Decision discovery using clinical decision support system decision log data for supporting the nurse decision-making process.

BACKGROUND: Decision-making in healthcare is increasingly complex; notably in hospital environments where the information density is high, e.g., emergency departments, oncology departments, and psychiatry departments. This study aims to discover decisions from logged data to improve the decision-making process. METHODS: The Design Science Research Methodology (DSRM) was chosen to design an artifact (algorithm) for the discovery and visualization of decisions. The DSRM's different activities are explained, from the definition of the problem to the evaluation of the artifact. During the design and development activities, the algorithm itself is created. During the demonstration and evaluation activities, the algorithm was tested with an authentic synthetic dataset. RESULTS: The results show the design and simulation of an algorithm for the discovery and visualization of decisions. A fuzzy classifier algorithm was adapted for (1) discovering decisions from a decision log and (2) visualizing the decisions using the Decision Model and Notation standard. CONCLUSIONS: In this paper, we show that decisions can be discovered from a decision log and visualized for the improvement of the decision-making process of healthcare professionals or to support the periodic evaluation of protocols and guidelines.

Homecare workers - an untapped resource in preventing emergency department visits among older individuals? A qualitative interview study from Sweden.

BACKGROUND: Older individuals with functional decline and homecare are frequent visitors to emergency departments (ED). Homecare workers (HCWs) interact regularly with their clients and may play a crucial role in their well-being. Therefore, this study explores if and how HCWs perceive they may contribute to the prevention of ED visits among their clients. METHODS: In this qualitative study, 12 semi-structured interviews were conducted with HCWs from Sweden between July and November 2022. Inductive thematic analysis was used to identify barriers and facilitators to prevent ED visits in older home-dwelling individuals. RESULTS: HCWs want to actively contribute to the prevention of ED visits among clients but observe many barriers that hinder them from doing so. Barriers refer to care organisation such as availability to primary care staff and information transfer; perceived attitudes towards HCWs as co-workers; and client-related factors. Participants suggest that improved communication and collaboration with primary care and discharge information from the ED to homecare services could overcome barriers. Furthermore, they ask for support and geriatric education from primary care nurses which may result in increased respect towards them as competent staff members. CONCLUSIONS: HCWs feel that they have an important role in the health management of older individuals living at home. Still, they feel as an untapped resource in the prevention of ED visits. They deem that improved coordination and communication between primary care, ED, and homecare organisations as well as proactive care would enable them to add significantly to the prevention of ED visits.

Predicting the need for urgent endoscopic intervention in lower gastrointestinal bleeding: a retrospective review.

BACKGROUND: Lower gastrointestinal bleeding (LGIB) is a common reason for emergency department visits and subsequent hospitalizations. Recent data suggests that low-risk patients may be safely evaluated as an outpatient. Recommendations for healthcare systems to identify low-risk patients who can be safely discharged with timely outpatient follow-up have yet to be established. The primary objective of this study was to determine the role of patient predictors for the patients with LGIB to receive urgent endoscopic intervention. METHODS: A retrospective chart review was performed on 142 patients. Data was collected on patient demographics, clinical features, comorbidities, medications, hemodynamic parameters, laboratory values, and diagnostic imaging. Logistic regression analysis, independent samples t-testing, Mann Whitney U testing for non-parametric data, and univariate analysis of categorical variables by Chi square test was performed to determine relationships within the data. RESULTS: On logistic regression analysis, A hemoglobin drop of > 20 g/L was the only variable that predicted endoscopic intervention (p = 0.030). Tachycardia, hypotension, or presence of anticoagulation were not significantly associated with endoscopic intervention (p > 0.05). CONCLUSIONS: A hemoglobin drop of > 20 g/L was the only patient parameter that predicted the need for urgent endoscopic intervention in the emergency department.

Social determinants of health and emergency department visits among older adults with multimorbidity: insight from 2010 to 2018 National Health Interview Survey.

BACKGROUND: Multimorbidity is prevalent among older adults and is associated with adverse health outcomes, including high emergency department (ED) utilization. Social determinants of health (SDoH) are associated with many health outcomes, but the association between SDoH and ED visits among older adults with multimorbidity has received limited attention. This study aimed to examine the association between SDoH and ED visits among older adults with multimorbidity. METHODS: A cross-sectional analysis was conducted among 28,917 adults aged 50 years and older from the 2010 to 2018 National Health Interview Survey. Multimorbidity was defined as the presence of two or more self-reported diseases among 10 common chronic conditions, including diabetes, hypertension, asthma, stroke, cancer, arthritis, chronic obstructive pulmonary disease, and heart, kidney, and liver diseases. The SDoH assessed included race/ethnicity, education level, poverty income ratio, marital status, employment status, insurance status, region of residence, and having a usual place for medical care. Logistic regression models were used to examine the association between SDoH and one or more ED visits. RESULTS: Participants' mean (± SD) age was 68.04 (± 10.66) years, and 56.82% were female. After adjusting for age, sex, and the number of chronic conditions in the logistic regression model, high school or less education (adjusted odds ratio [AOR]: 1.10, 95% confidence interval [CI]: 1.02-1.19), poverty income ratio below the federal poverty level (AOR: 1.44, 95% CI: 1.31-1.59), unmarried (AOR: 1.19, 95% CI: 1.11-1.28), unemployed status (AOR: 1.33, 95% CI: 1.23-1.44), and having a usual place for medical care (AOR: 1.46, 95% CI 1.18-1.80) was significantly associated with having one or more ED visits. Non-Hispanic Black individuals had higher odds (AOR: 1.28, 95% CI: 1.19-1.38), while non-Hispanic Asian individuals had lower odds (AOR: 0.71, 95% CI: 0.59-0.86) of one or more ED visits than non-Hispanic White individuals. CONCLUSION: SDoH factors are associated with ED visits among older adults with multimorbidity. Systematic multidisciplinary team approaches are needed to address social disparities affecting not only multimorbidity prevalence but also health-seeking behaviors and emergent healthcare access.

Incidence and outcomes of emergency department patients requiring emergency general surgery: a 5-year retrospective cohort study.

AIMS: Patients undergoing emergency general surgery are at high risk of complications and death. Our objectives were to estimate the incidence of emergency general surgery in a Swiss University Hospital, to describe the characteristics and outcomes of patients undergoing such procedures, and to study the impact of age on clinical outcomes. METHODS: This was a retrospective cohort study of adult patients who visited the emergency department (ED) of Geneva University Hospitals between January 2015 and December 2019. Routinely collected data were extracted from electronic medical records. The primary outcome was the incidence of emergency general surgery among patients visiting the emergency department, defined as general surgery within three days of emergency department admission. We also assessed demographic characteristics, mortality, intensive care unit admission and patient disposition. Multivariable log-binomial regression was used to study the associations of age with intensive care unit (ICU) admission, one-year mortality and dependence at discharge. Age was modelled as a continuous variable using restricted cubic splines and we compared older patients (75th percentile) with younger patients (25th percentile). RESULTS: Between January 2015 and December 2019, a total of 310,914 emergency department visits met our inclusion criteria. Among them, 3592 patients underwent emergency general surgery within 3 days of emergency department admission, yielding an annual incidence of 116 events per 10,000 emergency department visits (95% CI: 112-119), with a higher incidence in females and young patients. Overall, 5.3% of patients were admitted to ICU, 7.8% were dependent on rehabilitation or assisted living at discharge and 4.8% were dead after one year. Older patients had a higher risk of ICU admission (adjusted risk ratio (aRR) 2.9 [1.5-5.4]), dependence at discharge (aRR 15.3 [5.5-42.4]) and one-year mortality (aRR 5.4 [2.2-13.4]). CONCLUSION: Emergency department visits resulting in emergency general surgery are frequent, but their incidence decreases with patient age. Mortality, ICU admission and dependence at discharge following emergency general surgery are more frequent in older patients. Taking into account the increased risk for older patients, a shared process is appropriate for making more informed decisions about their options for care.

Associations of Health Care Utilization and Therapeutic Alliance in Patients with Advanced Cancer.

Introduction: Therapeutic alliance (TA), or the extent to which patients feel a sense of caring and trust with their physician, may have an impact on health care utilization. We sought to determine if TA is associated with: (1) emergency department (ED) visits within 30 days of death and (2) hospice enrollment. Methods and Materials: This is a secondary analysis of data from a randomized clinical trial. We used restricted cubic splines to assess the relationship between TA scores and health care utilization. Results: Six hundred seventy-two patients were enrolled in the study, with 331 (49.3%) dying within 12 months. Patients with higher TA were less likely to have an ED visit in the last 30 days of life, but there was no evidence of a relationship between TA and enrollment in hospice. Conclusions: Higher TA was associated with decreased ED visits within 30 days of death. There was no association between TA and rates of hospice enrollment. Clinical Registration Number: NCT02712229.

Cat owners do not provide more reliable weight estimates for cats compared with veterinary professionals in an emergency setting.

OBJECTIVES: The aim of the present study was to assess the accuracy of weight estimation in cats provided by pet owners, veterinary technicians, house officers (interns and residents) and attending clinicians in an emergency room (ER). An additional objective was to determine whether carrying the cat contributed to a more accurate weight estimate. METHODS: A total of 72 cats presented to an ER and were enrolled in the study. Pet owners, veterinary technicians, house officers and attending clinicians were asked to record the cats' estimated weights on individual data collection cards. The actual weights of the cats were then obtained and compared with participants' estimations. RESULTS: There were no significant differences between weight estimates provided by pet owners, veterinary technicians, house officers and attending clinicians. Similarly, neither the length of experience of the veterinary staff nor carrying the cat had an effect on the provision of a more accurate weight estimate. CONCLUSIONS AND RELEVANCE: Pet owners are no better at weight estimation of cats in the ER setting compared with veterinary professionals. Carrying the cat did not improve the accuracy of weight estimation among veterinary professionals. The mean cat weight of 4.9 kg could be used as an average cat weight in an emergency situation for an adult cat.

Tobacco Smoking or Nicotine Phenotype and Severity of Clinical Presentation at the Emergency Department (SMOPHED): Protocol for a Noninterventional Observational Study.

BACKGROUND: In the last few years, several nicotine products have become available as alternatives to smoking tobacco. While laboratory and limited clinical studies suggest that these devices are less toxic compared to classic tobacco cigarettes, very little is known about their epidemiological impact. Visiting the emergency department (ED) often represents the first or even the only contact of patients with the health care system. Therefore, a study conducted at the ED to assess the impact of these products on health can be reliable and reflect a real-life setting. OBJECTIVE: The aim of this noninterventional observational study (SMOPHED study) is to analyze the association between the severity of clinical presentation observed during ED visits among patients using various nicotine products and the subsequent outcomes, specifically hospitalization and mortality. METHODS: Outcomes (hospitalization and mortality in the ED) will be examined in relation to various patterns of nicotine products use. We plan to enroll approximately 2000 participants during triage at the ED. These individuals will be characterized based on their patterns of tobacco and nicotine consumption, identified through a specific questionnaire. This categorization will allow for a detailed analysis of how different usage patterns of nicotine products correlate with the clinical diagnosis made during the ED visits and the consequent outcomes. RESULTS: Enrollment into the study started in March 2024. We enrolled a total of 901 participants in 1 month (approximately 300 potential participants did not provide the informed consent to participate). The data will be analyzed by a statistician as soon as the database is completed. Full data will be published by December 2024. CONCLUSIONS: There is substantial debate about the harm reduction potential of alternative nicotine products in terms of their smoking-cessation and risk-reduction potential. This study represents an opportunity to document epidemiological data on the link between the use of different types of nicotine products and disease diagnosis and severity during an ED visit, and thus evaluate the harm reduction potential claims for these products. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/54041.

Adult Cancer Patients' Perceptions of Factors That Influence Hospital Admissions.

PURPOSE/AIMS: To explore cancer patients' perceptions of factors that influence hospital readmissions. DESIGN: A cross-sectional, prospective design was employed utilizing a 1-time survey and brief interviews to measure patients' perceptions and unplanned hospital admissions. METHODS AND VARIABLES: The principal investigator collected data from medical record review, the Hospital Admission Survey, and interviews to measure patient characteristics and perceptions of influencing factors that contributed to an unplanned hospital admission upon admission. Data were analyzed using descriptive statistics to categorize patient perceptions of influencing factors of unplanned hospital admissions. RESULTS: The top reasons for admission were symptoms of uncontrolled gastrointestinal, pain, fever, and respiratory problems. The majority perceived the admission was unavoidable and wanted to avoid an admission. Perceived influencing factors were related to survey categories of 1) communication (ie, cannot reach physician anytime, cannot get a next-day appointment, medical problems are out of control, advised to go to the emergency department) and 2) home environment (ie, unable to adequately manage symptoms at home and hospital admission is the best place for care). Other survey categories of patient education and palliative care were not perceived as influencing or contributing factors. CONCLUSIONS: These findings highlight opportunities for clinical nurse specialists to target these vulnerable patients and provide expert consultation to address potential barriers and gaps in utilization of appropriate supportive services that may reduce unplanned hospital admissions.

Utility of the LACE index to assess risk of mortality and readmission in patients with spinal infections.

Retrospective cohort study. To assess the utility of the LACE index for predicting death and readmission in patients with spinal infections (SI). SIs are severe conditions, and their incidence has increased in recent years. The LACE (Length of stay, Acuity of admission, Comorbidities, Emergency department visits) index quantifies the risk of mortality or unplanned readmission. It has not yet been validated for SIs. LACE indices were calculated for all adult patients who underwent surgery for spinal infection between 2012 and 2021. Data were collected from a single academic teaching hospital. Outcome measures included the LACE index, mortality, and readmission rate within 30 and 90 days. In total, 164 patients were analyzed. Mean age was 64.6 (± 15.1) years, 73 (45%) were female. Ten (6.1%) patients died within 30 days and 16 (9.8%) died within 90 days after discharge. Mean LACE indices were 13.4 (± 3.6) and 13.8 (± 3.0) for the deceased patients, compared to 11.0 (± 2.8) and 10.8 (± 2.8) for surviving patients (p = 0.01, p < 0.001), respectively. Thirty-seven (22.6%) patients were readmitted ≤ 30 days and 48 (29.3%) were readmitted ≤ 90 days. Readmitted patients had a significantly higher mean LACE index compared to non-readmitted patients (12.9 ± 2.1 vs. 10.6 ± 2.9, < 0.001 and 12.8 ± 2.3 vs. 10.4 ± 2.8, p < 0.001, respectively). ROC analysis for either death or readmission within 30 days estimated a cut-off LACE index of 12.0 points (area under the curve [AUC] 95% CI, 0.757 [0.681-0.833]) with a sensitivity of 70% and specificity of 69%. Patients with SI had high LACE indices that were associated with high mortality and readmission rates. The LACE index can be applied to this patient population to predict the risk of early death or unplanned readmission.

Critical Assessment of the Management of Unstable Angina in a Specialized Cardiology Emergency Room. / Avaliação Crítica do Manejo da Angina Instável em Pronto-Socorro Terciário de Cardiologia.

BACKGROUND: The management of unstable angina (UA) presents a challenge due to its subjective diagnosis and limited representation in randomized clinical trials that inform current practices. OBJECTIVES: This study aims to identify key factors associated with the indication for invasive versus non-invasive stratification in this population and to evaluate factors associated with stratification test results. METHODS: This retrospective cohort study included patients hospitalized with UA over a consecutive 20-month period. To assess factors associated with stratification strategies, patients were divided into invasive stratification (coronary angiography) and non-invasive stratification (other methods) groups. For the analysis of factors related to changes in stratification tests, patients were categorized into groups with or without obstructive coronary artery disease (CAD) or ischemia, as per the results of the requested tests. Comparisons between groups and multiple logistic regression analyses were performed, with statistical significance set at a 5% level. RESULTS: A total of 729 patients were included, with a median age of 63 years and a predominance of males (64.6%). Factors associated with invasive stratification included smoking (p = 0.001); type of chest pain (p < 0.001); "crescendo" pain (p = 0.006); TIMI score (p = 0.006); HEART score (p = 0.011). In multivariate analysis, current smokers (OR 2.23, 95% CI 1.13-4.8), former smokers (OR 2.19, 95% CI 1.39-3.53), and type A chest pain (OR 3.39, 95% CI 1.93-6.66) were independently associated. Factors associated with obstructive CAD or ischemia included length of hospital stay (p < 0.001); male gender (p = 0.032); effort-induced pain (p = 0.037); Diamond-Forrester score (p = 0.026); TIMI score (p = 0.001). In multivariate analysis, only chest pain (type B chest pain: OR 0.6, 95% CI 0.38-0.93, p = 0.026) and previous CAD (OR 1.42, 95% CI 1.01-2.0, p = 0.048) were independently associated. CONCLUSION: The type of chest pain plays a crucial role not only in the diagnosis of UA but also in determining the appropriate treatment. Our results highlight the importance of incorporating pain characteristics into prognostic scores endorsed by guidelines to optimize UA management.

FUNDAMENTO: O manejo da angina instável (AI) é um desafio devido ao seu diagnóstico subjetivo e à sua escassa representação em ensaios clínicos randomizados que determinem as práticas atuais. OBJETIVOS: O objetivo deste estudo é identificar os principais fatores associados à indicação de estratificação invasiva ou não nessa população e avaliar os fatores associados às alterações nos exames de estratificação. MÉTODOS: Coorte retrospectiva de pacientes internados por AI, em um período de 20 meses consecutivos. Para avaliar os fatores associados à estratégia de estratificação, os pacientes foram divididos em estratificação invasiva (cinecoronariografia) e não invasiva (demais métodos). Para análise de fatores relacionados às alterações nos exames de estratificação, os pacientes foram divididos em grupos com ou sem doença arterial coronariana (DAC) obstrutiva ou isquemia, conforme resultados dos exames solicitados. Foram realizadas comparações entre grupos e análise de regressão logística múltipla, com significância estatística definida em um nível de 5%. RESULTADOS: 729 pacientes foram incluídos, com mediana de idade de 63 anos e predomínio do sexo masculino (64,6%). Estiveram associados à estratificação invasiva: tabagismo (p = 0,001); tipo de dor torácica (p < 0,001); dor "em crescendo" (p = 0,006); escore TIMI (p = 0,006); escore HEART (p = 0,011). Na análise multivariada, tabagistas (OR 2,23, IC 95% 1,13-4,8), ex-tabagistas (OR 2,19, IC 1,39-3,53) e dor torácica tipo A (OR 3,39, IC 95% 1,93-6,66) estiveram associados de forma independente. Estiveram associados à DAC obstrutiva ou isquemia: tempo de internação hospitalar (p < 0,001); sexo masculino (p = 0,032); dor desencadeada por esforço (p = 0,037); Diamond-Forrester (p = 0,026); escore TIMI (p = 0,001). Na análise multivariada, apenas dor torácica (dor torácica tipo B: OR 0,6, IC 95% 0,38-0,93, p = 0,026) e DAC prévia (OR 1,42, IC 95% 1,01-2,0, p = 0,048) estiveram associadas de maneira independente. CONCLUSÕES: O tipo de dor torácica desempenha um papel crucial não apenas no diagnóstico da AI, mas também na definição do tratamento adequado. Nossos resultados destacam a importância de incorporar características da dor aos escores prognósticos endossados pelas diretrizes, para otimização do manejo da AI.

The role of Ottawa ankle rules in geriatric emergency department visits.

BACKGROUND: Ankle injuries are a common reason for visits to the emergency department (ED). An effective diagnosis and treatment process is crucial for the swift recovery of patients and for alleviating congestion in EDs. This study aims to evaluate the adequacy and effectiveness of the Ottawa Ankle Rules (OAR) in geriatric patients presenting to the emergency department (ED). METHODS: Between February 2022 and November 2022, 160 patients aged 65 and older (118 women, 42 men) who presented to the ED with isolated ankle injuries were included in the study. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the OAR. RESULTS: The study found fractures in 37.5% of patients. The sensitivity of the OAR was 98.33%, the specificity was 86%, the negative predictive value was 98.85%, and the positive predictive value was 80.82%. CONCLUSION: This study demonstrates that the OAR is highly sensitive in the geriatric population but shows some limitations in terms of specificity and positive predictive value. These results support the effectiveness of using the OAR in evaluating ankle injuries in the geriatric population but also highlight the need for cautious application due to the potential for false-positive outcomes.

The Diagnosis and Treatment of Adult Urinary Tract Infections in the Emergency Department.

Emergency medicine has been called the art of "making complicated clinical decisions with limited information." This description is particularly relevant in the case of diagnosis and treatment of urinary tract infections (UTIs). Although common, UTIs are often challenging to diagnose given the presence of non-specific signs and symptoms and over-reliance on laboratory findings. This review provides an interdisciplinary interpretation of the primary literature and practice guidelines, with a focus on diagnostic and antimicrobial stewardship in the emergency department.

Communicable Disease Screening and Human Immunodeficiency Virus Prevention in the Emergency Department.

Emergency departments (ED) provide care to populations with high rates of communicable diseases, like HIV, hepatitis C virus, and syphilis. For many patients, the ED is their sole entry point into the healthcare system and they do not routinely access screening and prevention services elsewhere. As such, the ED can serve an important public health role through communicable disease identification, treatment, and prevention. In this article, we examine national recommendations, peer-reviewed literature, and expert consensus to provide cutting edge strategies for implementing communicable infectious disease screening and prevention programs into routine ED care.

A questionnaire survey on the implementation of palliative care in the emergency department in China.

OBJECTIVES: This study was conducted to characterize the need for palliative care and its effect on patients with end-stage disease in the emergency department (ED). DESIGN: This was a prospective cohort study. A questionnaire survey was administered to patients with end-stage disease who were admitted to the resuscitation room of the ED and expected to live less than 6 months. RESULTS: A total of 82 of 2095 patients admitted to the resuscitation room were included. Only 1 (1.22%) patient had ever received palliative care before admission. Nine patients received palliative care consultation after admission, and they were more likely to select medical places of death accompanied by their families and do not resuscitate orders at the end of life after consultation (P < 0.05). Whether the disease had previously been actively treated and the number of children impacted the choice of treatment at the end of life (P < 0.05). CONCLUSIONS: Among patients with end-stage disease admitted to the ED, knowledge of palliative care was lacking. Palliative care could help them avoid the damage caused by pointless resuscitation.

Selecting an e-cigarette for use in smoking cessation interventions and healthcare services: findings from patient and public consultation for the COSTED trial.

OBJECTIVES: The Cessation of Smoking Trial in the Emergency Department (COSTED) trial aims to ascertain whether brief advice, the provision of an e-cigarette starter kit and referral to stop smoking services (SSS), increases smoking cessation in people attending the emergency department. Patient and public involvement (PPI) and scoping work were undertaken to select an appropriate e-cigarette for the trial. DESIGN AND SETTING: PPI consultation and feasibility scoping about potential devices with a professional and lay panel, all based in England. Consultation was via email, telephone or video interview. This work took place between April and July 2021, prior to recruitment commencing for the COSTED trial. PARTICIPANTS: A professional panel (n=7) including representatives from academia, SSS and the independent vaping industry, and a PPI lay panel (n=3) who smoke or vape. RESULTS: The professional panel recommended a shortlist of devices which were tested by the PPI lay panel. Key criteria for selecting an appropriate e-cigarette for smoking cessation intervention include satisfaction, usability, affordability and availability. Simplicity of use was highlighted by the PPI lay panel, who found refillable devices complex, and availability of consumables was highlighted as more important than price by both panels. The pod device selected for inclusion was rated highly for satisfaction and usability and had mid-price range and consumables which were widely available. CONCLUSIONS: To select the most appropriate device for the COSTED trial, each criterion required assessment to ensure the best fit to the intervention context and needs of the target population. There is a need for guidance to help enable decision-making about choice of vape products, tailored to service users' needs. We propose a bespoke checklist template, based on our findings, to assist with this process. This has applicability to the recent government announcement of a 'Swap to Stop' programme, offering a vaping starter kit to smokers across England, allowing services flexibility to shape their own programmes and models of delivery. TRIAL REGISTRATION NUMBER: Clinical trial number NCT04854616; pre-results.

Association of household net worth with healthcare costs after radical cystectomy using real-world data.

BACKGROUND: Financial toxicity of bladder cancer care may influence how patients utilize healthcare resources, from emergency department (ED) encounters to office visits. We aim to examine whether greater household net worth (HHNW) confers differential access to healthcare resources after radical cystectomy (RC). METHODS: This population-based cohort study examined the association between HHNW and healthcare utilization costs in the 90 days post-RC in commercially insured patients with bladder cancer. Costs accrued from the index hospitalization to 90 days after including health plan costs (HPC) and out-of-pocket costs (OPC). Multivariable logistic regression models were generated by encounter (acute inpatient, ED, outpatient, and office visit). RESULTS: A total of 141,903 patients were identified with HHNW categories near evenly distributed. Acute inpatient encounters incurred the greatest HPC and OPC. Office visits conferred the lowest HPC while ED visits had the lowest OPC. Black patients harbored increased odds of an acute inpatient encounter (OR 1.22, 95% CI 1.16-1.29) and ED encounter (OR 1.20, 95% CI 1.14-1.27) while Asian (OR 0.76, 95% CI 0.69-0.85) and Hispanic (OR 0.74, 95% CI 0.69-0.78, p < 0.001) patients had lower odds of an outpatient encounter, compared to White counterpart. Increasing HHNW was associated with decreasing odds of acute inpatient or ED encounters and greater odds of office visits. CONCLUSIONS: Lower HHNW conferred greater risk of costly inpatient encounters while greater HHNW had greater odds of less costly office visits, illustrating how financial flexibility fosters differences in healthcare utilization and lower costs. HHNW may serve as a proxy for financial flexibility and risk of financial hardship than income alone.

Areas of consensus on unwarranted and warranted transfers between nursing homes and emergency care facilities in Norway: a Delphi study.

BACKGROUND: Transferring residents from nursing homes (NHs) to emergency care facilities (ECFs) is often questioned as many are terminally ill and have access to onsite care. While some NH to ECF transfers have merit, avoiding other transfers may benefit residents and reduce healthcare system costs and provider burden. Despite many years of research in this area, differentiating warranted (i.e., appropriate) from unwarranted NH to ECF transfers remains challenging. In this article, we report consensus on warranted and unwarranted NH to ECF transfers scenarios. METHODS: A Delphi study was used to identify consensus regarding warranted and unwarranted NH to ECF transfers. Delphi participants included nurses (RNs) and medical doctors (MDs) from NHs, out-of-hours primary care clinics (OOHs), and hospital-based emergency departments. A list of 12 scenarios and 11 medical conditions was generated from the existing literature on causes and medical conditions leading to transfers, and pilot tested and refined prior to conducting the study. Three Delphi rounds were conducted, and data were analyzed using descriptive and comparative statistics. RESULTS: Seventy-nine experts consented to participate, of whom 56 (71%) completed all three Delphi rounds. Participants reached high or very high consensus on when to not transfer residents, except for scenarios regarding delirium, where only moderate consensus was attained. Conversely, except when pain relieving surgery was required, participants reached low agreement on scenarios depicting warranted NH to ECF transfers. Consensus opinions differ significantly between health professionals, participant gender, and rurality, for seven of the 23 transfer scenarios and medical conditions. CONCLUSIONS: Transfers from nursing homes to emergency care facilities can be defined as warranted, discretionary, and unwarranted. These categories are based on the areas of consensus found in this Delphi study and are intended to operationalize the terms warranted and unwarranted transfers between nursing homes and emergency care facilities.

The identification of WHO emergency signs in children by nurses at triage in an emergency department.

BACKGROUND: The World Health Organization recommends the use of a three-tier triage system to recognise a sick child in low- and middle-income countries. The three tiers are based on standardised emergency and priority signs. No studies have evaluated the prevalence or reliable detection of these emergency signs. AIMS: To determine the prevalence of WHO emergency signs and the underlying causes, and to determine whether nurses could reliably detect these signs in children presenting to the emergency department at Port Moresby General Hospital in Papua New Guinea. METHODS: A prospective study measured inter-rater agreement between nurses at triage and a blinded second assessor trained in paediatrics. RESULTS: The prevalence of emergency signs was 16.7%: 32 of 192 children had these signs at presentation; 18 (9.4%) had severe respiratory distress; 10 (5.2%) had severe dehydration; and 3 (1.6%) had convulsions. There was an acceptable inter-rater agreement between nurses and doctors (Cohen's Kappa score >0.4) for some signs: subcostal recession, intercostal recession, nasal flaring, lethargy, weak volume pulses, convulsions, sunken eyes and a poor conscious state. Obstructed breathing, cyanosis, tracheal tug and cold hands and feet were less commonly detected and had poor inter-rater agreement (Kappa score <0.4). CONCLUSIONS: Effective screening at triage can enable prompt emergency treatment by nurses and can help focus doctors' attention on children who require it most. There is a need for additional training in the identification of some emergency signs. ABBREVIATIONS: CED: children's emergency department; ETAT: emergency triage assessment and treatment; HCC: Hospital Care for Children; PMGH: Port Moresby General Hospital; PNG: Papua New Guinea; WHO: World Health Organization.