Non-emergency department (ED) interventions to reduce ED utilization: a scoping review.

BACKGROUND: Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs. METHODS: This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population. RESULTS: Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions. CONCLUSION: A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.

Behavioral transition of a fish school in a crowded environment.

In open water, social fish gather to form schools, in which fish generally align with each other. In this work, we study how this social behavior evolves when perturbed by artificial obstacles. We measure the behavior of a group of zebrafish in the presence of a periodic array of pillars. When the pillar density is low, the fish regroup with a typical interdistance and a well-polarized state with parallel orientations, similarly to their behavior in open-water conditions. Above a critical density of pillars, their social interactions, which are mostly based on vision, are screened and the fish spread randomly through the aquarium, orienting themselves along the free axes of the pillar lattice. The abrupt transition from natural to artificial orientation happens when the pillar interdistance is comparable to the social distance of the fish, i.e., their most probable interdistance. We develop a stochastic model of the relative orientation between fish pairs, taking into account alignment, antialignment, and tumbling, from a distribution biased by the environment. This model provides a good description of the experimental probability distribution of the relative orientation between the fish and captures the behavioral transition. Using the model to fit the experimental data provides qualitative information on the evolution of cognitive parameters, such as the alignment or the tumbling rates, as the pillar density increases. At high pillar density, we find that the artificial environment imposes its geometrical constraints to the fish school, drastically increasing the tumbling rate.

Unraveling the causes of the Seoul Halloween crowd-crush disaster.

As the world steadily recovers from the COVID-19 pandemic, managing large gatherings becomes a critical concern for ensuring crowd safety. The crowd-crush disaster in Seoul in 2022 highlights the need for effective predictive crowd management techniques. In this study, an empirical analysis of this incident is conducted using data from various sources, and model-based simulations are created to replicate hazardous crowd conditions in high-risk areas. In the empirical analysis, mobile device data indicates a significant increase in population above normal levels in the disaster area just hours before the incident occurred. In the simulations, a hydrodynamic model is employed to simulate a bidirectional collision, which quantitatively demonstrates that the average density during the crush reached 7.57 ped/m2 (with a maximum of (9.95)ped/m2). Additionally, the average crowd pressure peaked at 1,063 N/m (with a maximum of 1,961 N/m), and the maximum velocity entropy was 10.99. Based on these findings, it can be concluded that the primary causes of the disaster were the substantial population, bidirectional collision, and escalating panic. The results of controlled simulations under various management strategies are then presented. By implementing effective crowd management techniques, crowd safety can be enhanced through quantitative comparisons of these key indicators.

Prison overcrowding and ill-treatment: sentence reduction as a reparation measure. A view from Latin America and Europe.

INTRODUCTION: In recent years mass protest movements have taken to the streets in many countries across the world. Despite strong international and domestic legal protections for the right to freedom of peaceful assembly and other fundamental human rights, entire assemblies are frequently labelled violent and less lethal weapons are used to disperse them. METHODS: This article examines the weapons often used by police against public assemblies. Focusing on striking weapons (batons), chemical irri-tants, kinetic impact projectiles and stun grenades, the article uses examples from various countries to illustrate how these weapons are being used and the associated human rights and health impacts. Re-sults: Worrying trends identified include the use of dangerous or untested equipment, such as thermal foggers to deploy chemical irritants; the use of inherently abusive weapons, such as whips or sjam-boks; and the increasing use of certain types of munitions, specifically indiscriminate kinetic impact projectiles. DISCUSSION: The article seeks to support medical and legal professionals becoming more familiar with the weapons being used in the countries they practice in, the effects of those weapons, and clinical aspects in the presentation and care of those exposed.

A prospective randomised controlled trial investigating household SARS-CoV-2 transmission in a densely populated community in Cape Town, South Africa - the transmission of COVID-19 in crowded environments (TRACE) study.

BACKGROUND: South Africa's first SARS-CoV-2 case was identified 5th March 2020 and national lockdown followed March 26th. Households are an important location for secondary SARS-CoV-2 infection. Physical distancing and sanitation - infection mitigation recommended by the World Health Organization (WHO) at the time - are difficult to implement in limited-resource settings because of overcrowded living conditions. METHODS: This study (ClinicalTrials.gov NCT05119348) was conducted from August 2020 to September 2021 in two densely populated, low socioeconomic Cape Town community sub-districts. New COVID-19 index cases (ICs) identified at public clinics were randomised to an infection mitigation intervention (STOPCOV) delivered by lay community health workers (CHWs) or standard of care group. STOPCOV mitigation measures included one initial household assessment conducted by a CHW in which face masks, sanitiser, bleach and written information on managing and preventing spread were provided. This was followed by regular telephonic follow-up from CHWs. SARS-CoV-2 PCR and IgM/IgG serology was performed at baseline, weeks 1, 2, 3 and 4 of follow-up. RESULTS: The study randomised 81 ICs with 245 HHCs. At baseline, no HHCs in the control and 7 (5%) in the intervention group had prevalent SARS-CoV-2. The secondary infection rate (SIR) based on SARS-CoV-2 PCR testing was 1.9% (n = 2) in control and 2.9% (n = 4) in intervention HHCs (p = 0.598). At baseline, SARS-CoV-2 antibodies were present in 15% (16/108) of control and 38% (52/137) of intervention participants. At study end incidence was 8.3% (9/108) and 8.03% (11/137) in the intervention and control groups respectively. Antibodies were present in 23% (25/108) of control HHCs over the course of the study vs. 46% (63/137) in the intervention arm. CHWs made twelve clinic and 47 food parcel referrals for individuals in intervention households in need. DISCUSSION: Participants had significant exposure to SARS-CoV-2 infections prior to the study. In this setting, household transmission mitigation was ineffective. However, CHWs may have facilitated other important healthcare and social referrals.

Emergency Department Visits And Hospital Capacity In The US: Trends In The Medicare Population During The COVID-19 Pandemic.

Although emergency department (ED) and hospital overcrowding were reported during the later parts of the COVID-19 pandemic, the true extent and potential causes of this overcrowding remain unclear. Using data on the traditional fee-for-service Medicare population, we examined patterns in ED and hospital use during the period 2019-22. We evaluated trends in ED visits, rates of admission from the ED, and thirty-day mortality, as well as measures suggestive of hospital capacity, including hospital Medicare census, length-of-stay, and discharge destination. We found that ED visits remained below baseline throughout the study period, with the standardized number of visits at the end of the study period being approximately 25 percent lower than baseline. Longer length-of-stay persisted through 2022, whereas hospital census was considerably above baseline until stabilizing just above baseline in 2022. Rates of discharge to postacute facilities initially declined and then leveled off at 2 percent below baseline in 2022. These results suggest that widespread reports of overcrowding were not driven by a resurgence in ED visits. Nonetheless, length-of-stay remains higher, presumably related to increased acuity and reduced available bed capacity in the postacute care system.

[Process nurse: the experience of the Emergency Department of Fano]. / Infermiere di processo: l'esperienza del Pronto Soccorso di Fano.

. Process nurse: the experience of the Emergency Department of Fano. INTRODUCTION: Overcrowding in Emergency Departments (ED) is a common worldwide phenomenon. Strategies are needed to manage the excessive influx and length of stay in the Accidents and Emergency (A&E) ward, which may adversely affect the organization of care. The process nurse (PN) has been proposed, but the literature lacks rigorous studies on its effectiveness. PURPOSE: The pilot study was conducted to evaluate how the PN affects thre length of stay and drop-out rate after triage of selected users accessing the A&E. METHODS: The PN was introduced in the A&E of the Santa Croce Hospital in Fano-AST Pesaro Urbino. Users with codes 3, 4, 5 and the most frequent causes for A&E visits were included. The length of stay and drop-out rate after triage were compared between users assigned to the PN and those who, at the same time and with the same problem and access codes, followed the standard process. RESULTS: In November 2022, 943 users were enrolled, 214 cared by the PN and 729 with standard care. The mean time spent in the A&E was significantly lower in the PN group (206.7 ± SD 144.2 minutes vs 282.4 ± SD 208.9 minutes, p <0.0001). The discharge rate was higher in the PN group (89.7% vs 75.3% p <0.0001), while the drop-out rate was lower (9.8% vs 24.1% p <0.0001). CONCLUSIONS: The results highlight the potentialities of PN in the A&E and at triage, emphasizing its ability to speed up, facilitate, and optimize care pathways.

Effect of access block on emergency department crowding calculated by NEDOCS score.

OBJECTIVE: Emergency department (ED) crowding poses a significant challenge in healthcare systems globally, leading to delays in patient care and threatening public health and staff well-being. Access block, characterized by delays in admitting patients awaiting hospitalization, is a primary contributor to ED overcrowding. To address this issue, the National Emergency Department Overcrowding Study (NEDOCS) score provides an objective framework for assessing ED crowding severity. This study aims to evaluate the impact of access block on ED crowding using the NEDOCS score and to explore strategies for mitigating overcrowding through scenarios over a 39-day period. METHODS: A single-center, prospective, observational study was conducted in an urban tertiary care referral center. The NEDOCS score was collected six times daily, including variables like total ED patients, ventilated patients, boarding patients, the longest waiting times, and durations of boarding patients. NEDOCS scores were recorded, and calculations were performed to assess the potential impact of eliminating access block in scenarios. RESULTS: NEDOCS scores ranged from 62.4 to 315, with a mean of 146, indicating consistent overcrowding. Analysis categorized ED conditions into different levels, revealing that over 81.2% of the time, the ED was at least overcrowded. The longest boarding patient's waiting duration was identified as the primary contributor to NEDOCS (48.8%). Scenarios demonstrated a significant decrease in NEDOCS when access block was eliminated through timely admissions. Shorter boarding times during non-working hours suggest the potential mitigating effect of external factors on the access barrier. Additionally, daytime measurements were associated with lower patient admissions and shorter wait times for initial assessment. CONCLUSION: Although ED crowding is a multifactorial problem, our study has shown that access block contribute significantly to this problem. The study emphasizes that eliminating access block through timely admissions could substantially alleviate crowding, highlighting the importance of addressing this issue to enhance ED efficiency and overall healthcare delivery.

Investigating the biological relevance of measuring gastrointestinal cortisol metabolite levels to assess stress responses in Atlantic salmon (Salmo salar L.) after an acute stress.

Monitoring stress levels of farmed Atlantic salmon (Salmo salar) is important to ensure fish welfare and optimize farm operations. Feces could be a promising matrix for assessing stress responses in fish, based on their properties of low-invasive sampling and allowing repeated sampling over time. Meanwhile, elevated levels of cortisol metabolites (CMs) in feces indicate the increases in plasma cortisol levels (PLA) after exposure to acute stress. However, the dynamics of fecal CMs following acute stress in Atlantic salmon remain unclear. In this study, a confinement stress involving chasing and crowding was conducted to investigate the responses of gastrointestinal CMs to an acute stressor in Atlantic salmon. The post-smolts, with an average weight of 155.21 g, were sampled before and at 30 min, 1.5, 6, 12, 18, 24, 36, and 48 h after the onset of stress. Blood and gastrointestinal contents from the stomach, proximal intestine, and distal intestine of each fish were collected and subsequently analyzed, using competitive enzyme-linked immunosorbent assay (ELISA). The results demonstrated that the pre-stress level of PLA was low (4.28 ± 6.13 ng/ml) and reached a peak within 30 min following stress. The levels of CMs in gastrointestinal contents from stomach (SCMs), proximal intestine (PCMs), and distal intestine (DCMs) in pre-stress group were 0.82 ± 0.50, 18.31 ± 6.14 and 16.04 ± 6.69 ng/g, respectively. Gastrointestinal CMs increased significantly within 30 min and the peak levels of SCMs (3.51 ± 3.75 ng/g), PCMs (68.19 ± 23.71 ng/g) and DCMs (65.67 ± 23.37 ng/g) were found at 1.5 h post-stress. The significant increases in PCMs and DCMs post-stress validate the biological relevance of measuring intestinal CMs for assessing acute stress responses in Atlantic salmon. No significant difference was noted between PCMs and DCMs across all samples, suggesting that intestinal contents can serve as a suitable matrix compared with feces when measuring the responses of CMs to acute stress. The time lag between the peak of PLA levels and their reflection in the intestinal contents exceeded 1 h, indicating that using intestinal contents as a matrix to assess stress levels in fish can extend and delay the sampling window. This study highlights valuable guidance for determining the optimal times to utilize intestinal contents for measuring stress responses, providing further insights into the dynamics of fecal CM following acute stress.

A study on deep learning model based on global-local structure for crowd flow prediction.

Crowd flow prediction has been studied for a variety of purposes, ranging from the private sector such as location selection of stores according to the characteristics of commercial districts and customer-tailored marketing to the public sector for social infrastructure design such as transportation networks. Its importance is even greater in light of the spread of contagious diseases such as COVID-19. In many cases, crowd flow can be divided into subgroups by common characteristics such as gender, age, location type, etc. If we use such hierarchical structure of the data effectively, we can improve prediction accuracy of crowd flow for subgroups. But the existing prediction models do not consider such hierarchical structure of the data. In this study, we propose a deep learning model based on global-local structure of the crowd flow data, which utilizes the overall(global) and subdivided by the types of sites(local) crowd flow data simultaneously to predict the crowd flow of each subgroup. The experiment result shows that the proposed model improves the prediction accuracy of each sub-divided subgroup by 5.2% (Table 5 Cat #9)-45.95% (Table 11 Cat #5), depending on the data set. This result comes from the comparison with the related works under the same condition that use target category data to predict each subgroup. In addition, when we refine the global data composition by considering the correlation between subgroups and excluding low correlated subgroups, the prediction accuracy is further improved by 5.6-48.65%.

Synergistic olfactory processing for social plasticity in desert locusts.

Desert locust plagues threaten the food security of millions. Central to their formation is crowding-induced plasticity, with social phenotypes changing from cryptic (solitarious) to swarming (gregarious). Here, we elucidate the implications of this transition on foraging decisions and corresponding neural circuits. We use behavioral experiments and Bayesian modeling to decompose the multi-modal facets of foraging, revealing olfactory social cues as critical. To this end, we investigate how corresponding odors are encoded in the locust olfactory system using in-vivo calcium imaging. We discover crowding-dependent synergistic interactions between food-related and social odors distributed across stable combinatorial response maps. The observed synergy was specific to the gregarious phase and manifested in distinct odor response motifs. Our results suggest a crowding-induced modulation of the locust olfactory system that enhances food detection in swarms. Overall, we demonstrate how linking sensory adaptations to behaviorally relevant tasks can improve our understanding of social modulation in non-model organisms.

Robust spatial self-organization in crowds of asynchronous pedestrians.

Human crowds display various self-organized collective behaviours, such as the spontaneous formation of unidirectional lanes in bidirectional pedestrian flows. In addition, parts of pedestrians' footsteps are known to be spontaneously synchronized in one-dimensional, single-file crowds. However, footstep synchronization in crowds with more freedom of movement remains unclear. We conducted experiments on bidirectional pedestrian flows (24 pedestrians in each group) and examined the relationship between collective footsteps and self-organized lane formation. Unlike in previous studies, pedestrians did not spontaneously synchronize their footsteps unless following external auditory cues. Moreover, footstep synchronization generated by external cues disturbed the flexibility of pedestrians' lateral movements and increased the structural instability of spatial organization. These results imply that, without external cues, pedestrians marching out of step with each other can efficiently self-organize into robust structures. Understanding how asynchronous individuals contribute to ordered collective behaviour might bring innovative perspectives to research fields concerned with self-organizing systems.

Does household size matter? Crowding and its effects on child development.

There is very little compelling evidence that household size negatively affects child development. In this study, the effects of household size on child development were analysed using data collected for a sample of 1311 four-year-old Jamaican children. Children's development was assessed using the Griffiths Mental Development Scales across six developmental domains: locomotor, personal-social, language, coordination, performance and practical reasoning. The findings suggest that children's locomotor and personal-social development are negatively affected by household crowding, with no significant effects observed for other domains. Additional results show that these adverse effects are strongest if the child lives in a single room compared to a separately detached house. This evidence speaks to the need to tailor policies towards access to good housing infrastructure and the provision of recreational spaces to encourage play and social interaction among children.

Pearls for Caring for the Boarding Psychiatric Patient in the Emergency Department.

BACKGROUND: Emergency department (ED) boarding of psychiatric patients is a national issue that continues to worsen at a disturbing rate. Implementing strategies in the ED to provide continuous care for patients can help secure patient safety. OBJECTIVE: The objective of this review is to discuss the boarding of psychiatric patients and its implications. It will focus on executing best clinical practices in managing boarding psychiatric patients in the ED. It will not focus on the treatment of substance use disorders. DISCUSSION: This article will address the pearls for management plans that can be implemented in the ED, alongside discussing pregnant and elderly patients. Risk factors, complications, and treatments for boarding psychiatric patients are discussed. CONCLUSIONS: Patients with psychiatric disorders boarding in the ED need careful consideration of management plans to mitigate patient safety events.

Health mediation does not reduce the readmission rate of frequent users of emergency departments living in precarious conditions: what lessons can be learned from this randomised controlled trial?

BACKGROUND: Severe overcrowding of emergency departments (EDs) affects the quality of healthcare. One factor of overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. The primary aim was to determine whether HM intervention for frequent users of EDs (FUED) living in precarious conditions could reduce the readmission rate at 90 days. METHODS: Between February 2019 and May 2022, we enrolled and interviewed 726 FUED in four EDs of southeastern France in this randomised controlled trial. The HM intervention started in the ED and lasted 90 days. In addition to the primary endpoint (first readmission at 90 days), secondary endpoints (readmission at 30 and 180 days, number of hospitalisations at 30, 90, 180 days, admissions for the same reasons as the first admission) were also studied. The outcomes were measured in the ED information systems. Statistical methods included an intention-to-treat analysis and a per-protocol analysis. Comparisons were adjusted for gender, age, ED, and health mediator. RESULTS: 46% of patients reported attending the ED because they felt their life was in danger, and 42% had been referred to the ED by the emergency medical dispatch centre or their GP; 40% of patients were considered to be in a serious condition by ED physicians. The proportion of patients who were readmitted at 90 days was high but did not differ between the control and the HM intervention groups (31.7% vs. 36.3%, p = 0.23). There was no significant difference in any of the secondary outcome measures between the control and HM intervention groups. Per-protocol analysis also showed no significant difference for the primary and secondary endpoints. CONCLUSIONS: This randomised controlled trial did not show that our health mediation intervention was effective in reducing the use of emergency services by FUED living in precarious conditions. Some limitations are discussed: the duration of the intervention (90 days), the long-term effects (> 6 months), the involvement of the ED staff. TRIAL REGISTRATION: Registered on clinicaltrials.gov as NCT03660215 on 4th September 2018.

Safety-in-Numbers for route choice of bicycle trips: A choice experiment approach for commuters.

Safety-in-Numbers (SiN) implies that the risk of collision per road user is less when there are more road users. Although the available literature has confirmed the existence of SiN as an objective measure of safety, the effect on perceived safety, especially in the context of bicycle riders, has received much less attention. This study investigates the SiN effect on the perceived safety of bicycle riders that influences route choice behavior. A stated preference survey was performed in the South Delhi district of Delhi. The effect of attributes like posted speed limit, the volume of motorized traffic, bicycle infrastructure, and bicycle traffic/ crowding on route choice behavior was investigated. A binary logit model was developed to quantify the effect of these attributes on route choice. The results indicate that, in general, riders prefer routes with more bicycle traffic, hence validating SiN. But the effect does not always hold. For some riders, in the presence of dedicated bicycle infrastructure, when the perceived safety is higher, the presence of more bicycle traffic acts as crowding and demotivates riders to choose that route. The study also reveals that riders prefer routes with a low volume of motorized traffic and dedicated bicycle infrastructure. The outcomes suggest that a policy that encourages infrastructural development to provide lateral separation will encourage more people, hence increasing bicycle mode share as well as the perceived safety of riders.