Priority in interhospital transfers of patients with severe COVID-19: development and prospective validation of a triage tool. / Desarrollo y validación prospectiva de la escala TIHCOVID: una herramienta de triaje y priorización del traslado interhospitalario de pacientes COVID-19 graves.

OBJECTIVES: To develop and validate a triage scale (Spanish acronym, TIHCOVID) to assign priority by predicting critical events in patients with severe COVID-19 who are candidates for interhospital transfer. MATERIAL AND METHODS: Prospective cohort study in 2 periods for internal (February-April 2020) and external (October-December 2020) validation. We included consecutive patients with severe COVID-19 who were transported by the emergency medical service of Catalonia. A risk model was developed to predict mortality based on variables recorded on first contact between the regional emergency coordination center and the transferring hospital. The model's performance was evaluated by means of calibration and discrimination, and the results for the first and second periods were compared. RESULTS: Nine hundred patients were included, 450 in each period. In-hospital mortality was 33.8%. The 7 predictors included in the final model were age, comorbidity, need for prone positioning, renal insufficiency, use of high-flow nasal oxygen prior to mechanical ventilation, and a ratio of PaO2 to inspired oxygen fraction of less than 50. The performance of the model was good (Brier score, 0.172), and calibration and discrimination were consistent. We found no significant differences between the internal and external validation steps with respect to either the calibration slopes (0.92 [95% CI, 0.91-0.93] vs 1.12 [95% CI, 0.6-1.17], respectively; P = .150) or discrimination (area under the curve, 0.81 [95% CI, 0.75-0.84] vs 0.85 [95% CI, 0.81-0.89]; P = .121). CONCLUSION: The TIHCOVID tool may be useful for triage when assigning priority for patients with severe COVID-19 who require transfer between hospitals.

OBJETIVO: Desarrollar y validar una escala predictiva de eventos críticos en pacientes con infección grave por COVID-19 candidatos a traslado interhospitalario (TIH) que facilite el triaje y la priorización del transporte sanitario. METODO: Estudio de cohortes prospectivo divido en dos periodos: validación interna (febrero-abril 2020) y validación externa (octubre-diciembre 2020). Se incluyeron consecutivamente los pacientes con infección grave por COVID-19 trasladados por el Sistema de Emergencias Médicas de Cataluña. Se construyó un modelo predictivo de las variables asociadas a la mortalidad recogidas en el momento del primer contacto entre el hospital emisor y el centro de coordinación. Se calculó el rendimiento del modelo y se comparó la validación interna y externa, evaluando la calibración y la discriminación. RESULTADOS: Se incluyeron 900 pacientes, 450 pacientes en cada periodo de estudio. La mortalidad durante el ingreso fue del 33,8%. Las 7 variables predictoras incluidas en el modelo final fueron edad, comorbilidad, pronación, insuficiencia renal aguda, uso de oxigenoterapia de alto flujo previa a la ventilación mecánica invasiva, tabaquismo activo y un valor de PaO2/FiO2 50. El modelo mostró un buen rendimiento (Brier = 0,172) y consistencia en la calibración y discriminación. No se objetivaron diferencias en la pendiente de calibración [0,92 (IC 95%: 0,91-0,93) vs 1,12 (IC 95%: 0,6-1,17); p = 0,150] ni en la capacidad discriminativa [ABC 0,81 (IC 95%: 0,75-0,84) vs ABC de 0,85 (IC 95%: 0,81-0,89), p = 0,121] entre la validación interna y externa. CONCLUSIONES: La escala TIHCOVID puede ser de ayuda para el triaje de pacientes con infección COVID-19 grave que precisan traslado interhospitalario.

Desarrollo y validación prospectiva de la escala TIHCOVID: una herramienta de triaje y priorización del traslado interhospitalario de pacientes COVID-19 graves / Priority in interhospital transfers of patients with severe COVID-19: development and prospective validation of a triage tool

Objetivo. Desarrollar y validar una escala predictiva de eventos críticos en pacientes con infección grave por COVID-19 candidatos a traslado interhospitalario (TIH) que facilite el triaje y la priorización del transporte sanitario. Método. Estudio de cohortes prospectivo divido en dos periodos: validación interna (febrero-abril 2020) y validación externa (octubre-diciembre 2020). Se incluyeron consecutivamente los pacientes con infección grave por COVID-19 trasladados por el Sistema de Emergencias Médicas de Cataluña. Se construyó un modelo predictivo de las variables asociadas a la mortalidad recogidas en el momento del primer contacto entre el hospital emisor y el centro de coordinación. Se calculó el rendimiento del modelo y se comparó la validación interna y externa, evaluando la calibración y la discriminación. Resultados. Se incluyeron 900 pacientes, 450 pacientes en cada periodo de estudio. La mortalidad durante el ingreso fue del 33,8%. Las 7 variables predictoras incluidas en el modelo final fueron edad, comorbilidad, pronación, insuficiencia renal aguda, uso de oxigenoterapia de alto flujo previa a la ventilación mecánica invasiva, tabaquismo activo y un valor de PaO2/FiO2 < 50. El modelo mostró un buen rendimiento (Brier = 0,172) y consistencia en la calibración y discriminación. No se objetivaron diferencias en la pendiente de calibración [0,92 (IC 95%: 0,91-0,93) vs 1,12 (IC 95%: 0,6-1,17); p = 0,150] ni en la capacidad discriminativa [ABC 0,81 (IC 95%: 0,75-0,84) vs ABC de 0,85 (IC 95%: 0,81-0,89), p = 0,121] entre la validación interna y externa. Conclusiones. La escala TIHCOVID puede ser de ayuda para el triaje de pacientes con infección COVID-19 grave que precisan traslado interhospitalario.

Objectives. To develop and validate a triage scale (Spanish acronym, TIHCOVID) to assign priority by predicting critical events in patients with severe COVID-19 who are candidates for interhospital transfer. Methods. Prospective cohort study in 2 periods for internal (February–April 2020) and external (October–December 2020) validation. We included consecutive patients with severe COVID-19 who were transported by the emergency medical service of Catalonia. A risk model was developed to predict mortality based on variables recorded on first contact between the regional emergency coordination center and the transferring hospital. The model’s performance was evaluated by means of calibration and discrimination, and the results for the first and second periods were compared. Results. Nine hundred patients were included, 450 in each period. In-hospital mortality was 33.8%. The 7 predictors included in the final model were age, comorbidity, need for prone positioning, renal insufficiency, use of high-flow nasal oxygen prior to mechanical ventilation, and a ratio of PaO2 to inspired oxygen fraction of less than 50. The performance of the model was good (Brier score, 0.172), and calibration and discrimination were consistent. We found no significant differences between the internal and external validation steps with respect to either the calibration slopes (0.92 [95% CI, 0.91–0.93] vs 1.12 [95% CI, 0.6–1.17], respectively; P = .150) or discrimination (area under the curve, 0.81 [95% CI, 0.75–0.84] vs 0.85 [95% CI, 0.81–0.89]; P = .121). Conclusion. The TIHCOVID tool may be useful for triage when assigning priority for patients with severe COVID-19 who require transfer between hospitals.

The Role of Vascular Imaging atReferral Centers in the Drip and Ship Paradigm.

BACKGROUND: In drip-and-ship protocols, non-invasive vascular imaging (NIVI) at Referral Centers (RC), although recommended, is not consistently performed and its value is uncertain. We evaluated the role of NIVI at RC, comparing patients with (VI+) and without (VI-) vascular imaging in several outcomes. METHODS: Observational, multicenter study from a prospective government-mandated population-based registry of code stroke patients. We selected acute ischemic stroke patients, initially assessed at RC from January-2016 to June-2020. We compared and analyzed the rates of patients transferred to a Comprehensive Stroke Center (CSC) for Endovascular Treatment (EVT), rates of EVT and workflow times between VI+ and VI- patients. RESULTS: From 5128 ischemic code stroke patients admitted at RC; 3067 (59.8%) were VI+, 1822 (35.5%) were secondarily transferred to a CSC and 600 (11.7%) received EVT. Among all patients with severe stroke (NIHSS ≥16) at RC, a multivariate analysis showed that lower age, thrombolytic treatment, and VI+ (OR:1.479, CI95%: 1.117-1.960, p=0.006) were independent factors associated to EVT. The rate of secondary transfer to a CSC was lower in VI+ group (24.6% vs. 51.6%, p<0.001). Among transferred patients, EVT was more frequent in VI+ than VI- (48.6% vs. 21.7%, p<0.001). Interval times as door-in door-out (median-minutes 83.5 vs. 82, p= 0.13) and RC-Door to puncture (median-minutes 189 vs. 178, p= 0.47) did not show differences between both groups. CONCLUSION: In the present study, NIVI at RC improves selection for EVT, and is associated with receiving EVT in severe stroke patients. Time-metrics related to drip-and-ship model were not affected by NIVI.

Effectiveness of Thrombectomy in Stroke According to Baseline Prognostic Factors: Inverse Probability of Treatment Weighting Analysis of a Population-Based Registry.

BACKGROUND AND PURPOSE:  In real-world practice, the benefit of mechanical thrombectomy (MT) is uncertain in stroke patients with very favorable or poor prognostic profiles at baseline. We studied the effectiveness of MT versus medical treatment stratifying by different baseline prognostic factors. METHODS:  Retrospective analysis of 2,588 patients with an ischemic stroke due to large vessel occlusion nested in the population-based registry of stroke code activations in Catalonia from January 2017 to June 2019. The effect of MT on good functional outcome (modified Rankin Score ≤2) and survival at 3 months was studied using inverse probability of treatment weighting (IPTW) analysis in three pre-defined baseline prognostic groups: poor (if pre-stroke disability, age >85 years, National Institutes of Health Stroke Scale [NIHSS] >25, time from onset >6 hours, Alberta Stroke Program Early CT Score <6, proximal vertebrobasilar occlusion, supratherapeutic international normalized ratio >3), good (if NIHSS <6 or distal occlusion, in the absence of poor prognostic factors), or reference (not meeting other groups' criteria). RESULTS:  Patients receiving MT (n=1,996, 77%) were younger, had less pre-stroke disability, and received systemic thrombolysis less frequently. These differences were balanced after the IPTW stratified by prognosis. MT was associated with good functional outcome in the reference (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.0 to 4.4), and especially in the poor baseline prognostic stratum (OR, 3.9; 95% CI, 2.6 to 5.9), but not in the good prognostic stratum. MT was associated with survival only in the poor prognostic stratum (OR, 2.6; 95% CI, 2.0 to 3.3). CONCLUSIONS:  Despite their worse overall outcomes, the impact of thrombectomy over medical management was more substantial in patients with poorer baseline prognostic factors than patients with good prognostic factors.

Comment on Lionte et al. Association of Multiple Glycemic Parameters at Hospital Admission with Mortality and Short-Term Outcomes in Acutely Poisoned Patients. Diagnostics 2021, 11, 361.

We have read with great interest the article by Lionte et al., "Association of multiple glycemic parameters at hospital admission with mortality and short-term outcomes in acutely poisoned patients", recently published in your journal [...].

Variabilidad regional en incidencia, características generales y resultados finales de la parada cardiaca extrahospitalaria en España: Registro OHSCAR / Regional variation in the incidence, general characteristics, and outcomes of prehospital cardiac arrest in Spain: the Out-of-Hospital Spanish Cardiac Arrest Registry

OBJETIVOS: Existe gran variabilidad internacional en la incidencia y los resultados en la atención a la parada cardiaca extrahospitalaria (PCRE). El objetivo es conocer si existe variabilidad en la incidencia, características y resultados en supervivencia en la atención a la PCRE por los servicios extrahospitalarios de emergencias (SEM) de España. MÉTODO: Análisis descriptivo, retrospectivo de los datos del registro OHSCAR correspondientes al periodo octubre2013-octubre 2014, que incluye pacientes atendidos por 19 SEM de España con intento de reanimación. Se recogieron los casos atendidos y variables clave sobre la asistencia a una PCRE: incidencia, características del paciente, del evento, de la actuación previa a los equipos de emergencias (EE), de la reanimación realizada, y de los principales tratamientos hospitalarios. Se comparó la situación neurológica al alta hospitalaria de los casos con ingreso hospitalario. RESULTADOS: La incidencia de casos con intento de reanimación y todas las características generales, salvo la distribución por sexo, presentaron diferencias estadísticamente significativas entre los SEM participantes (p < 0,001). Hubo diferencias significativas en los tratamientos hospitalarios recibidos y en los resultados finales, tanto en la proporción de pacientes que llegaron con pulso espontáneo al hospital, 30,5%, rango entre 21,3% y 56,1% (p < 0,001), como en el porcentaje de altas hospitalaria con categoría 1 o 2 de la clasificación Cerebral Perfomance Categories (CPC), sobre el total de ingresados, 31,8%, rango entre 17,2% y 58,3% (p < 0,001). CONCLUSIONES: Existe una importante variabilidad entre los SEM españoles en la incidencia de casos con intento de reanimación, en todas las variables clave y en la supervivencia al alta hospitalaria de la atención a la PCRE

BACKGROUND AND OBJECTIVE: The incidence and outcomes of care for out-of-hospital cardiac arrest (OHCA) vary greatly from country to country. We aimed to study variation in the incidence, characteristics, and outcomes of care for OHCAs given by Spanish prehospital emergency services. METHODS: Descriptive retrospective analysis of data from the Out-of-Hospital Spanish Cardiac Arrest Registry (OHSCAR) from October 2013 to October 2014. Attempts by 19 Spanish emergency services to resuscitate patients were studied. All OHCA cases were reviewed to obtain the following data: incidence, patient and event characteristics, prior emergencies, resuscitation attempts, and the main treatments provided in the hospital. If a patient was admitted, we compared the neurologic status on hospital discharge. RESULTS: Statistically significant differences were detected between emergency services (P< .0001) in the incidence of attempted resuscitation and all general characteristics except sex. Hospital treatments and outcomes also differed significantly: pulse had been restored on arrival of 30.5% of patients (range 21.3% to 56.1%, P< .001), and 31.8% of admitted patients were discharged in cerebral performance categories 1 or 2 (range 17.2% to58.3%,P< .001). CONCLUSION: Differences in the incidence of resuscitation attempts, key variables, and survival at discharge from the hospital are present in OHCA cases attended by prehospital emergency services in different regions of Spain

Regional variation in the incidence, general characteristics, and outcomes of prehospital cardiac arrest in Spain: the Out-of-Hospital Spanish Cardiac Arrest Registry. / Variabilidad regional en incidencia, características generales y resultados finales de la parada cardiaca extrahospitalaria en España: Registro OHSCAR.

OBJECTIVES: The incidence and outcomes of care for out-of-hospital cardiac arrest (OHCA) vary greatly from country to country. We aimed to study variation in the incidence, characteristics, and outcomes of care for OHCAs given by Spanish prehospital emergency services. MATERIAL AND METHODS: Descriptive retrospective analysis of data from the Out-of-Hospital Spanish Cardiac Arrest Registry (OHSCAR) from October 2013 to October 2014. Attempts by 19 Spanish emergency services to resuscitate patients were studied. All OHCA cases were reviewed to obtain the following data: incidence, patient and event characteristics, prior emergencies, resuscitation attempts, and the main treatments provided in the hospital. If a patient was admitted, we compared the neurologic status on hospital discharge. RESULTS: Statistically significant differences were detected between emergency services (P .0001) in the incidence of attempted resuscitation and all general characteristics except sex. Hospital treatments and outcomes also differed significantly: pulse had been restored on arrival of 30.5% of patients (range 21.3% to 56.1%, P .001), and 31.8% of admitted patients were discharged in cerebral performance categories 1 or 2 (range 17.2% to 58.3%, P .001). CONCLUSION: Differences in the incidence of resuscitation attempts, key variables, and survival at discharge from the hospital are present in OHCA cases attended by prehospital emergency services in different regions of Spain.

OBJETIVO: Existe gran variabilidad internacional en la incidencia y los resultados en la atención a la parada cardiaca extrahospitalaria (PCRE). El objetivo es conocer si existe variabilidad en la incidencia, características y resultados en supervivencia en la atención a la PCRE por los servicios extrahospitalarios de emergencias (SEM) de España. METODO: Análisis descriptivo, retrospectivo de los datos del registro OHSCAR correspondientes al periodo octubre 2013-octubre 2014, que incluye pacientes atendidos por 19 SEM de España con intento de reanimación. Se recogieron los casos atendidos y variables clave sobre la asistencia a una PCRE: incidencia, características del paciente, del evento, de la actuación previa a los equipos de emergencias (EE), de la reanimación realizada, y de los principales tratamientos hospitalarios. Se comparó la situación neurológica al alta hospitalaria de los casos con ingreso hospitalario. RESULTADOS: La incidencia de casos con intento de reanimación y todas las características generales, salvo la distribución por sexo, presentaron diferencias estadísticamente significativas entre los SEM participantes (p 0,001). Hubo diferencias significativas en los tratamientos hospitalarios recibidos y en los resultados finales, tanto en la proporción de pacientes que llegaron con pulso espontáneo al hospital, 30,5%, rango entre 21,3% y 56,1% (p 0,001), como en el porcentaje de altas hospitalaria con categoría 1 o 2 de la clasificación Cerebral Perfomance Categories (CPC), sobre el total de ingresados, 31,8%, rango entre 17,2% y 58,3% (p 0,001). CONCLUSIONES: Existe una importante variabilidad entre los SEM españoles en la incidencia de casos con intento de reanimación, en todas las variables clave y en la supervivencia al alta hospitalaria de la atención a la PCRE.

An Online Training Intervention on Prehospital Stroke Codes in Catalonia to Improve the Knowledge, Pre-Notification Compliance and Time Performance of Emergency Medical Services Professionals.

Strokes are a time-dependent medical emergency. The training of emergency medical service (EMS) professionals is essential to ensure the activation of stroke codes with pre-notification, as well as a rapid transfer to achieve early therapy. New assessment scales for the detection of patients with suspected large vessel occlusion ensures earlier access to endovascular therapy. The aim of this study was to evaluate the impact on an online training intervention focused on the Rapid Arterial oCclusion Evaluation (RACE) scoring of EMS professionals based on the prehospital stroke code in Catalonia from 2014 to 2018 in a pre-post intervention study. All Catalonian EMS professionals and the clinical records from primary stroke patients were included. The Kirkpatrick model guided the evaluation of the intervention. Data were collected on the knowledge on stroke recognition and management, pre-notification compliance, activated stroke codes and time performance of EMS professionals. Knowledge improved significatively in most items and across all categories, reaching a global achievement of 82%. Pre-notification compliance also improved significantly and remained high in the long-term. Increasingly higher notification of RACE scores were recorded from 60% at baseline to 96.3% in 2018, and increased on-site clinical care time and global time were also observed. Therefore, the online training intervention was effective for increasing EMS professionals' knowledge and pre-notification compliance upon stroke code activation, and the wide adoption of a new prehospital scale for the assessment of stroke severity (i.e., the RACE scale) was achieved.

Acute Stroke Care Is at Risk in the Era of COVID-19: Experience at a Comprehensive Stroke Center in Barcelona.

BACKGROUND AND PURPOSE: The purpose of the study is to analyze how the coronavirus disease 2019 (COVID-19) pandemic affected acute stroke care in a Comprehensive Stroke Center. METHODS: On February 28, 2020, contingency plans were implemented at Hospital Clinic of Barcelona to contain the COVID-19 pandemic. Among them, the decision to refrain from reallocating the Stroke Team and Stroke Unit to the care of patients with COVID-19. From March 1 to March 31, 2020, we measured the number of emergency calls to the Emergency Medical System in Catalonia (7.5 million inhabitants), and the Stroke Codes dispatched to Hospital Clinic of Barcelona. We recorded all stroke admissions, and the adequacy of acute care measures, including the number of thrombectomies, workflow metrics, angiographic results, and clinical outcomes. Data were compared with March 2019 using parametric or nonparametric methods as appropriate. RESULTS: At Hospital Clinic of Barcelona, 1232 patients with COVID-19 were admitted in March 2020, demanding 60% of the hospital bed capacity. Relative to March 2019, the Emergency Medical System had a 330% mean increment in the number of calls (158 005 versus 679 569), but fewer Stroke Code activations (517 versus 426). Stroke admissions (108 versus 83) and the number of thrombectomies (21 versus 16) declined at Hospital Clinic of Barcelona, particularly after lockdown of the population. Younger age was found in stroke admissions during the pandemic (median [interquartile range] 69 [64-73] versus 75 [73-80] years, P=0.009). In-hospital, there were no differences in workflow metrics, angiographic results, complications, or outcomes at discharge. CONCLUSIONS: The COVID-19 pandemic reduced by a quarter the stroke admissions and thrombectomies performed at a Comprehensive Stroke Center but did not affect the quality of care metrics. During the lockdown, there was an overload of emergency calls but fewer Stroke Code activations, particularly in elderly patients. Hospital contingency plans, patient transport systems, and population-targeted alerts must act concertedly to better protect the chain of stroke care in times of pandemic.

Atención prehospitalaria urgente de los pacientes pediátricos expuestos a tóxicos: características epidemiológico-clínicas y evaluación de la calidad asistencial / Prehospital emergency care of patients exposed to poisoning: Assessment of epidemiological, clinical characteristics and quality of care

Objetivo: Describir las características de los pacientes pediátricos con sospecha de intoxicación atendidos por unidades de soporte vital avanzado (SVA) y evaluar los indicadores de calidad (IC) para la atención urgente prehospitalaria de estos pacientes. Método: Estudio observacional de los pacientes menores de 18 años con exposición a tóxicos, que fueron atendidos por una unidad de SVA del Sistema de Emergencias Médicas en Cataluña, durante un año. Se definieron criterios de clínica grave. Se evaluaron 8 IC para la atención urgente prehospitalaria de los pacientes pediátricos intoxicados. Resultados: Se incluyó a 254 pacientes. La edad mediana fue de 14 años (p25-75 = 7-16), con exposición intencionada en el 50,8% de los casos. El tóxico más frecuentemente implicado fue el monóxido de carbono (CO) (33,8%). Presentó clínica de toxicidad el 48,8%, siendo grave en el 16,5%. La intencionalidad (OR 5,1; intervalo de confianza del 95%: 1,9-13,8) y el desconocimiento del tiempo transcurrido desde el contacto (OR 3,1; intervalo de confianza del 95%: 1,3-7,3) fueron factores de riesgo independientes asociados a clínica grave. Cinco IC no alcanzaron el estándar de calidad: disponibilidad de guías de actuación específicas, administración de carbón activado en pacientes seleccionados, aplicación de oxigenoterapia a la máxima concentración posible en intoxicación por CO, valoración electrocardiográfica en pacientes expuestos a sustancias cardiotóxicas y registro del conjunto mínimo de datos. Conclusiones: Los pacientes pediátricos expuestos a tóxicos y atendidos por unidades SVA presentan características propias. Destacan la implicación del CO y de los adolescentes con intoxicaciones voluntarias. La evaluación de los IC ha sido útil para detectar puntos débiles en la calidad asistencial de estos pacientes y desarrollar estrategias de mejora

Objective: To describe the characteristics of paediatric patients with suspected poisoning treated by advanced life support (ALS) units, and to evaluate quality indicators (QI) for the prehospital emergency care of these patients. Method: A one-year observational study of patients under 18 years of age exposed to poisoning and treated by an ALS unit of the Medical Emergency System in Catalonia. Severe clinical criteria were defined, with 8 QI being evaluated for prehospital emergency care of poisoned paediatric patients. Results: The study included a total of 254 patients, with a median age of 14 years-old (p25-75 = 7-16), with intentional poisoning in 50.8% of cases. The most frequently involved toxic agent was carbon monoxide (CO) (33.8%). Poisoning was found in 48.8% of those patients, being serious in 16.5%. Intentionally (OR 5.1; 95% CI: 1.9-13.8) and knowledge of the time of exposure (OD 3.1; 95% CI: 1.3-7.3) were independent risk factors associated with the appearance of severe clinical symptoms. Five QI did not reach the quality standard and included, availability of specific clinical guidelines, activated charcoal administration in selected patients, oxygen therapy administration at maximum possible concentration in carbon monoxide poisoning, electrocardiographic assessment in patients exposed to cardiotoxic substances, and recording of the minimum data set. Conclusions: Paediatric patients attended by ALS units showed specific characteristics, highlighting the involvement of CO and adolescents with voluntary poisoning. The QI assessment was useful to detect weak points in the quality of care of these patients and to develop strategies for improvement

[Prehospital emergency care of patients exposed to poisoning: Assessment of epidemiological, clinical characteristics and quality of care]. / Atención prehospitalaria urgente de los pacientes pediátricos expuestos a tóxicos: características epidemiológico-clínicas y evaluación de la calidad asistencial.

OBJECTIVE: To describe the characteristics of paediatric patients with suspected poisoning treated by advanced life support (ALS) units, and to evaluate quality indicators (QI) for the prehospital emergency care of these patients. METHOD: A one-year observational study of patients under 18 years of age exposed to poisoning and treated by an ALS unit of the Medical Emergency System in Catalonia. Severe clinical criteria were defined, with 8 QI being evaluated for prehospital emergency care of poisoned paediatric patients. RESULTS: The study included a total of 254 patients, with a median age of 14 years-old (p25-75 = 7-16), with intentional poisoning in 50.8% of cases. The most frequently involved toxic agent was carbon monoxide (CO) (33.8%). Poisoning was found in 48.8% of those patients, being serious in 16.5%. Intentionally (OR 5.1; 95% CI: 1.9-13.8) and knowledge of the time of exposure (OD 3.1; 95% CI: 1.3-7.3) were independent risk factors associated with the appearance of severe clinical symptoms. Five QI did not reach the quality standard and included, availability of specific clinical guidelines, activated charcoal administration in selected patients, oxygen therapy administration at maximum possible concentration in carbon monoxide poisoning, electrocardiographic assessment in patients exposed to cardiotoxic substances, and recording of the minimum data set. CONCLUSIONS: Paediatric patients attended by ALS units showed specific characteristics, highlighting the involvement of CO and adolescents with voluntary poisoning. The QI assessment was useful to detect weak points in the quality of care of these patients and to develop strategies for improvement.

Health care quality indicators and improvements to make in the prehospital care of adults exposed to carbon monoxide. / Indicadores de calidad y puntos de mejora en la asistencia prehospitalaria de los pacientes adultos expuestos a monóxido de carbono.

OBJECTIVES: To describe health care quality indicators in cases of carbon monoxide (CO) exposure attended by prehospital services and to explore factors associated with the use of pulse CO-oximetry (SpCO) for the noninvasive estimation of CO saturation of arterial blood. MATERIAL AND METHODS: Cohort study of patients exposed to CO and transported by advanced life support units of the Emergency Medical Services of Catalonia between January 2015 and December 2017. We selected 11 applicable quality indicators and used multivariate analysis to explore factors associated with the recording of SpCO. RESULTS: We studied 1676 cases of CO exposure. SpCO was recorded in 1108 cases (66.1%). CO saturation exceeded 10% in 358 patients (32.3%). Adherence was deficient in 5 of the 11 applicable quality indicators. Multivariate analysis showed less use of pulse CO-oximetry when another toxic exposure was present (odds ratio [OR], 0.34; 95% CI, 0.11- 1.00) and when the first responder was from the advanced life support service (OR, 0.43; 95% CI, 0.31-0.59). SpCO was used more in the presence of a history of mental health problems (OR, 3.01; 95% CI,1.27-7.17), headache (OR, 2.13; 95% CI, 1.2-3.72), and along with use of oxygen therapy (OR, 10.33; 95% CI, 5.46-19.53). CONCLUSION: Prehospital attendance of episodes of CO exposure is marked by failure to comply with some health care quality indicators. We detected factors associated with under use of SpCO as well as areas to target for improvement.

OBJETIVO: Investigar la calidad asistencial en los episodios de exposición a monóxido de carbono (CO) asistidos por unidades prehospitalarias mediante indicadores de calidad (IC) y las variables relacionadas con el uso del pulsicooxímetro para medir de forma incruenta el porcentaje de saturación de la hemoglobina con CO (SpCO). METODO: . Estudio de cohorte de los episodios de exposición a CO atendidos por las unidades de soporte vital avanzado (SVA) del Sistema de Emergencias Médicas de Cataluña. Se seleccionaron 11 IC y se diseñó un análisis multivariante para investigar las variables relacionadas con el uso del pulsicooxímetro. RESULTADOS: Se recogieron 1.676 episodios de exposición a CO. En 1.108 (66,1%) se registró la SpCO con pulsicooxímetro, siendo SpCO > 10% en 358 (32,3%). De los 11 IC, cinco no alcanzaron el estándar recomendado. El análisis multivariante mostró un menor uso del pulsicooxímetro cuando había asociación con otro tóxico, OR 0,34 (IC 95% 0,11-1,00) y cuando la primera asistencia era realizada por SVA médico, OR 0,43 (IC 95% 0,31-0,59). Hubo mayor uso del pulsicooxímetro ante la presencia de antecedentes psiquiátricos OR 3,01 (IC 95% 1,27-7,17), la cefalea OR 2,13 (IC 95% 1,22-3,72) y el uso de oxigenoterapia OR 10,33 (5,46-19,53). CONCLUSIONES: En la asistencia prehospitalaria de los episodios de exposición al CO existe una falta de cumplimiento de algunos IC. Hay variables relacionadas con la infrautilización del pulsicooxímetro, con puntos de mejora.

Impacto de las consultas y triajes telefónicos pediátricos en el uso del servicio de urgencias hospitalario / Pediatric televisits and telephone triage: impact on use of a hospital emergency department

Objetivos: Analizar las características de las teleconsultas y triajes telefónicos pediátricos atendidos por CatSalut Respon y describir su impacto sobre la actitud y la decisión final de los padres-usuarios de acudir o no a urgencias. Método: Estudio observacional transversal. Durante la teleconsulta los pacientes se clasificaron según los niveles del sistema español de triaje. Aquellos que fueron derivados a urgencias se volvieron a clasificar en el hospital, y se compararon los niveles de triaje. Posteriormente, se realizó una llamada de verificación. Se recogieron variables sociodemográficas y clínicas. Resultados: Se analizaron 370 teleconsultas, fundamentalmente no urgentes (n = 300; 81%). Un 20,3% (n = 75) fueron derivadas a urgencias. La fiebre (p = 0,002) y las dudas de medicación (p < 0,001) fueron motivos significativos de teleconsulta no urgente. Casi un 46% de los casos con niveles de gravedad altos en el triaje de la llamada también fueron clasificados con niveles de gravedad altos en el triaje posterior realizado en el servicio de urgencias hospitalario, mostrando una concordancia moderada. Más del 50% de los padres tenían intención de acudir a urgencias antes de la teleconsulta y un 46% cambiaron de actitud tras realizar esta llamada. Conclusiones: Fiebre y dudas de medicación fueron motivos estadísticamente significativos de teleconsulta no urgente. La consulta telefónica produjo un cambio de actitud en casi la mitad de los padres

Objectives: To analyze the characteristics of remote telephone consultations (televisits) and triage of pediatric emergencies attended by the 24-hour emergency service of Catalonia (CatSalut Respon), and to describe the impact of televisits on callers' decisions about whether or not to come to the emergency department and their opinion of the call service. Methods: Observational cross-sectional study. During the call, cases were classified according the Spanish and Andorran triage system. Patients who were sent to the hospital underwent triage again, and the 2 assigned triage levels were compared. The families were later called to check data and ask their opinion of the service. Sociodemographic and clinical data related to the cases were recorded. Results: A total of 370 televisits were made. Most cases (300, 81%) were not emergencies. Seventy-five callers (20.3%) were advised to go to an emergency department. Fever (P = .002) and questions about medication (P < .001) were the problems significantly associated with nonurgent cases. Nearly 46% of the cases classified as serious during telephone triage were also considered serious when the child was brought to the emergency department. The rate of agreement between the 2 triage levels was moderate. Over half the parents stated they had intended to go to the hospital before calling the service; 46% changed their mind based on the call. Conclusions: Fever and questions about medication were significantly associated with televisits for nonurgent cases. Nearly half the parents changed their mind about going to the emergency department after a televisit

Pediatric televisits and telephone triage: impact on use of a hospital emergency department. / Impacto de las consultas y triajes telefónicos pediátricos en el uso del servicio de urgencias hospitalario.

OBJECTIVES: To analyze the characteristics of remote telephone consultations (televisits) and triage of pediatric emergencies attended by the 24-hour emergency service of Catalonia (CatSalut Respon), and to describe the impact of televisits on callers' decisions about whether or not to come to the emergency department and their opinion of the call service. MATERIAL AND METHODS: Observational cross-sectional study. During the call, cases were classified according the Spanish and Andorran triage system. Patients who were sent to the hospital underwent triage again, and the 2 assigned triage levels were compared. The families were later called to check data and ask their opinion of the service. Sociodemographic and clinical data related to the cases were recorded. RESULTS: A total of 370 televisits were made. Most cases (300, 81%) were not emergencies. Seventy-five callers (20.3%) were advised to go to an emergency department. Fever (P = .002) and questions about medication (P < .001) were the problems significantly associated with nonurgent cases. Nearly 46% of the cases classified as serious during telephone triage were also considered serious when the child was brought to the emergency department. The rate of agreement between the 2 triage levels was moderate. Over half the parents stated they had intended to go to the hospital before calling the service; 46% changed their mind based on the call. CONCLUSION: Fever and questions about medication were significantly associated with televisits for nonurgent cases. Nearly half the parents changed their mind about going to the emergency department after a televisit.

OBJETIVO: Analizar las características de las teleconsultas y triajes telefónicos pediátricos atendidos por CatSalut Respon y describir su impacto sobre la actitud y la decisión final de los padres-usuarios de acudir o no a urgencias. METODO: Estudio observacional transversal. Durante la teleconsulta los pacientes se clasificaron según los niveles del sistema español de triaje. Aquellos que fueron derivados a urgencias se volvieron a clasificar en el hospital, y se compararon los niveles de triaje. Posteriormente, se realizó una llamada de verificación. Se recogieron variables sociodemográficas y clínicas. RESULTADOS: Se analizaron 370 teleconsultas, fundamentalmente no urgentes (n = 300; 81%). Un 20,3% (n = 75) fueron derivadas a urgencias. La fiebre (p = 0,002) y las dudas de medicación (p < 0,001) fueron motivos significativos de teleconsulta no urgente. Casi un 46% de los casos con niveles de gravedad altos en el triaje de la llamada también fueron clasificados con niveles de gravedad altos en el triaje posterior realizado en el servicio de urgencias hospitalario, mostrando una concordancia moderada. Más del 50% de los padres tenían intención de acudir a urgencias antes de la teleconsulta y un 46% cambiaron de actitud tras realizar esta llamada. CONCLUSIONES: Fiebre y dudas de medicación fueron motivos estadísticamente significativos de teleconsulta no urgente. La consulta telefónica produjo un cambio de actitud en casi la mitad de los padres.

Opinión de los responsables de los servicios de urgencias hospitalarios de Cataluña acerca de la creación de la especialidad de Medicina de Urgencias y Emergencias / Catalan hospital emergency department heads’ opinions on the creation of a residency program for specializing in emergency medicine

Objetivo: Conocer la opinión de los responsables de los servicios de urgencias hospitalarios (SUH) de Cataluña respecto al soporte e impacto que tendría la creación de la especialidad primaria de Medicina de Urgencias y Emergencias (MUE). Método: Se solicitó la opinión a los responsables de SUH respecto al respaldo a una futura especialidad primaria de MUE (personal, en su servicio y en su hospital) y la estimación del impacto (cualitativo y económico) que tendría en su SUH. Se compararon las respuestas en función del tipo de hospital y SUH y de su afiliación a la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES). Resultados: Contestaron 79 de los 82 responsables de los SUH de Cataluña (96%), que percibieron una posición favorable a la creación de la especialidad, tanto ellos personalmente (93,7%; IC 95%: 85,8-97,9) como en sus SUH (88,6%; 79,4- 94,7) y hospitales (48,7%; 36,7-59,6). El 82,0% (71,7-89,8) opinó que la especialidad tendría un efecto positivo a corto plazo y el 94,8% (87,2-98,6) que también lo tendría a medio-largo plazo, y respecto al impacto económico, la opinión mayoritaria fue que sería neutro (60,3%; 48,6-71,2). Los responsables de SUH con actividad media, de hospitales privados y no afiliados a SEMES consideraron más frecuentemente que la creación de la especialidad encarecería el SUH (p < 0,05). Conclusiones: Los responsables de los SUH catalanes tienen una opinión favorable y también la perciben en su servicio y su hospital respecto a la creación de la especialidad primaria de MUE y consideran que tendría efectos beneficiosos a corto, medio y largo plazo para el SUH, con un escaso impacto económico (AU)

Objective: To understand the opinions of emergency department (ED) heads in Catalonia on their support for a residency program for specializing in emergency medicine (EM) and on their beliefs about the impact such a program would have. Methods: Heads of ED were asked if there would be support (from them, their staff, and their hospital) for a residency program to train specialists in EM. They were also asked their opinion on the impact that specialization would have on quality of care and costs in their department. Responses were compared by type of hospital and ED and by affiliation or not with the Spanish Society of Emergency Medicine (SEMES). Results: Responses were received from 79 of the 82 heads of hospital EDs in Catalonia (96%). They reported that favorable opinions toward creation of an EM specialization were held by them personally (93.7%; 95% CI, 85.8%–97.9%), by their in their departments (88.6%; 95% CI, 79.4%–94.7%), and by staff in their hospitals (48.7%; 95% CI, 36.7%–59.6%). A majority thought that the impact of specialization would be good in the short term (82.0%; 95% CI, 71.7%–89.8%) and in the medium and long term (94.8%; 95% CI, 87.2%–98.6%). The respondents were neutral about whether there would be an impact on costs (60.3%; 95% CI, 48.6%–71.2%). More heads in mid-sized hospitals, private hospitals, and nonmembers of SEMES thought that creating a specialty would raise ED costs (p<0,05). Conclusions: The heads of Catalan ED, their staff, and their hospitals’ staffs hold favorable opinions of the proposal to create a residency program allowing specialization in EM. They foresee short-, medium-, and long-term benefits for the EDs and scarce impact on costs (AU)

[Catalan hospital emergency department heads' opinions on the creation of a residency program for specializing in emergency medicine]. / Opinión de los responsables de los servicios de urgencias hospitalarios de Cataluña acerca de la creación de la especialidad de Medicina de Urgencias y Emergencias.

OBJECTIVES: To understand the opinions of emergency department (ED) heads in Catalonia on their support for a residency program for specializing in emergency medicine (EM) and on their beliefs about the impact such a program would have. MATERIAL AND METHODS: Heads of ED were asked if there would be support (from them, their staff, and their hospital) for a residency program to train specialists in EM. They were also asked their opinion on the impact that specialization would have on quality of care and costs in their department. Responses were compared by type of hospital and ED and by affiliation or not with the Spanish Society of Emergency Medicine (SEMES). RESULTS: Responses were received from 79 of the 82 heads of hospital EDs in Catalonia (96%). They reported that favorable opinions toward creation of an EM specialization were held by them personally (93.7%; 95% CI, 85.8%-97.9%), by their in their departments (88.6%; 95% CI, 79.4%-94.7%), and by staff in their hospitals (48.7%; 95% CI, 36.7%-59.6%). A majority thought that the impact of specialization would be good in the short term (82.0%; 95% CI, 71.7%-89.8%) and in the medium and long term (94.8%; 95% CI, 87.2%-98.6%). The respondents were neutral about whether there would be an impact on costs (60.3%; 95% CI, 48.6%-71.2%). More heads in mid-sized hospitals, private hospitals, and nonmembers of SEMES thought that creating a specialty would raise ED costs (p<0,05). CONCLUSION: The heads of Catalan ED, their staff, and their hospitals' staffs hold favorable opinions of the proposal to create a residency program allowing specialization in EM. They foresee short-, medium-, and long-term benefits for the EDs and scarce impact on costs.

OBJETIVO: Conocer la opinión de los responsables de los servicios de urgencias hospitalarios (SUH) de Cataluña respecto al soporte e impacto que tendría la creación de la especialidad primaria de Medicina de Urgencias y Emergencias (MUE). METODO: Se solicitó la opinión a los responsables de SUH respecto al respaldo a una futura especialidad primaria de MUE (personal, en su servicio y en su hospital) y la estimación del impacto (cualitativo y económico) que tendría en su SUH. Se compararon las respuestas en función del tipo de hospital y SUH y de su afiliación a la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES). RESULTADOS: Contestaron 79 de los 82 responsables de los SUH de Cataluña (96%), que percibieron una posición favorable a la creación de la especialidad, tanto ellos personalmente (93,7%; IC 95%: 85,8-97,9) como en sus SUH (88,6%; 79,4- 94,7) y hospitales (48,7%; 36,7-59,6). El 82,0% (71,7-89,8) opinó que la especialidad tendría un efecto positivo a corto plazo y el 94,8% (87,2-98,6) que también lo tendría a medio-largo plazo, y respecto al impacto económico, la opinión mayoritaria fue que sería neutro (60,3%; 48,6-71,2). Los responsables de SUH con actividad media, de hospitales privados y no afiliados a SEMES consideraron más frecuentemente que la creación de la especialidad encarecería el SUH (p < 0,05). CONCLUSIONES: Los responsables de los SUH catalanes tienen una opinión favorable y también la perciben en su servicio y su hospital respecto a la creación de la especialidad primaria de MUE y consideran que tendría efectos beneficiosos a corto, medio y largo plazo para el SUH, con un escaso impacto económico.

Estudio SUHCAT (1): mapa físico de los servicios de urgencias hospitalarios de Cataluña / SUHCAT study, part 1: a map of the physical characteristics of hospital emergency services in Catalonia

Objetivo: Describir las características físicas de los servicios de urgencias hospitalarios (SUH) de Cataluña y su relación con diferentes características del SUH y del hospital. Método: Se entrevistó a los jefes de 79 de los 82 SUH de Cataluña (96%) que respondieron un cuestionario de 353 preguntas. Una parte de ellas hacía referencia a las características físicas y estructurales de los SUH. Las respuestas se tabularon globalmente y de forma detallada en función de la actividad del SUH (alta, media o baja), el uso del hospital (privado o público) y la complejidad del hospital público (alta tecnología o alta resolución, de referencia, comarcal). Resultados: En la mitad de SUH, su estructura física fue construida o reformada en los 4 años previos. El 59,5% de los SUH cuenta con un área observación (AO) (más los SUH de alta actividad y los hospitales públicos de mayor complejidad). El 35% tiene unidad de corta estancia en su hospital: en el 68% trabajan urgenciólogos, en el 46% éstos son los únicos facultativos especialistas y el 61% depende del SUH. En 2011, los SUH realizaron 3.949.885 atenciones (0,53 atenciones por habitante y año), el 16% en hospitales privados. La mediana (p25-p75) de ingresos fue del 9% (6-12). Un 34,2% incrementa su actividad por motivos de temporalidad turística, durante los cuales sólo el 37,0% aumenta el personal y el 18,5% la estructura. Los índices de fallecimientos, altas sin atención médica y reconsultas a las 72 horas son de 0,05% (0,00-0,13), 1,1% (0,3-2,5) y 4,5% (3,5-5,6), respectivamente (todos ellos mejores en los SUH de menor actividad, los hospitales privados y los hospitales públicos de menor complejidad). El 77,2% colocan identificativos a los pacientes y el 20,3% a los acompañantes, el 84,8% permite el acompañamiento permanente en el área de primera asistencia (APA) y el 59,5% en el AO. Un 36,7% de SUH no tiene ningún tipo de vigilancia (más frecuente en SUH de baja actividad, en hospitales privados y en hospitales públicos de baja complejidad). La superficie dedicada a actividad asistencial es 364 m2 (230-1200), con 13 boxes (7-26) en APA (2 para pacientes críticos) y 8 (4-13) en AO. Estos espacios se calificaron insuficientes en el 50,7% de SUH (más frecuente en hospitales públicos que privados) y su calidad deficiente el 16,5%. En caso de necesidad, las APA pueden aumentar su capacidad un 11% (0-50%) y las AO un 0% (0-5%). La disponibilidad de pruebas complementarias depende del tipo de SUH y de hospital. El 44,3% y el 13,7% tienen la radiología convencional y el escáner, respectivamente, en el propio SUH. El 49,4% dispone de ecógrafo propio y un 10% (0-30%) de sus urgenciólogos sabe utilizarlo. La informatización de la información asistencial es superior al 90% con la excepción del ECG digitalizado (48,8%) y la receta electrónica (25,5%). El 74,7% de SUH dispone de los tiempos asistenciales, pero sólo un 10% los muestra a los usuarios. Conclusiones: El presente estudio pone de manifiesto la realidad estructural de los SUH catalanes y señala diversas oportunidades de mejora

Objective: To describe the physical characteristics of hospital emergency departments in Catalonia, Spain, with reference to other characteristics of the departments and the hospitals. Methods: The heads of 79 of the 82 hospital emergency departments in Catalonia (96%) responded to a 353-item questionnaire and were personally interviewed. This study analyzes information from items referring to the departments' facilities. Statistics were compiled for the entire dataset and for three levels of emergency department volumen (high, medium, and low), for private and public hospital status, and for complexity of public hospitals (technologically well equipped, comprehensive general, other referral, or local). Results: Half the departments had premises built or remodelled in the last 4 years; 59.5% had an observation area. Such areas were more often available in high-volume hospitals and public health service hospitals with a higher degree of complexity. A short-stay area was available in 35% of the emergency departments: 68% had staff physicians who were specialized in emergency medicine, 46% were staffed exclusively by emergency physicians, and 61% were under the emergency department’s supervision. In 2011, these departments managed 3 949 885 emergencies (0.53 visits/inhabitant/ y); 16% were handled in private hospitals. The median (25th-75th percentile) admission rate was 9% (6%-12%). Volume increased during the high tourist season for 34.2% of the departments; only 37.0% of them hired additional staff at these times and 18.5% increased the available space. Rates for mortality, discharge without care, and revisits within 72 hours were 0.05% (0.00-0.13), 1.1% (0.3-2.5), and 4.5% (3.5-5.6), respectively. All these rates were lower in lower-volume hospitals, private hospitals, and less complex public hospitals. Patient identification bracelets were used in 77.2% of the departments. An accompanying person was allowed at all times in the initial assessment area in 84.8% and in the observation area in 59.5%. Security personnel were not provided in 36.7% of the departments; this rate was higher in lower-volume hospitals, private hospitals, and less complex public hospitals. The departments had a median surface area of 364 (230-1200) m2, 13 (7-26) initial treatment rooms or spaces (2 for critical cases), and 8 (4-13) observation-area beds. A 50,7% of the respondents considered their facilities were inadequate (an opinion expressed more often for public hospitals than for private ones), and 16,5% reported that the quality of available spaces was unsatisfactory. The area designated for initial treatment could be increased at 11% (0%–50%) of the hospitals, but 0% (0%-5%) could increase the number of observation beds. The availability of complementary tests was related to type of emergency department and hospital. Conventional radiography could be performed in 44.3% of the departments and computed tomography in 13.7%. Although 49.4% had ultrasound machines, only 10% (0%-30%) of the emergency physicians knew how to use one. High-quality information systems were in place in 90% of the hospitals, although only 48.8% had digitized electrocardiography and 25.5% could prescribe electronically. Although 74.7% of the departments compiled time statistics, only 10% shared the information with users. Conclusions: This study reveals the physical conditions of Catalan hospital emergency departments and identifies several ways they can be improved

Estudio SUHCAT (2): mapa funcional de los servicios de urgencias hospitalarios de Cataluña / SUHCAT study, part 2: a map of the functional characteristics of hospital emergency services in Catalonia

Objetivo: Describir las características organizativas y funcionales de los servicios de urgencias hospitalarios (SUH) de Cataluña y la de los médicos y enfermeros que trabajan en ellos. Método: Los responsables de 79 de los 82 SUH de Cataluña (96%) respondieron a preguntas referentes a organización y estructura directiva y ejecutiva del SUH, sistema de triaje, relación con los sistemas de emergencias médicas (SEM), volumen y características contractuales y demográficas de los médicos y enfermeros, así como de organización de su trabajo. Se estimaron los puestos de trabajo a tiempo completo para médicos y enfermeros existentes en los SUH en función de las horas totales anuales contratadas. Se analizaron las respuestas según la actividad del SUH (alta, media o baja), el uso del hospital (privado o público) y la complejidad del hospital público (alta tecnología o alta resolución, referencia, comarcal). Resultados: El 69,6% se organiza como servicio y el 53,2% tiene un jefe de servicio. El 68,4% organiza la asistencia en diferentes circuitos, preferentemente basados en un modelo mixto (triaje y especialidad). El 77,2% dispone de un sistema estructurado de triaje, casi siempre funcionando permanentemente, y en el 80,3% enfermería es la encargada. El Modelo Andorrano de Triaje es el más extendido, que clasificó como categorías 1, 2, 3, 4 y 5 al 0,7%, 5,5%, 28,2%, 47,9% y 17,8% de los pacientes, respectivamente. La organización de la jornada de los médicos es predominantemente a turnos (53,2%, preferentemente de 12 horas) y mixta (turnos y guardias, 30,4%). En 2012 se contrataron 4.894.264 horas de trabajo médico y 3.836.579 de trabajo enfermero, que suponen, respectivamente, 2.899 y 2.368 puestos de trabajo teóricos a jornada completa. De las horas de trabajo médico, el 50,4% las desarrollan médicos con contratos directamente vinculados a urgencias (73% fijos y 27% no fijos o interinos), el 19,1% médicos de otros (AU)

Objective: To describe the organization and functional characteristics of hospital emergency departments (ED) in Catalonia, Spain, as well as to describe the how these departments are staffed with physicians and nurses. Methods: The heads of 79 of the 82 hospital EDs in Catalonia (96%) responded to questions about the management structure of their department, their triage systems, relations with out-of-hospital emergency medical services, volume, contractual arrangements with staff, demographic characteristics of physicians and nurses on staff, and how their work is organized. A theoretical estimate of the number of full-time staff positions for physicians and nurses in each department was based on the total number of contracted hours each year. Statistics were compiled for three levels of ED volume (high, medium, and low), for private and public hospital status, and for level of complexity of public hospitals (technologically well equipped, comprehensive general, other referral, or local). Results: ED were organizationally separate in 69.6% of the hospitals, and 53.2% had their own department head. Organization was based on care pathways in 68.4%; the pathways usually followed a mixed model reflecting triage and specialty. A structured triage system was operating in 77.2% and was in use at all times in nearly all those departments; in 80.3%, nurses were in charge of triage. The Andorran Triage Model was the system most widely used. Triage levels 1 through 5 accounted for 0.7%, 5.5%, 28.2%, 47.9%, and 17.8% of the emergency patients, respectively. Physicians' assignments were organized in shifts (preferably 12 hours) in 53.2% of the EDs or in a combination of shifts and on-call schedules (30.4%). A total of 4 894 264 physician hours and 3 836 579 nurse hours were contracted in 2012; that number would correspond to 2899 full-time staff positions for physicians and 2368 for nurses. Physicians contracted directly by the EDs covered 50.4% of the hours (73% of the contracted physicians had permanent contracts and 27% were on temporary or training contracts); 19.1% of the hours were covered by physicians from other departments and 30.6% were covered by residents. Most of the fully trained physicians were specialists in family and community medicine (24%) and internal medicine (16.6%); 11.3% had not done residency training in a specialty. The EDs were staffed by physicians from Spain (62.8%), from other European Union (EU) countries (2.1%), and from non-EU countries (17.7%). Many of these characteristics were significantly different according to hospital category. Conclusions: In Catalonia differ in their organization and functional characteristics and in staffing characteristics. These EDs generate full-time employment for over 5000 physicians and nurses (AU)