Emergent and Urgent Craniotomies in Pediatric Patients: Resource Utilization and Cost Analysis.

BACKGROUND: Pediatric neurosurgeons are occasionally tasked with performing surgery expeditiously to preserve a child's neurologic faculties and life. OBJECTIVE: This study examines the etiologies, outcomes, and costs for urgent or emergent craniotomies at a Level I Pediatric Trauma center over a 7-year time period. METHODS: A retrospective review was conducted for each patient who underwent an emergent or urgent craniotomy within 24 hours of presentation between January 2010 and April 2017. Demographic, clinical, and surgical details were recorded for a total of 48 variables. Any readmission within 90 days was analyzed. Hospital charges for each admission and readmission were collected and adjusted for inflation to October 2018 values. RESULTS: Among the 223 children who underwent urgent or emergent craniotomies, the majority were admitted for traumatic injuries (n = 163, 73.1%). The most common traumatic mechanism was fall (n = 51, 22.9%), and the most common non-traumatic cause was tumor (n = 21, 9.4%). Overall, craniotomies were typically performed for hematoma evacuation of one type or combination (n = 115, 51.6%) during off-peak times (n = 178, 79.8%). Seventy-seven (34.5%) subjects experienced 1 or more postoperative events, 22 of whom returned to the operating room. There were 13 (5.8%) and 33 (14.8%) readmissions within 30 days and 90 days of discharge, respectively. Non-trauma patients (compared with trauma patients) and polytrauma (compared with isolated head injury) had greater healthcare needs, resulting in higher charges. CONCLUSION: Most urgent or emergent pediatric craniotomies were performed for the treatment of traumatic injuries involving hematoma evacuation, but non-traumatic patients were more complex requiring greater resources.

Ambulatory care sensitive conditions hospitalization for emergencies rates in Colombia.

OBJECTIVE: To analyze the emergency hospitalizations trend for ambulatory care sensitive conditions between 2011 and 2015 in a health insureance company of the Colombian Social Security General System. METHODS: A log-linear analysis based on age-adjusted hospitalization rates for ambulatory care sensitive conditions in the Entidad Promotora de Salud Sanitas was used to estimate the annual percentage change in these rates and to identify joinponts of the rates. Data was collected from administrative sources. RESULTS: There were 38,530 hospitalizations for ambulatory care sensitive conditions in 26,501 Entidad Promotora de Salud Sanitas enrollees, with a significant decrease in hospitalization rates. The annual percentage change estimated for the period was -9.5% with no significant joinpoints throughout the time interval. CONCLUSIONS: A significant reduction in hospital admissions due to ambulatory care sensitive conditions in Entidad Promotora de Salud Sanitas enrollees were reported for the last five years in this study.

Ambulatory care sensitive conditions hospitalization for emergencies rates in Colombia

ABSTRACT OBJECTIVE To analyze the emergency hospitalizations trend for ambulatory care sensitive conditions between 2011 and 2015 in a health insureance company of the Colombian Social Security General System. METHODS A log-linear analysis based on age-adjusted hospitalization rates for ambulatory care sensitive conditions in the Entidad Promotora de Salud Sanitas was used to estimate the annual percentage change in these rates and to identify joinponts of the rates. Data was collected from administrative sources. RESULTS There were 38,530 hospitalizations for ambulatory care sensitive conditions in 26,501 Entidad Promotora de Salud Sanitas enrollees, with a significant decrease in hospitalization rates. The annual percentage change estimated for the period was -9.5% with no significant joinpoints throughout the time interval. CONCLUSIONS A significant reduction in hospital admissions due to ambulatory care sensitive conditions in Entidad Promotora de Salud Sanitas enrollees were reported for the last five years in this study.

Apostle Islands National Lakeshore: A Review of Search and Rescue and Emergency Medical Services Operations, 2006-2015.

INTRODUCTION: Apostle Islands National Lakeshore (APIS) lies at the northern tip of Wisconsin and is home to a network of 21 islands along Lake Superior. The goal of this report is to investigate search and rescue (SAR) and emergency medical services (EMS) trends at APIS in an effort to improve visitor safety and resource allocation. METHODS: This study is a retrospective analysis reviewing APIS SAR reports and annual EMS summary reports from January 1, 2006, to December 31, 2015. Information related to incident type, incident date, individual demographic characteristics and activities, injury/illness type, cost, and contributing factors were recorded and analyzed in frequency tables. RESULTS: From 2006 to 2015, APIS SAR conducted 133 total missions assisting 261 individuals-200 not injured/ill, 57 injured/ill, and 4 fatalities. Median cost per SAR incident involving aircraft totaled $21,695 (range: $2,993-141,849), whereas incidents not involving aircraft had a median cost of $363 (range: $35-8,830). Nonmotorized boating was the most common activity resulting in SAR incidents. All 4 fatalities were attributed to drowning while kayaking or swimming. Cold-related injury/illness accounted for nearly half of all injuries/illnesses (45%) with the most commonly reported contributing factor being high winds. EMS responded to a total of 134 incidents. Trauma and first aid accounted for 43% and 34% of EMS workload, respectively. CONCLUSIONS: Overall, this study highlights the hazards associated with the frigid and rough conditions of Lake Superior. The reported results aim to help APIS personnel more saliently convey risks to visitors and plan appropriately in an effort to decrease the need for future rescues.

Cost analysis of improving emergency care for aged care residents under a Hospital in the Nursing Home program in Australia.

BACKGROUND: This study aims to examine the costs associated with a Hospital in the Nursing Home (HiNH) program in Queensland Australia directed at patients from residential aged care facilities (RACFs) with emergency care needs. METHODS: A cost analysis was undertaken comparing the costs under the HiNH program and the current practice, in parallel with a pre-post controlled study design. The study was conducted in two Queensland public hospitals: the Royal Brisbane and Women's Hospital (intervention hospital) and the Logan Hospital (control hospital). Main outcome measures were the associated incremental costs or savings concerning the HiNH program provision and the acute hospital care utilisation over one year after intervention. RESULTS: The initial deterministic analysis calculated the total induced mean costs associated with providing the HiNH program over one year as AU$488,116, and the total induced savings relating to acute hospital care service utilisation of AU$8,659,788. The total net costs to the health service providers were thus calculated at -AU$8,171,671 per annum. Results from the probabilistic sensitivity analysis (based on 10,000 simulations) showed the mean and median annual net costs associated with the HiNH program implementation were -AU$8,444,512 and-AU$8,202,676, and a standard deviation of 2,955,346. There was 95% certainty that the values of net costs would fall within the range from -AU$15,018,055 to -AU$3,358,820. CONCLUSIONS: The costs relating to implementing the HiNH program appear to be much less than the savings in terms of associated decreases in acute hospital service utilisation. The HiNH service model is likely to have the cost-saving potential while improving the emergency care provision for RACF residents.

Interhospital transfer delays emergency abdominal surgery and prolongs stay.

BACKGROUND: Interhospital transfer of patients requiring emergency surgery is common practice. It has the potential to delay surgical intervention, increase rate of complications and thus length of hospital stay. METHODS: A retrospective cohort study was conducted of adult patients who underwent emergency surgery for abdominal pain at a large metropolitan hospital in New South Wales (Hospital A) in 2013. The impact of interhospital transfer on time to surgical intervention, post-operative length of stay and overall length of stay was assessed. RESULTS: Of the 910 adult patients who underwent emergency surgery for abdominal pain at Hospital A in 2013, 31.9% (n = 290) were transferred by road ambulance from a local district hospital (Hospital B). The leading surgical procedures performed were appendicectomy (n = 299, 32.9%), cholecystectomy (n = 174, 19.1%), gastrointestinal endoscopy (n = 95, 10.4%), cystoscopy (n = 86, 9.5%), hernia repair (n = 45, 4.9%), salpingectomy (n = 19, 2.1%) and oversewing of perforated peptic ulcer (n = 13, 1.4%). Overall, interhospital transfer (n = 290, 31.9%) was associated with increases in mean time to surgical intervention (14.2 h, P < 0.001), post-operative length of stay (1.1 days, P = 0.001) and overall length of stay (1.6 days, P < 0.001). Delayed surgical intervention was observed across all procedure types except surgery for perforated peptic ulcer, where transferred patients underwent surgery within a comparable timeframe to direct admissions. CONCLUSION: Interhospital transfer delays surgical intervention and increases length of hospital stay. This mandates attention due to the implications for patient outcomes and added burden to the healthcare system. The system did, however, show capability to appropriately expedite surgery for acutely life-threatening cases.

[Assistance medicine, a novel discipline of emergency medicine]. / A sürgosségi ellátás új területe: az assistance orvostan.

The number of international travels has been continuously increasing since World War II. Though the travelers' demand for safer ways of travelling appeared, only a handful of them sought pretravel advices. This is the reason why 50% of the travelers have to face some kind of medical problem during their journey. If they have travel insurance, the company's assistance team organizes, monitors and covers their abroad treatment. A doctor of the assistance team has to find her/his ways in various fields: not only a multidisciplinary medical knowledge is a must for a professional like this, but she/he needs to have a good grasp of the basic idea behind the insurance policy, too. Also, she/he should be familiar with the public health care systems of different countries and some legal knowledge is also needed. If the patients are unable to continue their trip, they must be repatriated. Making a decision about the repatriation's timing and modality requires interdisciplinary medical experience and the approach of a critical care/emergency doctor. Among further tasks for the assistance team's doctor one can find medical escort and on-spot medical visit for foreign patients. Both of these two aforementioned medical activities are highly different from - for example - a general practitioner's routine. That is the reason why an assistance doctor has to be familiar with the critical and emergency care. Organizing and monitoring medical treatment for a traveler abroad, providing medical escort, making decisions about repatriation and providing medical help for a foreign patient all fall within the competence of a new medical discipline, the assistance medicine. Creating a body of knowledge, collecting appropriate protocols and establishing postgraduate courses for assistance medicine diplomas are the tasks of the critical care and emergency medicine professionals.

Characteristics favouring a delayed disposition decision in the emergency department.

BACKGROUND: The working hours of a hospital affects efficiency of care within the emergency department (ED). Understanding the influences on ED time intervals is crucial for process redesign to improve ED patient flow. AIM: To assess characteristics that affect patients' transit through an ED. METHODS: Retrospective cohort study from 2004 to 2010 of 268 296 adult patients who presented to the ED of an urban tertiary-referral Australian teaching hospital. RESULTS: After adjustment for Australasian Triage Scale (ATS) category, every decade increase in age meant patients spent an additional 2 min in the ED waiting to be seen (P < 0.001) and an extra 29-min receiving treatment (P < 0.001). For every additional 10 patients in the ED, the 'waiting time' (WT) phase duration increased by 20 min (P < 0.001) and the 'Assessment and Treatment Time' (ATT) phase duration increased by 26 min (P < 0.001). When patients arrived outside working hours, the WT phase duration increased by 20 min (P < 0.001). When seen outside working hours, the ATT phase duration increased by 34.5 min (P < 0.001). CONCLUSION: Extrinsic to the patients themselves and in addition to ED overcrowding, the working hours of the hospital affected efficiency of care within the ED. Not only should the whole of the hospital be involved in improving efficient and safe transit of patients through an ED, but the whole of the day and every day of the week deserve attention.

Qualitative process analysis and modelling of emergency care workflow and interface management: identification of critical process steps.

OBJECTIVES: Over the past few years, the number of patients attending emergency services has increased steadily. As a result, emergency departments (EDs) worldwide face frequent crowding, with the risk of reduced treatment quality and impaired patient outcome, patient and staff dissatisfaction and inefficient use of ED resources. A qualitative process analysis and process modelling was used as a method to detect critical process steps in the ED with respect to time and efficiency. METHODS: The analysis was carried out by independent external process experts. Over a period of 1 week, the complete treatment process of 25 patients was recorded. The monitoring of overall activities, decision points, causalities and interfaces was based on the treatment of 100 additional patients and on interviews with nurses and physicians. The project was closed with the identification of the three most critical process steps and modelling of the standard emergency care process in an event-process chain (EPC). RESULTS: The most time-crucial steps detected by the analysis were the process of developing a tentative diagnosis, including consultation and advice seeking by inexperienced physicians, the interface to imaging diagnostics and the search of hospital beds for inpatients. The results were visualized by standardized modelling of an event-process chain (EPC). CONCLUSION: The process analysis helped to identify inefficient process steps in the ED. Modelling with EPC is a useful tool to visualize and to understand the complexity of the emergency medical care and to identify key performance indicators for effective quality management.

The organization, function, and outcomes of ST-elevation myocardial infarction networks worldwide: current state, unmet needs and future directions.

The organization of networks in order to better coordinate and to faster offer reperfusion strategies for acute ST-elevation myocardial infarction (STEMI) is an important recommendation of recent versions of international guidelines. This article focusses on similarities and dissimilarities of world-wide networks, highlights essential network components, offers insights into still unmet needs and discusses potential measures to further improve quality of STEMI treatment.

Emergency demand and repeat attendances by older patients.

BACKGROUND: Population ageing is projected to impact on health services utilisation including Emergency Departments (ED), with older patients reportedly having a high rate of return visits. We describe and compare patterns in ED utilisation between older and younger adults, and quantify the proportion and rate of return visits. METHODS: Population-based retrospective analysis of metropolitan Melbourne public hospital ED data, 1999/2000 to 2008/2009. Numbers of patients, presentations, re-presentations and rates per 1000 population were calculated, with comparison of older (aged ≥ 70 years) and younger (15-69 years) attendances. RESULTS: Population growth in each age group was similar over the study period, yet ED presentations rose by 72% for older adults compared with a 59% increase for younger adults. Rates per 1000 population rose with increasing age. Of the population aged ≥ 70 years, 39% presented to ED compared with 17% of the population aged 15-69 years in 2008/2009. Twenty-seven per cent of the increase in older adult presentations was driven by a cohort who attended ≥ 4 times in 2008/2009. The number of older patients presenting ≥ 4 times doubled over the decade, contributing to 23% of all older presentations in 2008/2009. ED length of stay rose with increasing age; 69% of older adults remained in ED for ≥ 4 h compared with 39% of younger adults in 2008/2009. The number of older adult ED hospital admissions doubled over the decade. CONCLUSIONS: Older patients are disproportionately represented among ED attendances. They also have an increasing propensity to re-present to ED, indicating a need to identify the clinical, social and health system-related risk factors for re-attendance by specific patients.

Answering when opportunity knocks - SATS goes global.

One local doctor, by grasping random overlapping educational opportunities, has become the catalyst for 'Doctors without Borders' (MSF) wanting to adopt the South African Triage Scale (SATS) as its standard emergency protocol for resource-poor countries world-wide.

Factors associated with prolonged emergency department length of stay for admitted children.

OBJECTIVE: To estimate the prevalence of and to identify factors associated with prolonged emergency department length-of-stay (ED-LOS) for admitted children. METHODS: Data were from the 2001-2006 National Hospital Ambulatory Medical Care Survey. The primary outcome was prolonged ED-LOS (defined as total ED time >8 hours) among admitted children. Predictor variables included patient-level (eg, demographics including race/ethnicity, triage score, diagnosis, and admission to inpatient bed vs intensive care unit), physician-level (intern/resident vs attending physician), and system-level (eg, region, metropolitan area, ED and hospital type, time and season, and diagnostic and therapeutic procedures) factors. Multivariable logistic regression was performed to identify independent predictors of prolonged ED-LOS. RESULTS: Median ED-LOS for admitted children was 3.7 hours. Thirteen percent of pediatric patients admitted from the ED experienced prolonged ED-LOS. Factors associated with prolonged ED-LOS for admitted children were Hispanic ethnicity (odds ratio [OR], 1.76; 95% confidence interval [95% CI], 1.10-2.81), ED arrival between midnight and 8 a.m. (OR, 2.80; 95% CI, 1.87-4.20), winter season (January-March: OR, 1.81; 95% CI, 1.20-2.74), computed tomography scan or magnetic resonance imaging (OR, 1.65; 95% CI, 1.05-2.58), and intravenous fluids or medications (OR, 1.81; 95% CI, 1.10-2.97). Children requiring ICU admissions (OR, 0.29; 95% CI, 0.11-0.77) or receiving pulse oximetry in the ED (OR, 0.52; 95% CI, 0.34-0.81) had a lower risk of experiencing prolonged ED-LOS. CONCLUSIONS: We found that prolonged ED-LOS occurs frequently for admitted pediatric patients and is associated with Hispanic ethnicity, presentation during winter season, and early morning arrival. Potential strategies to reduce ED-LOS include improved availability of interpreter services and enhanced staffing and additional inpatient bed availability during winter season and overnight hours.