Clinician consensus on "Inappropriate" presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland.

BACKGROUND: Utilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the "appropriateness" of attendances to the ED in Ireland. METHODS: The Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels. RESULTS: The National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered "inappropriate" (k = 0.341; p < 0.001). For attendances deemed "appropriate" the admission rate was 47% compared to 0% for "inappropriate" attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites. CONCLUSIONS: Multidisciplinary clinicians agree that "inappropriate" use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.

Are we there yet?' Distance to definitive care for Irish patients in the Better Data, Better Planning (BDBP) study.

BACKGROUND: Residing long distances from definitive care compromises patient safety and, in rural Ireland, travel distance to health care can be substantial, particularly in light of national General Practitioner (GP) shortages and hospital reconfigurations. The aim of this research is to describe the profile of patients attending Irish Emergency Departments (EDs) in terms of distance from GP care and definitive care in the ED. METHOD: The 'Better Data, Better Planning' (BDBP) census was a multi-centre, cross-sectional study of n=5 urban and rural EDs in Ireland throughout 2020. At each site, all adults presenting over a 24-h census period were eligible for inclusion. Data were collected on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED, with analysis in SPSS. RESULTS: For n=306 participants, median distance to a GP was 3 km (range 1-100 km) and median distance to the ED was 15 km (range 1-160km). Most participants (n=167, 58%) lived within 5 km of their GP and within 10 km of the ED (n=114, 38%). However, 8% of patients lived ≥15 km from their GP and 9% of patients lived ≥50 km from their nearest ED. Patients living >50 km from the ED were more likely to be transported by Ambulance (p<0.05). CONCLUSIONS: Proximity to health services, by geographical location, is poorer in rural regions, so it's important that these patients have equity of access to definitive care. Therefore, expansion of alternative care pathways in the community and additional resourcing of the National Ambulance Service with enhanced aeromedical support is essential in the future.

The impact of COVID-19 on an Irish Emergency Department (ED): a cross-sectional study exploring the factors influencing ED utilisation prior to and during the pandemic from the patient perspective.

BACKGROUND: The collateral damage of SARS-CoV-2 is a serious concern in the Emergency Medicine (EM) community, specifically in relation to delayed care increasing morbidity and mortality in attendances unrelated to COVID-19. The objectives of this study are to describe the profile of patients attending an Irish ED prior to, and during the pandemic, and to investigate the factors influencing ED utilisation in this cohort. METHODS: This was a cross-sectional study with recruitment at three time-points prior to the onset of COVID-19 in December 2019 (n = 47) and February 2020 (n = 57) and post-Lockdown 1 in July 2020 (n = 70). At each time-point all adults presenting over a 24 h period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. Data analysis was performed in SPSS and included descriptive and inferential statistics. RESULTS: The demographic and clinical profile of patients across time-points was comparable in terms of age (p = 0.904), gender (p = 0.584) and presenting complaint (p = 0.556). Median length of stay in the ED decreased from 7.25 h (IQR 4.18-11.22) in February to 3.86 h (IQR 0.41-9.14) in July (p ≤ 0.005) and differences were observed in disposition (p ≤ 0.001). COVID-19 influenced decision to attend the ED for 31% of patients with 9% delaying presentation. Post-lockdown, patients were less likely to attend the ED for reassurance (p ≤ 0.005), for a second opinion (p ≤ 0.005) or to see a specialist (p ≤ 0.05). CONCLUSIONS: Demographic and clinical presentations of ED patients prior to the first COVID-19 lockdown and during the reopening phase were comparable, however, COVID-19 significantly impacted health-seeking behaviour and operational metrics in the ED at this phase of the pandemic. These findings provide useful information for hospitals with regard to pandemic preparedness and also have wider implications for planning of future health service delivery.

The "better data, better planning" census: a cross-sectional, multi-centre study investigating the factors influencing patient attendance at the emergency department in Ireland.

BACKGROUND: Internationally Emergency Department (ED) crowding is a significant health services delivery issue posing a major risk to population health. ED crowding affects both the quality and access of health services and is associated with poorer patient outcomes and increased mortality rates. In Ireland the practising of "Corridor Medicine" and "Trolley Crises" have become prevalent. The objectives of this study are to describe the demographic and clinical profile of patients attending regional EDs and to investigate the factors influencing ED utilisation in Ireland. METHODS: This was a multi-centre, cross-sectional study and recruitment occurred at a selection of urban and rural EDs (n = 5) in Ireland throughout 2020. At each site all adults presenting over a 24 h census period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. RESULTS: Demographics differed significantly between ED sites in terms of age (p ≤ 0.05), socioeconomic status (p ≤ 0.001), and proximity of health services (p ≤ 0.001). Prior to ED attendance 64% of participants accessed community health services. Most participants (70%) believed the ED was the "best place" for emergency care or attended due to lack of awareness of other services (30%). Musculoskeletal injuries were the most common reason for presentation to the ED in this study (24%) and almost a third of patients (31%) reported presenting to the ED for an x-ray or scan. CONCLUSIONS: This study has identified regional and socioeconomic differences in the drivers of ED presentations and factors influencing ED attendance in Ireland from the patient perspective. Improved awareness of, and provision of alternative care pathways could potentially decrease ED attendances, which would be important in the context of reducing ED crowding during the COVID-19 pandemic. New strategies for integration of acute care in the community must acknowledge and plan for these issues as a universal approach is unlikely to be implemented successfully due to regional factors.

The 2018/19 Ebola epidemic the Democratic Republic of the Congo (DRC): epidemiology, outbreak control, and conflict.

The Democratic Republic of Congo (DRC) (formerly Zaire) was the location of the first Ebola outbreak, in 1976, and since then there have been a total of ten outbreaks in different parts of the country. The current outbreak, the first in eastern DRC (North Kivu and Ituri provinces), began in July 2018, and by December 2019, there had been 3262 cases and 2232 deaths. Within weeks of the first reported cases, the World Health Organisation (WHO) and the DRC Ministry of Health (MOH) initiated a major response programme, with laboratory support, international agencies providing personnel, and material resources. Unlike previous Ebola outbreaks, including the west Africa epidemic, a proven vaccine, and trial therapeutic agents have been available as part of the outbreak response. Two therapeutic agents, mAb114 and REGN-EB3, both monoclonal antibody derived, have shown case fatality rates (CFR) of around 30%, compared to the overall of 66%. Despite these positive interventions, the outbreak has continued for eighteen months. Underlying the outbreak response has been a high number of violent incidents by local militias, and community mistrust and lack of involvement that has hampered many aspects of the response programme. As a result, many cases are not reported early and not transferred to treatment centres, deaths and increased transmission occur in the community, and the response programme is reaching only a proportion of the cases. New strategies to improve community participation, and integrate the Ebola response into the existing health structure are planned to improve the programme effectiveness.

Can advanced paramedics in the field diagnose patients and predict hospital admission?

BACKGROUND: Accurate patient diagnosis in the prehospital environment is essential to initiate suitable care pathways. The advanced paramedic (AP) is a relatively recent role in Ireland, and refers to a prehospital practitioner with advanced life-support skills and training. OBJECTIVES: The objectives of this study were to compare the diagnostic decisions of APs with emergency medicine (EM) physicians, and to investigate if APs, as currently trained, can predict the requirement for hospital admission. METHODS: A prospective study was initiated, whereby each emergency ambulance call received via the statutory 999 system was recorded by the attending AP. The AP was asked to provide a clinical diagnosis for each patient, and to predict if hospital admission was required. The data was then cross-referenced with the working diagnosis of the receiving emergency physician and the hospital admission records. RESULTS: A total of 17 APs participated in the study, and 1369 emergency calls were recorded over a 6-month period. Cases where a general practitioner attended the scene were excluded from the concordance analysis. Concordance with the receiving emergency physician represents 70% (525/748) for all cases of AP diagnosis, and is mirrored with 70% (604/859) correct hospital admission predictions. CONCLUSIONS: AP diagnosis and admission prediction for emergency calls is similar to other emergency medical services systems despite the relative recency of the AP programme in Ireland. Recognition of non-concordance case types may identify priorities for AP education, and drive future AP practice in areas such as 'treat and refer'.