Does X-ray imaging by GPC at emergency care access points in the Netherlands change patient flow and reduce ED crowding? A cohort study.

OBJECTIVE: Organizing out-of-hours emergency care is a challenge in many countries. In the Netherlands, general practitioner cooperatives (GPCs) and emergency departments (EDs) are increasingly working together, creating one emergency care access point (ECAP). This has redirected the majority of patients with musculoskeletal problems from the ED to the GPC in out-of-hours care, due to the treatment of self-referrals by the general practitioner (GP). Only a minority of the GPs at ECAPs have the possibility to request X-rays, and expanding these facilities could reduce patient presentations to the ED even more. The aim of our study was to explore patient flow and possible reductions in ED referrals at an ECAP with X-ray facilities for GPs. METHODS: This retrospective cohort study examines all patients that visited an ECAP at a general city hospital in the Netherlands and had an X-ray imaging requested by the GPC between January 1, 2014 and December 31, 2014. General practitioner cooperatives could request X-rays between 5 pm and 10 pm on weekdays and between 8 am and 10 pm during weekends. Recorded data included sex, age, number and type of X-ray, X-ray abnormalities, referral to the ED, and treatment. The annual number of patients presenting to the GPC and ED in 2014 were gathered. Patient outcome was stated negative when the X-ray revealed no abnormality. RESULTS: A total of 2243 patients received 2663 X-ray examinations. The mean age was 31 years and 48% was male. A total of 1517 (68%) patients were treated at the GPC without an ED referral, a reduction of 4.5% of the annual ED patients. CONCLUSIONS: With a majority (68%) of the patients examined and treated at the GPC, X-ray facilities at ECAPs will substantially reduce ED population, change patient flow, and have a positive effect on ED crowding. Implementing 24/7 X-ray facilities at all ECAPs will further enhance these effects.

The impact on emergency department utilization and patient flows after integrating with a general practitioner cooperative: an observational study.

Introduction. A new model, an emergency care access point (ECAP) for after-hours emergency care, is emerging in The Netherlands. This study assessed the effect on emergency department (ED) utilization and patient flows. Methods. Routinely recorded clinical ED patient data, covering a six-year period, was collected. Segmented regression analysis was used to analyze after-hours changes over time. Results. 59.182 patients attended the ED before the start of the ECAP and 51.513 patients after, a decrease of 13%. Self-referred ED patients decreased 99.5% (OR 0.003; 95% CI 0.002-0.004). Referred patients increased by 213.4% and ED hospital admissions increased by 20.2%. A planned outpatient follow-up increased by 5.8% (OR 1.968 95% CI 1.870-2.071). The latter changed from fewer contacts to more contacts (OR 1.015 95% CI 1.013-1.017). Consultations at the regional genereral practitioner cooperative (GPC) increased by 26.0% (183.782 versus 232.246). Conclusion. ECAP implementation resulted in a decrease in ED utilization, a near absence of self-referring patients, and a higher probability of hospital admission and clinical follow-up. This suggests either an increase of ED patients with a higher acuity or a lower threshold of admitting referred patients compared to self-referred patients. Overall, increased collaboration with after-hours primary care and emergency care seemed to optimize ED utilization.

Intraoperative values of S-100 protein, myelin basic protein, lactate, and albumin in the CSF and serum of neurosurgical patients.

OBJECTIVES: To assess the concentrations of S-100 protein, myelin basic protein (MBP), and lactate, and the (CSF)/serum albumin ratio (Qalb) during intracranial neurosurgical procedures. METHODS: Samples of CSF from 91 patients with various CNS diseases were obtained by aspiration of cisternal CSF at the beginning of surgery (before starting surgical manipulation of the brain) and concentrations of S-100 protein, MBP, and lactate, and Qalb were determined. At the same time blood was sampled for determination of serum S-100 protein concentration. Patients were divided into three groups according to the aetiology of their CNS disease (intracranial haemorrhage, n=11; benign intracranial mass lesion, n=52; malignant neoplastic disease, n=28). Radiological and intraoperative characteristics were documented. RESULTS: In each of these three groups median values of all four CSF variables measured were raised. The occurrence of brain oedema and a midline shift correlated significantly with raised concentrations of MBP and Qalb. Breaching of the arachnoid layer, documented at surgery for benign lesions, correlated with higher concentrations of MBP, lactate, CSF S-100 protein, and Qalb. CONCLUSIONS: Intraoperative values of S-100 protein, MBP, lactate, and Qalb are increased in patients with intracranial haemorrhage, benign intracranial mass lesion, and malignant neoplastic disease. Breaching of the arachnoid layer and oedema is associated with higher concentrations of some of the aforementioned proteins. These biochemical data can serve as a basis for further research into CSF specific proteins.

A new actigraph for long-term registration of the duration and intensity of tremor and movement.

Actigraphy, the long-term measurement of human movement with a small solid state recorder, is gaining acceptance as a useful method in many research fields. Currently available actigraphs assess or estimate the movement duration per time interval. However, the output gives no information on movement type or intensity, and cannot be used in subjects suffering from tremor. The present paper describes a new type of actigraph, that has been developed primarily for the long-term evaluation of motor symptoms in Parkinson patients. The device is the first to discriminate tremor from other movements and to assess both duration and intensity of the two types of movement. It is based on a Motorola 68HC805B6 microcontroller and contains: an accelerometer, programmable gain stages, programmable low- and highpass filters, a programmable level comparator, a peak detector, interface circuits, a real time clock, data storage, and control circuitry. The micro-controller performs a period amplitude sequence analysis (PASA) on the conditioned accelerometer signal, and stores four output variables (tremor duration, tremor amplitude, movement duration, and movement amplitude) at the end of programmable time intervals. The analysis of fluctuations in the motor symptoms of, e.g., Parkinson patients using this actigraph can be of great help in the pharmacological management of symptoms.