients from NHIRD matched by age and gender as the comparison group. Changes in healthcare utilization 1 year before and 1 year after the date of the index date (MMT initiation) were compared within and between MMT and comparison groups. Results: During the 1-year period following MMT, the hospitalization length was considerably decreased, while the number of outpatient visits, emergency department (ED) visits, and ED expenditure significantly increased in MMT patients. Multivariable linear regression with the difference-in-difference approach revealed that all the categories of healthcare utilization increased, except for a minor increase of outpatient expenditure and a slight decrease of hospitalization length for the MMT group relative to the comparison group. Increases in utilization of the departments of psychiatry and infectious diseases of the MMT patients were considerable. Conclusion: MMT is associated with increased healthcare utilization, and departments of psychiatry and infectious diseases play substantial roles. Policy-makers should warrant access for all who need healthcare by ensuring the availability of the treatment for drug dependence. [ABSTRACT FROM AUTHOR]

Background: Stroke is a devastating disease, but it is treatable with alteplase or tissue plasminogen activator (tPA). The effectiveness of tPA is highly time-dependent, meaning rapid treatment is critical. Fast treatment with tPA has been reported in many urban hospitals, but hospitals in rural locations struggle to reduce treatment times. This qualitative study examines current thrombolysis processes in one urban and two rural hospitals in Nova Scotia, Canada, by mapping and comparing the treatment process in these settings for acute ischemic stroke (AIS) patients, and by analyzing the healthcare professionals views on various treatment topics. Methods: Structured interviews were conducted with healthcare professionals involved in stroke treatment across the three sites. The interviews focused on the various activities in the thrombolysis treatment at each site. Additionally, participants were asked about the following 10 topics: comfort treating acute ischemic stroke patients; perceptions about tPA; appropriate tPA treatment window; stroke patient priority; tPA availability; patient consent; urban-rural treatment differences; efficiency of their treatment process; treatment delays; and suggested process improvements. Results were analyzed using the Framework Method, as well as through the development of process maps. Results: Twenty three healthcare professionals were interviewed at 2 rural hospitals and 1 urban hospital. Acute ischemic stroke patients are triaged as the highest or urgent priority at each included site. Physicians are more hesitant to treat with tPA in rural settings. A total of 11 urban-rural treatment differences were noted by the rural sites. Additionally, 11 patient-related and 29 system treatment delays were described. A process map was developed for each site, representing the arrival by ambulance and by private vehicle pathways. Conclusions: Guidelines and clear protocols are critical in reducing treatment times and ensuring consistent access to treatment. The majority of treatment delays encountered are system delays, which can be appropriately planned for to reduce delays within the care pathway. There is a general consensus that there is an urban-rural treatment gap for acute ischemic stroke patients in Nova Scotia, and that continuing education is key in rural hospitals to improve Emergency Department (ED) physician comfort with treating patients with tPA. [ABSTRACT FROM AUTHOR]

Pain is a complex symptom to assess properly and it is often poorly managed in the Emergency Department. The majority of research has focused on exploring oligoanalgesia in samples of patients with heterogeneous injuries. The occurrence of oligoanalgesia in a homogeneous injury, such as Colles fracture, has yet to be explored. A retrospective chart review was conducted to determine the incidence of oligoanalgesia in adults with Colles fractures admitted to two urban Emergency Departments in Western Canada. Data were collected from one hundred fifty charts from a 5-year period (2009-2014). Age and gender predicted of pain assessment (p =.019), but were not significantly associated with receipt of an opioid or pain reassessment. Pain reassessment was only completed in 47% of patients who received an initial pain assessment; this was significantly different from current best practice standards (p =.0002). [ABSTRACT FROM AUTHOR]

Objectives: The diagnosis of sepsis in the Emergency Department (ED) is challenging and a reliable biomarker is needed. The current study aimed to evaluate the diagnostic accuracy of monocyte distribution width (MDW) for the early identification of sepsis in the ED. Methods: We performed a large observational study including consecutive adult patients (≥18 years of age) presenting to the ED between September and November 2019, with an order for complete blood count (CBC) evaluation. A total of 2,215 patients were enrolled and classified based on Sepsis-2 criteria as the control group (1,855), infection group (172), Systemic Inflammatory Response Syndrome (SIRS) group (100), and sepsis group (88). Results: MDW levels were higher in patients with sepsis than in all other groups (p<0.001). ROC curve analysis showed an optimal diagnostic accuracy of MDW for sepsis prediction at a cut-off point of 23.5, with an AUC of 0.964, sensitivity and specificity of 0.920 and 0.929, respectively. Conclusions: Our findings encourage further investigation to validate the use of MDW as a screening tool for the early identification of patients at risk of sepsis in the ED. [ABSTRACT FROM AUTHOR]

A core performance target for the English National Health Service (NHS) concerns waiting times at Emergency Departments (EDs), with the aim of minimising long waits. We investigate the drivers of long waits. We analyse weekly data for all major EDs in England from April 2011 to March 2016. A Poisson model with ED fixed effects is used to explore the impact on long (> 4 h) waits of variations in demand (population need and patient case-mix) and supply (emergency physicians, introduction of a Minor Injury Unit (MIU), inpatient bed occupancy, delayed discharges and long-term care). We assess overall ED waits and waits on a trolley (gurney) before admission. We also investigate variation in performance among EDs. The rate of long overall waits is higher in EDs serving older patients (4.2%), where a higher proportion of attendees leave without being treated (15.1%), in EDs with a higher death rate (3.3%) and in those located in hospitals with greater bed occupancy (1.5%). These factors are also significantly associated with higher rates of long trolley waits. The introduction of a co-located MIU is significantly and positively associated with long overall waits, but not with trolley waits. There is substantial variation in waits among EDs that cannot be explained by observed demand and supply characteristics. The drivers of long waits are only partially understood but addressing them is likely to require a multi-faceted approach. EDs with high rates of unexplained long waits would repay further investigation to ascertain how they might improve. [ABSTRACT FROM AUTHOR]

A patient’s stay at a hospital may encompass various departments or units. Since many critical and complex problems occur at the interfaces of healthcare delivery systems, safe and efficient transitions between the departments within a hospital has significant importance. This paper presents a Markov chain-based model to study patient transitions between emergency department, intensive or critical care unit, and hospital ward in small and medium-sized community hospitals. To make the analytical study tractable, an iteration method is introduced to approximate the system performance during transitions, including direct transferring probabilities without waiting, average patient occupancy in each department, and average patient length of stay. In addition, system properties, such as monotonicity and sensitivity, are analyzed. It is shown that such a method has a high accuracy in performance estimation and can be used to study and improve patient transitions in small or medium-sized hospitals. [ABSTRACT FROM AUTHOR]

Objectives: Aim of this study was to characterize acute poisoning and snakebite cases and their outcome in the Emergency Department (ED). Methods: This was a prospective study done in the ED of a tertiary healthcare center. Study included 184 patients of acute poisoning and 16 cases of snakebite. Data regarding demographics, type, time, and mode of poisoning, lag time in reaching the hospital, initiation of treatment, first aid, in-hospital treatment, and comorbid illness were obtained. Data regarding requirement of antidote, duration of hospitalization, and outcome were also obtained. Results: Out of 200 cases, 181 (90.5%) were adults and 19 (9.5%) were of pediatric age group. Poisoning was common among males (57%) than females (43%). Majority (40%) were from the age group of 21–30 years. Out of 200, 115 (57.5%) poisonings were suicidal, 68 (34%) were accidental, and 17 (8.5%) were homicidal. Acute poisonings included corrosive 54 (27%), drug overdose 26 (13%), organophosphorus compounds 20 (10%), rodenticides 20 (10%), and symptomatic snakebite 16 (8%). Seventy-two (36%) were admitted with a median hospital stay of 6 days with 5 (2.5%) deaths. Logistic regression analysis revealed poorer outcome for 15–30 years age [OR 12.6 (1.6–97.5), P = 0.015], males [OR 2.5 (1.4–4.4) P = 0.04], patients coming from >30 km [OR 4.3 (1.5–12.1), P = 0.006]. Conclusion: Our study demonstrated an increased incidence of corrosive ingestion. With increasing rates of suicidal ingestions, there is a need for holistic approach to manage mental health issues at primary care level. [ABSTRACT FROM AUTHOR]

Purpose: While emergency department nurses in Indonesia are critical to quality care, the role lacks recognition and standard practices and regulation of scope of practice are absent. This research explored the role of nurses in Indonesian EDs. Method: The conceptual lens applied in the research was grounded theory. The main data source was 51 semi- structured interviews with 43 ED nurses, three directors of nursing, three nurse leaders and two nurse educators. Data were also generated through observations and memos. Results: Two key categories were constructed; shifting work boundaries and lack of authority. Shifting work boundaries was symbolic of a lack of professional authority and legitimized knowledge. Lack of authority reflected the dimension of professional autonomy through the nexus of power and knowledge. The interrelationship of these two concepts constructed a core category, securing legitimate power, which underpinned the positioning of nursing in Indonesia. Conclusions: The interconnection between political gains, tertiary knowledge, professional regulation and implementation of gender-sensitive policies was critical to the development of the ED role, the positioning of nursing within the health care system and improvement in quality of care. [ABSTRACT FROM AUTHOR]

The lean manufacturing approach plays a vital role in reducing waste and enhancing productivity in the production environment and service setups. Lean manufacturing-based techniques might be employed in evaluating the efficiencies of different rooms in emergency departments (EDs) and hospitals. A lean thinking approach may be used in testing the usage of the existing facilities planned and constructed for patients' use. In the present study, the management principles of lean manufacturing-based methodology have been used to test the usage of the ED services. Two vital rooms of the ED viz. rapid response trauma (RR-Trauma) and rapid response medical (RR-Medical) are studied in terms of crowding and bed occupancy. Using the concept of takt time (TT), an individual department's efficiency and relative efficiency have been calculated to judge the effectiveness of the ED services. A case of a governmental, non-profit and teaching hospital in the southern region of Saudi Arabia has been studied to see the effect of staffed bed redistribution based on lean manufacturing concept. It has been revealed that ED is facing crowding and frequent critical ambulance diversion problems which require a management intervention to go for staffed bed redistribution to accommodate all of the patients' arrivals. Furthermore, the optimal allocation of resources is essentially be achieved to enhance the efficiency and effectiveness of ED rooms. Based on the lean manufacturing concept, the acceptable TT and efficiency for ED rooms are recommended. [ABSTRACT FROM AUTHOR]

Objectives: To assess the usefulness of the neutrophil-to-lymphocyte ratio (NLR) as a predictive factor of acute mesenteric ischemia (AMI) in patients presenting at the emergency department (ED) with acute abdominal pain.Methods: This is a retrospective case-control study of patients older than 16 years admitted to the ED with acute abdominal pain with CT and histologic confirmation. The study group corresponded to patients with abdominal CT with radiological signs of AMI. The control group corresponded to patients with non-AMI findings in abdominal CT. Association measurements of NLR with radiological signs were compared with a paired-sample t test, and multivariate regression performed to analyze potential correlations. To assess the diagnosis capacity of NLR, ROC curves were calculated.Results: A total of 61 patients were included (32 cases and 29 controls). The cases of AMI showed higher mortality (43.8% vs 6.9%, p < 0.01) and higher NLR on the limit of statistical significance (13.8 vs 8.7, p = 0.053). Patients with AMI due to occlusion of the superior mesenteric artery (SMA) showed a higher NLR (8.3 vs 22.3, p < 0.001). The area under the curve (AUC) of the NLR for AMI due to occlusion of the SMA was 0.88 (95% CI 0.7-1.0, p = 0.001). No patient with NLR < 5 presented AMI due to occlusion of the SMA. An NLR of 12.8 showed a sensitivity of 92% and a specificity of 74% for AMI due to occlusion of SMA.Conclusions: The NLR is a useful parameter of AMI of arterial origin due to occlusion of the SMA; it can help the clinician to raise suspicion of this diagnosis and the interpreting radiologist in the acquisition protocol for the CT study and would alert for an early surgical treatment. [ABSTRACT FROM AUTHOR]

Safe and efficient patient transitions are of critical importance to ensure patient safety and care quality. To study patient transitions, this paper presents a queueing network model-based iteration method to model and analyze transitions between emergency department, intensive care unit, and general ward within a hospital. Routings with feedback flows are considered under general arrival and service processes, and the effects of blocking on performance measures are presented for both the mean and variability. It is shown that the iteration procedure is convergent and leads to acceptable accuracy of estimation, for both small- and large-sized hospitals. In addition, the impacts of bed capacity, admission rate, as well as arrival and service time variabilities are discussed. Such a method provides an efficient way to study patient transitions within hospitals. Note to Practitioners—Many critical and complex problems occur at the interfaces of healthcare delivery systems. Within hospitals, transitions occur when patients are transferred between units such as emergency department, intensive care unit, and general ward. Although numerous studies on patient transitions have been carried out, most of them only focus on a single unit or transition without recognizing the importance of coordination among multiple units. However, understanding the complete patient flow throughout the hospital is crucial for hospital administrators in predicting the expected demand and planning resources appropriately. Thus, a quantitative model to study the transitions within the hospital by taking into account the interactions among all the involved departments is needed. In this paper, we present a queueing network model to evaluate patient transitions within hospitals. An iterative method is used to analyze transitions encompassing multiple departments. It is shown that such a method can result in close estimates of transition behavior and provide managerial insights to improve system performance. Moreover, the method is computationally efficient that it can be used to study very large-sized hospitals. [ABSTRACT FROM AUTHOR]

Background: Children and adolescents and young adults (AYAs) with cancer often experience severe respiratory morbidity and mortality from the therapies used to treat their cancers. Few studies have examined respiratory outcomes among this population using emergency department (ED) visits as an objective measure of respiratory health.Methods: ED visits for respiratory conditions were identified for children and AYAs diagnosed with cancer, 0-25 years of age, from 1997 through 2012 (2535 cases) and compared with a birthdate-matched and sex-matched cohort without cancer drawn from the general population (7605 controls). Negative binomial regression with robust standard errors was used to estimate incidence rates, rate ratios (RRs), and 95% confidence intervals for primary respiratory ED visits, combined and by diagnosis (asthma, respiratory disease, and respiratory infection) from 1997 through 2015. Analyses were performed for new cases (0 to <5 years from diagnosis) and survivors (5-18 years from diagnosis).Results: Subjects were followed for an average of 8 years (range, 0-18 years). Relative to the comparison cohort, cancer cases had higher incidence rates for all types of respiratory ED visits over both follow-up times. New cases had significantly higher RRs for any respiratory condition (RR, 4.14), respiratory disease (RR, 4.62), and respiratory infection (RR, 4.74). Among survivors, the RRs for any respiratory condition (RR, 2.00) and respiratory infection (RR, 2.10) were significantly elevated, although the magnitude tended to decline in survivorship. Demographic and clinical risk factors found to be associated with respiratory ED visits included Hispanic/other race/ethnicity, male sex, exposure to chemotherapy, diagnosis at a younger age, and a diagnosis of leukemia.Conclusions: The results of the current study demonstrated that children and AYAs with cancer face an increased burden of respiratory complications compared with a comparison cohort without cancer from diagnosis through survivorship. [ABSTRACT FROM AUTHOR]

The implementation of Point-of-Care Testing (PoCT) services across rural and remote emergency departments (EDs) by NSW Health Pathology has the potential to significantly improve timely access to results for certain types of pathology laboratory tests and help to deliver timely patient care. The aim of this study was to examine the impact of the implementation of PoCT on the length of stay (LOS) of patients in rural and remote EDs. A total of 3808 patients with a circulatory system illness were treated and discharged at any one of 22 rural and remote EDs during the study period. Generalised Estimating Equation (GEE) modelling was applied to examine whether the implementation of PoCT impacted the ED LOS with adjustment for a range of clinical variables. More patients were treated and discharged from these rural and remote EDs within 4-hours after the PoCT implementation (post-PoCT 86.8% versus pre-PoCT 84.3%). Although average ED LOS was 11 minutes shorter in the post-PoCT period, the impact of PoCT on ED LOS was not conclusive after considering other important clinical factors (p=0.07). This study is the one of the few to examine changes in LOS following the introduction of PoCT in EDs in Australia. The study also identified areas where more robust methods could be applied in the future as the quality of PoCT data improves to further assess the potential effects of this technology on practice and outcomes. [ABSTRACT FROM AUTHOR]

Background: Nursing home residents (NHRs) are often transferred to emergency departments (EDs). A great proportion of ED visits is considered inappropriate. There is evidence that male NHRs are more often hospitalised, but this is less clear for ED visits. It is unclear, which influence age has on ED visits. We aimed to study the epidemiology of ED visits in NHRs focusing on age- and sex-specific differences.Methods: A systematic review was carried out based on articles found in MEDLINE (via PubMed), CINAHL and Scopus. Articles published on or before Aug 31, 2017 were eligible. Two reviewers independently identified articles for inclusion. The quality of studies was assessed by the Joanna Briggs Institute critical appraisal tool for prevalence studies.Results: Out of 1192 references, we found seven studies meeting our inclusion criteria. Six studies were conducted in the USA or Canada. Overall, 29-62% of NHRs had at least one ED visit over the course of 1 year. Most studies assessing the influence of sex found that male residents visited EDs more frequently. All but one of the five studies with multivariable analyses reported a statistically significant positive association (with odds or rate ratios of 1.05-1.38). All studies assessed the influence of age. There was no clear pattern with some studies showing no association between ED visits and age and other studies reporting decreasing ED visits with increasing age or increasing proportions followed by a decrease in the highest age group. Studies used 85+ or 86+ years as the highest age category. Hospital admission rate ranged from 36.4 to 48.7%. There was no study reporting stratified analyses by age and sex. Only one study reported main diagnoses leading to ED visits stratified by sex.Conclusion: Male NHRs visit EDs more often than females, but there is no evidence on reasons. The association with age is unclear. Any future study on acute care of NHRs should assess the influence of age and sex. These studies should include large sample sizes to provide a more differentiated age categorisation.Trial Registration: PROSPERO CRD42017074845 . [ABSTRACT FROM AUTHOR]

We examined how demographic and clinical characteristics differ between emergency department (ED) visits for epilepsy (EP cohort) and ED visits for other reasons (non-EP cohort) in children with ASD. The data were drawn from the 2009 and 2010 Nationwide Emergency Department Sample. We performed both univariate and multivariate analyses to compare and contrast similarities and differences between EP cohort and non-EP cohort among children with ASD. The results showed ED visits in EP cohort were more likely to occur among adolescents aged 13-17 years, less likely to occur among children with co-occurring psychiatric conditions, and were more likely to co-occur with injury. We discussed some unique challenges for managing children with both ASD and epilepsy. [ABSTRACT FROM AUTHOR]