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We highlight the need for planning for mass workforce absentees as we prepare for subsequent surges. We suggest a multicomponent intervention including guiding return dates more by symptomatology and fitness for work rather than infectivity status.
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BACKGROUND: We initiated an emergency department (ED) opt-out screening programme for HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) at our hospital in Dublin, Ireland. The objective of this study was to determine screening acceptance, yield and the impact on follow-up care. METHODS: From July 2015 through June 2018, ED patients who underwent phlebotomy and could consent to testing were tested for HIV, HBV and HCV using an opt-out approach. We examined acceptance of screening, linkage to care, treatment and viral suppression using screening programme data and electronic health records. The duration of follow-up ranged from 1 to 36 months. RESULTS: Over the 36-month study period, there were 140 550 ED patient visits, of whom 88 854 (63.2%, 95% CI 63.0% to 63.5%) underwent phlebotomy and 54 817 (61.7%, 95% CI 61.4% to 62.0%) accepted screening for HIV, HBV and HCV, representing 41 535 individual patients. 2202 of these patients had a positive test result. Of these, 267 (12.1%, 95% CI 10.8% to 13.6%) were newly diagnosed with an infection and 1762 (80.0%, 95% CI 78.3% to 81.7%) had known diagnoses. There were 38 new HIV, 47 new HBV and 182 new HCV diagnoses. 81.5% (95% CI 74.9% to 87.0%) of known patients who were not linked were relinked to care after screening. Of the new diagnoses, 86.2% (95% CI 80.4 to 90.8%) were linked to care. CONCLUSION: Although high proportions of patients had known diagnoses, our programme was able to identify many new infected patients and link them to care, as well as relink patients with known diagnoses who had been lost to follow-up.
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Comportamento de Escolha , Serviços de Diagnóstico/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Programas de Rastreamento/normas , Adulto , Serviço Hospitalar de Emergência/organização & administração , Feminino , Infecções por HIV/diagnóstico , Hepatite B/diagnóstico , Hepatite C/diagnóstico , Humanos , Irlanda , Masculino , Programas de Rastreamento/métodos , Programas de Rastreamento/estatística & dados numéricos , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: Studies suggest 2 per 1000 people in Dublin are living with HIV, the level above which universal screening is advised. We aimed to assess the feasibility and acceptability of a universal opt-out HIV, Hepatitis B and Hepatitis C testing programme for Emergency Department patients and to describe the incidence and prevalence of blood-borne viruses in this population. METHODS: An opt-out ED blood borne virus screening programme was piloted from March 2014 to January 2015. Patients undergoing blood sampling during routine clinical care were offered HIV 1&2 antibody/antigen assay, HBV surface antigen and HCV antibody tests. Linkage to care where necessary was co-ordinated by the study team. New diagnosis and prevalence rates were defined as the new cases per 1000 tested and number of positive tests per 1000 tested respectively. RESULTS: Over 45 weeks of testing, of 10,000 patient visits, 8,839 individual patient samples were available for analysis following removal of duplicates. A sustained target uptake of >50% was obtained after week 3. 97(1.09%), 44(0.49%) and 447(5.05%) HIV, Hepatitis B and Hepatitis C tests were positive respectively. Of these, 7(0.08%), 20(0.22%) and 58(0.66%) were new diagnoses of HIV, Hepatitis B and Hepatitis C respectively. The new diagnosis rate for HIV, Hepatitis B and Hepatitis C was 0.8, 2.26 and 6.5 per 1000 and study prevalence for HIV, Hepatitis B and Hepatitis C was 11.0, 5.0 and 50.5 per 1000 respectively. CONCLUSIONS: Opt-out blood borne viral screening was feasible and acceptable in an inner-city ED. Blood borne viral infections were prevalent in this population and newly diagnosed cases were diagnosed and linked to care. These results suggest widespread blood borne viral testing in differing clinical locations with differing population demographic risks may be warranted.
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Infecções por HIV/diagnóstico , Hepatite B/diagnóstico , Hepatite C/diagnóstico , Programas de Rastreamento/métodos , Viremia/epidemiologia , Adulto , Estudos Transversais , Serviço Hospitalar de Emergência , Feminino , Antígenos HIV/sangue , Infecções por HIV/epidemiologia , Hepatite B/epidemiologia , Antígenos de Superfície da Hepatite B/sangue , Hepatite C/epidemiologia , Anticorpos Anti-Hepatite C/sangue , Hospitais Urbanos , Humanos , Irlanda/epidemiologia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Prevalência , Viremia/diagnóstico , Adulto JovemRESUMO
OBJECTIVE: The objective of this study was to develop a consensus among emergency medicine (EM) specialists working in Ireland for emergency department (ED) key performance indicators (KPIs). METHODS: The method employed was a three-round electronic modified-Delphi process. An online questionnaire with 54 potential KPIs was set up for round 1 of the Delphi process. The Delphi panel consisted of all registered EM specialists in Ireland. Each indicator on the questionnaire was rated using a five-point Likert-type rating scale. Agreement was defined as at least 70% of the responders rating an indicator as 'agree' or 'strongly agree' on the rating scale. Data were analysed using standard descriptive statistics. Data were also analysed as the mean of the Likert rating with 95% confidence intervals (95% CIs). Sensitivity of the ratings was examined for robustness by bootstrapping the original sample. Statistical analyses were carried out using SPSS version 16.0. RESULTS: The response rates in rounds 1, 2 and 3 were 86, 88 and 88%, respectively. Ninety-seven potential indicators reached agreement after the three rounds. In the context of the Donabedian structure-process-outcome framework of performance indicators, 41 (42%) of the agreed indicators were structure indicators, 52 (54%) were process indicators and four (4%) were outcome indicators. Overall, the top-three highest rated indicators were: presence of a dedicated ED clinical information system (4.7; 95% CI 4.6-4.9), ED compliance with minimum design standards (4.7; 95% CI 4.5-4.8) and time from ED arrival to first ECG in suspected cardiac chest pain (4.7; 95% CI 4.5-4.9). The top-three highest rated indicators specific to clinical care of children in EDs were: time to administration of antibiotics in children with suspected bacterial meningitis (4.6; 95% CI 4.5-4.8), separate area available within EDs (seeing both adults and children) to assess children (4.4; 95% CI 4.2-4.6) and time to administration of analgesia in children with forearm fractures (4.4; 95% CI 4.2-4.7). CONCLUSION: Employing a Delphi consensus process, it was possible to reach a consensus among EM specialists in Ireland on a suite of 97 KPIs for EDs.
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Medicina de Emergência/normas , Serviço Hospitalar de Emergência/normas , Indicadores de Qualidade em Assistência à Saúde , Adulto , Consenso , Técnica Delphi , Medicina de Emergência/tendências , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Irlanda , Inquéritos e QuestionáriosRESUMO
Aim. To evaluate the utility of a seizure care pathway for seizure presentations to the emergency department (ED) in order to safely avoid unnecessary admission and to provide early diagnostic and therapeutic guidance and minimize length of stay in those admitted. Methods. 3 studies were conducted, 2 baseline audits and a 12-month intervention study and prospective data was collected over a 12-month period (Nov 2008-09). Results. Use of the Pathway resulted in a reduction in the number of epilepsy related admissions from 341 in 2004 to 276 in 2009 (P = 0.0006); a reduction in the median length of stay of those admittedfrom 4-5 days in the baseline audits to 2 days in the intervention study (P ≤ 0.001); an improvement in time to diagnostic investigations such as CT brain, MRI brain and Electroencephalography (P ≤ 0.001, P ≤ 0.048, P ≤ 0.001); a reduction in readmission rates from 45.1% to 8.9% (P ≤ 0.001); and an improvement in follow-up times from a median of 16 weeks to 5 weeks (P < 0.001). From a safety perspective there were no deaths in the early discharged group after 12 months follow-up. Conclusion. The burden of seizure related admissions through the ED can be improved in a safe and effective manner by the provision of a seizure care pathway.
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BACKGROUND: The actual impact of emergency department (ED) 'wait' time on hospital mortality in patients admitted as a medical emergency has often been debated. We have evaluated the impact of such waits on 30-day mortality, for all medical patients over a 7-year period. METHODS: All patients admitted as medical emergencies by the ED between 2002 and 2008 were studied; we looked at the impact of time to medical referral and subsequent time to a ward bed on any inhospital death within 30 days. Significant univariate predictors of outcome, including Charlson's comorbidity and acute illness severity score, were entered into a multivariate regression model, adjusting the univariate estimates of the readmission status on mortality. RESULTS: We studied 23 114 consecutive acute medical admissions between 2002 and 2008. The triage category in the ED was highly predictive of subsequent 30-day mortality ranging from 4.8 (category 5) to 46.1% (category 1). After adjustment for all outcome predictors, including comorbidity and illness severity, both door-to-team and team-to-ward times were independent predictors of death within 30 days with respective odds ratios of 1.13 (95% confidence interval 1.07-1.18), and 1.07 (95% confidence interval 1.02-1.13). CONCLUSION: Delay to admission have been shown to be independently adversely related to mortality outcome. We recommend maximal target limits of 4 and 6 h for referrals and admissions, respectively, based on these mortality observations.
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Serviços Médicos de Emergência/organização & administração , Mortalidade Hospitalar , Humanos , Análise Multivariada , Admissão do Paciente/estatística & dados numéricos , Valor Preditivo dos Testes , Encaminhamento e Consulta/estatística & dados numéricos , Índice de Gravidade de Doença , Fatores de Tempo , Triagem/organização & administraçãoRESUMO
BACKGROUND: In 1998 'Dubdoc', Ireland's first out-of-hours general practice emergency service, opened in an outpatient suite in St James's Hospital with a separate entrance 300â m from the emergency department (ED). Dubdoc was established with the aim of providing an easy access out-of-hours service for ambulatory patients of those doctors supplying the service. AIM: To determine whether ED attendances for patients in the lower acuity triage categories 4 and 5 have changed since the establishment of 'Dubdoc'. METHODS: A retrospective review of all attendances at the 'Dubdoc' service was compared with attendances at the ED for triage categories 4 and 5 of the same hospital over a 9-year period (1999-2007 inclusive) for equivalent times of day. RESULTS: ED attendances during 'Dubdoc' hours have decreased as a proportion of all attendances for triage categories 4 and 5. ED attendances for triage categories 4 and 5 fell substantially during the study period. CONCLUSIONS: Although the presence of the 'Dubdoc' service has resulted in a decrease in ED attendances for triage categories 4 and 5, this is a minor proportion of the overall decrease in attendances in this group of patients.
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Plantão Médico/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Medicina Geral/organização & administração , Adulto , Plantão Médico/estatística & dados numéricos , Área Programática de Saúde , Serviço Hospitalar de Emergência/tendências , Humanos , Irlanda , Área de Atuação Profissional , Estudos Retrospectivos , Triagem/classificaçãoRESUMO
OBJECTIVE: To analyse the presence of women on the editorial teams of emergency medicine journals and the potential relationship between the pre-eminence of the journal and their presence. MATERIALS AND METHODS: In this cross-sectional study, we examined 10 journals cited under the heading of 'Emergency Medicine' by Thomson Scientific in the Journal Citation Reports and 14 additional emergency journals not cited but which publish investigations in emergency medicine. We evaluated the editorial board posted on their websites, determining the number of men and women occupying executive tasks, as well as the sex of the editor-in-chief of each journal. RESULTS: We identified 372 people working on the editorial teams (mean: 15.5, SD: 13.5), 49 being women (13.2%). Of these 372 people, 28 were editors-in-chief but only one was female (3.6%). We found no statistical differences between indexed and nonindexed emergency journals regarding female representation on the editorial team or in the position of editor-in-chief. Neither did we find any relationship between female presence and the pre-eminence of the indexed journals using impact factor as a surrogate marker. CONCLUSION: Very few women are found either on editorial teams or in editor-in-chief positions in the emergency medicine journals, irrespective of the pre-eminence of the journal. It should be investigated whether a negative journal bias underlies these findings.
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Políticas Editoriais , Serviços Médicos de Emergência/estatística & dados numéricos , Publicações Periódicas como Assunto/estatística & dados numéricos , Preconceito , Justiça Social , Estudos Transversais , Europa (Continente) , Feminino , Humanos , Masculino , Editoração , Fatores Sexuais , Estados UnidosRESUMO
We simulate freely jointed chains to investigate how knotting affects the overall shapes of freely fluctuating circular polymeric chains. To characterize the shapes of knotted polygons, we construct enveloping ellipsoids that minimize volume while containing the entire polygon. The lengths of the three principal axes of the enveloping ellipsoids are used to define universal size and shape descriptors analogous to the squared radius of gyration and the inertial asphericity and prolateness. We observe that polymeric chains forming more complex knots are more spherical and also more prolate than chains forming less complex knots with the same number of edges. We compare the shape measures, determined by the enveloping ellipsoids, with those based on constructing inertial ellipsoids and explain the differences between these two measures of polymer shape.
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Polímeros/química , Simulação por Computador , Modelos Moleculares , Conformação MolecularRESUMO
AIMS: The aim of this study was to evaluate the effect of introducing a European Society of Cardiology guideline-based Integrated Care Plan (ICP) for Syncope on hospital admissions and referral patterns to an outpatient Syncope Management Unit, of patients presenting to an Emergency Department (ED) with a syncopal episode and to determine the underlying causes of syncope. METHODS AND RESULTS: This study is a single-centre observational case series of consecutive adult patients presenting to the ED over a 5-month period. Two hundred and fourteen of 18 898 patients (1.1%) had a syncopal episode, 110 (51.4%) of whom were admitted. Forty-six (41.8%) admissions were indicated by the ICP. All potential cardiac syncope cases were admitted. There was a 500% increase in the overall number of referrals to the Syncope Management Unit with a small increase in the number of unnecessary referrals. CONCLUSION: The introduction of an ICP for syncope was not associated with any cases with potential adverse outcomes being lost to follow-up and resulted in increased referral rates to the syncope unit. However, hospitalization rates for syncope remain high, and a large number of patients requiring early outpatient assessment were not referred. There remains a need to develop further interventions to guide appropriate and safe syncope management in the ED.
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Serviço Hospitalar de Emergência , Fidelidade a Diretrizes , Guias de Prática Clínica como Assunto , Síncope/terapia , Adulto , Idoso , Prestação Integrada de Cuidados de Saúde , Serviço Hospitalar de Emergência/estatística & dados numéricos , Europa (Continente) , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Sociedades MédicasRESUMO
BACKGROUND AND PURPOSE: Noncontrast CT (NCCT) has become the standard Imaging study in the emergency department (ED) diagnosis of nephro- and ureterolithiasis. We undertook to audit the results from the first 500 NCCTs performed for patients presenting to the ED with suspected renal colic. PATIENTS AND METHODS: In a retrospective study at one institution from October 2003 to February 2006, 500 patients with suspected stone disease were investigated. In the study, NCCT findings, patient clinical records, and urinary microscopy results were evaluated for 166 women and 334 men. RESULTS: Renal or ureteral calculi were identified in 279 (56%) of NCCTs performed. Of the 500, 112 (19%) NCCTs performed identified unexpected intra-abdominal pathology. When the findings deemed to be of low clinical significance were excluded, the number of scans with additional pathology amounted to 67 (13%). These included vascular emergencies, new cancer diagnoses, and gastrointestinal conditions. CONCLUSIONS: The variety of diagnoses found unexpectedly on the NCCT that alter a patient's treatment demonstrates the pivotal role of NCCT in the triage of these patients rapidly toward optimal therapy. The rapid acquisition time of NCCT has enabled definitive ED patient diagnosis and less bed occupancy for clinically insignificant calculi.