Assistência à saúde mental nos serviços médicos de emergência: revisão integrativa / Asistencia a la salud mental en los servicios médicos de emergencia: revisión integrativa / Mental health care in emergency medical services: an integrative review

Objetivos: conhecer as características da assistência à saúde mental dispensada por profissionais de enfermagem nos serviços médicos de emergência. Método: revisão integrativa de literatura nas bases de dados Literatura Latino-Americano e do Caribe em Ciências da Saúde (LILACS), Publisher Medline (PUBMED), SciVerse Scopus (SCOPUS) e Cumulative Index to Nursing and Allied Health Literature (CINAHL), no período de março a junho de 2023, utilizando-se critérios de inclusão e exclusão previamente definidos. Resultados: obteve-se uma amostra final de 59 artigos os quais foram agrupados nas seguintes categorias temáticas: concepções em saúde mental, comunicação, intervenções, atendimento em rede, competência em cuidado em saúde mental e barreiras durante os atendimentos. Conclusão: o cuidado é feito de forma incipiente e permeado por elementos dificultadores. Os achados do presente estudo servem para rever e repensar práticas e políticas de cuidado em saúde mental e promover estratégias de aperfeiçoamento dos processos de trabalho.

Objetivos: conocer las características de la asistencia a la salud mental dispensada por profesionales de enfermería en los servicios médicos de emergencia. Método: revisión integrativa de literatura en las bases de datos Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS), Publisher Medline (PUBMED), SciVerse Scopus (SCOPUS) y Cumulative Index to Nursing and Allied Health Literature (CINAHL), en el período de marzo a junio de 2023, utilizando criterios de inclusión y exclusión previamente definidos. Resultados: se obtuvo una muestra final de 59 artículos los cuales fueron agrupados en las siguientes categorías temáticas: concepciones en salud mental, comunicación, intervenciones, atención en red, competencia en atención en salud mental y barreras durante los atendimientos. Conclusión: el cuidado es hecho de forma incipiente y permeado por elementos difíciles. Los hallazgos del presente estudio sirven para revisar y repensar prácticas y políticas de cuidado en salud mental y promover estrategias de perfeccionamiento de los procesos de trabajo.

Objective: to know the characteristics of mental health care provided by nursing professionals in emergency medical services. Method: integrative literature review in the databases Latin American and Caribbean Health Sciences Literature (LILACS), Publisher Medline (PUBMED), SciVerse Scopus (SCOPUS) and Cumulative Index to Nursing and Allied Health Literature (CINAHL), from March to June 2023, using previously defined inclusion and exclusion criteria. Results: the final sample included 59 articles, which were grouped into the following thematic categories: conceptions in mental health, communication, interventions, network care, competence in mental health care and barriers during care. Conclusion: care is done incipient and permeated by difficult elements. The findings of this study serve to review and rethink mental health care practices and policies and promote strategies for improving work processes.

The Emergency Medicine Physician Workforce: Projections for 2030.

STUDY OBJECTIVE: The goals of this study were to determine the current and projected supply in 2030 of contributors to emergency care, including emergency residency-trained and board-certified physicians, other physicians, nurse practitioners, and physician assistants. In addition, this study was designed to determine the current and projected demand for residency-trained, board-certified emergency physicians. METHODS: To forecast future workforce supply and demand, sources of existing data were used, assumptions based on past and potential future trends were determined, and a sensitivity analysis was conducted to determine how the final forecast would be subject to variance in the baseline inputs and assumptions. Methods included: (1) estimates of the baseline workforce supply of physicians, nurse practitioners, and physician assistants; (2) estimates of future changes in the raw numbers of persons entering and leaving that workforce; (3) estimates of the productivity of the workforce; and (4) estimates of the demand for emergency care services. The methodology assumes supply equals demand in the base year and estimates the change between the base year and 2030; it then compares supply and demand in 2030 under different scenarios. RESULTS: The task force consensus was that the most likely future scenario is described by: 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in 2030. CONCLUSION: The specialty of emergency medicine is facing the likely oversupply of emergency physicians in 2030. The factors leading to this include the increasing supply of and changing demand for emergency physicians. An organized, collective approach to a balanced workforce by the specialty of emergency medicine is imperative.

Impact of the SARS-COV-2 Pandemic on the Endovascular Treatment of Acute Stroke - an Italian Single-Center Experience.

OBJECTIVES: The SARS-CoV-2 pandemic greatly influenced the overall quality of healthcare. The purpose of this study was to compare the time variables for acute stroke treatment and evaluate differences in the pre-hospital and in-hospital care before and during the SARS-CoV-2 pandemic, as well as between the first and second waves. MATERIALS AND METHODS: Observational and retrospective study from an Italian hospital, including patients who underwent thrombectomy between January 1st 2019 and December 31st 2020. RESULTS: Out of a total of 594 patients, 301 were treated in 2019 and 293 in 2020. The majority observed in 2019 came from spoke centers (67,1%), while in 2020 more than half (52%, p < 0.01) were evaluated at the hospital's emergency room directly (ER-NCGH). When compared to 2019, time metrics were globally increased in 2020, particularly in the ER-NCGH groups during the period of the first wave (N = 24 and N = 56, respectively): "Onset-to-door":50,5 vs 88,5, p < 0,01; "Arrival in Neuroradiology - groin":13 vs 25, p < 0,01; "Door-to-groin":118 vs 143,5, p = 0,02; "Onset-to-groin":180 vs 244,5, p < 0,01; "Groin-to-recanalization": 41 vs 49,5, p = 0,03. When comparing ER-NCGH groups between the first (N = 56) and second (N = 49) waves, there was an overall improvement in times, namely in the "Door-to-CT" (47,5 vs 37, p < 0,01), "Arrival in Neuroradiology - groin" (25 vs 20, p = 0,03) and "Onset-to-groin" (244,5 vs 227,5, p = 0,02). CONCLUSIONS: During the SARS-CoV-2 pandemic, treatment for stroke patients was delayed, particularly during the first wave. Reallocation of resources and the shutting down of spoke centers may have played a determinant role.

Association of Affordable Care Act Implementation With Ambulance Utilization for Asthma Emergencies in New York City, 2008-2018.

Importance: Emergency medical services (EMS) are an essential component of the health care system, but the effect of insurance expansion on EMS call volume remains unclear. Objective: This study investigated the association between health insurance expansion and EMS dispatches for asthma, an ambulatory care-sensitive condition. We hypothesized that insurance expansion under the Patient Protection and Affordable Care Act (ACA) would be associated with decreased EMS dispatches for asthma emergencies. Design, Setting, and Participants: This cohort study examined 14 865 267 ambulance calls dispatched within New York City from 2008 to 2018, including 217 303 calls for asthma-related emergencies, and used interrupted time series analysis to study the change in the annual incidence of EMS dispatches for asthma emergencies after implementation of the ACA. Multivariable linear regression examined the association between the uninsured rate and the incidence of asthma-related dispatches, controlling for population demographic characteristics and air quality index. Exposures: Implementation of ACA on January 1, 2014. Main Outcomes and Measures: Incidence of EMS dispatches for asthma emergencies per 100 000 population per year (ie, asthma EMS dispatch rate) as classified by the 911 call-taker. Results: In this study of 217 303 EMS dispatches for asthma-related emergencies, there was a decrease in the asthma EMS dispatch rate after implementation of the ACA, from a mean (SD) of 261 (24) dispatches per 100 000 population per year preintervention to 211 (47) postintervention (P = .047). This decrease in asthma EMS dispatch rate after ACA implementation was significant on interrupted time series analysis. Prior to 2014, the annual asthma EMS dispatch rate was increasing by 11.8 calls per 100 000 population per year (95% CI, 6.1 to 17.4). After ACA implementation, the asthma EMS dispatch rate decreased annually by 28.5 calls per 100 000 population per year (95% CI, -37.6 to -19.3), a significant change in slope from the preintervention period (P < .001). Multivariable linear regression, controlling for percentage of individuals younger than age 18 years, degree of racial/ethnic diversity, median household income, and air quality index, found that a 1% decrease in the citywide uninsured rate was associated with a decrease of 98.9 asthma dispatches per 100 000 population per year (95% CI, 5.72-192.10; P = .04). Conclusions and Relevance: Insurance expansion within New York City under the ACA was associated with a significant reduction in the asthma EMS dispatch rate. Insurance expansion may be a viable method to reduce EMS utilization for ambulatory care-sensitive conditions such as asthma.

[French national emergency department's crisis: The outcome of a growing gap between health resources and needs?] / Crise nationale des urgences : le résultat d'un déséquilibre croissant entre offre et demande de soins ?

Overcrowding in Emergency Departments is often considered as an outcome of insufficient access to hospital beds or primary care, therefore a potential lack of health resources. We sought to describe the quantitative evolution of health resources in the French health care system, in comparison with demographic and epidemiologic parameters that reflect health needs. Overall, in the last decade, parameters of capacity and human resources stagnated while activity and spending increased jointly, stimulated by ageing of the population and chronic diseases mostly. Nevertheless, recent official previsions have again recommended to proceed with hospital bed reduction until 2030. This has led to a dangerous saturation of emergency care and to the ongoing systemic health crisis. This situation will require ambitious health resources reinforcement plans in both hospital and primary care. Furthermore, ageing of the population and chronic diseases must lead society to deliberate on the fundamental goals and funding of our health care system.

[Emergency overcrowding and hospital organization: Causes and solutions]. / La saturation de la structure des urgences et le rôle de l'organisation hospitalière : réflexions sur les causes et les solutions.

Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.

Collateral damage - Impact of a pandemic on stroke emergency services.

BACKGROUND: The COVID-19 pandemic's impact on stroke care is two-fold direct impact of the infection and indirect impact on non-COVID-19 diseases. Anecdotal evidence and clinical observation suggest that there is a decrease in the number of patients presenting with stroke during the pandemic. We aim to understand the impact of the COVID-19 pandemic on the utilization of stroke emergency services on a single comprehensive stroke center (CSC). METHODS: We performed a retrospective analysis of a prospectively maintained database and compared all emergency department (ED) encounters, acute stroke admissions (including TIA), and thrombectomy cases admitted in March 2017-2019 to patients admitted in March 2020 at a comprehensive stroke center. RESULTS: Number of total ED encounters (22%, p=0.005), acute ischemic strokes (40%, p=0.001), and TIAs (60%, p=0.163) decreased between March of 2017-2019 compared to March of 2020. The number of patients undergoing EVT in March 2020 was comparable to March 2017-2019 (p=0.430). CONCLUSION: A pandemic-related stay-at-home policy reduces the utilization of stroke emergency services at a CSC. This effect appears to be more prominent for ED encounters, all stroke admissions and TIAs, and less impactful for severe strokes. Given the relatively low prevalence of COVID-19 cases in our region, this decrement is likely related to healthcare seeking behavior rather than capacity saturation.

The Light Role CCP: A Blueprint for Far Forward Medical Support to Contemporary Operations.

November 2018 saw the deployment of a medical team with a remit to provide far forward medical support to UK, Coalition and indigenous forces. The delivery of this capability demanded a solution unique within the UK Defence Medical Services. The 'light role' casualty collection points provided emergency medical care to 475 casualties over a 4-month period. The success of the deployment was dependant on the ability to remain light and agile which brought with it logistical considerations. The clinical caseload was predominantly secondary blast injury and gunshot wound (GSW). The positioning of a Role 1 facility close to the front line of troops enabled early Damage Control Resuscitation including the delivery of blood products. MEDEVAC to Role 2 was enabled by indigenous forces. The unique situation demanded bespoke solutions for documentation and blood warming. The lessons learnt during the deployment may form a blueprint for future contingency operations.

Health-related quality of life and the burden of prolonged seizures in noninstitutionalized children with epilepsy.

OBJECTIVE: This study aimed to provide information on the burden of illness and health-related quality of life (HRQoL) in children with epilepsy who experience prolonged acute convulsive seizures (PACS) in the community setting, and to investigate factors that may predict poor HRQoL in this population. METHODS: Noninstitutionalized children (aged 3-16 years) who had experienced at least one PACS within the past year and had currently prescribed PACS rescue medication were enrolled in a cross-sectional study in Germany, Italy, Spain, and the United Kingdom (Practices in Emergency and Rescue medication For Epilepsy managed with Community-administered Therapy 3 [PERFECT-3]). Clinicians, parents/guardians, and patients completed web-based questionnaires regarding clinical characteristics, PACS frequency, and day-to-day impairment. Patients' HRQoL was rated by clinicians, parents/guardians, and patients themselves using the 5-dimension EuroQol questionnaire (EQ-5D) and summarized as a utility score. Potential predictors of poor HRQoL were tested in individual univariate generalized linear models and a global multivariable model. RESULTS: Enrolled children (N = 286) had experienced 1-400 PACS (median: 4) in the past year. Clinicians reported that 216/281 patients (76.9%) had learning disabilities of varying severity. Mean EQ-5D utility scores rated by clinicians (n = 279), parents (n = 277), and patients (n = 85) were 0.52 (standard deviation: 0.41), 0.51 (0.39), and 0.74 (0.29), respectively. Increasing PACS frequency, increasing severity of learning disability, and specialist school attendance were significantly associated with decreasing EQ-5D utility score. In the multivariable model, having learning disabilities was the best predictor of poor HRQoL. SIGNIFICANCE: Health-related quality of life was very poor in many children with epilepsy whose PACS were managed with rescue medication in the community, with learning disability being the most powerful predictor of patients' HRQoL. Mean EQ-5D utility scores were lower (worse) than published values for many other chronic disorders, indicating that optimal treatment should involve helping children and their families to manage learning disabilities and day-to-day impairments, in addition to preventing seizures.

Fall-related emergency department visits and hospitalizations among community-dwelling older adults: examination of health problems and injury characteristics.

BACKGROUND: Fall injuries and related healthcare use among older adults are increasing in the United States. This study examined chronic illnesses, sensory and memory problems, and injury characteristics that were associated with ED visits and hospitalizations among older adults who received medical attention for fall injuries within a 91-day reference period. METHODS: Data were from the publicly available 2013-2017 US National Health Interview Survey files (unweighted N = 1840 respondents aged > 60 years with fall injuries). We first described socioeconomic, health/mental health, healthcare utilization, and injury characteristics among three groups: those who neither visited an ED nor were hospitalized for their fall injury, those who visited an ED only, and those who were hospitalized. Then, using multinomial logistic regression analysis, we examined associations of healthcare utilization (ED visit only and hospitalization vs. no ED visit/hospitalization) with chronic illnesses, other health problems, and injury characteristics, controlling for socioeconomic factors. RESULTS: Of older adults who received medical attention for fall injuries, a little more than one-third had an ED visit only and a little less than a fifth had an overnight hospital stay. Multivariable analysis showed that lung disease and memory problems were associated with higher risk of ED visit only; hip and head injuries, facial injuries, and broken bones/fractures (from any type of injury) were more likely to result in hospitalization than other injuries. Fall injuries sustained inside the home, falls from loss of balance/dizziness, and living alone were also more likely to result in hospitalization. CONCLUSIONS: These healthcare utilization findings indicate the significant toll that fall injuries exact on older adults and healthcare systems. Fall prevention should target risk factors that are specific to serious injuries requiring costly care. Strategies for implementing scalable, adaptable, and measurable fall prevention models by primary care and emergency medical service providers and ED staff are needed.

Potential added value of the new emergency care dataset to ED-based public health surveillance in England: an initial concept analysis.

INTRODUCTION: For the London Olympic and Paralympic Games in 2012, a sentinel ED syndromic surveillance system was established to enhance public health surveillance by obtaining data from a selected network of EDs, focusing on London. In 2017, a new national standard Emergency Care Dataset was introduced, which enabled Public Health England (PHE) to initiate the expansion of their sentinel system to national coverage. Prior to this initiative, we estimated the added value, and potential additional resource use, of an expansion of the sentinel surveillance system. METHODS: The detection capabilities of the sentinel and national systems were compared using the aberration detection methods currently used by PHE. Different scenarios were used to measure the impact on health at a local, subnational and national level, including improvements to sensitivity and timeliness, along with changes in specificity. RESULTS: The biggest added value was found to be for detecting local impacts, with an increase in sensitivity of over 80%. There were also improvements found at a national level with outbreaks being detected earlier and smaller impacts being detectable. However, the increased number of local sites will also increase the number of false alarms likely to be generated. CONCLUSION: We have quantified the added value of national ED syndromic surveillance systems, showing how they will enable detection of more localised events. Furthermore, national systems add value in enabling timelier public health interventions. Finally, we have highlighted areas where extra resource may be required to manage improvements in detection coverage.

Technological innovation for prehospital stroke triage: ripe for disruption.

BACKGROUND: With the benefit of mechanical thrombectomy firmly established, the focus has shifted to improved delivery of care. Reducing time from symptom onset to reperfusion is a primary goal. Technology promises tremendous opportunities in the prehospital space to achieve this goal. METHODS: This review explores existing, fledgling, and potential future technologies for application in the prehospital space. RESULTS: The opportunity for technology to improve stroke care resides in the detection, evaluation, triage, and transport of patients to an appropriate healthcare facility. Most prehospital technology remains in the early stages of design and implementation. CONCLUSION: The major challenges to tackle for future improvement in prehospital stroke care are that of public awareness, emergency medical service detection, and triage, and improved systems of stroke care. Thoughtfully applied technology will transform all these areas.

An Argument Against Cross-Platform Development: Lessons From an Augmented Reality App Prototype for Rural Emergency Responders.

BACKGROUND: Mobile augmented reality (MAR) apps offer potential support for emergency responders in rural areas. OBJECTIVE: In this report, we described lessons learned from the development process of augmented reality (AR) Farm Mapping to Assist, Protect and Prepare Emergency Responders (MAPPER), a MAR app that provides emergency responders onsite information about the agricultural operation they enter. METHODS: Cross-platform frameworks were used to create AR MAPPER to accommodate budget constraints and overcome issues with markerless MAR technologies. Although the single codebase and Web technologies streamlined development, cross-device hardware limitations impacted location accuracy, lengthened the development cycle, and required regular updates to third-party libraries. RESULTS: A hybrid development approach of using Web-based technologies with native tie-ins for specialized components and enhanced performance cut time and costs. This also led to consistency across multiple platforms and ensured that there is only a single set of source files to modify for Android and iPhone operating systems. Meanwhile, active development was delayed by some major hurdles. Apple and Google both released new versions of their operating systems, and the Wikitude framework issued four major updates, each of which brought with it some important enhancements and also led to some new issues. CONCLUSIONS: Developers should consider single platform native development to benefit from platform-specific MAR implementations and to avoid development, testing, and maintenance costs associated with cross-platform implementation. Emergency response organizations may be more likely to utilize a single platform across the devices used by their command staff. This also reduces the benefits of cross-platform development. Furthermore, providing map-based, non-AR cross-platform apps for landowners, farmers, and ranchers would help improve and maintain data quality, which is crucial for the utility and user experience of MAR apps.

Temporal Trends in Emergency Medical Services and General Practitioner Use for Acute Stroke After Australian Public Education Campaigns.

Background and Purpose- The Australian Stroke Foundation ran annual paid advertising between 2004 and 2014, using the FAST (Face, Arm, Speech, Time) campaign from 2006 and adding the message to call emergency medical services in 2007. In this study, we examined temporal trends in emergency medical services use and referrals from general practitioners in the Australian state of Victoria to evaluate the impact of these campaigns. Methods- Using data from 33 public emergency departments, contributing to the Victorian Emergency Minimum Dataset, we examined trends in emergency department presentations for 118 000 adults with an emergency diagnosis of stroke or transient ischemic attack between 2003 and 2015. Annual trends were examined using logistic regression using a precampaign period (January 2003 to August 2004) as reference and adjusting for demographic variables. Results- Compared with the precampaign period, significant increases in emergency medical services use were seen annually between 2008 and 2015 (all P<0.001, eg, 2015; adjusted odds ratio, 1.16; 95% CI, 1.10-1.23). In contrast, a decrease was seen in patients presenting via general practitioners across all campaign years (all P<0.001, eg, 2015; adjusted odds ratio, 0.48; 95% CI, 0.44-0.53). Conclusions- Since the Stroke Foundation campaigns began, a greater proportion of stroke and transient ischemic attack patients are presenting to hospital by emergency medical services and appear to be bypassing their general practitioners.

The Geriatric Emergency Department Intervention model of care: a pragmatic trial.

BACKGROUND: To evaluate a Geriatric Emergency Department Intervention (GEDI) model of service delivery for adults aged 70 years and older. METHODS: A pragmatic trial of the GEDI model using a pre-post design. GEDI is a nurse-led, physician-championed, Emergency Department (ED) intervention; developed to improve the care of frail older adults in the ED. The nurses had gerontology experience and education and provided targeted geriatric assessment and streamlining of care. The final format included 2.4 full time equivalent nurses working 7 days from 0700 h to 1730 h (1530 h at weekends). There were three implementations periods: pre-implementation (2012); a developmental phase from January 2013 to August 2015; and full implementation from September 2015 to August 2016. The outcomes measured were disposition (discharged home, admitted or died); ED length of stay; hospital length of stay; all cause in-hospital mortality within 28 days; time to ED re-presentation up to 28 days post-discharge; in-hospital costs. The setting was a tertiary hospital ED, with 385 beds, in Queensland, Australia. Approximately 53,000 patients presented to the ED annually with 20% aged 70 years and older. All patients over the age 70 who presented to the ED between January 2012 and August 2016 (n = 44,983) were included in the trial. RESULTS: Older persons who presented to the ED when the GEDI team were working had increased likelihoods of discharge (Hazard ratio (HR) = 1.19; 95% CI: 1.13-1.24) and reduced ED length of stay (HR = 1.42; 95% CI: 1.33-1.52) compared with those who presented when GEDI were not working. There was no increase in the risk of mortality (HR = 1.01; 95% CI = 0.23-4.43) or risk of same cause re-presentation to 28 days (HR = 1.21; 95% CI: 0.99-1.49). The GEDI service resulted in average cost savings per ED presentation of $35 [95% CI, $21, $49] and savings of $1469 [95% CI, $1105, $1834] per hospital admission. CONCLUSIONS: Implementation of a nurse-led physician-championed model of ED care, focused on frail older adults, reduced ED length of stay, hospital admission and if admitted, hospital length of stay and cost, without increasing mortality or same cause re-presentation. These increases were sustained over time and after the initial implementation team had changed roles. TRIAL REGISTRATION: Australian Clinical Trials Registration Number ACTRN12615001157561 - retrospectively registered on 29/10/2015. Data were retrieved via retrospective access to clinical information systems. First data access was on 1/7/2015.

Response time in the emergency services. Systematic review

Abstract The growth of the urban population raises concern about municipal public managers in the sense of providing emergency medical services (EMS) that are aligned with the needs of prehospital emergency medical care demanded by the population. The literature review aims at presenting the response time of emergency medical services in several parts of the world and discussing some factors that interfere in the result of this indicator such as GDP (Gross Domestic Product) percentage spent on health and life expectancy of countries. The study will also show that in some of the consulted articles, authors suggest to EMS recommendations for decreasing the response time using simulations, heuristics and metaheuristics. Response time is a basic indicator of emergency medical services, in such a way that researchers use the descriptive statistics to evaluate this parameter. Europe and the USA outstand in the publication of studies that present this information. Some articles use stochastic and mathematical methods to suggest models that simulate scenarios of response time reduction and suggest such proposals to the local EMS. Countries in which the response time was identified have a high index of human development and life expectancy between 74.7 and 83.7 years.