Carbon monoxide poisoning cases in the emergency department are increasing in the last decade in Jerusalem.

BACKGROUND AND AIMS: The aim of our study was to describe the epidemiology of Carbon monoxide poisoning in the Emergency Department. METHODS: A retrospective descriptive analysis of patients with Carbon monoxide poisoning who were presented to the Emergency Department of Hadassah hospital in Jerusalem from 2007 to 2016. All patients that were included are confirmed cases [carboxyhemoglobin level > 5%]. Sources of exposure, seasonal variation, and demographic characteristics were analyzed. RESULTS: There were 244 patients (60% males) with 37 family clusters that accounted for 135 (55.3%) patients. One hundred seventy-three (70.9%) patients presented during the winter months. The main sources of exposure were: non-gas residential heating system, mainly charcoal grills and kerosene stoves (n = 100, 41%). Other sources were fires (n = 70, 28.7%), faulty gas heater (n = 34, 13.9%) and smoking (n = 15, 6.1%). The estimated annual incidence increased from an average of 20.8 cases a year between 2007-2011 to an average of 34 cases in 2011-2016. High-risk poisoning (levels > 25%) occurred in 28 patients (11.5%). Factors associated with severe poisoning were female gender and exposure in clusters compared with individual patients. CONCLUSION: Our current study has showed an increase of Carbon Monoxide poisoning in contrary to our study performed in the previous decade. Fortunately, we did find a lower rate of cases with severe poisoning. Beside the implementation of safer standards for residential heating systems, customized public education is advised in order to lower rates of poisoning in the future. A predicted heavy snow fall should be considered a trigger for a public health warning regarding the risk of CO poisoning.

Social and structural determinants of emergency department use among Arab and Jewish patients in Jerusalem.

BACKGROUND: A growing body of research demonstrates that economic conditions and racial and ethnic disparities result in excessive overuse of emergency departments (EDs) by a small group of socioeconomically marginalized residents. Knowledge and understanding of these issues on the part of the healthcare team can promote equality by providing structurally competent care. This study aims to identify the major social and structural factors related to patterns of ED visits by Arab and Jewish patients in Israel, where access to health services is covered by universal national health insurance. METHODS: A cross-sectional study was conducted using questionnaires of ED patients in a tertiary care medical center in Jerusalem. The hospital is the largest of the three EDs in Jerusalem with over 90,000 adult patient visits a year. The sample was stratified by ethnicity, including 257 Jewish patients and 170 Arab patients. The outcome variable was repeat visits for the same reason to the ED within 30 days. RESULTS: There were differences between Jewish and Arab patients' social and structural characteristics, including health status, socioeconomic status, feeling of safety, and social support. There were also significant differences in some of the characteristics of health service utilization patterns, including ED repeat visits, language barriers when seeking healthcare in the community, and seeking information about medical rights. The variables associated with repeat visits were different between the two groups: among the Arab patients, repeat visits to the ED were associated with concerns about personal safety, whereas among the Jewish patients, they were associated with poverty. CONCLUSION: The study illustrates the gaps that exist between the Arab and Jewish population in Israel. The findings demonstrated significant differences between populations in both health status and access to health services. In addition, an association was found in each ethnic group between different structural factors and repeat ED requests. This study supports previous theories and findings of the relationship between structural and social factors and patterns of health services utilization.

Social and structural determinants and their associations with patient experience in the emergency department.

BACKGROUND: Improving patient experience and satisfaction in the emergency department (ED) is challenging but beneficial. Previous studies have shown an association between social and structural factors and patient satisfaction. This study examined the structural and social factors related to the ED patient experience among Jewish and Arab patients in a Jerusalem hospital. METHODS: A cross-sectional study was conducted among ED patients in a Jerusalem hospital. Data were collected via questionnaires. The sample included 257 Jewish patients and 170 Arab patients. The outcome variable was a positive or negative ED experience. RESULTS: Jewish and Arab patients had different factors related to ED experience. Cultural differences, including a language barrier and access to information, were associated with a negative experience among Arab patients. Among Jewish patients, frequent use of community health services was associated with a negative ED patient experience. CONCLUSION: This study shows an association between social and structural factors and patient experience, illustrating gaps for and vulnerability of different ethnic groups that affect their experience with healthcare services. Understanding these issues and implementing solutions formulated at the institutional and national levels can promote equity by providing structurally competent care.

An analysis of social determinants of health and structural competency training in global emergency medicine fellowship programs in the United States.

BACKGROUND: Clinicians must be aware of the structural forces that affect their patients to appropriately address their unique health care needs. This study aimed to assess the participation of global emergency medicine (GEM) fellowship programs in formal social determinants of health (SDH) and structural competency (SC) training to evaluate the existence and procedures of such programs. METHODS: A cross-sectional study conducted with a short, online survey with questions regarding the presence of curriculum focused on SDH, SC, educational metrics, and the desire for further formal training in this domain was sent to all 25 GEM fellowship directors through the Global Emergency Medicine Fellowship Consortium (GEMFC) email listserv. RESULTS: Eighty percent (20/25) of GEM fellowship directors responded to the survey. All (20/20) of participating fellowship programs included SDH and SC training in their didactic curriculum, and eight of 20 (40%) programs offered similar training for faculty. Additionally, 19 of 20 (95%) of respondents indicated interest in an open-source tool for emergency medicine (EM) fellowship training in SDH and SC. CONCLUSIONS: While multiple GEM programs offer formal training on SDH and SC, gaps exist regarding similar training for faculty. Additionally, there is a lack of metrics to determine fellows' comfort with the content of this training. As a majority of GEMFC programs requested, an open-source tool would allow a uniform curriculum and measurement of EM fellowship training in SDH and SC.

Structural Competency in Conflict Zones: Challenging Depoliticization in Israel.

Structural competency is the trained ability to discern and acknowledge how health care outcomes are shaped by larger political, social, economic, policy, and legal forces and structures. Although structural competency has become an increasingly known framework for training and teaching, especially in the United States, it has usually not been used in nursing and nursing education. Moreover, very little is known about how to implement structural competency programs in conflict zones. Due to depoliticization that often prevails in both the higher education system and the health care system, the political conflict and the structural violence that significantly impact people's health are rarely discussed in these systems. This article examines the potential contribution of structural competency training programs for nurses and nursing students in conflict areas by analyzing a program that has emphasized the impact of the Israeli-Palestinian conflict on the health of Jerusalem's Palestinian residents. The article explains how this program has challenged the denial and silencing of conflict-related sociopolitical issues. At the same time, this program has created heated disagreements and friction. We suggest that structural competency training programs that are adapted to the political context in question may help nurses become organic intellectual leaders and agents of social change for those whose voices are not heard.

The TOLERance Model for Promoting Structural Competency in Nursing.

BACKGROUND: Structural competency is the trained ability to recognize how social, political, economic, and legal structures shape diseases and symptoms. Although structural competency has become an increasingly accepted framework for training and teaching, it usually has not addressed nursing students and has not included marginalized patients as trainers. METHOD: This article analyzes a structural competency training model for nursing students that includes five components: Theory, Observations, Learning from patients, Engagement, and Research (the TOLERance model). RESULTS: The TOLERance model increases the understanding of the interrelation between the individual clinical level and the sociopolitical structural level. It encourages nursing students to actively engage in social, political, and policy issues that affect their patients' health and to advocate for policy change. CONCLUSION: The moral and professional commitment of nurses to their patients demands that they do not ignore the structural forces that are detrimental to their patients' health. The TOLERance model provides nursing students with skills and competencies that help them to fulfill this commitment. [J Nurs Educ. 2020;59(8):425-432.].

Lessons learned from an evaluation of referrals to the emergency department.

BACKGROUND: Emergency department (ED) crowding is an international phenomenon dependent on input, throughput, and output factors. This study aims to determine whether patterns of potentially unnecessary referrals from either primary care physicians (PCPs) or urgent care centers (UCCs) can be identified, thereby to reduce ED visits by patients who could be treated elsewhere. Literature from the United States reports up to 35% unnecessary referrals from UCCs. METHODS: A retrospective cohort study was conducted of patients referred to an ED in Jerusalem by either their PCP or a group of UCCs with a full range of laboratory tests and basic imaging capabilities between January 2017 and December 2017. The data were analyzed to identify referrals involving diagnoses, specialist consultations, and examinations unavailable in the PCP's office or UCC (e.g., ultrasound, CT, echocardiogram, or stress test); these referrals were considered necessary for completion of the patient work-up. If patients were evaluated by an ED physician and sent home after an examination or laboratory test available at least in the UCC, the referrals were considered potentially unnecessary. RESULTS: Significantly more referrals were made by PCPs than UCCs (1712 vs. 280, p < 0.001). Significant differences were observed for orthopedics, general surgery, and obstetrics/gynecology referrals (p = 0.039, p < 0.001, p = 0.003). A higher percentage of patients referred by PCPs had potentially unnecessary visits compared to patients referred by UCCs (13.9% vs. 7.9%, p = 0.005). CONCLUSION: A robust UCC system may help further reduce potentially unnecessary visits (including complex patients) to the ED.