Pediatric Emergency Department Visits Before and During the COVID-19 Pandemic - United States, January 2019-January 2022.

Emergency departments (EDs) in the United States remain a frontline resource for pediatric health care emergencies during the COVID-19 pandemic; however, patterns of health-seeking behavior have changed during the pandemic (1,2). CDC examined changes in U.S. ED visit trends to assess the continued impact of the pandemic on visits among children and adolescents aged 0-17 years (pediatric ED visits). Compared with 2019, pediatric ED visits declined by 51% during 2020, 22% during 2021, and 23% during January 2022. Although visits for non-COVID-19 respiratory illnesses mostly declined, the proportion of visits for some respiratory conditions increased during January 2022 compared with 2019. Weekly number and proportion of ED visits increased for certain types of injuries (e.g., drug poisonings, self-harm, and firearm injuries) and some chronic diseases, with variation by pandemic year and age group. Visits related to behavioral concerns increased across pandemic years, particularly among older children and adolescents. Health care providers and families should remain vigilant for potential indirect impacts of the COVID-19 pandemic, including health conditions resulting from delayed care, and increasing emotional distress and behavioral health concerns among children and adolescents.

EUAdb: A resource for COVID-19 test development and comparison.

Due to the sheer number of COVID-19 (coronavirus disease 2019) cases there is a need for increased world-wide SARS-CoV-2 testing capability that is both efficient and effective. Having open and easy access to detailed information about these tests, their sensitivity, the types of samples they use, etc. would be highly useful to ensure their reproducibility, to help clients compare and decide which tests would be best suited for their applications, and to avoid costs of reinventing similar or identical tests. Additionally, this resource would provide a means of comparing the many innovative diagnostic tools that are currently being developed in order to provide a foundation of technologies and methods for the rapid development and deployment of tests for future emerging diseases. Such a resource might thus help to avert the delays in testing and screening that was observed in the early stages of the pandemic and plausibly led to more COVID-19-related deaths than necessary. We aim to address these needs via a relational database containing standardized ontology and curated data about COVID-19 diagnostic tests that have been granted Emergency Use Authorizations (EUAs) by the FDA (US Food and Drug Administration). Simple queries of this actively growing database demonstrate considerable variation among these tests with respect to sensitivity (limits of detection, LoD), controls and targets used, criteria used for calling results, sample types, reagents and instruments, and quality and amount of information provided.

Asociación entre calidad de atención y el nivel de saturación del servicio de urgencias de un hospital de Hidalgo, México / Association between quality of care and the level of saturation of the emergency department of a hospital in Hidalgo, Mexico

La calidad de atención en los servicios médicos en México representa el reflejo de un conjunto de acciones que el sistema de salud ha encaminado para equilibrar la oferta de dichos servicios con la demanda de los usuarios y conseguir elevar su grado de satisfacción. OBJETIVO: Analizar la asociación entre calidad de atención y el nivel de saturación del servicio de urgencias de un hospital de Hidalgo, México. METODOLOGÍA: Se realizó una revisión sistemática en PubMed y SciELO - Scientific Electronic Library Online en el mes de marzo del año 2020, mediante las palabras clave: calidad de atención médica, servicios de urgencia hospitalaria, antecedentes de calidad en México, nivel de saturación de los servicios de urgencia médica, calidad en el sistema de salud mexicano. También se buscó "google académico" con los mismos términos, la búsqueda se realizó en español. RESULTADOS: La calidad técnica de la atención, valorada mediante el apego a Protocolos de atención médica y Guías de Práctica Clínica, denota áreas de oportunidad, principalmente en primer nivel de atención, tiempos de espera prolongados, días de hospitalización, los errores médicos, entre otros se perciben como asociados a la mala calidad de la atención. CONCLUSIÓN: Por los resultados detectados en las referencias consultadas, es necesario analizar los nichos del sistema que se encuentran en mayor estado de vulnerabilidad como lo es el nivel de saturación del servicio de urgencias, trabajar en los indicadores de calidad de la atención con recursos materiales y humanos, de lo contrario los resultados ante la saturación de los servicios de salud continuaran con percepción negativa, esto es, resultados no positivos

The quality of care in medical services in Mexico reflects the set of actions that the health system has aimed to balance the supply of these services with the demand of users and to increase their degree of satisfaction. AIM: To analyze the association between quality of care and the level of saturation of the emergency department of a hospital in Hidalgo, Mexico. METHODOLOGY: A systematic review was carried out in PubMed and SciELO - Scientific Electronic Library Online in March 2020, using the keywords: quality of medical care, hospital emergency services, quality history in Mexico, level of saturation of services of medical emergency, quality in the Mexican health system. We also searched for "academic google" with the same terms, the search was carried out in Spanish. RESULTS: The technical quality of care, valued through adherence to protocols of medical care and Clinical Practice Guidelines, denotes areas of opportunity, mainly in the first level of care, long waiting times, days of hospitalization, medical errors, among others. perceived as associated with poor quality of care. CONCLUSION: Due to the results detected in the references consulted, it is necessary to analyze the niches of the system that are in the highest state of vulnerability, such as the level of saturation of the emergency service, work on the quality of care indicators with material and human resources Otherwise, the results in the face of the saturation of health services will continue with a negative perception, that is, non-positive results

El error de no planificar las emergencias en salud pública / The error of not planning public health emergencies

No disponible

Appropriateness of emergency care use: a retrospective observational study based on professional versus patients' perspectives in Taiwan.

OBJECTIVE: The objectives of this study are to refine the measurement of appropriate emergency department (ED) use and to provide a natural observation of appropriate ED use rates based on professional versus patient perspectives. SETTING: Taiwan has a population of 23 million, with one single-payer universal health insurance scheme. Taiwan has no limitations on ED use, and a low barrier to ED use may be a surrogate for natural observation of users' perspectives in ED use. PARTICIPANTS: In 7 years, there were 1 835 860 ED visits from one million random samples of the National Health Insurance Database. MEASURES: Appropriate ED use was determined according to professional standards, measured by the modified Billings New York University Emergency Department (NYU-ED) algorithm, and further analysed after the addition of prudent patient standards, measured by explicit process-based and outcome-based criteria. STATISTICAL ANALYSES: The area under the receiver operating characteristic curve (AUC) was used to reflect the performance of appropriate ED use measures, and sensitivity analyses were conducted using different thresholds to determine the appropriateness of ED use. The generalised estimating equation model was used to measure the associations between appropriate ED use based on process and outcome criteria and covariates including sex, age, occupation, health status, place of residence, medical resources area, date and income level. RESULTS: Appropriate ED use based on professional criteria was 33.5%, which increased to 63.1% when patient criteria were added. The AUC, which combines both professional and patient criteria, was high (0.85). CONCLUSIONS: The appropriate ED use rate nearly doubled when patient criteria were added to professional criteria. Explicit process-based and outcome-based criteria may be used as a supplementary measure to the implicit modified Billings NYU-ED algorithm when determining appropriate ED use.

Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital. / Implementação de um modelo de triagem cirúrgica para casos urgentes em um hospital terciário.

OBJECTIVE: to evaluate the applicability of the "Timing of Acute Care Surgery" (TACS) color classification system in a tertiary public hospital of a developing country. METHODS: we conducted a longitudinal, retrospective study in a single center, from March to August 2016 and the same period in 2017. We opted for the selection of four surgical specialties with high demand for emergencies, previously trained on the TACS system. For comparisons with the previous classifications, we considered emergencies as reds and oranges and urgencies, as yellow, with an ideal time interval for surgery of one hour and six hours, respectively. RESULTS: non-elective procedures accounted for 61% of the total number of surgeries. The red, orange and yellow classifications were predominant. There was a significant improvement in the time before surgery in the yellow color after the TACS system. Day and night periods influenced the results, with better ones during the night. CONCLUSION: this is the first study to use the TACS system in the daily routine of an operating room. The TACS system improved the time of attendance of surgeries classified as yellow.

OBJETIVO: avaliar a aplicabilidade do sistema de classificação de cores "Timing of Acute Care Surgery" (TACS) em um hospital público terciário de um país em desenvolvimento. MÉTODOS: estudo longitudinal, retrospectivo, de um único centro, de março a agosto de 2016 e o mesmo período em 2017. Optou-se pela seleção de quatro especialidades cirúrgicas com alta demanda de urgências, as quais foram previamente treinadas sobre o sistema TACS. Para comparação com as classificações prévias de urgência e emergência, emergências foram consideradas como vermelhas e laranjas e urgências como amarelas, com intervalo de tempo ideal para cirurgia de uma hora e de seis horas, respectivamente. RESULTADOS: os procedimentos não eletivos representaram 61% do número total de cirurgias. As classificações vermelha, laranja e amarela foram predominantes. Houve melhora significativa do tempo para a cirurgia na cor amarela após o sistema TACS. Períodos diurnos e noturnos influenciaram os resultados, com melhores resultados durante o período noturno. CONCLUSÃO: este é o primeiro estudo que usou o sistema TACS no dia a dia de um centro cirúrgico, e demonstrou que o sistema TACS melhorou o tempo de atendimento das cirurgias classificadas como amarelas.

Impact of establishment of a color code in emergency caesareans in secondary health care maternity.

In 2008, a tertiary health care maternity set up a colour code organization for emergency caesarean to reduce the delay between decision and birth to thirty minutes. The aim of this study is to determine the feasibility of the implementation in secondary health care maternity. MATERIALS AND METHODS: This retrospective study was conducted in secondary health care maternity and it was divided in two phases: phase I corresponding to the period before the implementation of colour code and phase II, to the period after the implementation of colour code. All patients who had an emergency caesarean were included. Then, we compared the decision to birth delay between the two phases and the neonatal state. RESULTS: Two hundred and twenty patients were included (one hundred and thirteen for the first phase and one hundred and seven for the second). The rate of caesarean sections realized within thirty minutes was no different between two groups. Decision to birth delay is variable and tends to decrease between two phases (-7 min for orange code, p = 0.91; and -15 min for red code, p = 0.0769). The medium pH is the same in both groups (7.30, p = 0.22) and the rate of transfer in neonatology is 29% for the first group and 13% in the second (p = 0.004) CONCLUSION: This protocol has resulted in better care for patients who had an emergency caesarean section. Two elements are to be noticed as follows: a reduction of decision to birth delay for extremely emergency caesarean (p = 0.0769) and less transfer in neonatology (p = 0.004).

Implementação de um modelo de triagem cirúrgica para casos urgentes em um hospital terciário / Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital

RESUMO Objetivo: avaliar a aplicabilidade do sistema de classificação de cores "Timing of Acute Care Surgery" (TACS) em um hospital público terciário de um país em desenvolvimento. Métodos: estudo longitudinal, retrospectivo, de um único centro, de março a agosto de 2016 e o mesmo período em 2017. Optou-se pela seleção de quatro especialidades cirúrgicas com alta demanda de urgências, as quais foram previamente treinadas sobre o sistema TACS. Para comparação com as classificações prévias de urgência e emergência, emergências foram consideradas como vermelhas e laranjas e urgências como amarelas, com intervalo de tempo ideal para cirurgia de uma hora e de seis horas, respectivamente. Resultados: os procedimentos não eletivos representaram 61% do número total de cirurgias. As classificações vermelha, laranja e amarela foram predominantes. Houve melhora significativa do tempo para a cirurgia na cor amarela após o sistema TACS. Períodos diurnos e noturnos influenciaram os resultados, com melhores resultados durante o período noturno. Conclusão: este é o primeiro estudo que usou o sistema TACS no dia a dia de um centro cirúrgico, e demonstrou que o sistema TACS melhorou o tempo de atendimento das cirurgias classificadas como amarelas.

ABSTRACT Objective: to evaluate the applicability of the "Timing of Acute Care Surgery" (TACS) color classification system in a tertiary public hospital of a developing country. Methods: we conducted a longitudinal, retrospective study in a single center, from March to August 2016 and the same period in 2017. We opted for the selection of four surgical specialties with high demand for emergencies, previously trained on the TACS system. For comparisons with the previous classifications, we considered emergencies as reds and oranges and urgencies, as yellow, with an ideal time interval for surgery of one hour and six hours, respectively. Results: non-elective procedures accounted for 61% of the total number of surgeries. The red, orange and yellow classifications were predominant. There was a significant improvement in the time before surgery in the yellow color after the TACS system. Day and night periods influenced the results, with better ones during the night. Conclusion: this is the first study to use the TACS system in the daily routine of an operating room. The TACS system improved the time of attendance of surgeries classified as yellow.

Relación entre la asignación del nivel de triaje y las características y experiencia del personal de enfermería / Triage level assignment and nurse characteristics and experience

OBJETIVO: Investigar la relación entre las características demográficas y experiencia de los enfermeros que realizan triaje y la asignación de pacientes a un determinado nivel de urgencia. MÉTODO: Estudio observacional retrospectivo llevado a cabo durante 1 año en el área de triaje de un hospital universitario terciario que usa el Model Andorrà de Triatge/Sistema Español de Triage (MAT/SET). VARIABLES: edad, sexo, experiencia en enfermería, experiencia en triaje, turno de trabajo, nivel asistencial donde trabajaban, número de triajes realizados y porcentaje de pacientes asignados a cada nivel de triaje. RESULTADOS: Se incluyeron 50 enfermeros (5 hombres y 45 mujeres) con una edad de 45 (DE 9) años que efectuaron 67.803 triajes. Los enfermeros del turno mañana clasificaban más pacientes en el nivel 5 que las de turno tarde (7,9% frente a 5,5%, p = 0,003). Este mayor porcentaje en el nivel 5 también se registraba de forma significativa cuanta más edad tenía el enfermero (β = 0,092, p = 0,037) y cuanta mayor experiencia acumulaba (β = 0,103, p = 0,017). El número de triajes efectuados por cada enfermero se relacionó, significativa y directamente, con el porcentaje de pacientes clasificados en nivel 3 (β = 0,003, p = 0,006) e, inversamente, con el porcentaje de pacientes clasificados en nivel 4 (β = -0,002, p = 0,008) y en nivel 5 (β = -0,001, p = 0,017). CONCLUSIÓN: Se ha objetivado una relación entre la edad, la experiencia acumulada, el turno de trabajo y el número total de triajes que efectúa un enfermero con el nivel de triaje asignado

OBJECTIVE: To study the relation between nursing staff demographics and experience and their assignment of triage level in the emergency department. Methods. One-year retrospective observational study in the triage area of a tertiary care urban university hospital that applies the Andorran-Spanish triage model. Variables studied were age, gender, nursing experience, triage experience, shift, usual level of emergency work the nurse undertakes, number of triage decisions made, and percentage of patients assigned to each level. Results. Fifty nurses (5 men, 45 women) with a mean (SD) age of 45 (9) years triaged 67 803 patients during the year. Nurses classified more patients in level 5 on the morning shift (7.9%) than on the afternoon shift (5.5%) (P=.003). The difference in the rate of level-5 triage classification became significant when nurses were older (β = 0.092, P=.037) and experience was greater (β = 0.103, P=.017). The number of triages recorded by a nurse was significantly and directly related to the percentage of patients assigned to level 3 (β = 0.003, P=.006) and inversely related to the percentages assigned to level 4 (β = -0.002, P=.008) and level 5 (β = -0.001, P=.017). Conclusion. We found that triage level assignments were related to age, experience, shift, and total number of patients triaged by a nurse

Emergency Department Overcrowding in Turkey: Reasons, Facts and Solutions.

INTRODUCTION: The purpose of this study was to determine the factors affecting the long waiting times of the patients in a university hospital. METHODS: This study included 3000 of the adults above 18 years and pediatric trauma patients under 18 years who applied to emergency department between February 2009 and April 2009. The examination period of the physician, length of stay, length of hospitalization, waiting times for hospitalization and follow up times in the emergency department were recorded. Moreover, the patients were divided into four groups according to the reasons for waiting. RESULTS: In our study, the time period between 4 pm-12 pm was determined as the busiest time for the applications. Average length of stay in the emergency department for 3000 patients was 146.7±160.2 minutes. The length of stay for the patients consulted was longer than the length of stay for the ones who were not consulted. Because of the fact that our hospital did not have appropriate bed capacity, 41.1% of the patients waited less than two hours, 13. 4% of the patients waited more than 8 hours. It was also found that the waiting times of the Group two patients (206,7±145,2 minutes) was longer than Group one (95,5±73,9 minutes) patients and the waiting times of Group three patients (470,7±364,7 minutes) was longer than Group one patients. CONCLUSIONS: In conclusion, cooperation of the managers, relevant departments and a multidisciplinary approach are necessary to achieve the goals to reduce overcrowding in the emergency departments.

A traffic-light coding system to organize emergency surgery across surgical disciplines.

BACKGROUND: Emergency surgery is associated with night-time procedures and disruption of elective surgery. An analysis was undertaken of the effect of classifying emergency operations uniformly with a three-tier urgency colour code and the use of dedicated daytime operating rooms. METHODS: Observed changes from 2001 to 2012 in the number, timing and ability to meet the urgency-designated colour code deadline were retrieved from the computer-based operating theatre organization system for all emergency operations. RESULTS: The number of emergency operations performed annually ranged from 3330 to 4341, with an increasing trend. The proportion of night-time emergency operations decreased from 27.4 per cent (2563 of 9347) before to 23.5 per cent (7731 of 32,959) after introduction of the colour coding system in 2004 (χ2 = 61.94, 1 d.f., P < 0.001). In 2007, owing to long preoperative delays in patients with acute appendicitis and acute cholecystitis, colour codes for these patients were upgraded from 'orange' to 'red' and from 'yellow' to 'orange' respectively. The proportion of patients operated on with a red code before and after this change increased from 45.2 per cent (5831 of 12,907 operations) to 62.7 per cent (13,020 of 20,778 operations; χ2 = 986.99, 1 d.f., P < 0.001). In 2012, the office-hours raw utilization time for the principal emergency operation theatre was 85.4 per cent. CONCLUSION: The structural separation of elective and emergency surgery, the use of dedicated daytime operating theatres and the implementation of a universal classification of emergency operations reduced night-time surgery, improved the efficiency of operating theatre utilization during daytime, shortened preoperative delay in patients requiring urgent surgery, and enabled monitoring and corrective actions for providing emergency surgery services.

Veupap (valoración enfermera de la urgencia pediátrica en atención primaria). Diseño y validación preliminar / Design and preliminary validation of a tool for nursing assessment and classification for pediatric patients in primary health care emergency. «Veupap»

Objetivo: Diseño de un instrumento de valoración y clasificación enfermera para pacientes pediátricos en urgencias de atención primaria. Diseño: Revisión bibliográfica exhaustiva de sistemas de valoración y clasificación de pacientes urgentes, trabajo en grupos de expertos, creación del instrumento y prueba de su validez, fiabilidad y facilidad de uso en condiciones habituales de funcionamiento del servicio. Emplazamiento: Servicio de urgencias pediátrico Dr. Jaime Chaves. Tenerife. Islas Canarias. Participantes: Nueve enfermeras y nueve pediatras con formación y experiencia en la atención pediátrica de urgencias. Las pruebas de validez y fiabilidad se realizan sobre una muestra de 200 pacientes pediátricos que acudían solicitando atención al Servicio de Urgencias, previa solicitud de consentimiento informado. Intervenciones: Sesiones formativas, motivacionales y de consenso del grupo experto. Con los pacientes, las enfermeras aplican el instrumento de clasificación a prueba y los pediatras su método habitual de clasificación experta. Mediciones principales: Motivos de consulta, nivel de clasificación obtenido con el instrumento por dos enfermeras de forma independiente al ingreso, nivel de clasificación otorgado por el pediatra especialista al alta. Resultados: Versión definitiva del instrumento con los campos de valoración y documentos anexos. Las pruebas de validez arrojan una sensibilidad del 100% y una especificidad del 94% y una concordancia entre enfermera y pediatra del 83%, y las de fiabilidad un acuerdo entre enfermeras del 76% (p<0,001 en general). Conclusiones: El instrumento, denominado VEUPAP (Valoración Enfermera de la Urgencia Pediátrica en Atención Primaria), resulta válido, fiable, sencillo y útil para su aplicación en atención primaria (AU)

Objective: Design a tool for nursing assessment and classification for pediatric patients in primary care emergency. Design: Comprehensive literature review of systems of evaluation and classification of urgent patients, work in groups of experts, creation of the instrument and test its validity, reliability and ease of use in normal operation conditions of service. Location: Pediatric Emergency Department Dr. Jaime Chaves. Tenerife. Canary Islands. Participants: Nine nurses and nine pediatricians with training and experience in emergency pediatric care. The validity and reliability tests are performed on a sample of 200 pediatric patients who came calling attention to the emergency service alter request informed consent. Interventions: Training sessions, motivational and expert group consensus. Nurses apply the classification tool to test at patient entry and level of classification given by the pediatrician at discharge. Results: Final version of the instrument with the fields of assessment and related documents. Validity tests show a sensitivity of 100% and a specificity of 94% and a concordance between nurse and pediatric of 83% and reliability agreement among nurses of 76% (p <0.001 in all cases). Conclusions: The instrument, called VEUPAP (Nurse Pediatric Emergency Valuation in Primary Care), is valid, reliable, simple and useful for application in primary care (AU)

Áreas organizativas específicas y circuitos preferentes para patologías prevalentes en urgencias / Specific organisational areas and preferential circuits for prevalent pathologies in emergency care

El incremento de la demanda y las habituales situacionesde colapso de los Servicios de UrgenciasHospitalarios (SUH) obliga a continuos cambios organizativosen busca de un óptimo funcionamiento y unaasistencia de mayor calidad.Los principales cambios se han basado en la implantaciónde diferentes sistemas de triaje, a fin deestructurar la atención en función de la urgencia, y elcambio adaptativo en la asistencia médica mediantediferentes fórmulas, como la derivación sin visita, lasáreas de visita rápida (fast-track areas) y los circuitosasistenciales específicos, como las unidades de dolortorácico, de código ictus o de código sepsis, entre lasmás extendidas en los SUH.Por otro lado, los SUH se han visto obligados a buscary utilizar métodos que favorezcan el flujo de salidade los pacientes desde los propios servicios, la mayorparte de las veces entorpecida por la mala gestión decamas hospitalarias por parte de las administracionessanitarias. Para ello se utilizan diferentes alternativas ala hospitalización convencional como son: unidades deobservación, unidades de estancia corta, hospitales dedía y hospitalización domiciliaria(AU)

The increase in demand and the normal situationsof overload of the Hospital Emergency Department(HED) make continuous organisational changes compulsoryin the search for optimum working and greaterquality of care.The main changes have been based on the implementationof different triage systems, with the aim ofstructuring care according to urgency, and adaptivechange in the medical service through different formulae,such as referrals without consultation, fast-trackareas and specific care circuits, such as units for thoracicpain, stoke code or sepsis code, amongst the mostwidespread in HED.On the other hand, HEDs have been forced to seekand use methods that favour the discharge of patients,often hindered by poor management of hospital bedsby the health administrations. Hence, different alternativesto hospitalisation are suggested, such as: observationunits, short stay units, day hospitals and hospitalisationat home(AU)

[Color-codes implementation shortens the decision-to-delivery interval of emergency C-sections]. / La mise en oeuvre des codes "couleur" réduit le délai décision-naissance des césariennes urgentes.

OBJECTIVES: To assess the efficiency of a new tool designed to shorten the decision-to-delivery interval (DDI) for emergency C-sections (CS). MATERIALS AND METHODS: DDI comparisons during three 6-month periods in a third level maternity. In stage A we evaluated the spontaneous DDI, in stage B the DDI was measured after the introduction of a color-code communication tool related to the degree of urgency for CS (amber code indicated urgent CS with an ideal DDI of 30 min and red code for very urgent CS with an ideal DDI of 15 min). In stage C we assessed the impact of the color-codes related protocols implementation. RESULTS: Two hundred and fifty-three C-sections were included (211 urgent CS and 42 very urgent CS). Mean DDI decreased significantly from 42 min to 24 min between period A and period C for amber codes (corresponding to 43.2% and 82.1% of the objectives respectively) and from 24.9 min to 10.7 min for red codes (20% et 83.3% of the objectives). CONCLUSION: This study suggests that color-codes and their related application protocols significantly shorten the DDI during the evaluation periods.

2009 OPPS rule is good news for EDs.

For once, the final Outpatient Prospective Payment System payment rule issued by the Centers for Medicare & Medicaid Services generally has been praised by emergency medicine observers. There are, however, some new wrinkles you should be aware of, because they could save - or cost - you money: A separate coding category has been established for EDs that are not open 24/7. The payment rates are lower than those in full-time EDs, except for Level 5 visits. Imaging procedures have been grouped into five milies," and multiple tests on the same patient within the same family will be reimbursed as if only a single test was performed. Visits coded for "trauma response with critical care" will be reimbursed at a rate nearly three times as high as last year's rate.

Comparison of different methods of risk stratification in urgent and emergency surgery.

BACKGROUND: The aim was to compare a number of risk scoring systems prospectively in a cohort of patients who underwent non-elective surgery. METHODS: This was a cohort study of 2349 consecutive patients who had urgent or emergency surgery in a district general hospital in the UK. All patients were scored prospectively using the Revised Goldman Cardiac Risk Index (RGCRI), Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), Surgical Risk Score (SRS) and Biochemistry and Haematology Outcome Models (BHOM). Actual 30-day and 1-year survival rates were compared with the predicted outcomes using receiver-operator characteristic (ROC) curves and Hosmer-Lemeshow analysis. RESULTS: Some 141 patients (6.0 per cent) died within 30 days of operation. This increased to 254 (10.8 per cent) by 1 year. The area under the ROC curve for death within 30 days was 0.90 for P-POSSUM, 0.85 for SRS, 0.84 for BHOM and 0.73 for RGCRI. Only the first three risk scores were able to discriminate accurately within the groups (area under ROC curve over 0.8), with no significant variation between expected and observed mortality rates confirmed by Hosmer-Lemeshow analysis. Similar results were found for the ability of each score to predict outcome at 1 year. CONCLUSION: P-POSSUM, SRS and BHOM scoring systems were all able to predict outcome after emergency and urgent surgery, but the SRS had the advantage of ease of calculation. BHOM requires only the most commonly available blood test data and the computer holding these data can easily perform the calculation.

Medicare's ambulance fee schedule dispatched.

Ambulance fees vary with the level of service and length of the beneficiary's trip. New fee schedule is expected to trim Medicare spending. Higher fees have been implemented for rural transports and air ambulance services. Lower fees have been implemented for urban transports. Providers and suppliers must revise chargemasters, policies, and procedures.