WtsWrng Interim Comparative Effectiveness Evaluation and Description of the Challenges to Develop, Assess, and Introduce This Novel Digital Application in a Traditional Health System.

Science and technology have evolved quickly during the two decades of the 21st century, but healthcare systems are grounded in last century's structure and processes. Changes in the way health care is provided are demanded; digital transformation is a key driver making healthcare systems more accessible, agile, efficient, and citizen-centered. Nevertheless, the way healthcare systems function challenges the development (Innovation + Development and regulatory requirements), assessment (methodological guidance weaknesses), and adoption of digital applications (DAs). WtsWrng (WW), an innovative DA which uses images to interact with citizens for symptom triage and monitoring, is used as an example to show the challenges faced in its development and clinical validation and how these are being overcome. To prove WW's value from inception, novel approaches for evidence generation that allows for an agile and patient-centered development have been applied. Early scientific advice from NICE (UK) was sought for study design, an iterative development and interim analysis was performed, and different statistical parameters (Kappa, B statistic) were explored to face development and assessment challenges. WW triage accuracy at cutoff time ranged from 0.62 to 0.94 for the most frequent symptoms attending the Emergency Department (ED), with the observed concordance for the 12 most frequent diagnostics at hospital discharge fluctuating between 0.4 to 0.97; 8 of the diagnostics had a concordance greater than 0.8. This experience should provoke reflective thinking for DA developers, digital health scientists, regulators, health technology assessors, and payers.

Factors associated with erroneous emergency department noncardiac chest pain classifications in men and women. / Análisis individualizado por sexo de los factores asociados a la clasificación inicial errónea en urgencias del dolor torácico como no coronario.

OBJECTIVES: To analyze the frequency and clinical characteristics associated with erroneous initial classifications of noncardiac chest pain (NCP) in men and women. MATERIAL AND METHODS: We analyzed all case records in which chest pain was initially classified as noncardiac in origin according to clinical signs and electrocardiograms evaluated in our emergency department between 2008 and 2017. We considered the initial evaluation of NCP to be in error if the final diagnosis was acute coronary syndrome. A risk model for an erroneous initial classification of NCP was developed based on multivariable analysis of our patient data. We also used multivariable analysis to explore associations between 10 clinical signs of chest pain and an erroneous initial NCP classification. The data for men and women were analyzed separately. RESULTS: NCP was the initial classification for 8093 women; their median (interquartile range) age was 54 (38-73) years. The classification was in error for 72 women (0.9%). Odds ratios (ORs) showed that patient risk factors associated with an erroneous NCP classification in the women in our series were obesity (OR, 0.40; 95% CI, 0.17- 0.97) and cocaine consumption (OR, 5.18; 95% CI, 1.16-23.2). Clinical risk factors associated with erroneous NCP classification in women were recent physical exertion (OR, 2.01; 95% CI, 1.21-3.33), radiation exposure (OR, 2.05; 95% CI, 1.23-3.41), and vegetative symptoms (OR, 1.86; 95% CI, 1.02-3.41). For 9979 men with a median age of 47 (33-64) years, NCP was the initial classification; in 83 of the men (0.8%) the classification was erroneous. Patient factors associated with erroneous NCP classification in men were age over 40 years (OR, 1.74; 95% CI, 1.04-2.91) and hypertension (OR, 0.45; 95% CI, 0.24-0.84). No clinical signs of chest pain in men were associated with error. CONCLUSION: More clinical characteristics are associated with an erroneous classification of NCP in women. Our findings underline the need to assess the possibility of acute coronary syndrome differently in women, in whom the signs have usually been considered to be atypical.

OBJETIVO: Analizar de forma independiente en mujeres y hombres la frecuencia y las características clínicas asociadas a una clasificación inicial errónea (CIE) en urgencias del dolor torácico (DT) como no coronario. METODO: Se analizan todas las consultas por DT atendidas en urgencias entre 2008 y 2017 clasificadas inicialmente (historia clínica y ECG) como DT no coronario. Se consideró como CIE si el diagnóstico final fue síndrome coronario agudo (SCA). Se crearon dos modelos multivariable, uno con 10 factores de riesgo, y otro con 10 características clínicas del DT, en los que se investigó la asociación de estas variables con una CIE. Se analizaron independientemente mujeres y hombres. RESULTADOS: Se analizaron 8.093 mujeres con DT clasificado inicialmente como no coronario (edad mediana: 54 años, RIC: 38-73), 72 con CIE (0,9%). Los factores de riesgo asociados independientemente a CIE fueron obesidad (OR = 0,40; IC 95% = 0,17-0,97) y consumo de cocaína (5,18; 1,16-23,2), y las características clínicas fueron relación con el esfuerzo (2,01; 1,21-3,33), existencia de irradiación (2,05; 1,23-3,41) y síntomas vegetativos acompañantes (1,86; 1,02-3,41). Se analizaron 9.979 hombres (edad mediana: 47 años, RIC: 33-64), 83 con CIE (0,8%). Los factores de riesgo asociados a CIE fueron edad > 40 años (1,74; 1,04-2,91) e hipertensión (0,45; 0,24-0,84). No hubo características clínicas del DT asociadas a CIE. CONCLUSIONES: En las mujeres con dolor torácico, se idenfitican más características asociadas al error de clasificación que en los hombres. Este estudio remarca la necesidad de análisis independiente por sexo en el SCA, en el que clásicamente se ha considerado la clínica en las mujeres como atípica.

Factors associated with late presentation to the emergency department in patients complaining of chest pain.

OBJECTIVE: We investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP). METHODS: All CP cases attended at a single ED (2008-2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS). RESULTS: The cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS. CONCLUSION: Some characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS. PRACTICE IMPLICATIONS: Patient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.

Influence of previous coronary artery bypass grafting in the difficulty of acute coronary syndrome diagnosis.

OBJECTIVES: To investigate whether the diagnosis of acute coronary syndrome (ACS) in coronary artery bypass grafting (CABG) patients with chest pain (CP) is more difficult based on the initial clinical and electrocardiogram (ECG) findings. METHODS: We included consecutive CP patients attended at a single emergency department (ED) during a 10-year period. CABG status and the final diagnosis of ACS were considered as stated in the ED discharge report. We evaluated the frequency of 21 CP characteristics (CPC) and four ECG signatures, their individual and collective association with ACS, and ED length of stay (LOS) in CABG and non-CABG patients. RESULTS: We included 34 429 patients [median age: 61 years; female: 41.8%; CABG: 2204 patients (6.4%)], and ACS was diagnosed in 6727 (19.5%; CABG/non-CABG 37.2%/18.3%; P < 0.001). CABG patients more frequently had CPC and ECG findings typically associated with ACS, but their final association with ACS was weaker than in non-CABG patients (only significant after adjustment for attendant diaphoresis, throat irradiation, ST-segment elevation and T-wave inversion). The collective discriminative capacity was significantly lower in CABG patients (area under the curve 0.710 vs. 0.793; P < 0.001), even after adjustment (0.708 vs. 0.790; P < 0.001). ED LOS was longer for CABG patients, overall (P < 0.001) and for patients diagnosed with ACS (P = 0.008) and non-ACS (P < 0.001), but these differences disappeared after adjustment. CONCLUSION: CABG substantially reduces the diagnostic performance of CPC and ECG findings to suggest ACS. A longer LOS in the ED in CABG patients is more related to their baseline characteristics than to CABG itself.

External validation of an emergency department triage algorithm for chest pain patients.

BACKGROUND: We aimed to externally validate an emergency department triage algorithm including five hierarchical clinical variables developed to identify chest pain patients at low risk of having an acute coronary syndrome justifying delayed rather than immediate evaluation. METHODS: In a single-centre cohort enrolling 29,269 consecutive patients presenting with chest pain, the performance of the algorithm was compared against the emergency department discharge diagnosis. In an international multicentre study enrolling 4069 patients, central adjudication by two independent cardiologists using all data derived from cardiac work-up including follow-up served as the reference. Triage towards 'low-risk' required absence of all five clinical 'high-risk' variables: history of coronary artery disease, diabetes, pressure-like chest pain, retrosternal chest pain and age above 40 years. Safety (sensitivity and negative predictive value (NPV)) and efficacy (percentage of patients classified as low risk) was tested in this initial proposal (Model A) and in two additional models: omitting age criteria (Model B) and allowing up to one (any) of the five high-risk variables (Model C). RESULTS: The prevalence of acute coronary syndrome was 9.4% in the single-centre and 28.4% in the multicentre study. The triage algorithm had very high sensitivity/NPV in both cohorts (99.4%/99.1% and 99.9%/99.1%, respectively), but very low efficacy (6.2% and 2.7%, respectively). Model B resulted in sensitivity/NPV of 97.5%/98.3% and 96.1%/89.4%, while efficacy increased to 14.2% and 10.4%, respectively. Model C resulted in sensitivity/NPV of 96.7%/98.6% and 95.2%/91.3%, with a further increase in efficacy to 23.1% and 15.5%, respectively. CONCLUSION: A triage algorithm for the identification of low-risk chest pain patients exclusively based on simple clinical variables provided reasonable performance characteristics possibly justifying delayed rather than immediate evaluation in the emergency department.

Prehospital emergency services in Catalonia: the SEPHCAT analysis. / Estudio SEPHCAT: análisis de los servicios de emergencias prehospitalarios en Cataluña.

OBJECTIVES: To describe the main characteristics of all prehospital emergency services (SEPHs, the Catalan acronym) in Catalonia (the SEPHCAT study). MATERIAL AND METHODS: A professional survey researcher interviewed the medical directors of all services in Catalonia, using a questionnaire prepared by the authors. Questions covered aspects related to organization, professional staffing and employment conditions, as well as the staff's training, instructional activity and research. Only closed answers were collected. The survey reflected the situation in 2015. RESULTS: We identified 13 SEPHs (11 in the public health service and 2 private companies). Together they received 2 482 627 calls (16.4% to private services) and attended 943 849 emergencies (11.8% attended by private companies). Three hundred thirty-six basic life support units and 73 advanced life support units were reported. They were mostly considered to be of sufficient size and quality. The SEPHs contracted 1374845 person-hours/y (753995 physician-hours and 620 850 nurse-hours; 23.4% in private companies). These figures correspond to 815 full-time staff positions (447 for physicians and 368 for nurses). The numbers of physicians and nurses working were relatively stable during the morning, afternoon and evening shifts but decreased during the midnight-to-early-morning shift (physicians, by 31%; nurses, by 9%). A majority of the physicians employed were trained in family and community medicine (56.8%), but 21.3% had no specialized training; 6.5% had PhD degrees. SEPH physicians (61.5%) and nurses (46.2%) also taught undergraduate medical students; 46.2% of physicians and 84.6% of nurses taught postgraduate medical courses. Both undergraduate medical and nursing students were received in the same measure for practical training by 15.4% of the SEPHs; 69.2% also offered practical training for physicians at the postgraduate level and 76.9% trained postgraduate nurses. CONCLUSION: SEPHs in Catalonia are very active, and private companies account for nearly 12% of the activity. Together the public and private sectors employ a large number of physicians and nurses. Staff members are involved in training others but are less involved in research.

OBJETIVO: Describir las principales características de todos los servicios de emergencias prehospitalarios (SEPH) existentes en Cataluña. METODO: Una encuestadora profesional entrevistó a los responsables clínicos de todos los SEPH de Cataluña. La encuesta fue preparada por los autores, y abordaba diversos aspectos organizativos, profesionales, laborales, formativos, docentes y de investigación. Las preguntas contenidas en la encuesta solo permitían respuestas cerradas, y hacían referencia a la situación en 2015. RESULTADOS: Se identificaron 13 SEPH (11 públicos, 2 privados), que recibieron 2.482.627 consultas (16,4% a SEPH privados) y realizaron 943.849 atenciones (11,8% por SEPH privados). Había 336 bases de soporte vital básico y 73 de avanzado, con instalaciones mayoritariamente consideradas de tamaño suficiente y calidad buena. Se contrataron 1.374.845 horas anuales (753.995 de médico y 620.850 de enfermero), el 23,4% de ellas por SEPH privados, que globalmente corresponderían a 815 puestos de trabajo a jornada completa (447 de médico, 368 de enfermero). La dotación de médicos/enfermeros era relativamente estable durante el día, pero decaía un 31%/9% de madrugada. La especialidad médica mayoritaria era medicina familiar y comunitaria (56,8%), el 21,3% no tenía formación especializada, y el 6,5% tenía título de doctor. Había médicos/enfermeros profesores universitarios de grado en el 61,5%/46,2% de los SEPH; y de postgrado en el 46,2%/84,6%. Recibían estudiantes de medicina/enfermería en prácticas de grado el 15,4%/15,4% de los SEPH, y de postgrado el 69,2%/76,9%. CONCLUSIONES: La actividad de los SEPH en Cataluña es elevada; un 12% la desarrollan SEPH privados, y globalmente implica a un número alto de médicos y enfermeros, los cuales además desarrollan un rol docente y, en menor medida, investigador.

Nontraumatic chest pain and suspicion of acute coronary syndrome: associated clinical and electrocardiographic findings on initial evaluation. / Asociación entre los datos clínicos y electrocardiográficos iniciales en pacientes con dolor torácico no traumático y la sospecha inicial y el diagnóstico final de síndrome coronario agudo.

OBJECTIVES: To analyze clinical data and electrocardiographic (ECG) findings obtained during the initial evaluation of patients with nontraumatic chest pain (NTCP). To explore associations between these findings and the initial and final diagnoses of acute coronary syndrome (ACS). To assess which variables initially over- or underestimate risk ACS. MATERIAL AND METHODS: Consecutive patients with NTCP attended in a chest pain unit during the 10-year period of 2008-2017 were included if the suspected and discharge diagnoses of interest (ACS or non-ACS) had been recorded. Thirtythree independent variables (demographic, 2; cardiovascular, 5; chest pain, 22; ECG, 4). We included all variables in models to calculate crude and adjusted odds ratios (ORs) between each independent variable and the initial and final diagnoses. The adjusted ORs were compared to determine whether the initial and final diagnoses of ACS differed significantly in relation to the variables. RESULTS: A total of 34 552 patient visits were attended. The ORs for the 33 variables were significantly associated with initial and final NTCP classification as ACS or non-ACS, and in many cases the association was confirmed by the adjusted ORs. The adjusted ORs for 19 variables were significantly different in their relation to the initial and final diagnoses of ACS: 10 overpredicted the probability of the diagnosis and 9 underpredicted it. CONCLUSION: The variables traditionally used to warn of ACS in emergency patients with NTCP identify individuals likely to be initially and finally diagnosed with ACS. However, some of these variables overestimate or underestimate the risk of a final ACS diagnosis. Emergency medicine physicians should be aware of variables associated with underestimation of risk.

OBJETIVO: Evaluar la utilidad del cuestionario COPD Asessment Test (CAT) para valorar la recuperación de la exacerbación de la enfermedad pulmonar obstructiva crónica (EA-EPOC). Evaluar si la puntuación CAT aumenta la capacidad predictiva de mala evolución de una escala de gravedad para EA-EPOC. METODO: Se incluyeron las consultas consecutivas por DTNT en una unidad de dolor torácico durante 10 años (2008-2017) en las que se disponía de los diagnósticos inicial de sospecha (SCA/no SCA) y final de alta de urgencias (SCA/no SCA). Se incluyeron 33 variables independientes (2 demográficas, 5 comorbilidad cardiovascular, 22 dolor torácico, 4 datos ECG). Se calcularon las odds ratio (OR) para la clasificación (inicial y final) como SCA para cada variable independiente, crudas y ajustadas en modelos globales que incluían todas ellas. En estos modelos ajustados se comparó si las OR para la clasificación inicial y final como SCA eran significativamente diferentes. RESULTADOS: Se incluyeron 34.552 visitas. Las 33 variables analizadas mostraron asociación significativa para la clasificación inicial y final del DTNT como SCA, y en muchos casos esta asociación se mantuvo en el modelo ajustado. Diecinueve variables mostraron OR significativamente diferentes para la sospecha inicial de SCA que para el diagnóstico final de SCA: 10 sobrestimaban la asociación final y 9 la subestimaban. CONCLUSIONES: Los datos clínicos iniciales clásicamente utilizados para sospechar SCA pacientes con DTNT en urgencias identifican todos ellos individualmente a pacientes con riesgo incrementado de ser clasificado inicial y finalmente como SCA; sin embargo, algunos de ellos sobreestiman y otros subestiman inicialmente el riesgo final. Los urgenciólogos debieran sensibilizarse más con estos datos subestimados.

Changes in cases of nontraumatic chest pain treated in a chest pain unit over the 10-year period of 2008-2017. / Evolución de las características de las visitas por dolor torácico no traumático en una unidad de dolor torácico durante un periodo de 10 años (2008-2017).

OBJECTIVES: To analyze changes in the characteristics of consecutively treated patients attended in the chest pain unit of a hospital emergency department over a 10-year period. MATERIAL AND METHODS: All patients presenting with nontraumatic chest pain (NTCP) were included. We analyzed changes over time in epidemiologic characteristics, initial diagnostic classification (on clinical and electrocardiographic evaluation), final diagnosis (on discharge), and time until these diagnoses. RESULTS: A total of 34 552 consecutive patients with a mean (SD) age of 59 (13) years were included; 42% were women. The annual number of visits rose over time. Visits were fewer in summer and more numerous on workdays and between the hours of 8 AM and 4 PM (P<.001, both comparisons). The number of women increased over time (up 0.29% annually, P<.05) as did the number of patients under the age of 50 years (up 0.92% annually, P<.001). With time, patients had fewer cardiovascular risk factors and less often had a history of ischemic heart disease. Fewer cases of NTCP had signs suggestive of acute coronary syndrome (ACS). ACS was ruled out at the time of initial and final diagnoses in 52.2% and 80.4%, respectively, and these percentages which rose over the 10-year period by 1.86% (P<.001) and 0.56% (P=.04). Time to initial diagnosis did not change. However, time to final diagnosis did increase (P<.001), and the delay was longer in patients diagnosed with ACS (P<.001). CONCLUSION: The chest pain unit was more active at the end of the period, in keeping with the increase in patients with NTCP whose characteristics were not typical of coronary disease. The percentages of patients initially and finally diagnosed with ACS decreased with time.

OBJETIVO: Analizar la evolución de las características epidemiológicas de las visitas atendidas de forma consecutiva en una unidad de dolor torácico (UDT) de un servicio de urgencias hospitalario (SUH) durante un periodo de 10 años. METODO: Se incluyeron todas las visitas por dolor torácico no traumático (DTNT), analizándose la evolución temporal de las características epidemiológicas, de la clasificación diagnóstica inicial (evaluación clínica inicial y electrocardiograma) y final (al alta de la UDT), y los tiempos necesarios para alcanzar las mismas. RESULTADOS: Se incluyeron 34.552 pacientes consecutivos con una edad media 59 (DE 13) años, el 42% mujeres. Se observó un incrementó en el número anual de visitas a la UDT (p < 0,001), menor afluencia los meses de verano (p < 0,001), y mayor los días laborables (p < 0,001) y de 8-16 horas (p < 0,001). Se comprobó que progresivamente más pacientes eran mujeres (+0,29% anual, p < 0,05), menores de 50 años (+0,92%, p < 0,001), con más factores de riesgo cardiovascular, menos antecedentes de cardiopatía isquémica y con DTNT menos sugestivo de síndrome coronario agudo (SCA). La clasificación diagnóstica inicial y final descartó SCA en un 52,2% y un 80,4% de pacientes, respectivamente, hecho que aumentó progresivamente durante el periodo evaluado (+1,86%, p < 0,001; y +0,56%, p = 0,04; respectivamente). El tiempo de clasificación inicial no se modificó, pero se incrementó el necesario para la clasificación final (p < 0,001), que resultó superior en pacientes con diagnóstico final de SCA (p < 0,001). CONCLUSIONES: Se observa un mayor uso de la UDT tras su creación, causado por un incremento de pacientes con DTNT de características no típicamente coronarias, disminuyendo el porcentaje de clasificados inicial y finalmente como debidos a SCA.

Triage level assignment and nurse characteristics and experience. / Relación entre la asignación del nivel de triaje y las características y experiencia del personal de enfermería.

OBJECTIVES: To study the relation between nursing staff demographics and experience and their assignment of triage level in the emergency department. MATERIAL AND METHODS: One-year retrospective observational study in the triage area of a tertiary care urban university hospital that applies the Andorran-Spanish triage model. Variables studied were age, gender, nursing experience, triage experience, shift, usual level of emergency work the nurse undertakes, number of triage decisions made, and percentage of patients assigned to each level. RESULTS: Fifty nurses (5 men, 45 women) with a mean (SD) age of 45 (9) years triaged 67 803 patients during the year. Nurses classified more patients in level 5 on the morning shift (7.9%) than on the afternoon shift (5.5%) (P=.003). The difference in the rate of level-5 triage classification became significant when nurses were older (ß = 0.092, P=.037) and experience was greater (ß = 0.103, P=.017). The number of triages recorded by a nurse was significantly and directly related to the percentage of patients assigned to level 3 (ß = 0.003, P=.006) and inversely related to the percentages assigned to level 4 (ß = -0.002, P=.008) and level 5 (ß = -0.001, P=.017). CONCLUSION: We found that triage level assignments were related to age, experience, shift, and total number of patients triaged by a nurse.

OBJETIVO: Investigar la relación entre las características demográficas y experiencia de los enfermeros que realizan triaje y la asignación de pacientes a un determinado nivel de urgencia. METODO: Estudio observacional retrospectivo llevado a cabo durante 1 año en el área de triaje de un hospital universitario terciario que usa el Model Andorrà de Triatge/Sistema Español de Triage (MAT/SET). Variables: edad, sexo, experiencia en enfermería, experiencia en triaje, turno de trabajo, nivel asistencial donde trabajaban, número de triajes realizados y porcentaje de pacientes asignados a cada nivel de triaje. RESULTADOS: Se incluyeron 50 enfermeros (5 hombres y 45 mujeres) con una edad de 45 (DE 9) años que efectuaron 67.803 triajes. Los enfermeros del turno mañana clasificaban más pacientes en el nivel 5 que las de turno tarde (7,9% frente a 5,5%, p = 0,003). Este mayor porcentaje en el nivel 5 también se registraba de forma significativa cuanta más edad tenía el enfermero (ß = 0,092, p = 0,037) y cuanta mayor experiencia acumulaba (ß = 0,103, p = 0,017). El número de triajes efectuados por cada enfermero se relacionó, significativa y directamente, con el porcentaje de pacientes clasificados en nivel 3 (ß = 0,003, p = 0,006) e, inversamente, con el porcentaje de pacientes clasificados en nivel 4 (ß = ­0,002, p = 0,008) y en nivel 5 (ß = ­0,001, p = 0,017). CONCLUSIONES: Se ha objetivado una relación entre la edad, la experiencia acumulada, el turno de trabajo y el número total de triajes que efectúa un enfermero con el nivel de triaje asignado.

Improvement of emergency department patient flow using lean thinking.

OBJECTIVE: To apply lean thinking in triage acuity level-3 patients in order to improve emergency department (ED) throughtput and waiting time. DESIGN: A prospective interventional study. SETTING: An ED of a tertiary care hospital. PARTICIPANTS: Triage acuity level-3 patients. INTERVENTION(S): To apply lean techniques such as value stream mapping, workplace organization, reduction of wastes and standardization by the frontline staff. MAIN OUTCOME MEASURE(S): Two periods were compared: (i) pre-lean: April-September, 2015; and (ii) post-lean: April-September, 2016. Variables included: median process time (time from beginning of nurse preparation to the end of nurse finalization after doctor disposition) of both discharged and transferred to observation patients; median length of stay; median waiting time; left without being seen, 72-h revisit and mortality rates, and daily number of visits. There was no additional staff or bed after lean implementation. RESULTS: Despite an increment in the daily number of visits (+8.3%, P < 0.001), significant reductions in process time of discharged (182 vs 160 min, P < 0.001) and transferred to observation (186 vs 176 min, P < 0.001) patients, in length of stay (389 vs 329 min, P < 0.001), and in waiting time (71 vs 48 min, P < 0.001) were achieved after lean implementation. No significant differences were registered in left without being seen rate (5.23% vs 4.95%), 72-h revisit rate (3.41% vs 3.93%), and mortality rate (0.23% vs 0.15%). CONCLUSION: Lean thinking is a methodology that can improve triage acuity level-3 patient flow in the ED, resulting in better throughput along with reduced waiting time.

Analysis of 15 years of emergency service interaction with schools. / Análisis de una experiencia de 15 años de interacción entre urgencias y la comunidad educativa.

EN: For 15 years without interruption, the emergency department of the Hospital Clínic de Barcelona has been holding annual educational sessions for students in their last year of obligatory secondary school. The sessions are organized in collaboration with 3 other entities: the primary care center affiliated with the hospital and serving the area and adjacent to it (THE CAPSBE), the city's emergency ambulance service, and the University of Barcelona. Each year the session lasts 4 hours and covers such content as the organization of the city's emergency medical care (at primary care centers, in prehospital settings, and at the hospital) and the main reasons adolescents require emergency care (related to drugs, traffic accidents, psychiatric disorders, eating disorders, and gynecologic problems). The project seeks to develop the students' sense of social responsibility and to transfer knowledge to the community where the organizers carry out their usual work. The sessions are educational, providing key information intended to encourage individual reflection as well as debate in the student community outside of school hours. A total of 56 secondary schools and 12 260 students between the ages of 15 and 18 years old have participated thus far. This article presents a basic outline of the sessions, reports feedback from the students and their teachers, and analyzes whether there have been significant changes in their opinions over time. Our purpose is to provide information useful to other emergency health services that might consider starting similar programs in which they can interact with their community schools.

ES: Desde hace 15 años, el Área de Urgencias del Hospital Clínic de Barcelona, en colaboración con CAPSBE (su centro de salud adyacente), el Sistema d'Emergències Mèdiques y la Univesitat de Barcelona, viene realizando ininterrumpidamente unas jornadas anuales dirigidas a alumnos de último curso de enseñanza secundaria obligatoria (ESO), de una duración de 4 horas, y en las que se abordan los aspectos organizativos de la atención médica urgente (en atención primaria, prehospitalaria y hospitalaria) en Barcelona, así como los principales motivos de consulta médica urgente en los adolescentes (drogas, accidentes de tráfico, trastornos psiquiátricos y de conducta alimentaria, y urgencias ginecológicas). La actividad se enmarca dentro del desarrollo de una cultura de responsabilidad social corporativa y de transmisión de conocimiento a la comunidad en la que estos centros sanitarios desarrollan su actividad habitual. Las jornadas tienen una finalidad divulgativa y proporcionan claves que puedan generar tanto la reflexión individual del alumnado como el debate conjunto posterior en la escuela. Durante estos 15 años han participado del curso 56 centros de ESO y 10.260 alumnos de entre 15 y 18 años. El objetivo del presente artículo es recoger los aspectos fundamentales de esta actividad, conocer la opinión de los alumnos y profesores de ESO, y analizar si han existido cambios significativos en estas opiniones durante este periodo de tiempo, con la finalidad de que otros servicios de urgencias puedan plantearse la instauración de actividades similares que les permitan una interacción con la comunidad educativa de su entorno.

[A new artificial intelligence tool for assessing symptoms in patients seeking emergency department care: the Mediktor application]. / Experiencia de Mediktor®: un nuevo evaluador de síntomas basado en inteligencia artificial para pacientes atendidos en el servicio de urgencias.

OBJECTIVES: To analyze agreement between diagnoses issued by the Mediktor application and those of an attending physician, and to evaluate the usefulness of this application in patients who seek emergency care. MATERIAL AND METHODS: Prospective observational study in a tertiary care university hospital emergency department. Patients with medical problems and surgical conditions (surgery and injuries) who did not require immediate emergency care responded to the Mediktor questions on a portable computer tablet. The software analyzed the answers and provided a list of 10 possible preliminary diagnoses in order of likelihood. The patient and the attending physician were blinded to the list to so that the usual care process would not be altered. The level of agreement between the physician's diagnosis and the Mediktor diagnosis was analyzed. RESULTS: A total of 1015 patients were included; 622 cases were considered valid for study. Cases were excluded if the patients did not meet the inclusion criteria, they did not have a discharge diagnosis, they had a final diagnosis expressed as a symptom or their final diagnosis was not included in the Mediktor database. The physician's diagnosis (the gold standard) coincided with one of the 10 MEDIKTOR diagnoses in 91.3% of the cases, with one of the first 3 diagnoses in 75.4%, and with the first diagnosis in 42.9%. Sensitivity was over 92% and specificity over 91% in the majority of common diagnostic groups; the κ statistic ranged from 0.24 to 0.98. CONCLUSION: The Mediktor application is a reliable diagnostic aid for the most prevalent problems treated in a hospital emergency department. The general public finds it easy to use.

OBJETIVO: Analizar la concordancia entre los diagnósticos emitidos por Mediktor® con el realizado por el médico responsable, así como valorar la utilidad de este dispositivo en pacientes que acuden a un servicio de urgencias (SU). METODO: Estudio observacional prospectivo realizado en el SU de un hospital terciario universitario. A los pacientes con patologías médicas y quirúrgicas (cirugía y traumatología) que no precisaban asistencia médica inmediata se les entregó una tableta digital para responder al interrogatorio de Mediktor®. Según las respuestas, el software adjudicaba un listado de 10 prediagnósticos ordenados por probabilidad, que se ocultaban al paciente y al médico responsable, para no modificar el proceso habitual. Posteriormente se analizó el grado de coincidencia entre el diagnóstico médico y los diagnósticos ofrecidos por Mediktor®. RESULTADOS: 1.015 pacientes fueron incluidos, de los que 622 se consideraron casos válidos para el estudio. Se excluyeron los pacientes que no cumplían los criterios de inclusión, sin diagnóstico al alta, con diagnóstico final expresado como síntoma y aquellos con diagnósticos no incluidos en Mediktor®. Las coincidencias entre el diagnóstico médico (patrón oro) y los diez diagnósticos de Mediktor® fueron de un 91,3%, en los tres primeros diagnósticos de un 75,4% y en el primer diagnóstico de un 42,9%. Según los grupos de diagnósticos más frecuentes, se objetivó una sensibilidad > 92% y una especificidad > 91% en la mayoría de ellos, con un índice kappa que osciló entre el 0,24 y el 0,98. CONCLUSIONES: Mediktor® es una herramienta fiable para ayudar al diagnóstico de las enfermedades más prevalentes de un SU y fácil de utilizar por el público en general.

[Accuracy in the medication history and reconciliation errors in the emergency department]. / Adecuación de la historia farmacoterapéutica y errores de conciliación en un servicio de urgencias.

BACKGROUND AND OBJECTIVE: To assess the accuracy of pharmaceutical anamnesis obtained at the Emergency Department (ED) of a tertiary referral hospital and to determine the prevalence of medication reconciliation errors (RE). MATERIAL AND METHOD: This was a single-center, prospective, interventional study. The home medication list obtained by a pharmacist was compared with the one recorded by a doctor to identify inaccuracies. Subsequently, the home medication list was compared with the active prescription at the ED. All unexplained discrepancies were checked with the doctor in charge to evaluate if a RE has occurred. An univariate analysis was performed to identify factors associated with RE. RESULTS: The pharmacist identified a higher number of drugs than doctors (6.89 versus 5.70; P<0.05). Only 39% of the drugs obtained by doctors were properly written down in the patient's record. The main cause of discrepancy was omission of information regarding the name of the drug (39%) or its dosage (33%). One hundred and fifty-seven RE were identified and they affected 85 patients (43%), mainly related to information omission (62%). Age and polymedication were identified as main risk factors of RE. The presence of a caregiver or relative in the ED was judged to be a protective factor. No relationship was found between inaccuracies in the registries and RE. CONCLUSIONS: The process of obtaining a proper pharmaceutical anamnesis still needs improvement. The pharmacist may play a role in the process of obtaining a good quality anamnesis and increase patient safety by detecting RE. Better information systems are needed to avoid this type of incidents.

[Difficulties with the prescription and administration of antibiotics in routine hospital emergency department care: a survey study]. / Detección mediante encuesta de las dificultades con las que se encuentra el personal sanitario en la prescripción y administración de antibióticos en la práctica clínica diaria de un servicio de urgencias hospitalario.

OBJECTIVES: To detect the problems hospital emergency room staff have when prescribing and administering antibiotics. MATERIAL AND METHODS: A 14-item questionnaire was designed to assess staff members' knowledge of the importance of starting antibiotic treatment promptly, assigning appropriate dosing intervals, adjusting for renal function, and switching to oral therapy. Agreement with each item was expressed on a 5-point Likert scale. Items with a rate of appropriate response of less than 75% were targeted for specific attention. RESULTS: Two hundred questionnaires were distributed to the staff and 150 were returned completed (response rate, 75%). The following items were targeted for attention based on rates of appropriate response of less than 75%: clear medical orders (65%), understanding the implication of early empirical antibiotic therapy on prognosis in serious infections (67%), estimation of the prevalence of renal insufficiency (42%), assumption that a creatinine serum level under < 1.6 mg/dL is safe (33%), use of glomerular filtration rate to adjust dose according to renal function (47%), and an understanding of switching from intravenous to oral treatment (60%). CONCLUSION: This study revealed the difficulties medical and nursing staff have in prescribing and administering antibiotics in a hospital emergency department. The results can facilitate improvements in antibiotic therapy by pinpointing areas to target for specific training interventions or the design of electronic prescribing aids.

OBJETIVO: Detectar las barreras con las que se encuentra el personal sanitario en la prescripción y administración de antibióticos en un servicio de urgencias hospitalario (SUH). METODO: Se diseñó una encuesta con 14 ítems para valorar el grado de conocimiento de la importancia de la precocidad en el inicio de tratamiento antibiótico, los intervalos de dosificación adecuados, el ajuste a la función renal y la terapia secuencial. Las respuestas a cada ítem fueron cualitativas con 5 categorías. Se consideró que los ítems que obtuvieron una respuesta correcta menor del 75% precisaban de una intervención específica. RESULTADOS: Se recogieron 150 encuestas cumplimentadas de las 200 repartidas entre el personal sanitario (tasa de respuesta del 75%). Los ítems con una respuesta correcta menor del 75% y que por tanto se consideró que requerían de una intervención específica fueron: la claridad en la órdenes médicas (65%), el conocimiento de la implicación del tratamiento antibiótico empírico precoz en el pronóstico de las infecciones graves (67%), la estimación de la prevalencia de la insuficiencia renal (42%), un valor de creatinina sérica inferior a 1,6 mg/dl considerado como seguro (33%), el filtrado glomerular como parámetro que se debe utilizar para ajustar la dosis a la función renal (47%) y el conocimiento de la terapia secuencial (60%). CONCLUSIONES: Este estudio permite conocer las dificultades con las que se encuentra el personal sanitario a la hora de prescribir y administrar antibióticos en un SUH y facilita el diseño de estrategias de mejora que incluyan desde formación específica a técnicas de prescripción electrónica.

[Nurse-led educational intervention in patients with atrial fibrillation discharged from the emergency department reduces complications and shortterm admissions]. / Una intervención educativa de enfermería al alta de urgencias disminuye complicaciones e ingresos a corto plazo en pacientes con fibrilación auricular.

OBJECTIVES: To assess whether a nurse-led patient educational intervention for patients with atrial fibrillation (AF) discharged from the emergency department (ED) can improve the patients' understanding of arrhythmia and its treatment and reduce the number of complications and arrhythmia-related admissions. MATERIAL AND METHODS: Prospective study of an intervention. Patients diagnosed with AF discharged from the ED were studied in 2 groups. Intervention-group patients received instruction about AF, its treatment, precautions to take, warning signs, and pulse-taking. They also received an information leaflet. The control group patients were discharged without specific instruction. At 30 and 90 days, the patients' records were reviewed and follow-up telephone interviews were undertaken in order to assess their understanding of arrhythmia, the presence of complications, and whether they had returned for emergency care or had been hospitalized. RESULTS: We enrolled 240 patients (116 in the intervention group and 124 in the control group); the mean (SD) age was 76 (11) years and 138 (58%) were women. The intervention group patients remembered more warning signs of AF than did patients in the control group (P=.012) and they also understood their treatment better (P=.004). Fewer important arrhythmia-related complications were experienced in the intervention group (13.8%) than in the control group (24.2%) (P=.040). Fewer intervention patients had been admitted with heart failure at 30 days (0.8% vs 6.4% in the control group; P=.023); there were also fewer all-cause admissions at 90 days (11.2% vs 20.9%; P=.041). CONCLUSION: A nurse-led educational intervention on discharge from the ED improved patients' understanding of AF and decreased the number of complications, short-term admissions for heart failure, and mid-term all-cause admissions.

OBJETIVO: Conocer si una intervención educativa de enfermería al alta de urgencias en pacientes con fibrilación auricular (FA) aumenta el conocimiento sobre la arritmia y su tratamiento, y disminuye complicaciones e ingresos asociados. METODO: Estudio prospectivo de intervención. Pacientes diagnosticados de FA dados de alta de urgencias fueron aleatorizados en dos grupos: 1) Intervención: instrucción sobre FA, tratamiento, precauciones, síntomas de alarma y control del pulso; tríptico informativo individualizado y 2) Control: sin intervención específica. A los 30 y 90 días se hizo un seguimiento telefónico y una revisión del historial clínico para evaluar el conocimiento de la arritmia, y la existencia de complicaciones, consultas a urgencias e ingresos hospitalarios. RESULTADOS: Se incluyeron 240 pacientes, 116 intervención y 124 control, de edad media 76 (11) años, 138 (58%) mujeres. A los 30 y 90 días, los pacientes del grupo de intervención conocían más los signos de alarma de la FA o su tratamiento (p = 0,012 y p = 0,004 respectivamente). Menos pacientes del grupo intervención presentaron complicaciones relevantes asociadas a la arritmia (13,8% vs 24,2%, p = 0,040), además, ingresaron menos por insuficiencia cardiaca a los 30 días (0,8% vs 6,4%, p = 0,023) y menos por cualquier causa a los 90 días (11,2% vs 20,9%, p = 0,041). CONCLUSIONES: Una intervención educativa de enfermería al alta de urgencias aumenta el conocimiento sobre FA y disminuye complicaciones, ingresos por insuficiencia cardiaca a corto plazo e ingresos globales a medio plazo.

[Catalan hospital emergency department heads' opinions on the creation of a residency program for specializing in emergency medicine]. / Opinión de los responsables de los servicios de urgencias hospitalarios de Cataluña acerca de la creación de la especialidad de Medicina de Urgencias y Emergencias.

OBJECTIVES: To understand the opinions of emergency department (ED) heads in Catalonia on their support for a residency program for specializing in emergency medicine (EM) and on their beliefs about the impact such a program would have. MATERIAL AND METHODS: Heads of ED were asked if there would be support (from them, their staff, and their hospital) for a residency program to train specialists in EM. They were also asked their opinion on the impact that specialization would have on quality of care and costs in their department. Responses were compared by type of hospital and ED and by affiliation or not with the Spanish Society of Emergency Medicine (SEMES). RESULTS: Responses were received from 79 of the 82 heads of hospital EDs in Catalonia (96%). They reported that favorable opinions toward creation of an EM specialization were held by them personally (93.7%; 95% CI, 85.8%-97.9%), by their in their departments (88.6%; 95% CI, 79.4%-94.7%), and by staff in their hospitals (48.7%; 95% CI, 36.7%-59.6%). A majority thought that the impact of specialization would be good in the short term (82.0%; 95% CI, 71.7%-89.8%) and in the medium and long term (94.8%; 95% CI, 87.2%-98.6%). The respondents were neutral about whether there would be an impact on costs (60.3%; 95% CI, 48.6%-71.2%). More heads in mid-sized hospitals, private hospitals, and nonmembers of SEMES thought that creating a specialty would raise ED costs (p<0,05). CONCLUSION: The heads of Catalan ED, their staff, and their hospitals' staffs hold favorable opinions of the proposal to create a residency program allowing specialization in EM. They foresee short-, medium-, and long-term benefits for the EDs and scarce impact on costs.

OBJETIVO: Conocer la opinión de los responsables de los servicios de urgencias hospitalarios (SUH) de Cataluña respecto al soporte e impacto que tendría la creación de la especialidad primaria de Medicina de Urgencias y Emergencias (MUE). METODO: Se solicitó la opinión a los responsables de SUH respecto al respaldo a una futura especialidad primaria de MUE (personal, en su servicio y en su hospital) y la estimación del impacto (cualitativo y económico) que tendría en su SUH. Se compararon las respuestas en función del tipo de hospital y SUH y de su afiliación a la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES). RESULTADOS: Contestaron 79 de los 82 responsables de los SUH de Cataluña (96%), que percibieron una posición favorable a la creación de la especialidad, tanto ellos personalmente (93,7%; IC 95%: 85,8-97,9) como en sus SUH (88,6%; 79,4- 94,7) y hospitales (48,7%; 36,7-59,6). El 82,0% (71,7-89,8) opinó que la especialidad tendría un efecto positivo a corto plazo y el 94,8% (87,2-98,6) que también lo tendría a medio-largo plazo, y respecto al impacto económico, la opinión mayoritaria fue que sería neutro (60,3%; 48,6-71,2). Los responsables de SUH con actividad media, de hospitales privados y no afiliados a SEMES consideraron más frecuentemente que la creación de la especialidad encarecería el SUH (p < 0,05). CONCLUSIONES: Los responsables de los SUH catalanes tienen una opinión favorable y también la perciben en su servicio y su hospital respecto a la creación de la especialidad primaria de MUE y consideran que tendría efectos beneficiosos a corto, medio y largo plazo para el SUH, con un escaso impacto económico.

Exercise echocardiography and multidetector computed tomography for the evaluation of acute chest pain.

INTRODUCTION AND OBJECTIVES: Up to 4% of patients with acute chest pain, normal electrocardiogram, and negative troponins present major adverse cardiac events as a result of undiagnosed acute coronary syndrome. Our aim was to compare the diagnostic performance of multidetector computed tomography and exercise echocardiography in patients with a low-to-intermediate probability of coronary artery disease. METHODS: We prospectively included 69 patients with acute chest pain, normal electrocardiogram, and negative troponins who underwent coronary tomography angiography and exercise echocardiography. Patients with coronary stenosis ≥ 50% or Agatston calcium score ≥ 400 on coronary tomography angiography or positive exercise echocardiography, or with inconclusive results, were admitted to rule out acute coronary syndrome. RESULTS: An acute coronary syndrome was confirmed in 17 patients (24.6%). This was lower than the suspected 42% based on coronary tomography angiography (P<.05) and not significantly different than the suspected 29% based on the results of exercise echocardiography (P=.56). Exercise echocardiography was normal in up to 37% of patients with pathological findings on coronary tomography angiography. The latter technique provided a higher sensitivity (100% vs 82.3%; P=.21) but lower specificity (76.9% vs 88.4%; P=.12) than exercise echocardiography for the diagnosis of acute coronary syndrome, although without reaching statistical significance. Increasing the stenosis cutoff point to 70% increased the specificity of coronary tomography angiography to 88.4%, while maintaining high sensitivity. CONCLUSIONS: Coronary tomography angiography offers a valid alternative to exercise echocardiography for the diagnosis of acute coronary syndrome among patients with low-to-intermediate probability of coronary artery disease. A combination of both techniques could improve the diagnosis of acute coronary syndrome.

Changes in the etiology, incidence and prognosis of acute lower respiratory track infections in human immunodeficiency virus patients.

AIM: To describe the incidence, the changes in the etiology and the prognosis of lower respiratory tract infection (LRTI) in HIV infected patients, presenting by the first time to the Emergency Department (ED), during years 2000-2010. STUDY DESIGN: Prospective collection of data. METHODS: Data were collected on the first visit of HIV-infected patients at our ED due to a LRTI, (defined according to the criteria of the European Respiratory Society), between 1/1/2000 and 31/12/2010. A series of epidemiological and laboratory variables as well as the need for admission to the intensive care unit (ICU). LRTI etiology were also collected. The influence ofthe mentioned variables on 30-day mortality were analyzed. RESULTS: One hundred thirty one patients were included. LRTI represented 27% of visits to the ED by HIV-infected patients. Mean age was 39±9 years. 72% of patients were males. 18% required admission to the ICU. The most frequent LRTI was pneumonia by P. jiroveci in 35 cases, bacterial penumonia in 27 and pulmonary tuberculosis in 20. LRTI incidence gradually reduced significantly over time from 6.13 × 1000 patients/year in year 2000 to 0.23 × 1000 patients/year in 2010 (p<0.05). Overall mortality was 14%. Logistic regression analysis showed that admission to ICU (p<0.004) and viral load (p<0.029) were independent variables predicting mortality. CONCLUSION: LRTI is a pathology with a decreasing incidence, probably related to the widespread utilization increased of HAART regimens. lts etiology has also been changing, but with a non negligible mortality, mostly when ICU admission was required.