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1.
Crit Care Resusc ; 21(4): 274-83, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31778634

RESUMO

BACKGROUND: Clinically apparent cerebral oedema during diabetic ketoacidosis (DKA) is rare and more common in children and young adults. Subclinical oedema with mild brain dysfunction is more frequent, with unknown long term effects. Rapid tonicity changes may be a factor although not well studied. Guidelines recommend capping hypertonicity resolution at ≤ 3 mOsmol/kg/h. OBJECTIVES: To audit current DKA management in the emergency department (ED) and in the intensive care unit (ICU) for tonicity benchmark compliance, and to determine interactions between plasma tonicity, plasma glucose concentrations and blood haemoglobin concentrations. METHODS: Twenty-five adult DKA admissions from ED to ICU were studied retrospectively. Blood gas and electrolyte data were sequenced for 24 hours from first ED blood sample. RESULTS: Sampling was frequent (median, 11 times per day; range, 6-26). Tonicity reduction was largely accomplished by the first ICU blood sample and exceeded 3 mOsmol/ kg/h in 72% of admissions. Correlation with haemoglobin reduction (haemodilution) rates exceeded correlation with glucose rates (R2 = 0.52 v 0.38). In benchmark noncompliant admissions, haemodilution was more rapid (6.1 g/L/h v 2.1 g/L/h; P = 0.001). Although also true of glucose reduction (4.5 mmol/L/h v 2.2 mmol/L/h; P = 0.007), there was no interaction between haemodilution and glucose reduction (R2 = 0.09). CONCLUSIONS: Major tonicity reductions often exceeding guidelines were common by ICU admission. Correcting DKA-induced hypertonicity at ≤ 3 mOsmol/kg/h requires controlled hyperglycaemia correction and, based on our data, avoidance of high fluid replacement rates; for example, sufficient to reduce haemoglobin concentrations by > 3 g/L/h, unless there is evidence of intravascular hypovolaemia.


Assuntos
Cuidados Críticos/métodos , Estado Terminal/terapia , Cetoacidose Diabética/terapia , Hemodiluição , Glicemia/metabolismo , Criança , Cetoacidose Diabética/sangue , Cetoacidose Diabética/metabolismo , Serviço Hospitalar de Emergência/organização & administração , Hospitalização , Humanos , Unidades de Terapia Intensiva/organização & administração , Estudos Retrospectivos , Adulto Jovem
2.
BMC Health Serv Res ; 19(1): 687, 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31601199

RESUMO

BACKGROUND: Social inequities are widening globally, contributing to growing health and health care inequities. Health inequities are unjust differences in health and well-being between and within groups of people caused by socially structured, and thus avoidable, marginalizing conditions such as poverty and systemic racism. In Canada, such conditions disproportionately affect Indigenous persons, racialized newcomers, those with mental health and substance use issues, and those experiencing interpersonal violence. Despite calls to enhance equity in health care to contribute to improving population health, few studies examine how to achieve equity at the point of care, and the impacts of doing so. Many people facing marginalizing conditions experience inadequate and inequitable treatment in emergency departments (EDs), which makes people less likely to access care, paradoxically resulting in reliance on EDs through delays to care and repeat visits, interfering with effective care delivery and increasing human and financial costs. EDs are key settings with potential for mitigating the impacts of structural conditions and barriers to care linked to health inequities. METHODS: EQUIP is an organizational intervention to promote equity. Building on promising research in primary health care, we are adapting EQUIP to emergency departments, and testing its impact at three geographically and demographically diverse EDs in one Canadian province. A mixed methods multisite design will examine changes in key outcomes including: a) a longitudinal analysis of change over time based on structured assessments of patients and staff, b) an interrupted time series design of administrative data (i.e., staff sick leave, patients who leave without care being completed), c) a process evaluation to assess how the intervention was implemented and the contextual features of the environment and process that are influential for successful implementation, and d) a cost-benefit analysis. DISCUSSION: This project will generate both process- and outcome-based evidence to improve the provision of equity-oriented health care in emergency departments, particularly targeting groups known to be at greatest risk for experiencing the negative impacts of health and health care inequities. The main deliverable is a health equity-enhancing framework, including implementable, measurable interventions, tested, refined and relevant to diverse EDs. TRIAL REGISTRATION: Clinical Trials.gov # NCT03369678 (registration date November 18, 2017).


Assuntos
Assistência à Saúde/normas , Serviço Hospitalar de Emergência/normas , Equidade em Saúde/organização & administração , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Colúmbia Britânica , Protocolos Clínicos , Serviço Hospitalar de Emergência/organização & administração , Humanos , Índios Norte-Americanos/estatística & dados numéricos , Análise de Séries Temporais Interrompida , Serviços de Saúde Mental/normas , Serviços de Saúde Mental/estatística & dados numéricos , Atenção Primária à Saúde/organização & administração , Racismo/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Violência/estatística & dados numéricos
3.
West J Emerg Med ; 20(5): 710-716, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31539326

RESUMO

INTRODUCTION: The emergency department (ED) has long served as a safety net for the uninsured and those with limited access to routine healthcare. This study aimed to compare the characteristics and severity of ED visits in an Illinois academic medical center (AMC) and community hospital (CH) of a single health system before and after the implementation of the Affordable Care Act (ACA). METHODS: This was a retrospective record review of 357,764 ED visits from January 1, 2011-December 31, 2016, of which 74% were at the AMC and 26% at the CH. We assessed the severity of ED visits by applying the previously validated Ballard algorithm, which classifies ED visits as non-emergent, intermediate, or emergent. Descriptive analyses were conducted to compare the characteristics of ED visits before and after the implementation of the ACA. We conducted multilevel logistic regression analysis to examine the odds of non-emergent compared to intermediate/emergent ED visits by the ACA implementation status controlling for patient demographic characteristics, insurance status, and multiple visits per patient. RESULTS: ED visits for patients with Medicaid or other governmental coverages increased in the post-ACA compared to pre-ACA period (Pre: 33.2 % vs Post: 38.3% at the AMC, and Pre: 29.7% vs Post: 35.1% at the CH). A statistically significant decrease in ED visits for uninsured patients was observed at the AMC and CH in the post-ACA period compared to the pre-ACA period (Pre: 12.1% vs Post: 6.4%, and Pre: 13.9% vs Post: 9.8%, respectively). Results from the regression analysis showed a significant decreased odds of non-emergent vs intermediate/emergent ED visits during the post-ACA period compared to the pre-ACA period at the AMC (odds ratio [OR] 0.68; confidence interval [CI], 0.66-0.70). However, an increased odds of non-emergent vs. intermediate/emergent ED visits was observed at the CH (OR 1.09; CI, 1.04-1.14). CONCLUSION: Similar to other Medicaid expansion states, ED utilization for uninsured patients decreased at both the AMC and the CH in the post-ACA period. While Medicaid visits for children < 18 years declined in the post-ACA period, it increased for ages 21 to 65 years of age. Contrary to our hypothesis, the severity of emergent ED visits increased in the post-ACA period but not at the CH.


Assuntos
Centros Médicos Acadêmicos/economia , Assistência à Saúde/economia , Serviço Hospitalar de Emergência/organização & administração , Hospitais Comunitários/economia , Patient Protection and Affordable Care Act/organização & administração , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Humanos , Illinois , Lactente , Cobertura do Seguro , Masculino , Medicaid , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
4.
West J Emerg Med ; 20(5): 799-802, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31539337

RESUMO

INTRODUCTION: Mobile health (mHealth) has the potential to change how patients make healthcare decisions. We sought to determine the readiness to use mHealth technology in underserved communities. METHODS: We conducted a cross-sectional survey of patients presenting with low-acuity complaints to an urban emergency department (ED) with an underserved population. Patients over the age of two who presented with low-acuity complaints were included. We conducted structured interview with each patient or parent (for minors) about willingness to use mHealth tools for guidance. Analysis included descriptive statistics and univariate analysis based on age and gender. RESULTS: Of 560 patients included in the survey, 80% were adults, 64% female, and 90% Black. The mean age was 28 ± 9 years for adults and 9 ± 5 years for children. One-third of patients reported no primary care physician, and 55% reported no access to a nurse or clinician for medical advice. Adults were less likely to have access to phone consultation than parents of children (odds ratio [OR] 0.49, 95% confidence interval [CI], 0.32 - 0.74), as were males compared to females (OR 0.52, 95% CI, 0.37-0.74). Most patients (96%) reported cellular internet access. Two-thirds of patients reported using online references. When asked how they would behave if an mHealth tool advised them that their current health problem was low risk, 69% of patients responded that they would seek care in an outpatient clinic instead of the ED (30%), stay home and not seek urgent medical care (28%), or use telehealth (11%). CONCLUSION: In this urban community we found a large capacity and willingness to use mHealth technology in medical triage.


Assuntos
Assistência Ambulatorial/métodos , Serviço Hospitalar de Emergência/organização & administração , Disparidades em Assistência à Saúde/estatística & dados numéricos , Encaminhamento e Consulta , Telemedicina/estatística & dados numéricos , Saúde da População Urbana , Adolescente , Adulto , Criança , Estudos Transversais , Feminino , Humanos , Masculino , Área Carente de Assistência Médica , Inquéritos e Questionários , Estados Unidos , Adulto Jovem
5.
Pediatrics ; 144(4)2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31515299

RESUMO

BACKGROUND: Diagnostic delays in the pediatric emergency department (ED) can lead to unnecessary interventions and prolonged ED length of stay (LOS), especially in patients with diabetes mellitus evaluated for diabetic ketoacidosis (DKA). At our institution, baseline DKA determination time (arrival to diagnosis) was 86 minutes, and 61% of patients did not meet DKA criteria. Subsequently, intravenous (IV) placement occurred in 85% of patients without DKA. We aimed to use point-of-care (POC) testing to reduce DKA determination time from 86 to 30 minutes and to reduce IV placements in patients without DKA from 85% to 20% over 18 months. METHODS: Four key interventions (POC tests, order panels, provider guidelines, and nursing guidelines) were tested by using plan-do-study-act cycles. DKA determination time was our primary outcome, and secondary outcomes included the percentage of patients receiving IV placement and ED LOS. Process measures included the rate of use of POC testing and order panels. All measures were analyzed on statistical process control charts. RESULTS: Between January 2015 and July 2018, 783 patients with diabetes mellitus were evaluated for DKA. After all 4 interventions, DKA determination time decreased from 86 to 26 minutes (P < .001). In patients without DKA, IV placement decreased from 85% to 36% (P < .001). ED LOS decreased from 206 to 186 minutes (P = .009) in patients discharged from the hospital after DKA evaluation. POC testing and order panel use increased from 0% to 98% and 90%, respectively. CONCLUSIONS: Using quality-improvement methodology, we achieved a meaningful reduction in DKA determination time, the percentage of IV placements, and ED LOS.


Assuntos
Cetoacidose Diabética/diagnóstico , Cetoacidose Diabética/terapia , Serviço Hospitalar de Emergência/organização & administração , Testes Imediatos , Melhoria de Qualidade , Tempo para o Tratamento , Adolescente , Glicemia/análise , Criança , Pré-Escolar , Diagnóstico Tardio/prevenção & controle , Diabetes Mellitus Tipo 1/complicações , Feminino , Hidratação , Guias como Assunto , Hospitais Pediátricos , Humanos , Hipoglicemiantes/uso terapêutico , Lactente , Insulina/uso terapêutico , Tempo de Internação , Masculino , Equipe de Assistência ao Paciente , Wisconsin , Adulto Jovem
6.
Scand J Trauma Resusc Emerg Med ; 27(1): 88, 2019 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-31533807

RESUMO

BACKGROUND: Much effort has been made to explore how patients with advanced chronic illness and their families experience care when they attend the Emergency Department, and many studies have investigated how healthcare professionals perceive Palliative Care provision in the Emergency Department. Various models exist, but nonetheless incorporating palliative care into the Emergency Department remains challenging. Considering both healthcare professionals' and users' perspective on problems encountered in delivering and receiving appropriate palliative care within this context may provide important insight into meaningful targets for improvements in quality of care. Accordingly, this study aims at exploring issues in delivering palliative care in the Emergency Department from the perspective of both providers and users, as part of a larger project on the development and implementation of a quality improvement program in Italian Emergency Departments. METHODS: A qualitative study involving focus group interviews with Emergency Department professionals and semi-structured interviews with patients with palliative care needs in the Emergency Department and their relatives was conducted. Both datasets were analyzed using Thematic Analysis. RESULTS: Twenty-one healthcare professionals, 6 patients and 5 relatives participated in this study. Five themes were identified: 1) shared priorities in Emergency Department among healthcare professionals and patients, 2) the information provided by healthcare professionals and that desired by relatives, 3) perception of environment and time, 4) limitations and barriers to the continuity of care, and 5) the contrasting interpretations of giving and receiving palliative care. CONCLUSIONS: This study provides insights into targets for changes in Italian Emergency Departments. Room for improvement relates to training for healthcare professionals on palliative care, the development of a shared care pathway for patients with palliative care needs, and the optimization of Emergency Department environment. These targets will be the basis for the development of a quality improvement program in Italian Emergency Departments.


Assuntos
Atitude do Pessoal de Saúde , Doença Crônica/terapia , Serviço Hospitalar de Emergência/organização & administração , Pessoal de Saúde/normas , Cuidados Paliativos/organização & administração , Pesquisa Qualitativa , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
7.
BMC Health Serv Res ; 19(1): 558, 2019 Aug 09.
Artigo em Inglês | MEDLINE | ID: mdl-31399096

RESUMO

BACKGROUND: Some of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments. However, for multi-center evaluations, standardized documentation is necessary. The AKTIN project ("National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany") has used the "German Emergency Department Medical Record" (GEDMR) published by the German Interdisciplinary Association of Intensive and Emergency Care as the documentation standard for its national data registry. METHODS: Until March 2016 the documentation standard in ED was the pen-and-paper version of the GEDMR. In April 2016 we implemented the GEDMR in a timeline-based EDIS. Related to this, we compared the availability of structured treatment information of traumatological patients between pen-and-paper-based and electronic documentation, with special focus on the treatment time. RESULTS: All 796 data fields of the 6 modules (basic data, severe trauma, patient surveillance, anesthesia, council, neurology) were adapted for use with the existing EDIS configuration by a physician working regularly in the ED. Electronic implementation increased availability of structured anamnesis and treatment information. However, treatment time was increased in electronic documentation both immediately (2:12 ± 0:04 h; n = 2907) and 6 months after implementation (2:18 ± 0:03 h; n = 4778) compared to the pen-and-paper group (1:43 ± 0:02 h; n = 2523; p < 0.001). CONCLUSIONS: We successfully implemented standardized documentation in an EDIS. The availability of structured treatment information was improved, but treatment time was also increased. Thus, further work is necessary to improve input time.


Assuntos
Documentação/estatística & dados numéricos , Registros Eletrônicos de Saúde/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Sistema de Registros/estatística & dados numéricos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Alemanha , Humanos , Masculino , Estudos Retrospectivos
8.
Surgery ; 166(4): 587-592, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31447104

RESUMO

BACKGROUND: Our regional trauma organization, which comprises 7 trauma centers, 30 acute care hospitals and free-standing emergency departments, and 42 emergency medical services agencies, conducted possibly the largest mass-casualty drill to date, totaling 445 victims at 3 sites involving 11 hospitals and 25 agencies and organizations. METHODS: The drill was preceded by a tabletop exercise 4 months beforehand called Operation Continued Care Full-Scale Exercise, which consisted of simulated terrorist events at 3 sites to wound 445 moulaged patients. Four law enforcement and 5 fire and emergency medical services departments and 16 supporting organizations and agencies were involved in transporting patients to 11 different hospitals. The 7 objectives for the event addressed coordinating emergency operations, sustaining adequate communications, updating regional bed status, processing resource requests, triaging patients, tracking patients, and patient identification. RESULTS: Of the 445 transported patients, 270 (60%) were entered correctly into the state patient tracking system; 68 (25.2%) upgrades and 34 (12.6%) downgrades from scene triage categories were noted. Multiple opportunities for improvement were identified, with major weaknesses noted in communication and coordination from event sites to the regional trauma organizations and hospitals. CONCLUSION: The size and complexity of the drill provided experience and knowledge to facilitate future disaster preparedness and highlighted weaknesses in communication and coordination. Large, multijurisdictional, multiagency exercises provide opportunities to stress, evaluate, and improve regional disaster preparedness.


Assuntos
Defesa Civil/organização & administração , Planejamento em Desastres/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Incidentes com Feridos em Massa/mortalidade , Transporte de Pacientes/organização & administração , Centros de Traumatologia/organização & administração , Feminino , Bombeiros/estatística & dados numéricos , Humanos , Comunicação Interdisciplinar , Masculino , Incidentes com Feridos em Massa/prevenção & controle , Inovação Organizacional , Controle de Qualidade , Triagem , Estados Unidos
10.
Pediatrics ; 144(3)2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31434688

RESUMO

BACKGROUND: Substantial variability exists in the care of febrile, well-appearing infants. We aimed to assess the impact of a national quality initiative on appropriate hospitalization and length of stay (LOS) in this population. METHODS: The initiative, entitled Reducing Variability in the Infant Sepsis Evaluation (REVISE), was designed to standardize care for well-appearing infants ages 7 to 60 days evaluated for fever without an obvious source. Twelve months of baseline and 12 months of implementation data were collected from emergency departments and inpatient units. Ill-appearing infants and those with comorbid conditions were excluded. Participating sites received change tools, run charts, a mobile application, live webinars, coaching, and a LISTSERV. Analyses were performed via statistical process control charts and interrupted time series regression. The 2 outcome measures were the percentage of hospitalized infants who were evaluated and hospitalized appropriately and the percentage of hospitalized infants who were discharged with an appropriate LOS. RESULTS: In total, 124 hospitals from 38 states provided data on 20 570 infants. The median site improvement in percentages of infants who were evaluated and hospitalized appropriately and in those with appropriate LOS was 5.3% (interquartile range = -2.5% to 13.7%) and 15.5% (interquartile range = 2.9 to 31.3), respectively. Special cause variation toward the target was identified for both measures. There was no change in delayed treatment or missed bacterial infections (slope difference 0.1; 95% confidence interval, -8.3 to 9.1). CONCLUSIONS: Reducing Variability in the Infant Sepsis Evaluation noted improvement in key aspects of febrile infant management. Similar projects may be used to improve care in other clinical conditions.


Assuntos
Serviço Hospitalar de Emergência/normas , Hospitalização , Tempo de Internação , Melhoria de Qualidade , Sepse/diagnóstico , Diagnóstico Tardio , Serviço Hospitalar de Emergência/organização & administração , Medicina Baseada em Evidências , Humanos , Lactente , Recém-Nascido , Capacitação em Serviço , Sepse/tratamento farmacológico , Tempo para o Tratamento , Estados Unidos
11.
Crit Care Clin ; 35(4): 535-550, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31445603

RESUMO

The "daily disasters" within the ebb and flow of routine critical care provide a foundation of preparedness for the less-frequent, larger events that affect most health care organizations at some time. Although large disasters can overwhelm, those who strengthen processes and habits through daily practice will be the best prepared to manage them.


Assuntos
Cuidados Críticos , Planejamento em Desastres , Serviço Hospitalar de Emergência , Unidades de Terapia Intensiva , Cuidados Críticos/organização & administração , Planejamento em Desastres/organização & administração , Desastres , Serviço Hospitalar de Emergência/organização & administração , Humanos , Unidades de Terapia Intensiva/organização & administração , Incidentes com Feridos em Massa , Capacidade de Resposta ante Emergências/organização & administração , Triagem
12.
Emerg Med J ; 36(9): 558-563, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31366625

RESUMO

BACKGROUND: Prolonged wait times prior to triage outside the emergency department (ED) were a major problem at our institution, compromising patient safety. Patients often waited for hours outside the ED in hot weather leading to exhaustion and clinical deterioration. The aim was to decrease the median waiting time to triage from 50 min outside ED for patients to <30 min over a 4-month period. METHODS: A quality improvement (QI) team was formed. Data on waiting time to triage were collected between 12 pm and 1 pm. Data were collected by hospital attendants and recorded manually. T1 was noted as a time of arrival outside the ED, and T2 was noted as the time of first medical contact. The QI team used plan-do-study-act cycles to test solutions. Change ideas to address these gaps were tested during May and June 2018. Change ideas were focused on improving the knowledge and skills of staff posted in triage and reducing turnover of triage staff. Data were analysed using run chart rules. RESULTS: Within 6 weeks, the waiting time to triage reduced to <30 min (median, 12 min; IQR, 11 min) and this improvement was sustained for the next 8 weeks despite an increase in patient load. CONCLUSION: The authors demonstrated that people new to QI could use improvement methods to address a specific problem. It was the commitment of the frontline staff, with the active support of senior leadership in the department that helped this effort succeed.


Assuntos
Serviço Hospitalar de Emergência/organização & administração , Segurança do Paciente , Melhoria de Qualidade , Centros de Atenção Terciária/organização & administração , Triagem/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Implementação de Plano de Saúde , Humanos , Índia , Equipe de Assistência ao Paciente/organização & administração , Reorganização de Recursos Humanos/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Centros de Atenção Terciária/estatística & dados numéricos , Fatores de Tempo , Triagem/estatística & dados numéricos
13.
Am J Health Syst Pharm ; 76(16): 1226-1230, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31369114

RESUMO

PURPOSE: A national survey performed in 2007 found that only 23% of American College of Surgeons (ACS) trauma centers involved pharmacists in trauma resuscitation. This study describes interval change in use, perceptions, and responsibilities from 2007 to 2017. METHODS: Of the 419 trauma centers identified from the ACS website, contact information was available for 335. In March 2017, a survey assessing hospital demographics, pharmacist coverage and services, and perception of pharmacist value and use was emailed to the identified trauma representatives. Data were analyzed using descriptive statistics and chi-square analysis, as appropriate. RESULTS: The response rate was 33% (110/335). Pharmacist involvement with trauma resuscitation increased significantly from 23% in 2007 to 70% (p < 0.001) and in 71% of trauma centers was provided by pharmacists practicing within the emergency department. Pharmacist involvement was greatest in the Midwest (p < 0.01), but with similar distribution with regards to ACS designation, institution type, and patient volume. Common bedside responsibilities include calculating dosages (96%), preparing medications (89%), and providing medication information (79%), while trauma program/administrative responsibilities (45%) include trauma team education, pharmacy operations, medication safety, quality improvement data collection, research, review of quality assurance cases, ACS accreditation preparation, and others. The primary reason for not considering pharmacist involvement was unfamiliarity with these roles/benefits. CONCLUSION: Pharmacists are an increasingly important component of the trauma team, as evidenced by growth over the last decade. In addition to clinical benefit at the bedside, pharmacists can support the regular activities of a trauma program in many meaningful ways.


Assuntos
Equipe de Assistência ao Paciente/organização & administração , Farmacêuticos/organização & administração , Papel Profissional , Ressuscitação , Ferimentos e Lesões/terapia , Adulto , Criança , Estudos Transversais , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Seguimentos , Humanos , Masculino , Equipe de Assistência ao Paciente/estatística & dados numéricos , Serviço de Farmácia Hospitalar/organização & administração , Serviço de Farmácia Hospitalar/estatística & dados numéricos , Inquéritos e Questionários/estatística & dados numéricos , Centros de Traumatologia/organização & administração , Centros de Traumatologia/estatística & dados numéricos , Estados Unidos
14.
Emerg Med Pract ; 21(8): 1-28, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31339254

RESUMO

Direct oral anticoagulant (DOAC) agents have become commonly used over the last 9 years for treatment and prophylaxis for thromboembolic conditions, following approvals by the United States Food and Drug Administration. These anticoagulant agents, which include a direct thrombin inhibitor and factor Xa inhibitors, offer potential advantages for patients over warfarin; however, bleeding emergencies with DOACs can present diagnostic and therapeutic challenges because, unlike traditional anticoagulants, their therapeutic effect cannot be easily monitored directly with common clotting assays. This review examines the growing body of evidence on the uses and risks of DOACs in the emergency department, including initiation of therapy and reversal strategies.


Assuntos
Anticoagulantes/efeitos adversos , Administração Oral , Anticoagulantes/uso terapêutico , Antitrombinas/efeitos adversos , Antitrombinas/uso terapêutico , Gerenciamento Clínico , Serviços Médicos de Emergência/métodos , Serviço Hospitalar de Emergência/organização & administração , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Humanos , Tempo de Protrombina/métodos , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia/métodos
15.
Medicina (Kaunas) ; 55(7)2019 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-31324028

RESUMO

Background and objectives: In this study, the accuracy of point-of-care ultrasonography (POCUS) was compared to radiography (XR) in the diagnosis of fractures, the determination of characteristics of the fractures, and treatment selection of fractures in patients admitted to the emergency department (ED) due to trauma and suspected long bone (LB) fractures. Materials and Methods: The patients were included in the study, who were admitted to ED due to trauma, and had physical examination findings suggesting the presence of fractures in LB (humerus, radius, ulna, femur, tibia, and fibula). The patients were evaluated by two emergency physicians (EP) in ED. The first EP examined LBs with POCUS and the second EP examined them with XR. LBs were evaluated on the anterior, posterior, medial, and lateral surfaces and from the proximal joint to the distal one (shoulder, elbow, wrist, hip, knee, and ankle joint) in both longitudinal and transverse axes with POCUS. Results: A total of 205 patients with suspected LB fractures were included in the study. LB fractures were determined in 99 patients with XR and in 105 patients with POCUS. The sensitivity, specificity, positive predictive value, negative predictive value of POCUS in determining the fractures were 99%, 93%, 93%, and 99%, respectively, compared to XR. Compared to XR, POCUS was able to determine 100% of fissure type fractures (kappa (κ) value: 0.765), 83% of linear fractures (κ: 0.848), 92% of fragmented fractures(κ: 0.756), 67% of spiral fractures (κ:0.798), 75% of avulsion type fractures (κ: 0.855), and 100% of full separation type fractures (κ: 0.855). Conclusions: This study has demonstrated that POCUS has a high sensitivity in diagnosing LB fractures. POCUS has a high sensitivity in identifying fracture characteristics. POCUS can be used as an alternative imaging method to XR in the diagnosis of LB fractures and in the determination of fracture characteristics.


Assuntos
Fraturas Ósseas/diagnóstico , Radiografia/normas , Ultrassonografia/normas , Adolescente , Adulto , Animais , Criança , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Fêmur/lesões , Fíbula/lesões , Humanos , Úmero/lesões , Masculino , Pessoa de Meia-Idade , Sistemas Automatizados de Assistência Junto ao Leito/normas , Estudos Prospectivos , Radiografia/métodos , Tíbia/lesões , Ultrassonografia/métodos
16.
BMC Health Serv Res ; 19(1): 506, 2019 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-31331341

RESUMO

BACKGROUND: Emergency department (ED) crowding and prolonged length of stay (LOS) are associated with delays in treatment, adverse outcomes and decreased patient satisfaction. Hospital restructuring and mergers are often associated with increased ED crowding. The aim of this study was to explore ED crowding and LOS in Norway's largest ED before and after an increased catchment area. METHODS: The catchment area of Akershus University Hospital increased by approximately 150,000 inhabitants in 2011, from 340,000 to 490,000. In this retrospective study, admissions to the ED during a six-year period, from Jan 1st 2010 to Dec 31st 2015 were included and analyzed. RESULTS: A total of 179,989 admissions were included (51.0% men). The highest occupancy rate was in the age group 70-79 years. Following the increase in the catchment area, the annual ED admissions increased by 8343 (40.9%) from 2010 to 2011, and peaked in 2013 (34,002). Mean LOS increased from 3:59 h in 2010 to 4:17 in 2012 (highest), and decreased to 3:45 h in 2015 after staff, capacity and organizational measures. In 2010, 37.9% of the ED patients experienced crowding, and this proportion increased to between 52.9-77.6% in 2011-2015. Crowding peaked between 4 and 5 PM. CONCLUSIONS: LOS increased and crowding was more frequent after a major increase in the hospital's catchment area in Norway's largest emergency department. Even after 5 years, the LOS was higher than before the expansion, mainly because of the throughput and output components, which were not properly adapted to the changes in input.


Assuntos
Aglomeração , Serviço Hospitalar de Emergência , Tempo de Internação , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/organização & administração , Feminino , Hospitalização , Hospitais Universitários , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Noruega , Estudos Retrospectivos , Adulto Jovem
17.
West J Emerg Med ; 20(4): 654-665, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31316707

RESUMO

Introduction: Canadian emergency departments (ED) are struggling to provide timely emergency care. Very few studies have assessed attempts to improve ED patient flow in the rural context. We assessed the impact of SurgeCon, an ED patient-management protocol, on total patient visits, patients who left without being seen (LWBS), length of stay for departed patients (LOSDep), and physician initial assessment time (PIA) in a rural community hospital ED. Methods: We implemented a set of commonly used methods for increasing ED efficiency with an innovative approach over 45 months. Our intervention involved seven parts comprised of an external review, Lean training, fast track implementation, patient-centeredness approach, door-to-doctor approach, performance reporting, and an action-based surge capacity protocol. We measured key performance indicators including total patient visits (count), PIA (minutes), LWBS (percentage), and LOSDep (minutes) before and after the SurgeCon intervention. We also performed an interrupted time series (ITS) analysis. Results: During the study period, 80,709 people visited the ED. PIA decreased from 104.3 (±9.9) minutes to 42.2 (±8.1) minutes, LOSDep decreased from 199.4 (±16.8) minutes to 134.4(±14.5) minutes, and LWBS decreased from 12.1% (±2.2) to 4.6% (±1.7) despite a 25.7% increase in patient volume between pre-intervention and post-intervention stages. The ITS analysis revealed a significant level change in PIA - 19.8 minutes (p<0.01), and LWBS - 3.8% (0.02), respectively. The change over time decreased by 2.7 minutes/month (p< 0.001), 3.0 minutes/month (p<0.001) and 0.4%/month (p<0.001) for PIA, LOSDep, and LWBS, after the intervention. Conclusion: SurgeCon improved the key wait-time metrics in a rural ED in a country where average wait times continue to rise. The SurgeCon platform has the potential to improve ED efficiency in community hospitals with limited resources.


Assuntos
Protocolos Clínicos , Eficiência Organizacional , Serviço Hospitalar de Emergência/organização & administração , Hospitais Comunitários , Hospitais Rurais , Humanos , Análise de Séries Temporais Interrompida , Terra Nova e Labrador , Triagem
18.
Medicina (Kaunas) ; 55(7)2019 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-31319486

RESUMO

Symmetrical peripheral gangrene (SPG) is a rare entity characterized by ischemic changes of the distal extremities with maintained vascular integrity. We present the case of a 64-year-old man with bilateral necrotic toes and deranged liver function tests. This was thought to be related to severely depressed ejection fraction from non-ischemic etiology, presumably chronic alcohol ingestion. We hope that awareness of SPG and association with a low output state will aid in early detection and prevention.


Assuntos
Baixo Débito Cardíaco/complicações , Gangrena/etiologia , Insuficiência Cardíaca/complicações , Baixo Débito Cardíaco/etiologia , Ecocardiografia/métodos , Eletrocardiografia/métodos , Serviço Hospitalar de Emergência/organização & administração , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade
19.
Implement Sci ; 14(1): 73, 2019 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-31319857

RESUMO

BACKGROUND: Full capacity protocol (FCP) is an internationally recognized intervention designed to address emergency department (ED) crowding. Despite FCP international recognition and positive effects on hospital performance measures, many hospitals, even the most crowded ones, have not implemented FCP. We conducted this study to identify the core components of FCP, explore the key barriers and facilitators associated with the FCP implementation, and provide practical recommendations on how to overcome those barriers. METHODS: To identify the core components of FCP, we used a non-experimental approach. We conducted semi-structured interviews with key informants (e.g., division chiefs, medical directors) involved in the implementation of FCP. We used the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis. We used a template analysis approach to determine the relevance of the CFIR constructs to implementing the FCP. We analyzed the responses to the interview questions about FCP definition and FCP key principles, compared different hospitals' FCP official documents, and consulted with the original FCP developer. We then used an adaptation framework to categorize the core components of FCP into three main groups. Finally, we summarized practical recommendations for each barrier based on information provided by the interviewees. RESULTS: A total of 32 interviews were conducted. We observed that FCP has evolved from the idea of transferring boarded patients from ED hallways to inpatient hallways to a practical hospital-wide intervention with several components and multiple levels. The key determinant of successful FCP implementation was collaboration with inpatient nursing staff, as they were often reluctant to have patients boarded in inpatient hallways. Other determinants of successful FCP implementation were reaching consensus about the criteria for activation of each FCP level and actions in each FCP level, modifying the electronic health records system, restructuring the inpatient units to have adequate staffing and resources, complying with external regulations and policies such as fire marshal guidelines, and gaining hospital leaders' support. CONCLUSIONS: The key determinant in implementing FCP is creating a supportive and cooperative hospital culture and encouraging key stakeholders, including inpatient nursing staff, to acknowledge that crowding is a hospital-wide problem that requires a hospital-wide response.


Assuntos
Aglomeração , Serviço Hospitalar de Emergência/organização & administração , Política Organizacional , Avaliação de Programas e Projetos de Saúde/métodos , Melhoria de Qualidade/organização & administração , Humanos
20.
Medicina (Kaunas) ; 55(7)2019 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-31315254

RESUMO

Granulomatosis with polyangiitis (GPA) is a systemic granulomatous inflammatory disease characterized by small-to-medium vessel vasculitis due to Central Anti-Neutrophil Cytoplasmic Antibody (C-ANCA). GPA commonly involves the lungs and the kidneys. Among the pulmonary manifestations, diffuse alveolar hemorrhage (DHA) is a rare presentation of GPA that can present with hemoptysis leading to acute onset of anemia and hemodynamic instability. An active diagnostic workup including serologic titer of C-ANCA, imaging, intensive care, and aggressive immunosuppression is the key to DAH management. We report a case of DAH secondary to GPA that presented with hemoptysis leading to severe anemia, initially resuscitated symptomatically and started on plasmapheresis with pulse steroids and cyclophosphamide. Timely diagnosis and management led to a remarkable recovery of the pulmonary symptoms and imaging findings of DAH.


Assuntos
Granulomatose com Poliangiite/tratamento farmacológico , Imunossupressores/uso terapêutico , Plasmaferese/métodos , Anticorpos Anticitoplasma de Neutrófilos/análise , Anticorpos Anticitoplasma de Neutrófilos/sangue , Biomarcadores/análise , Biomarcadores/sangue , Serviço Hospitalar de Emergência/organização & administração , Feminino , Granulomatose com Poliangiite/diagnóstico , Granulomatose com Poliangiite/fisiopatologia , Humanos , Pessoa de Meia-Idade , Radiografia/métodos
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