HIV testing services and HIV self-testing programming within emergency care in Kenya: a qualitative study of healthcare personnel to inform enhanced service delivery approaches.

In Kenya, persons insufficiently engaged in HIV Testing Services (HTS) are often treated in emergency departments (ED). There are limited data from healthcare workers on ED-HTS. A qualitative study was completed to understand challenges and facilitators for ED-HTS and HIV self-testing (HIVST). Data were collected via six focus groups of healthcare workers. Data were inductively analyzed and mapped to the Capability-Opportunity-Motivation Behavioral Model. Focus groups were completed with 49 healthcare workers: 18 nurses, 15 HIV counselors, 10 physicians and 6 administrators. HTS challenges included staff burdens, resources access, deficiencies in systems integration and illness severity. HTS facilitators included education of healthcare workers and patients, services coordination, and specific follow-up processes. HIVST challenges included accuracy concerns, follow-up barriers and psychosocial risks. HIVST facilitators were patient autonomy and confidentiality, resource utilization and ability to reach higher-risk persons. Mapping to the Capability-Opportunity-Motivation Behavioral Model interventions within the domains of knowledge, decision processes, environmental aspects, social influences and professional identities could support enhanced ED-HTS with integrated HIVST delivery. This study provided insights into challenges and facilitators on ED-HTS and identifies pragmatic approaches to improve healthcare workers' behaviors and abilities to provide services to persons already in contact with healthcare.

Examination of workload perception, burnout, and perceived organizational support in emergency healthcare professionals: A structural equation model.

Job stress is one of the important factors affecting employee behavior. One of the most important factors in reducing burnout caused by stress is organizational support. In this context, the aim of this study is to identify the moderating role of perceived organizational support in the effect of workload perception on burnout within the emergency healthcare professionals' universe. The data for this study were collected from 703 health professionals working in emergency health services in three major cities of Turkey. The relationships and the model of the study is analyzed by the Structural Equation Model technique. The results indicate that perceived workload is a factor that causes employee burnout, and perceived organizational support is a factor that reduces employee burnout. This study contributes to researchers and health managers by revealing the importance of workload planning and organizational activities that support employees to reduce burnout in health workers.

Experiences and views of people who frequently call emergency ambulance services: A qualitative study of UK service users.

INTRODUCTION: People who call emergency ambulances frequently are often vulnerable because of health and social circumstances, have unresolved problems or cannot access appropriate care. They have higher mortality rates. Case management by interdisciplinary teams can help reduce demand for emergency services and is available in some UK regions. We report results of interviews with people who use emergency ambulance services frequently to understand their experiences of calling and receiving treatment. METHODS: We used a two-stage recruitment process. A UK ambulance service identified six people who were known to them as frequently calling emergency services. Through third-sector organisations, we also recruited nine individuals with healthcare experiences reflecting the characteristics of people who call frequently. We gained informed consent to record and transcribe all telephone interviews. We used thematic analysis to explore the results. RESULTS: People said they make frequent calls to emergency ambulance services as a last resort when they perceive their care needs are urgent and other routes to help have failed. Those with the most complex health needs generally felt their immediate requirements were not resolved and underlying mental and physical problems led them to call again. A third of respondents were also attended to by police and were arrested for behaviour associated with their health needs. Those callers receiving case management did not know they were selected for this. Some respondents were concerned that case management could label frequent callers as troublemakers. CONCLUSION: People who make frequent calls to emergency ambulance services feel their health and care needs are urgent and ongoing. They cannot see alternative ways to receive help and resolve problems. Communication between health professionals and service users appears inadequate. More research is needed to understand service users' motivations and requirements to inform design and delivery of accessible and effective services. PATIENT OR PUBLIC CONTRIBUTION: People with relevant experience were involved in developing, undertaking and disseminating this research. Two public contributors helped design and deliver the study, including developing and analysing service user interviews and drafting this paper. Eight public members of a Lived Experience Advisory Panel contributed at key stages of study design, interpretation and dissemination. Two more public contributors were members of an independent Study Steering Committee.

Emergency health services use and medically-treated suicidal behaviors following depression screening among adolescents: A longitudinal cohort study.

The primary goal of depression screening is to reduce adverse psychiatric outcomes, which may have downstream implications for reducing avoidable health services use. The objective of this study was to examine the association of depression screening with emergency health services use and medically-treated suicidal behaviors among adolescents in the U.S. This longitudinal cohort study used insurance claims data from 57,732 adolescents who had at least one well-visit between 2014 and 2017. Propensity score matching was used to compare adolescents who were screened for depression to similar adolescents who were not screened for depression during the well-visit. Outcomes were examined over two-year follow-up and included emergency department use and inpatient hospitalizations for depression-related reasons, mental health-related reasons, and any reason as well as medically-treated suicidal behaviors. Log-binomial regression models were used to examine associations between depression screening and each outcome in the matched sample. Heterogeneity of associations by sex was examined with interaction terms. Being screened for depression was not consistently associated with emergency department use (depression-related reasons: RR = 1.00, 95% CI = 0.76-1.30; mental health-related reasons: RR = 1.02, 95% CI = 0.80-1.29; any reason: RR = 0.96, 95% CI = 0.83-1.11), inpatient hospitalizations (depression-related reasons: RR = 1.05, 95% CI = 0.84-1.31; mental health-related reasons: RR = 1.16, 95% CI = 1.00-1.33; any reason: RR = 1.05, 95% CI = 0.99-1.12), or medically-treated suicidal behaviors (RR = 0.83, 95% CI = 0.51-1.36). Associations were similar in magnitude among male and female adolescents. The results of this study suggest that depression screening, as it is currently practiced in the U.S., may not deter avoidable health services use among adolescents.

A bacteraemia risk prediction model: development and validation in an emergency medicine population.

OBJECTIVE: Design a risk model to predict bacteraemia in patients attended in emergency departments (ED) for an episode of infection. METHODS: This was a national, prospective, multicentre, observational cohort study of blood cultures (BC) collected from adult patients (≥ 18 years) attended in 71 Spanish EDs from October 1 2019 to March 31, 2020. Variables with a p value < 0.05 were introduced in the univariate analysis together with those of clinical significance. The final selection of variables for the scoring scale was made by logistic regression with selection by introduction. The results obtained were internally validated by dividing the sample in a derivation and a validation cohort. RESULTS: A total of 4,439 infectious episodes were included. Of these, 899 (20.25%) were considered as true bacteraemia. A predictive model for bacteraemia was defined with seven variables according to the Bacteraemia Prediction Model of the INFURG-SEMES group (MPB-INFURG-SEMES). The model achieved an area under the curve-receiver operating curve of 0.924 (CI 95%:0.914-0.934) in the derivation cohort, and 0.926 (CI 95%: 0.910-0.942) in the validation cohort. Patients were then split into ten risk categories, and had the following rates of risk: 0.2%(0 points), 0.4%(1 point), 0.9%(2 points), 1.8%(3 points), 4.7%(4 points), 19.1% (5 points), 39.1% (6 points), 56.8% (7 points), 71.1% (8 points), 82.7% (9 points) and 90.1% (10 points). Findings were similar in the validation cohort. The cut-off point of five points provided the best precision with a sensitivity of 95.94%, specificity of 76.28%, positive predictive value of 53.63% and negative predictive value of 98.50%. CONCLUSION: The MPB-INFURG-SEMES model may be useful for the stratification of risk of bacteraemia in adult patients with infection in EDs, together with clinical judgement and other variables independent of the process and the patient.

Consensus on improving the comprehensive care of patients with acute heart failure. / Consenso para la mejora de la atención integral de los pacientes con insuficiencia cardíaca aguda.

The latest acute heart failure consensus document from the Spanish Society of Cardiology, Spanish Society of Internal Medicine, and Spanish Society of Emergency Medicine was published in 2015, which made an update covering the main novelties regarding acute heart failure from the last few years necessary. These include publication of updated European guidelines on heart failure in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding acute heart failure such as early treatment, intermittent treatment, advanced heart failure, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to acute heart failure and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Emergency Department Presentations and Youth Suicide: A Case-Control Study.

OBJECTIVE: We estimate associations between emergency department (ED) diagnoses and suicide among youth to guide ED care. METHOD: This ED-based case-control study used data from the Office of the Chief Coroner and all EDs in Ontario, Canada. Cases ( n = 697 males and n = 327 females) were aged 10 to 25 years who died by suicide in Ontario between April 2003 and March 2014, with an ED contact in the year before their death. Same-aged ED-based controls were selected during this time frame. Crude and adjusted odds ratios (aORs) and 95% confidence intervals were calculated. RESULTS: Among youth diagnosed with a mental health problem at their most recent ED contact (41.9% cases, 5% controls), suicide was elevated among nonfatal self-inflicted: 'other' injuries, including hanging, strangulation, and suffocation in both sexes (aORs > 14); cut/pierce injuries in males (aOR > 5); poisonings in both sexes (aORs > 2.2); and mood and psychotic disorders in males (aORs > 1.7). Among those remaining, 'undetermined' injuries and poisonings in both sexes (aORs > 5), 'unintentional' poisonings in males (aOR = 2.1), and assault in both sexes (aORs > 1.8) were significant. At least half of cases had ED contact within 106 days. CONCLUSIONS: The results highlight the need for timely identification and treatment of mental health problems. Among those with an identified mental health problem, important targets for suicide prevention efforts are youth with self-harm and males with mood and psychotic disorders. Among others, youth with unintentional poisonings, undetermined events, and assaults should raise concern.

Injuries prior and subsequent to index poisoning with medication among adolescents: a national study based on Norwegian patient registry.

BACKGROUND: Adolescents treated for self-poisoning with medication have a high prevalence of mental health problems and constitute a high-risk population for self-harm repetition. However, little is known about whether this population is also prone to injuries of other forms. METHODS: Data were extracted from the Norwegian Patient Registry to include all incidents of treated injuries in adolescents aged 10-19 years who were treated for self-poisoning with medication during 2008-2011. This longitudinal approach allowed for the inclusion of injuries of various forms both before and after the index poisoning with medication. Gender differences and associations of injuries with recorded deliberate self-harm or psychiatric comorbidity at index poisoning were analysed. Forms of injury and psychiatric illnesses were coded according to the ICD-10 system. RESULTS: 1497 adolescents treated for self-poisoning with medication were identified from the source database, including 1144 (76.4%) girls and 353 (23.6%) boys. For these 1497 adolescents a total of 2545 injury incidents were recorded in addition to the index poisoning incidents, consisting of 778 injury incidents taking place before the index poisoning and 1767 incidents taking place subsequently. Altogether 830 subjects (55.4%) had an injury treated either before or after the index poisoning. Injuries to the hand and wrist as well as injuries to the head, neck and throat were predominant in males. Females were more likely to repeat poisoning with medication, particularly those with psychiatric disorders. CONCLUSION: Adolescents treated for poisoning with medication represent a high-risk population prone to both prior and subsequent injuries of other forms, and should be assessed for suicidal intent and psychiatric illness.

Telestroke Adoption Among Community Hospitals in North Carolina: A Cross-Sectional Study.

OBJECTIVE: This study identifies community and hospital characteristics associated with adoption of telestroke among acute care hospitals in North Carolina (NC). METHODS: Our sample included 107 hospitals located in NC. Our analytic dataset included variables from the American Hospital Association (AHA) annual survey, AHA Health IT supplement, Healthcare Cost Report Information System, and Centers for Disease Control and Prevention's WONDER online database. We supplemented our secondary sources with data on telestroke adoption and market-level variables developed for NC. We used the Consolidated Framework for Implementation Research and previous telehealth studies to guide selection of variables. We conducted a multivariate logistic regression to determine associations with telestroke adoption. RESULTS: Proportion of discharges that are Medicare (odds ratio [OR] = 1.93, P < .04) and total operating margin (OR = 2.89, P = .00) were positively associated with telestroke adoption. Critical access hospital status was positively associated with telestroke adoption, although not at P < .05 (OR = 5.61, P = .07). Distance to the nearest hospital with a telestroke program (OR = .91, P = .01) and volume of emergency department visits (OR = .98, P < .05) were both negatively associated with telestroke adoption. CONCLUSIONS: Our study is novel in its focus on telestroke adoption and use of variables not included in previous telehealth analyses. Our findings suggest some hospitals have neither the financial resources nor the ability to pool resources for acquiring needed technology, and differences in adoption may result in geographic inequities in access to telestroke services.

Addressing geographic access barriers to emergency care services: a national ecologic study of hospitals in Brazil.

BACKGROUND: Unequal distribution of emergency care services is a critical barrier to be overcome to assure access to emergency and surgical care. Considering this context it was objective of the present work analyze geographic access barriers to emergency care services in Brazil. A secondary aim of the study is to define possible roles to be assumed by small hospitals in the Brazilian healthcare network to overcome geographic access challenges. METHODS: The present work can be classified as a cross-sectional ecological study. To carry out the present study, data of all 5843 Brazilian hospitals were categorized among high complexity centers and small hospitals. The geographical access barriers were identified through the use of two-step floating catchment area method. Once concluded the previous step an evaluation using the Getis-Ord-Gi method was performed to identify spatial clusters of municipalities with limited access to high complexity centers but well covered by well-equipped small hospitals. RESULTS: The analysis of accessibility index of high complexity centers highlighted large portions of the country with nearly zero hospital beds by inhabitant. In contrast, it was possible observe a group of 1595 municipalities with high accessibility to small hospitals, simultaneously with a low coverage of high complexity centers. Among the 1595 municipalities with good accessibility to small hospitals, 74% (1183) were covered by small hospitals with at least 60% of minimum emergency service requirements. The spatial clusters analysis aggregated 589 municipalities with high values related to minimum emergency service requirements. Small hospitals in these 589 cities could promote the equity in access to emergency services benefiting more than eight million people. CONCLUSIONS: There is a spatial disequilibrium within the country with prominent gaps in the health care network for emergency services. Taking this challenge into consideration, small hospitals could be a possible solution and foster equity in access to emergency and surgical care. However more investments in are necessary to improve small hospitals capabilities to fill this gap.

Access to emergency care services: a transversal ecological study about Brazilian emergency health care network.

OBJECTIVES: Studies of health geography are important in the planning and allocation of emergency health services. The geographical distribution of health facilities is an important factor in timely and quality access to emergency services; therefore, the present study analyzed the emergency health care network in Brazil, focusing the analysis at the roles of small hospitals (SHs). STUDY DESIGN: Cross-sectional ecological study. METHODS: Data were collected from 9429 hospitals of which 3524 were SHs and 5905 were high-complexity centers (HCCs). For analytical purposes, we considered four specialties when examining the proxies of emergency care capability: adult, pediatrics, neonatal, and obstetric. We analyzed the spatial distribution of hospitals, identifying municipalities that rely exclusively on SHs and the distance of these cities from HCCs. RESULTS: More than 14 and 30 million people were at least 120 km away from HCCs with an adult intensive care unit (ICU) and pediatric ICU, respectively. For neonatal care distribution, 12% of the population was more than 120 km away from a health facility with a neonatal ICU. The maternities situation is different from other specialties, where 81% of the total Brazilian population was within 1 h or less from such health facilities. CONCLUSION: Our results highlighted a polarization in distribution of Brazilian health care facilities. There is a concentration of hospitals in urban areas more developed and access gaps in rural areas and the Amazon region. Our results demonstrate that the distribution of emergency services in Brazil is not facilitating access to the population due to geographical barriers associated with great distances.

Emergency admission predictive risk stratification models: assessment of implementation consequences (PRISMATIC 2): protocol for a mixed methods study.

BACKGROUND: Emergency admissions are costly, increasingly numerous, and associated with adverse patient outcomes. Policy responses have included the widespread introduction of emergency admission risk stratification (EARS) tools in primary care. These tools generate scores that predict patients' risk of emergency hospital admission and can be used to support targeted approaches to improve care and reduce admissions. However, the impact of EARS is poorly understood and there may be unintended consequences. AIM: To assess effects, mechanisms, costs, and patient and healthcare professionals' views related to the introduction of EARS tools in England. DESIGN & SETTING: Quasi-experimental mixed methods design using anonymised routine data and qualitative methods. METHOD: We will apply multiple interrupted time series analysis to data, aggregated at former Clinical Commissioning Group level, to look at changes in emergency admission and other healthcare use following EARS introduction across England. We will investigate GP decision-making at practice level using linked general practice and secondary care data to compare case-mix, demographics, indicators of condition severity and frailty associated with emergency admissions before and after EARS introduction. We will undertake interviews (n~48) with GPs and healthcare staff to understand how patient care may have changed. We will conduct focus groups (n=2) and interviews (n~16) with patients to explore how they perceive that communication of individual risk scores might affect their experiences and health seeking behaviours. CONCLUSION: Findings will provide policymakers, healthcare professionals, and patients, with a better understanding of the effects, costs and stakeholder perspectives related to the introduction of EARS tools.

Impact of specialized training for emergency department nurses screening or undetected HIV infection: the "Urgències VIHgila" project experience. / Impacto de una formación específica y generalizada de los profesionales de enfermería en el despistaje en urgencias de infección oculta por VIH: experiencia del proyecto "Urgències VIHgila".

OBJECTIVES: To evaluate the impact of specialized training for nurses on selective screening for undetected HIV infection in the emergency department. MATERIAL AND METHODS: The intervention group was comprised of 6 emergency departments that had been participating in a screening program (the "Urgències VIHgila" project) for at least 3 months. Nurses on all shifts attended training sessions that emphasized understanding the circumstances that should lead to suspicion of unidentified HIV infection and the need to order serology. Two studies were carried out: 1) a quasi-experimental pre-post study to compare the number of orders for HIV serology in each time period and measures of sensitivity, and 2) a case-control study to compare the changes made in the 6 hospitals where specialized training was provided (cases) vs 6 control hospitals in the HIV screening program where no training was given. RESULTS: A total of 280 HIV serologies were ordered for the 81015 patients (0.3%) attended during the period before training; 331 serologies were ordered for the 79620 patients in the period after training (0.4%). The relative increase in serologies was 20.3% (95% CI, 2.9% to 34.5%; P = .022). The relative increase in measures of sensitivity ranged between 19% and 39%, consistent with the main comparison. Serologies in the control group decreased between periods, from 0.9% to 0.8%, indicating a relative decrease of 15.7% (95% CI, -25.1% to -6.2%; P = .001). The absolute number of patients tested in the training group was 0.2% higher in the training hospitals (95% CI, 0.11% to 0.31%; P .001) than in the control hospitals. CONCLUSION: Training nurses to screen for undetected HIV infection in the emergency department increased the number of patients tested, according to the pre-post and case-control comparisons.

OBJETIVO: Evaluar el impacto de una formación específica para enfermería en el servicio urgencias (SU) sobre el despistaje selectivo de infección por VIH oculta. METODO: Participaron 6 SU adheridos al programa "Urgències VIHgila" con un mínimo de 3 meses y se realizaron sesiones formativas para los diferentes turnos. Las sesiones enfatizaban en qué circunstancias debía sospecharse infección oculta VIH y la necesidad de solicitar serología. Se realizaron dos estudios: 1) cuasiexperimental pre/post, que comparó la tasa de solicitudes VIH entre ambos periodos, con diversos análisis de sensibilidad; 2) caso-control, que comparó el cambio entre periodos de los 6 SU con formación (caso) con el cambio en otros 6 SU que no tuvieron formación (control). RESULTADOS: Se realizaron serologías de VIH a 280 de los 81.015 pacientes atendidos durante el periodo preintervención (0,3%) y a 331 de los 79.620 del periodo posintervención (0,4%). El incremento relativo fue del 20,3% (IC 95% de +2,9% a +34,5%; p = 0,022). Los análisis de sensibilidad mostraron incrementos relativos congruentes con el análisis principal (entre 19% y 39%). En el grupo control hubo descenso de solicitudes entre periodos, del 0,9% al 0,8% (descenso relativo del 15,7%, IC 95% de ­25,1% a­6,2%; p = 0,001). El grupo caso, en relación con el grupo control, tuvo un incremento absoluto de 0,2% (IC 95% de +0,11 a +0,31%, p 0,001) de pacientes testados. CONCLUSIONES: La formación de enfermería para despistaje de la infección VIH oculta en urgencias incrementa el número de pacientes investigados, tanto comparado con el periodo previo a la formación como comparado con SU sin formación específica para enfermería.

Value of the soluble urokinase-type plasminogen activator receptor as a predictor of prognosis in patients attended in hospital emergency departments. / Capacidad del biomarcador suPAR para estratificar el pronóstico en pacientes atendidos en servicios de urgencias hospitalarios.

OBJECTIVES: To determine the value of the soluble urokinase-type plasminogen activator receptor (suPAR) for predicting outcomes in emergency department (ED) patients. Secondary objectives were 1) to measure the predictive value of the usual decision points, 2) to identify patients at low risk for mortality who could be safely discharged from the ED, and 3) to measure the correlation between suPAR and other biomarkers. MATERIAL AND METHODS: Prospective observational cohort study of patients attended in the EDs of participating hospitals. We recorded sociodemographic variables, comorbidity, variables related to the acute episode, prognostic markers commonly used in EDs, and suPAR concentration. Outcome variables were the need for hospital admission during the index episode, ED revisits within 90 days, and 90-day mortality. RESULTS: A total of 990 patients with a median (interquartile range) age of 68 (53-81 years) were studied; 50.8% were men. The median suPAR concentration was 3.8 (2.8-6.0) ng/mL, and 112 patients (11.31%) required admission. At 90 days there were 276 revisits (27.9% of the cohort), and 47 patients (4.74%) had died. Mortality was lower (1%) in patients with suPAR concentrations less than 4 ng/mL (52.5%), and fewer of these patients revisited (24.4%) or required hospitalization (20.6%) than patients with suPAR concentrations higher than 6 ng/mL (mortality, 13.5%; revisits, 39.6%; admissions, 56.3%). A suPAR concentration over 6 ng/mL was associated with 90-day mortality and revisits (adjusted hazard ratios and 95% CIs of 4.61 [1.68-12.67] and 1.59 [1.13-2.10]), respectively. The high suPAR concentration was also associated with hospital admission (odds ratio, 1.62 [0.99-2.62]). CONCLUSION: A suPAR concentration of less than 4 ng/mL identifies patients at low risk of 90-day mortality and revisits or need for hospitalization, whereas a suPAR concentration higher than 6 ng/mL is associated with higher risk for these outcomes.

OBJETIVO: Determinar la capacidad del receptor soluble del activador del plasminógeno tipo uroquinasa (suPAR) para la estratificación pronóstica en pacientes atendidos en servicios de urgencias hospitalarios (SUH). Los objetivos secundarios son: 1) medir la capacidad de los `puntos de decisión habituales, 2) identificar una población de bajo riesgo de mortalidad que puede darse de alta de forma segura desde el SUH, y 3) medir la correlación entre suPAR y otros biomarcadores. METODO: Estudio observacional de cohortes prospectivo de pacientes atendidos en SUH. Se registraron variables sociodemográficas, de comorbilidad, datos del episodio agudo, biomarcadores de uso común en urgencias y suPAR. Las variables de resultado fueron la necesidad de ingreso en el episodio índice, reconsulta al SUH y mortalidad a los 90 días. RESULTADOS: Se incluyeron 990 pacientes, la edad fue de 68 (53-81) años, 50,8% eran hombres, la mediana de suPAR fue de 3,8 (2,8-6,0) ng/ml, 112 pacientes (11,31%) requirieron ingreso. En el seguimiento a 90 días hubo 276 reconsultas (27,9%) y 47 pacientes (4,74%) fallecieron. Los pacientes con suPAR 4 ng/ml (52,5%) tenían menor mortalidad (1%), menor reconsulta (24,4%) y menor necesidad de ingreso hospitalario (20,6%), que pacientes con suPAR 6 ng/ml (mortalidad 13,5%, reconsulta 39,6% e ingreso 56,3%). Un suPAR 6 ng/ml mostró una hazard ratio (IC 95%) ajustada de 4,61 (1,68-12,67) para predecir mortalidad a 90 días y de 1,59 (1,13-2,10) para la reconsulta, y una odds ratio de 1,62 (0,99-2,62) para la necesidad de ingreso hospitalario. CONCLUSIONES: Un valor de suPAR 4 ng/ml identifica pacientes con riesgo bajo de mortalidad a 90 días, de reconsulta y de necesidad de ingreso, mientras que los pacientes con suPAR 6 ng/ml tienen mayor mortalidad, reconsulta y necesidad de ingreso.

Effect of a clinical pharmacist on 30-day revisits following discharge from an emergency department: a randomized controlled clinical trial. / Efecto del farmacéutico clínico en las reconsultas a los 30 días posalta del servicio de urgencias: ensayo clínico controlado.

OBJECTIVES: To evaluate a clinical pharmacist's inclusion in emergency department (ED) care in terms of the effect on on 30-day revisits after discharge from the ED and patient satisfaction. MATERIAL AND METHODS: Randomized, controlled parallel-group pragmatic trial in a university hospital ED. Recruited patients were randomly assigned to a control group for standard care only or an intervention group to receive standard care plus the attention of a clinical pharmacist integrated into the care team to optimize the selection and evaluation of medications and provide pharmacotherapeutic education on the patient's discharge. The primary outcome was unplanned revisits within 30 days after discharge because of the same complaint that led to the initial ED visit. Between-group differences were analyzed with Kaplan-Meier survival curves and log-rank tests. The association between the intervention and time to the outcome event was explored with multivariate Cox proportional hazard regression analysis. RESULTS: A total of 1001 patients were enrolled (intervention, 500; control, 501). Patients in both groups were similar. A majority were women (61.5%), and the median age (interquartile range) was 51 years (33-65 years). The pharmacist's intervention significantly reduced the number of 30-day revisits to any ED: 25 (6.3%) revisited vs 66 (16.7%) in the control group. The adjusted hazard ratio (aHR) was 0.29 (95% CI, 0.17-0.50). Fifteen patients (3.0%) from the intervention group revisited the same ED vs 32 (6.5%) from the control group (aHR, 0.46 [95% CI, 0.24-0.87]). More patients expressed satisfaction in the intervention group (87.2%) than in the control group ( 83.2%) (P .05). CONCLUSION: Including a clinical pharmacist in ED care substantially reduces the number of 30-day revisits and increases patient satisfaction.

OBJETIVO: Determinar el efecto de la inclusión del farmacéutico clínico en el servicio de urgencias (SU) en las reconsultas durante 30 días posalta y la satisfacción de los pacientes. METODO: Ensayo clínico controlado, aleatorizado, paralelo y pragmático, realizado en el SU de un hospital universitario. Los pacientes reclutados fueron asignados aleatoriamente al grupo control (GC) que recibió la atención habitual o al grupo intervenido (GI) que recibió además la atención de un farmacéutico clínico, el cual se integró al equipo clínico para optimizar la selección, evaluación y educación farmacoterapéutica en el SU y al alta. El desenlace primario fue reconsultas no programadas 30 días posaltarelacionadas con la atención inicial al SU. Las diferencias entre grupos se analizaron por curvas de supervivencia de Kaplan-Meier y prueba de log-rank. La asociación entre intervención y tiempo al evento fue analizada mediante regresión multivariada de riesgos proporcionales de Cox y se expresó como hazard ratio ajustada (HRa). RESULTADOS: Un total de 1.001 pacientes ingresaron al estudio (GI = 500 y GC = 501). Ambos grupos eran similares, predominaron las mujeres (61,5%), edad 51 años (RIC: 33-65). La intervención redujo significativamente las reconsultas a cualquier centro durante 30 días posalta comparado con GC [25 (6,3%) vs 66 (16,7%); HRa: 0,29 (IC 95%: 0,17-0,50)] y para el mismo centro [15 (3,0%) vs 32 (6,5%); HRa: 0,46 (IC 95%: 0,24-0,87)]. La satisfacción del usuario fue mayor en el GI que GC (87,2% vs 83,2%; p 0,05). CONCLUSIONES: La inclusión del farmacéutico clínico en un SU reduce sustancialmente las reconsultas durante 30 días posalta y mejora la satisfacción de los usuarios.

Long-term risk of death in patients with infection attended by prehospital emergency services. / Modelo de riesgo de mortalidad a largo plazo en pacientes con infección atendidos por servicios de emergencias prehospitalarios.

OBJECTIVES: To develop and validate a risk model for 1-year mortality based on variables available from early prehospital emergency attendance of patients with infection. MATERIAL AND METHODS: Prospective, observational, noninterventional multicenter study in adults with suspected infection transferred to 4 Spanish hospitals by advanced life-support ambulances from June 1, 2020, through June 30, 2022. We collected demographic, physiological, clinical, and analytical data. Cox regression analysis was used to develop and validate a risk model for 1-year mortality. RESULTS: Four hundred ten patients were enrolled (development cohort, 287; validation cohort, 123). Cumulative mortality was 49% overall. Sepsis (infection plus a Sepsis-related Organ Failure Assessment score of 2 or higher) was diagnosed in 29.2% of survivors vs 56.7% of nonsurvivors. The risk model achieved an area under the receiver operating characteristic curve of 0.89 for 1-year mortality. The following predictors were included in the model: age; institutionalization; age-adjusted Charlson comorbidity index; PaCO2; potassium, lactate, urea nitrogen, and creatinine levels; fraction of inspired oxygen; and diagnosed sepsis. CONCLUSION: The model showed excellent ability to predict 1-year mortality based on epidemiological, analytical, and clinical variables, identifying patients at high risk of death soon after their first contact with the health care system.

OBJETIVO: Diseñar y validar un modelo de riesgo con variables determinadas a nivel prehospitalario para predecir el riesgo de mortalidad a largo plazo (1 año) en pacientes con infección. METODO: Estudio multicéntrico, observacional prospectivo, sin intervención, en pacientes adultos con sospecha infección atendidos por unidades de soporte vital avanzado y trasladados a 4 hospitales españoles entre el 1 de junio de 2020 y el 30 de junio de 2022. Se recogieron variables demográficas, fisiológicas, clínicas y analíticas. Se construyó y validó un modelo de riesgo para la mortalidad a un año usando una regresión de Cox. RESULTADOS: Se incluyeron 410 pacientes, con una tasa de mortalidad acumulada al año del 49%. La tasa de diagnóstico de sepsis (infección e incremento sobre el SOFA basal $ 2 puntos) fue del 29,2% en supervivientes frente a un 56,7% en no supervivientes. El modelo predictivo obtuvo un área bajo la curva de la característica operativa del receptor para la mortalidad a un año fue de 0,89, e incluyó: edad, institucionalización, índice de comorbilidad de Charlson ajustado por edad, presión parcial de dióxido de carbono, potasio, lactato, nitrógeno ureico en sangre, creatinina, saturación en relación con fracción inspirada de oxígeno y diagnóstico de sepsis. CONCLUSIONES: El modelo desarrollado con variables epidemiológicas, analíticas y clínicas mostró una excelente capacidad predictiva, y permitió identificar desde el primer contacto del paciente con el sistema sanitario, a modo de evento centinela, casos de alto riesgo.

Impact of opening a new emergency department on healthcare service and patient outcomes: analyses based on linking ambulance, emergency and hospital databases.

BACKGROUND: Emergency department (ED) crowding caused by access block is an increasing public health issue and has been associated with impaired healthcare delivery, negative patient outcomes and increased staff workload. AIM: To investigate the impact of opening a new ED on patient and healthcare service outcomes. METHODS: A 24-month time series analysis was employed using deterministically linked data from the ambulance service and three ED and hospital admission databases in Queensland, Australia. RESULTS: Total volume of ED presentations increased 18%, while local population growth increased by 3%. Healthcare service and patient outcomes at the two pre-existing hospitals did not improve. These outcomes included ambulance offload time: (Hospital A PRE: 10 min, POST: 10 min, P < 0.001; Hospital B PRE: 10 min, POST: 15 min, P < 0.001); ED length of stay: (Hospital A PRE: 242 min, POST: 246 min, P < 0.001; Hospital B PRE: 182 min, POST: 210 min, P < 0.001); and access block: (Hospital A PRE: 41%, POST: 46%, P < 0.001; Hospital B PRE: 23%, POST: 40%, P < 0.001). Time series modelling indicated that the effect was worst at the hospital furthest away from the new ED. CONCLUSIONS: An additional ED within the region saw an increase in the total volume of presentations at a rate far greater than local population growth, suggesting it either provided an unmet need or a shifting of activity from one sector to another. Future studies should examine patient decision making regarding reasons for presenting to a new or pre-existing ED. There is an inherent need to take a 'whole of health service area' approach to solve crowding issues.

Predictors of Urgent Dialysis Following Ambulance Transport to the Emergency Department in Patients Treated With Maintenance Hemodialysis.

Background: Patients receiving maintenance hemodialysis frequently require ambulance transport to the emergency department (ambulance-ED transport). Identifying predictors of outcomes after ambulance-ED transport, especially the need for timely dialysis, is important to health care providers. Objective: The purpose of this study was to derive a risk-prediction model for urgent dialysis after ambulance-ED transport. Design: Observational cohort study. Setting and Patients: All ambulance-ED transports among incident and prevalent patients receiving maintenance hemodialysis affiliated with a regional dialysis program (catchment area of approximately 750 000 individuals) from 2014 to 2018. Measurements: Patients' vital signs (systolic blood pressure, oxygen saturation, respiratory rate, and heart rate) at the time of paramedic transport and time since last dialysis were utilized as predictors for the outcome of interest. The primary outcome was urgent dialysis (defined as dialysis in a monitored setting within 24 hours of ED arrival or dialysis within 24 hours with the first ED patient blood potassium level >6.5 mmol/L) for an unscheduled indication. Secondary outcomes included, hospitalization, hospital length of stay, and in-hospital mortality. Methods: A logistic regression model to predict outcomes of urgent dialysis. Discrimination and calibration were assessed using the C-statistic and Hosmer-Lemeshow test. Results: Among 878 ED visits, 63 (7.2%) required urgent dialysis. Hypoxemia (odds ratio [OR]: 4.04, 95% confidence interval [CI]: 1.75-9.33) and time from last dialysis of 24 to 48 hours (OR: 3.43, 95% CI: 1.05-11.9) and >48 hours (OR: 9.22, 95% CI: 3.37-25.23) were strongly associated with urgent dialysis. A risk-prediction model incorporating patients' vital signs and time from last dialysis had good discrimination (C-statistic 0.8217) and calibration (Hosmer-Lemeshow goodness of fit P value .8899). Urgent dialysis patients were more likely to be hospitalized (63% vs 34%), but there were no differences in inpatient mortality or length of stay. Limitations: Missing data, requires external validation. Conclusion: We derived a risk-prediction model for urgent dialysis that may better guide appropriate transport and care for patients requiring ambulance-ED transport.

Contexte: Les patients sous hémodialyse chronique doivent souvent être transportés au service des urgences par ambulance (transport ambulance-SU). Il est important pour les prestataires de soins de santé que l'on détermine les facteurs prédictifs des résultats après un transport ambulance-SU, en particulier le besoin de dialyze d'urgence. Objectifs: Cette étude visait à établir un modèle de prédiction du risque pour une dialyze d'urgence après un transport ambulance-SU. Type d'étude: Étude de cohorte observationnelle. Participants et cadre de l'étude: Tous les transports ambulance-SU de patients incidents et prévalents recevant une hémodialyse chronique affiliée à un program régional de dialyze (zone desservant environ 750 000 personnes) entre 2014 et 2018. Prédicteurs: Les signes vitaux du patient (pression artérielle systolique, saturation en oxygène, fréquence respiratoire et fréquence cardiaque) au moment du transport par ambulance et le temps écoulé depuis la dernière dialyze. Résultats: La dialyze d'urgence (définie comme une dialyze en environnement monitoré dans les 24 heures suivant l'arrivée aux urgences ou une dialyze dans les 24 heures avec une première mesure du taux de potassium sanguin aux urgences supérieure à 6,5 mmol/L) pour une indication non programmée. Résultats secondaires: hospitalization, durée du séjour à l'hôpital et mortalité à l'hôpital. Méthodologie: Un modèle de régression logistique a servi à prédire le résultat de dialyze d'urgence. La discrimination et la calibration ont été évalués à l'aide de la statistique C et du test Hosmer-Lemeshow. Résultats: Parmi les 878 visites aux urgences, 63 (7,2 %) ont nécessité une dialyze d'urgence. L'hypoxémie (rapport de cote [RC]: 4,04; IC à 95 %: 1,75-9,33) et des périodes de 24 à 48 heures (RC: 3,43; IC à 95 %: 1,05-11,9) et de plus de 48 heures (RC: 9,22; IC à 95 %: 3,37-25,23) depuis la dernière dialyze sont les facteurs qui ont été les plus fortement associés à une dialyze d'urgence. Un modèle de prédiction du risque intégrant les signes vitaux du patient et le temps depuis la dernière dialyze a présenté une bonne discrimination (statistique C: 0,8217) et une bonne calibration (qualité de l'ajustement selon Hosmer-Lemeshow: P =,8899). Les patients qui avaient reçu une dialyze d'urgence étaient plus susceptibles d'être hospitalisés (63% contre 34%), mais aucune différence n'a été observée pour le taux de mortalité ou la durée du séjour en milieu hospitalier. Limites: Données manquantes, validation externe requise. Conclusion: Nous avons dérivé un modèle de prédiction du risque de dialyze d'urgence susceptible de mieux guider le transport et les soins appropriés pour les patients nécessitant un transport ambulance-SU.

The Maryland (USA) Critical Care Coordination Center (C4): From Pandemic to Permanence.

INTRODUCTION: The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland's (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care. METHODS: The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation. RESULTS: Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide. CONCLUSION: The C4 has played an integral role in the State of Maryland's pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.

An Analysis of Drug Use-Related Curriculum Documents for Paramedic Students in British Columbia.

BACKGROUND AND AIMS: Paramedics attend an unprecedented number of drug poisoning events daily in British Columbia (BC), Canada, due to the ongoing public health crisis related to an increasingly toxic and unregulated street supply of illicit drugs. Paramedics have the potential to support alternative models of care to reduce harm, but their perspectives toward harm reduction initiatives are polarized. Understanding the drug-related substance use content in paramedic curriculum documents is important for deploying effective harm-mitigating programs. The aim of this study was to determine how illicit drug-related substance curriculum prepares paramedics for practice in British Columbia. METHODS: We performed a document analysis of curriculum documents in BC's paramedic training institutions, the primary program textbook, and the 2011 National Occupational Competency Profile (NOCP) for Paramedics in Canada. We used O'Leary's eight-step process to guide the planning and procedure of the analysis. We analyzed and coded documents both inductively and deductively and subsequently combined, refined, and used the codes to inform the development of themes via reflexive thematic analysis. The Checklist for Assessment and Reporting of Document Analysis (CARDA) tool was used to report our analysis. RESULTS: Of the 45 documents analyzed, 23 included codes relevant to the research questions. Paramedics are primarily taught to care for people who use drugs in an acute drug poisoning response only, with little consideration of holistic care and no meaningful mention of harm reduction. Some stigmatizing language was found within the content. CONCLUSIONS: Many opportunities to introduce holistic models of care for people who use drugs along the entire continuum of care are unaddressed by paramedic curriculum documents in BC. Curriculum developers should include people who have lived and living experience of drug use in the co-design of educational programs involving their care. Further qualitative analyses are required to evaluate the relationship between paramedic education and provider-based stigma.