'Delayed discharges and boarders': a 2-year study of the relationship between patients experiencing delayed discharges from an acute hospital and boarding of admitted patients in a crowded ED.

OBJECTIVE: Many believe that hospital crowding manifesting in the ED with the boarding of admitted patients is a result of significant numbers of acute hospital beds being occupied by patients awaiting discharge to nursing homes, step-down facilities or home with or without additional support. This observational study was performed to establish the actual relationship between boarders in the ED and patients experiencing delayed discharge. METHODS: Data relating to the number of patients in the ED and their points in their patient pathway were entered into a logbook on a daily basis by the most senior doctor on duty. 630 days of observations of patients boarded in the ED were compared with the number of inpatients with delayed discharges, obtained from the hospital information system, to see if large numbers of inpatients with delayed discharges are associated with crowding in the ED. RESULTS: Two years of data showed an annual ED census of more than 47 000, with a daily mean ED admission rate of 29.85 patients and a daily mean ED boarding figure of 29 patients. A mean of 15.4% of the 823 hospital beds was occupied by patients with delayed discharges, and the hospital ran at, or near, full capacity (99%-105%) all the time. Results obtained highlighted a statistically significant relationship between delayed discharges in the hospital and ED crowding as a result of boarders (p value<0.001, with a regression coefficient of 0.16, 95% CI 0.12 to 0.20). The study also showed that the number of boarders was related to the number of ED admissions in the preceding 24 hours (p=0.036, with a regression coefficient of 0.14, 95% CI 0.05 to 0.28). CONCLUSIONS: Delayed hospital discharges significantly contribute to crowding in the ED. Healthcare systems should target timely discharge of inpatients experiencing delayed discharge in an urgent and efficient manner to improve timely access to acute hospital beds for patients requiring emergency admission.

The 'who are all these people?' study.

BACKGROUND: Overcrowding of emergency departments (EDs) adversely affects the delivery of emergency care and results in increased patient mortality. OBJECTIVE AND METHODS: To examine what contributes to the ED crowd and to specifically examine the patient associated population. The ED in which the research was performed is consistently one of the most overcrowded in Ireland. RESULTS: On average 66.7% of the patients in the ED during the study period were boarded awaiting a hospital bed following full processing by the ED staff and agreement by the on-call team that admission was required. The most overcrowded part of the department was the majors area. In this area 55.5% of those present were patients, visitors accounted for 16.6% of occupants, nursing staff 11%, on-call teams 7% and the ED doctors 6.3%. CONCLUSIONS: Knowing who the people in the crowd are helps to guide management decisions about how the crowd might be reduced. Our department now has a strict accompanying person/visitor policy that limits the number of visitors to patients and limits visiting times for those relatives with a patient who is experiencing a prolonged stay in the ED.

Did not wait patient management strategy (DNW PMS) study.

OBJECTIVES: This study was undertaken to assess the usefulness of senior emergency medicine specialists' review of all 'did not wait' (DNW) patients' triage notes and the recall of at-risk patients. METHODS; A prospective study of all DNW patients was performed from 1 January to 31 December 2008. Following a daily review of charts of those who failed to wait to be seen, those patients considered to be at risk of adverse outcome were contacted by the liaison team and advised to return. Data were gathered on all DNW patients on the Oracle database and interrogated using the Diver solution. RESULTS: 2872 (6.3%) of 45,959 patients did not wait to be seen. 107 (3.7%) were recalled on the basis of senior emergency medicine doctor review of the patients' triage notes. Variables found to be associated with increased likelihood of being recalled included triage category (p<0.001), male sex (p<0.004) and certain clinical presentations. The presenting complaints associated with being recalled were chest pain (p<0.001) and alcohol/drug overdose (p=0.001). 9.4% of DNW patients required admission following recall. CONCLUSION: The systematic senior doctor review of triage notes led to 3.7% of patients who failed to wait being recalled. 9.4% of those recalled required acute admission. The daily review of DNW patients' triage notes and the recalling of at-risk patients is a valuable addition to our risk management strategy.

A rare case of spontaneous spinal epidural hematoma in a 43-year-old man.

Spontaneous spinal epidural hematoma is a rare neurosurgical condition that is often difficult to diagnose in the emergency department and can cause permanent neurological deficits if diagnosis is delayed or incorrect. We present the case of a 43-year-old man who was initially investigated for cardiac events, suspected posterior circulation stroke, or arterial dissection. All investigations were normal, which led us to perform magnetic resonance imaging of the brain, neck, and cervicothoracic spine, which revealed spontaneous spinal epidural hematoma. Publication of this case raises awareness of this rare neurosurgical emergency and the importance of differential diagnosis to avoid misdiagnosis in patients presenting with sudden-onset cervicothoracic back pain radiating to the upper limbs bilaterally with neurological deficit and a history of discectomy or receiving anticoagulants. Our study highlights the importance of early discussions with the consultant and specialty involvement in such cases.

A retrospective application of the pulmonary embolism rule out criteria (PERC) of the American College of Physicians would reduce the number of CTPAS by 6% without a false negative in an Irish hospital.

BACKGROUND: Internationally, the number of computerised tomographic pulmonary angiographies (CTPAs) being performed to rule out pulmonary embolism (PE) has caused some concern. AIM: This study was performed to assess if the application of Pulmonary Embolism Rule-out Criteria (PERC) in an Irish Emergency Department (ED) would have helped to safely reduce the number of D-dimer assays and computed tomographic pulmonary angiographies (CTPAs) ordered. METHODS: The PERC was retrospectively calculated in all patients who underwent CTPA for possible PE. It was then established if the application of the PERC as per the American College of Physicians' (ACP) guidelines would have safely ruled out the need for further imaging. RESULTS: Of the 529 patients who underwent CTPA in the study, 63 patients (12%) had PE on CTPA. Had the PERC criteria been applied, no patient who had a PE would have been missed. In this study, PERC had 100% sensitivity and 14% specificity. DISCUSSION/CONCLUSION: Application of the PERC rule, as per the ACP guidelines, would have reduced the number of CTPAs performed by 32 (6%) without missing any patient with a proven pulmonary embolus.

Double Bolus Thrombolysis for Suspected Massive Pulmonary Embolism during Cardiac Arrest.

More than 70% of cardiac arrest cases are caused by acute myocardial infarction (AMI) or pulmonary embolism (PE). Although thrombolytic therapy is a recognised therapy for both AMI and PE, its indiscriminate use is not routinely recommended during cardiopulmonary resuscitation (CPR). We present a case describing the successful use of double dose thrombolysis during cardiac arrest caused by pulmonary embolism. Notwithstanding the relative lack of high-level evidence, this case suggests a scenario in which recombinant tissue Plasminogen Activator (rtPA) may be beneficial in cardiac arrest. In addition to the strong clinical suspicion of pulmonary embolism as the causative agent of the patient's cardiac arrest, the extremely low end-tidal CO2 suggested a massive PE. The absence of dilatation of the right heart on subxiphoid ultrasound argued against the diagnosis of PE, but not conclusively so. In the context of the circulatory collapse induced by cardiac arrest, this aspect was relegated in terms of importance. The second dose of rtPA utilised in this case resulted in return of spontaneous circulation (ROSC) and did not result in haemorrhage or an adverse effect.

A case report and review of the locked metacarpophalangeal joint.

A 59-year-old female with metacarpal joint locking is presented. The successful closed manipulation is described with a review of the literature.

Telemedicine in pre-hospital care: a review of telemedicine applications in the pre-hospital environment.

The right person in the right place and at the right time is not always possible; telemedicine offers the potential to give audio and visual access to the appropriate clinician for patients. Advances in information and communication technology (ICT) in the area of video-to-video communication have led to growth in telemedicine applications in recent years. For these advances to be properly integrated into healthcare delivery, a regulatory framework, supported by definitive high-quality research, should be developed. Telemedicine is well suited to extending the reach of specialist services particularly in the pre-hospital care of acute emergencies where treatment delays may affect clinical outcome. The exponential growth in research and development in telemedicine has led to improvements in clinical outcomes in emergency medical care. This review is part of the LiveCity project to examine the history and existing applications of telemedicine in the pre-hospital environment. A search of electronic databases including Medline, Excerpta Medica Database (EMBASE), Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for relevant papers was performed. All studies addressing the use of telemedicine in emergency medical or pre-hospital care setting were included. Out of a total of 1,279 articles reviewed, 39 met the inclusion criteria and were critically analysed. A majority of the studies were on stroke management. The studies suggested that overall, telemedicine had a positive impact on emergency medical care. It improved the pre-hospital diagnosis of stroke and myocardial infarction and enhanced the supervision of delivery of tissue thromboplasminogen activator in acute ischaemic stroke. Telemedicine presents an opportunity to enhance patient management. There are as yet few definitive studies that have demonstrated whether it had an effect on clinical outcome.

Oral flucloxacillin and phenoxymethylpenicillin versus flucloxacillin alone for the emergency department outpatient treatment of cellulitis: study protocol for a randomised controlled trial.

BACKGROUND: Oral flucloxacillin, either alone or in combination with phenoxymethylpenicillin, is a commonly prescribed antibiotic for the treatment of cellulitis, particularly in Ireland and the United Kingdom. This study aims to establish the non-inferiority of oral monotherapy (flucloxacillin alone) to dual therapy (flucloxacillin and phenoxymethylpenicillin) for the outpatient treatment of cellulitis in adults. METHODS/DESIGN: This study is a multicentre, randomised, double-blind, placebo-controlled trial of adults who present to the emergency department (ED) with cellulitis that is deemed treatable on an outpatient basis with oral antibiotics. After fulfilling specified inclusion and exclusion criteria, informed consent will be taken. Patients will be given a treatment pack containing 7 days of treatment with flucloxacillin 500 mg four times daily and placebo or flucloxacillin 500 mg four times daily and phenoxymethylpenicillin 500 mg four times daily. The primary outcome measure under study is the proportion of patients in each group in which there is greater than or equal to a 50% reduction in the area of diameter of infection from the area measured at enrolment at the end-of-treatment visit (7 to 10 days). Secondary endpoints include a health-related quality of life measurement as rated by the SF-36 score and the Extremity Soft Tissue Infection Score (not validated), compliance and adverse events. Patients will be followed up by telephone call at 3 days, end-of-treatment visit (EOT) at 7 to 10 days and test-of-cure (TOC) visit at 30 days. To achieve 90% power, a sample size of 172 patients per treatment arm is needed. This assumes a treatment success rate of 85% with oral flucloxacillin and phenoxymethylpenicillin, an equivalence threshold Δ = 12.5% and an α = 0.025. Non-inferiority will be assessed using a one-sided confidence interval on the difference of proportions between the two groups. Standard analysis including per-protocol and intention-to-treat will be performed. DISCUSSION: This trial aims to establish the non-inferiority of flucloxacillin monotherapy to dual therapy in the treatment of uncomplicated cellulitis among ED patients. In doing so, this trial will bridge a knowledge gap in this understudied and common condition and will be relevant to clinicians across several different disciplines.

The referral and complete evaluation time study.

INTRODUCTION: It has been suggested that inefficiency in the delivery of care in emergency departments (EDs) may contribute to their overcrowding. Specifically the duplication of work by the on take teams of the assessment already performed by the ED doctor has been identified as a possible contributor to prolonged waits for a hospital bed for those requiring admission. Anything that prolongs an individual patient's processing time will contribute to overcrowding. METHODS: This observational study was performed using a database of all patient attendances to examine the timeliness of the delivery of care to patients requiring admission through the ED and specifically to examine the impact of the referral process on the total time spent in the ED. RESULTS: Between August 2006 and February 2007, 6973 (25.4%) patients were referred to the on take teams and admitted. The mean total time in the ED for the 4092 (58.7%) medical patients was 21 h 16 min (standard deviation 12 h 24 min) as compared with 14 h 28 min (standard deviation 10 h 46 min) for the 2852 (40.9%) surgical admissions (P<0.001). The referral process accounted for an average of 16.6% of the patient journey through the ED while access block accounted for an average of 59.6%. CONCLUSION: The overwhelming reason for prolonged waits and overcrowding in Irish EDs is not the duplication of work inherent in the referral process but it is because of a lack of acute hospital capacity.