Is clinician reported practice in Western Australian emergency departments aligned with direct discharge pathway protocols for minor self-limiting fractures? A multi-centre professional survey.

OBJECTIVE: To determine ED clinician's current management for five common minor self-limiting fractures (MSLF) and evaluate practice against evidence-informed direct discharge pathway (DD) protocols. METHODS: A survey was provided to doctors, nurse practitioners and advanced scope physiotherapists working in seven metropolitan, public health EDs in Perth, Australia. The relative odds of ED location (e.g. which facility) and clinician level factors (e.g. country of initial training, years of ED experience, profession) on recommending care completely consistent with evidence informed direct discharge pathway protocols were estimated. RESULTS: Two hundred sixty-two clinicians completed the survey. There was variability in practice across all sites, with most reported care assessed at 60%-76% consistency with individual elements of DD care provision. Highest consistency was seen in lower limb immobilisation and DVT prophylaxis. Lowest consistency was seen in weight bearing advice, pain management and (boxer's) fracture reduction and immobilisation. There were very low levels of complete consistency, ranging from 9% (boxer's fracture) to 25% (radial head fracture). Two factors were associated with increased odds of completely consistent care: (i) clinician experience working in ED, with greater duration of practice associated with increased odds ratios (OR range, 1.6-3.3); and (ii) profession, where advanced scope physiotherapy was associated with increased odds ratios (OR range, 3.2-25.0). CONCLUSIONS: Survey results suggested system wide variation in ED fracture management practice and target areas for service improvement. Avenues for service improvement could include hospital wide agreed management plans for specific fractures and support for less experienced clinicians.

Health Care Professionals' Experiences With a Mobile Self-Care Solution for Low Complex Orthopedic Injuries: Mixed Methods Study.

BACKGROUND: To cope with the rising number of patients with trauma in an already constrained Dutch health care system, Direct Discharge (DD) has been introduced in over 25 hospitals in the Netherlands since 2019. With DD, no routine follow-up appointments are scheduled after the emergency department (ED) visit, and patients are supported through information leaflets, a smartphone app, and a telephone helpline. DD reduces secondary health care use, with comparable patient satisfaction and primary health care use. Currently, little is known about the experiences of in-hospital health care professionals with DD. OBJECTIVE: The aim of this study was to explore the experiences of health care professionals with the DD protocol to enhance durable adoption and improve the protocol. METHODS: We conducted a mixed methods study parallel to the implementation of DD in 3 hospitals. Data were collected through a preimplementation survey, a postimplementation survey, and semistructured interviews. Quantitative data were reported descriptively, and qualitative data were reported using thematic analysis. Outcomes included the Bowen feasibility parameters: implementation, acceptability, preliminary efficacy, demand, and applicability. Preimplementation expectations were compared with postimplementation experiences. Health care professionals involved in the daily clinical care of patients with low-complex, stable injuries were eligible for this study. RESULTS: Of the 217 eligible health care professionals, 128 started the primary survey, 37 completed both surveys (response rate of 17%), and 15 participated in semistructured interviews. Health care professionals expressed satisfaction with the DD protocol (median 7.8, IQR 6.8-8.9) on a 10-point scale, with 82% (30/37) of participants noting improved information quality and uniformity and 73% (27/37) of patients perceiving reduced outpatient follow-up and imaging. DD was perceived as safe by 79% (28/37) of participants in its current form, but a feedback system to reassure health care professionals that patients had recovered adequately was suggested to improve DD. The introduction of DD had varying effects on workload and job satisfaction among different occupations. Health care professionals expressed intentions to continue using DD due to increased efficiency, patient empowerment, and self-management. CONCLUSIONS: Health care professionals perceive DD as an acceptable, applicable, safe, and efficacious alternative to traditional treatment. A numerical in-app feedback system (eg, in-app communication tools or recovery scores) could alleviate health care professionals' concerns about adequate recovery and further improve DD protocols. DD can reduce health care use, which is important in times of constrained resources. Nonetheless, both advantages and disadvantages should be considered while evaluating this type of treatment. In the future, clinicians and policy makers can use these insights to further optimize and implement DD in clinical practice and guidelines.

Direct discharge for children with a greenstick or torus fracture of the wrist is a non-inferior satisfactory solution to traditional treatment.

PURPOSE: Direct Discharge protocols (DD) can alleviate strain on healthcare systems by reducing routine outpatient follow-up. These protocols include low-complex musculoskeletal injuries, such as isolated greenstick fractures or torus fractures of the wrist in children. While there is consensus on the effectiveness of DD, there is a lack of injury-specific powered studies. This study compares treatment satisfaction between DD and traditional treatment in children with a greenstick fracture or torus fractures of the wrist. METHODS: Children with isolated torus or greenstick fractures of the distal radius or ulna were eligible for inclusion before (pre-DD cohort) and after (DD cohort) the implementation of DD in four hospitals. Traditionally, patients receive a (soft) cast and minimally one routine outpatient follow-up appointment. With DD, patients are discharged directly from the ED after receiving a brace and information, summarized in a smartphone app and a helpline for questions during recovery. The primary outcome was patient or proxy treatment satisfaction (0 to 10), and a power analysis was performed to assess non-inferiority. Secondary outcomes included complications, functional outcomes measured in Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE), primary healthcare utilisation, and secondary healthcare utilisation (follow-up appointments and imaging). RESULTS: In total, 274 consecutive children were included to analyse the primary endpoint. Of these, 160 (58%) were male with a median age of 11 years (IQR 8 to 12). Pre-DD and DD treatment satisfaction did not vary statistically significantly for greenstick fractures (p = 0.09) and torus fractures (p = 0.93). No complications were observed. PROMIS UE showed no statistically significant differences before and after implementation of direct discharge protocol for torus (p = 0.99) or greenstick (p = 0.45) fractures. Secondary healthcare utilisation regarding follow-up was significantly lower in the DD-torus cohort compared to the pre-DD torus cohort, with a mean difference (MD) of - 1.00 follow-up appointments (95% Confidence Interval (CI) - 0.92 to - 1.13). Similar results were found in the pre DD-greenstick cohort compared to the pre-DD-greenstick cohort (MD): - 1.17 follow-up appointments, 95% CI - 1.09 to - 1.26). CONCLUSION: Direct Discharge is non-inferior to traditional treatment in terms of treatment satisfaction for paediatric patients with greenstick or torus fractures of the wrist compared to children treated with rigid immobilisation and routine follow-up. Furthermore, the results demonstrate no complications, comparable functional outcomes, and a statistically significant reduction of secondary healthcare utilisation, making DD a good solution to cope with strained resources for children with an isolated greenstick fracture or torus fracture of the wrist.

Direct discharge from the intensive care unit improved patient flow in a resource-pressured health system.

Critical care practice is constantly evolving. Pressures for bed availability in publicly funded healthcare systems have led to an increase in patients delayed in their discharge from critical care to the wards. This has resulted in more patients discharged directly home (DDH) from the intensive care unit (ICU). However, few formal pathways for DDH exist. We have performed a retrospective audit of the patients discharged home from our unit in the largest tertiary referral hospital in the Republic of Ireland from 2017 to 2022 to investigate their characteristics and the safety of this practice, given the understandable patient safety concerns raised.Results In total, 84 patients have been DDH from our unit between 2017 and 2022 from a total of 4747 patients. The overall rate of DDH increased year on year, and the vast majority of these patients were initially admitted from the emergency department or following elective major surgery. Most patients had an APACHE score of less than 11 points, and the majority were admitted for less than 3 days, with single organ failure. There was a gender divide, as greater than 60% of the patients admitted were male, with a mean age of 44.Conclusion DDH has been an important tool in improving patient flow through the hospital, avoiding unnecessary de-escalation to the ward for a select group of critical care patients. The re-admission rate in the year post-ICU discharge was very low, showing that DDH has not adversely impacted patient safety.

Direct or early Discharge of Acute Bacterial Skin and Skin Structure Infection patients from the Emergency Department/Unit: place in therapy of dalbavancin.

INTRODUCTION: Acute Bacterial Skin and Skin Structure Infections (ABSSSIs) are a common reason of Emergency Department (ED) access and account for a considerable number of hospital admissions and a high economic burden for the healthcare system. The long-acting lipoglycopeptides (LALs) allow for an outpatient management of subjects with ABSSSIs, still requiring parenteral therapy, but who do not need hospitalization. AREAS COVERED: The following topics were addressed: i) microbiological activity, efficacy, and safety of dalbavancin, ii) critical steps for the management of ABSSSIs in the ED (decision to hospitalize, risk of bacteremia and infection recurrence), iii) feasibility of direct/early discharge from the ED and potential advantage of dalbavancin. EXPERT OPINION: Authors' expert opinion was focused on drawing the profiles of patients who could benefit most from an antimicrobial therapy with dalbavancin in the ED and positioning this drug as a direct or early discharge strategy from the ED in order to avoid hospitalization and its complications. We have provided a therapeutic and diagnostic algorithm based on evidence from the literature and authors' expert opinion and suggest the use of dalbavancin in patients with ABSSSIs who are not eligible for oral therapies or Outpatient Parenteral Antibiotic Therapy (OPAT) programs and who would have otherwise been hospitalized only for antibiotic therapy.

Characteristics and Outcomes of Patients Discharged Directly Home From the Pediatric Intensive Care Unit.

Introduction: Patients admitted to the pediatric intensive care unit (PICU) typically transfer to an acute care floor prior to discharge (ACD). Various circumstances, including rapid clinical improvement, technology dependence, or capacity constraints, may lead to discharge directly to home from a PICU (DDH). This practice has been studied in adult intensive care units, but research is lacking for PICU patients. Methods: We aimed to describe characteristics and outcomes of patients requiring PICU admission who experienced DDH versus ACD. We conducted a retrospective cohort study of patients ≤18 years old admitted to our academic, tertiary care PICU between 1/1/15 and 12/31/20. Patients who died or were transferred to another facility were excluded. Baseline characteristics (including home ventilator dependence) and markers of illness severity, specifically the need for vasoactive infusion or new mechanical ventilation, were compared between groups. Admission diagnoses were categorized using the Pediatric Clinical Classification System (PECCS). Our primary outcome was hospital readmission within 30 days. Results: Of 4042 PICU admissions during the study period, 768 (19%) were DDH. Baseline demographic characteristics were similar, although DDH patients were more likely to have a tracheostomy (30% vs 5%, P < .01) and require a home ventilator at discharge (24% vs 1%, P < .01). DDH was associated with being less likely to have required a vasoactive infusion (7% vs 11%, P < .01), shorter median length of stay (LOS) (2.1 days vs 5.9 days, P < .01) and increased rate of readmission within 30 days of discharge (17% vs 14%, P < .05). However, repeat analysis after removing ventilator-dependent patients at discharge (n = 202) showed no difference in rates of readmission (14% vs 14%, P = .88). Conclusions: Direct discharge home from the PICU is a common practice. DDH and ACD groups had similar 30-day readmission rate when patient admissions with home ventilator dependence were excluded.

Laminating Structure for Interlayer Corona Discharge Treatment Toward Ion-Based Nanogenerators.

A corona discharge treatment (CDT) is utilized to maximize the performance of triboelectric nanogenerators (TENGs) by injecting extra electrons into the negative tribomaterials. Increased performance of CDT TENGs, however, exhibits rapid degradation due to the electron dissipation by air moisture or thermal emission. To overcome such drawbacks and circumvent such dissipation, the source of charges should be replaced with ionic charges. This study reports a Ag nanowires (NWs)-embedded laminating structure (AeLS) with a unique fabrication procedure for ionic charge injection by CDT. The injection of ions is achieved by interlayer-CDT (i-CDT), in which positive charges are dissipated by Ag NWs, and the opposite negative ions can remain on the outmost surface. The AeLS TENGs with i-CDT exhibit high performance, long-term stability, and durability. It shows voltage, current, and maximum power outputs of 380 V, 15 µA, and 827 mW m-2 , respectively. As a practical demonstration, rotational TENG integrated with a direct discharge system is realized, and its current and voltage reach 7.4 mA and 7800 V, respectively. This work can pave the way for the design of ion-based TENGs with high performance and long-lasting retention of triboelectric charges.

Healthcare utilization and satisfaction with treatment before and after direct discharge from the Emergency Department of simple stable musculoskeletal injuries in the Netherlands.

PURPOSE: To evaluate healthcare utilization and satisfaction with treatment before and after implementing direct discharge (DD) from the Emergency Department (ED) of patients with simple, stable musculoskeletal injuries. METHODS: Patients with simple, stable musculoskeletal injuries were included in two Dutch hospitals, both level-2 trauma centers: OLVG and Sint Antonius (SA), before (pre-DD-cohort) and after implementing DD (DD-cohort). With DD, no routine follow-up appointments are scheduled after the ED visit, supported by information leaflets, a smartphone application and a telephone helpline. Outcomes included: secondary healthcare utilization (follow-up appointments and X-ray/CT/MRI); satisfaction with treatment (scale 1-10); primary healthcare utilization (general practitioner (GP) or physiotherapist visited, yes/no). Linear regression was used to compare secondary healthcare utilization for all patients and per injury subgroup. Satisfaction and primary healthcare utilization were analyzed descriptively. RESULTS: A total of 2033 (OLVG = 1686; SA = 347) and 1616 (OLVG = 1396; SA = 220) patients were included in the pre-DD-cohort and DD-cohort, respectively. After DD, the mean number of follow-up appointments per patient reduced by 1.06 (1.13-0.99; p < 0.001) in OLVG and 1.07 (1.02-0.93; p < 0.001) in SA. Follow-up appointments reduced significantly for all injury subgroups. Mean number of follow-up X-rays per patient reduced by 0.17 in OLVG (p < 0.001) and 0.18 in SA (p < 0.001). Numbers of CT/MRI scans were low and comparable. In OLVG, mean satisfaction with treatment was 8.1 (pre-DD-cohort) versus 7.95 (DD-cohort), versus 7.75 in SA (DD-cohort only). In OLVG, 23.6% of pre-DD-cohort patients visited their GP, versus 26.1% in the DD-cohort, versus 13.3% in SA (DD-cohort only). Physiotherapist use was comparable. CONCLUSION: This study performed in a large population and additional hospital confirms earlier pilot results, i.e., that DD has the potential to effectively reduce healthcare utilization, while maintaining high levels of satisfaction. LEVEL OF EVIDENCE: II.

Direct discharge of patients with simple stable musculoskeletal injuries as an alternative to routine follow-up: a systematic review of the current literature.

PURPOSE: There is growing evidence that patients with certain simple stable musculoskeletal injuries can be discharged directly from the Emergency Department (ED), without compromising patient outcome and experience. This study aims to review the literature on the effects of direct discharge (DD) of simple stable musculoskeletal injuries, regarding healthcare utilization, costs, patient outcome and experience. METHODS: A systematic review was performed in Medline, Embase, CINAHL, Cochrane Library and Web of Science using PRISMA guidelines. Comparative and non-comparative studies on DD of simple stable musculoskeletal injuries from the ED in an adult/paediatric/mixed population were included if reporting ≥ 1 of: (1) logistic outcomes: DD rate (proportion of patients discharged directly); number of follow-up appointments; DD return rate; (2) costs; (3) patient outcomes/experiences: functional outcome; treatment satisfaction; adverse outcomes; other. RESULTS: Twenty-six studies were included (92% conducted in the UK). Seven studies (27%) assessed functional outcome, nine (35%) treatment satisfaction, and ten (38%) adverse outcomes. A large proportion of studies defined DD eligibility criteria as injuries being minor/simple/stable, without further detail. ED DD rate was 26.7-59.5%. Mean number of follow-up appointments was 1.00-2.08 pre-DD, vs. 0.00-0.33 post-DD. Return rate was 0.0-19.4%. Costs per patient were reduced by €69-€210 (ranging from - 38.0 to - 96.6%) post-DD. Functional outcome and treatment satisfaction levels were 'equal' or 'better' (comparative studies), and 'high' (non-comparative studies), post-DD. Adverse outcomes were low and comparable. CONCLUSIONS: This systematic review supports the idea that DD of simple stable musculoskeletal injuries from the ED provides an opportunity to reduce healthcare utilization and costs without compromising patient outcomes/experiences. To improve comparability and facilitate implementation/external validation of DD, future studies should provide detailed DD eligibility criteria, and use a standard set of outcomes. Systematic review registration number: 120779, date of first registration: 12/02/2019.

Visualization of Activated Area on Polymers for Evaluation of Atmospheric Pressure Plasma Jets.

The treatment of a polymer surface using an atmospheric pressure plasma jet (APPJ) causes a local increase of the surface free energy (SFE). The plasma-treated zone can be visualized with the use of a test ink and quantitatively evaluated. However, the inked area is shrinking with time. The shrinkage characteristics are collected using activation image recording (AIR). The recording is conducted by a digital camera. The physical mechanisms of activation area shrinkage are discussed. The error sources are analyzed and methods of error reduction are proposed. The standard deviation of the activation area is less than 3%. Three polymers, acrylonitrile butadiene styrene (ABS), high-density polyethylene (HDPE), and polyoxymethylene (POM), are examined as a test substrate material. Due to a wide variation range of SFE and a small hydrophobic recovery, HDPE is chosen. Since the chemical mixtures tend to temporal changes of the stoichiometry, the pure formamide test ink with 58 mN/m is selected. The method is tested for the characterization of five different types of discharge: (i) pulsed arc APPJ with the power of about 700 W; (ii) piezoelectric direct discharge APPJ; (iii) piezoelectric driven needle corona in ambient air; (iv) piezoelectric driven plasma needle in argon; and (v) piezoelectric driven dielectric barrier discharge (DBD). For piezoelectrically driven discharges, the power was either 4.5 W or 8 W. It is shown how the AIR method can be used to solve different engineering problems.

Adoption of direct discharge of simple stable injuries amongst (orthopaedic) trauma surgeons.

INTRODUCTION: The importance of routine follow-up of several relatively simple stable injuries (SSIs) is questionable. Multiple studies show that direct discharge (DD) of patients with SSIs from the Emergency Department results in patient outcomes and experiences comparable to 'standard care' with outpatient follow-up. The purpose of this study was to evaluate to which extent DD of SSIs has been adopted amongst trauma and orthopedic surgeons internationally, and to assess the variation in the management of these common injuries. METHODS: An online survey was sent to members of an international trauma- and orthopaedic surgery collaboration. Participants, all trauma- or orthopaedic surgeons, were presented with eleven hypothetical cases of patients with simple stable injuries in which they were asked to outline their treatment plan regarding number of follow-up appointments and radiographs, physiotherapy and when to start functional movement. The primary outcome was the proportion of surgeons selecting direct discharge (i.e. zero scheduled appointments), per injury. Secondary outcomes included clinical agreement (>80% of respondents answering similarly) on total number of follow-up appointments (0, 1 or ≥2), radiographs (0, 1 or ≥2), routine physiotherapy referral (yes/no) and when to start functional movement (weeks). RESULTS: 138 of 667 (20.7%) surgeons completed the survey. Adoption of direct discharge ranged from 4-45% of case examples. In 10 out of 11 cases, less than 25% of surgeons selected direct discharge. Clinical agreement regarding number of appointments and when to start functional movement was not reached for any of the injuries. There was clinical agreement on number of radiographs for one injury and for four injuries regarding routine referral to a physiotherapist. DISCUSSION: Despite available evidence, DD of SSIs has not been widely adopted worldwide. Practice variation still exists even for these common injuries. This variation suggests inefficiency and consequently unnecessarily high healthcare costs. (Orthopaedic) trauma surgeons are encouraged to evaluate their current treatment protocols of SSIs.

Discharge home from critical care: safety assessment in a resource constrained system.

BACKGROUND: High bed occupancy rates have delayed patient discharges from UK critical care units, especially in acute medical hospitals. As a result, more patients are discharged home directly from critical care (DH). METHODS: In this observational, retrospective study, we quantify the trends in DH from 2013 to 2018, and assess readmission rates and outcome in this group when compared to patients discharged from a ward, from 2014 to 2016. RESULTS: DH rates, as a proportion of critical care admissions, increased every year (2.47% in 2013 to 19.36% in 2018). In 2014-16, the most common admission diagnoses in DH patients were diabetic ketoacidosis (DKA; 35%), drug overdose (12%), seizures (8%) and respiratory failure (8%). DH patients were younger and had shorter critical care stay. Readmission rates in DH patients were comparable to the rest of the hospital. Patients with DKA and seizures were more likely to be readmitted. CONCLUSIONS: Our data suggest that direct home discharge from critical care is increasingly common but safe in selected patient groups.

Development of environmental risk assessment framework and methodology for consumer product chemicals in China.

Environmental risk assessment (ERA) methodologies for consumer product chemicals are well established in most developed regions including the United States, Canada, and the European Union. However, such methodologies are not yet fully developed for emerging economies, such as China. The objective of the present study was to develop an ERA framework involving an exposure methodology using conditions specific to China (i.e., physical setting, infrastructure, and consumers' habits and practice). Incorporated in this newly developed ERA framework for assessing consumer product chemicals were China's current regulatory screening and prioritization schemes as part of a tiered risk assessment approach. The framework started with tier 0, which utilized the existing Chinese regulatory qualitative method; tiers 1 and 2 were quantitative, and used deterministic and probabilistic methods that accounted for per capita residential water usage, wastewater treatment capability, and wastewater/in-stream dilution factors. Due to major differences in wastewater treatment infrastructure and water usage between urban versus rural regions in China, 2 scenarios were identified for quantitatively assessing environmental exposure: 1) urban with wastewater treatment, and 2) rural without wastewater treatment (i.e., direct discharge of wastewater). Our study presents the methodology of the framework with its technical rationale and the companion model Chera, and also provides an overview of the current status of ERA research in China. Environ Toxicol Chem 2019;38:250-261. © 2018 SETAC.