Self referral to accident and emergency department: patients' perceptions.

A study was conducted (a) to assess the number of patients registered with a south London general practice who over 11 weeks referred themselves to an accident and emergency department, (b) to identify the characteristics of those patients, and (c) to determine their perceptions of the services and resources available within their general practices and of the role of accident and emergency departments. Two hundred and thirty four patients referred themselves to a casualty department during the study period, of whom 217 (93%) were interviewed by means of a semistructured questionnaire. Of the 217 patients interviewed, only 15 had tried to contact their general practitioner before attending the casualty department. Eighty nine patients considered that their problem was urgent and required immediate attention and many that they would need an x ray examination. A substantial minority of patients thought that their doctor would not be available. It is concluded that patients'' perceptions of their problems and of access to their doctors are the main determinants of self referral to a casualty department. These findings have important implications for patient education.     

Patients’ Experiences of Cancer Diagnosis as a Result of an Emergency Presentation: A Qualitative Study

Introduction

Cancers diagnosed following visits to emergency departments (ED) or emergency admissions (emergency presentations) are associated with poor survival and may result from preventable diagnostic delay. To improve outcomes for these patients, a better understanding is needed about how emergency presentations arise. This study sought to capture patients'' experiences of this diagnostic pathway in the English NHS.

Methods

Eligible patients were identified in a service evaluation of emergency presentations and invited to participate. Interviews, using an open-ended biographical structure, captured participants'' experiences of healthcare services before diagnosis and were analysed thematically, informed by the Walter model of Pathways to Treatment and NICE guidance in an iterative process.

Results

Twenty-seven interviews were conducted. Three typologies were identified: A: Rapid investigation and diagnosis, and B: Repeated cycles of healthcare seeking and appraisal without resolution, with two variants where B1 appears consistent with guidance and B2 has evidence that management was not consistent with guidance. Most patients’ (23/27) experiences fitted types B1 and B2. Potentially avoidable breakdowns in diagnostic pathways caused delays when patients were conflicted by escalating symptoms and a benign diagnosis given earlier by doctors. ED was sometimes used as a conduit to rapid testing by primary care clinicians, although this pathway was not always successful.

Conclusions

This study draws on patients'' experiences of their diagnosis to provide novel insights into how emergency presentations arise. Through these typologies, we show that the typical experience of patients diagnosed through an emergency presentation diverges significantly from normative pathways even when there is no evidence of serious service failures. Consultations were not a conduit to diagnosis when they inhibited patients’ capacity to appraise their own symptoms appropriately and when they resulted in a reluctance to seek further healthcare.

Recommendations

The findings also point to potentially avoidable breakdowns in the diagnostic process. In particular, to encourage patients to return to the GP if symptoms escalate, a stronger emphasis is needed on diagnostic uncertainty in discussions between patients and doctors in both primary and secondary care. To improve appropriate access to rapid investigations, systems are needed for primary care to communicate directly with secondary care at the time of referral.     

Validation of the alternating conditional estimation algorithm for estimation of flexible extensions of Cox's proportional hazards model with nonlinear constraints on the parameters

Standard optimization algorithms for maximizing likelihood may not be applicable to the estimation of those flexible multivariable models that are nonlinear in their parameters. For applications where the model's structure permits separating estimation of mutually exclusive subsets of parameters into distinct steps, we propose the alternating conditional estimation (ACE) algorithm. We validate the algorithm, in simulations, for estimation of two flexible extensions of Cox's proportional hazards model where the standard maximum partial likelihood estimation does not apply, with simultaneous modeling of (1) nonlinear and time‐dependent effects of continuous covariates on the hazard, and (2) nonlinear interaction and main effects of the same variable. We also apply the algorithm in real‐life analyses to estimate nonlinear and time‐dependent effects of prognostic factors for mortality in colon cancer. Analyses of both simulated and real‐life data illustrate good statistical properties of the ACE algorithm and its ability to yield new potentially useful insights about the data structure.     

Impact of NHS walk-in centres on the workload of other local healthcare providers: time series analysis

ObjectivesTo assess the impact of NHS walk-in centres on the workload of local accident and emergency departments, general practices, and out of hours services.DesignTime series analysis in walk-in centre sites with no-treatment control series in matched sites.SettingWalk-in centres and matched control towns without walk-in centres in England.Participants20 accident and emergency departments, 40 general practices, and 14 out of hours services within 3 km of a walk-in centre or the centre of a control town.ResultsA reduction in consultations at emergency departments (–175 (95% confidence interval –387 to 36) consultations per department per month) and general practices (–19.8 (−53.3 to 13.8) consultations per 1000 patients per month) close to walk-in centres became apparent, although these reductions were not statistically significant. Walk-in centres did not have any impact on consultations on out of hours services.ConclusionIt will be necessary to assess the impact of walk-in centres in a larger number of sites and over a prolonged period, to determine whether they reduce the demand on other local NHS providers.

What is already known on this topic

One of the objectives for NHS walk-in centres was to reduce demand on other NHS services, particularly general practitioners'' services and accident and emergency departmentsStudies of walk-in centres in North America have indicated that such centres do not reduce demand on other healthcare servicesStudies of minor injuries units in the United Kingdom (which have some similarities with walk-in centres) indicate that these units substitute mainly for consultations in accident and emergency departments

What this study adds

The data imply that walk-in centres may moderate the increasing demand on general practice and reduce the number of consultations in accident and emergency departmentsThe high level of background variability in consultation rates means that any impact of a walk-in centre is not statistically significantTo draw robust conclusions about the impact of walk-in centres on other health providers will require study of a large number of sites over an extended period of time     

Emergency physicians and sexual involvement with patients: an Ontario survey

OBJECTIVE: To describe Ontario emergency physicians'' knowledge of colleagues'' sexual involvement with patients and former patients, their own personal experience of such involvement, and their attitudes toward postvisit relationships. DESIGN: Mailed survey. SETTING: Ontario. PARTICIPANTS: Emergency physicians practising in Ontario. RESULTS: Of 974 eligible mailed surveys, 599 (61.5%) were returned. Of these respondents, 52 (8.7%) reported being aware of a colleague in emergency practice who had been sexually involved with a patient or former patient. When describing their own behaviour, 37 respondents (6.2%) reported sexual involvement with a former patient. However, of this group, only 9 (25.0%) had met the patient in an emergency department. Thus, of the total number of respondents, only 1.5% (9/599) reported sexual involvement arising out of an emergency department visit. Most respondents (82.4%) agreed that it is inappropriate behaviour to ask a patient for a date after an emergency assessment and before the patient''s departure, and 66.4% felt that it is inappropriate to contact the patient after discharge. However, only 10.6% believed it to be unacceptable to request a social meeting after encountering a patient previously cared for in the emergency department in a nonprofessional setting. Most respondents (96.5%) did not believe that sexual involvement could ever be therapeutic for the patient. However, only 66% felt that it was always an abuse of power and 62.4% supported zero tolerance of all sexual involvement between physicians and patients. CONCLUSIONS: Vague regulatory guidelines currently in place have failed to dispel confusion regarding what is acceptable social behaviour for physicians providing emergency care. Our results support the need for clarification, and suggest a basis for guidelines that would be acceptable to the emergency medical community: that an emergency visit should not form the basis for the initiation of personal or sexual relationships, yet neither should it preclude their development in nonmedical settings.     

The new role of the hospital emergency department

The volume of medical services delivered within hospital emergency departments in the City of Saskatoon is increasing rapidly. These probably are not “new” medical services but rather represent a transfer of “old” services to the emergency departments from other sites where they were previously rendered. The visit to the emergency department is initiated more often by the patient than the doctor and once there the patient is treated in a relatively short period of time. The illnesses so managed do not have a diagnostic, therapeutic or prognostic uniformity but rather are characterized by their acute and totally unexpected onset. This acute and non-programmable nature of the illness makes it difficult to deliver the service in a physician''s office where the appointment system prevails and efficiently deals with the great majority of his patients. Data to determine whether or not this is a desirable development have not yet been obtained but it is clear that in its present usage the emergency department must be thought of as a facility which not only provides exceptional diagnostic and therapeutic equipment but as one which also provides a treatment facility without prior appointment available at any hour of the day or night.     

A rural emergency department.

The appropriate use of emergency departments is of growing concern. By knowing which patients are more likely to make inappropriate visits to these departments, efforts can be directed to encourage more suitable care. Our study was done in a rural county hospital in eastern New Mexico. Data were collected from all emergency department visits over a 4-week period. Patient and physician questionnaires were administered to assess aspects of emergency department use, including appropriateness based on published criteria, physicians'' opinion of appropriateness, groups who made inappropriate visits, and the perception of the need for and the urgency of a visit. We found that 32% of visits were inappropriate based on published criteria and 24% were considered inappropriate by physician opinion. Two groups with a high rate of inappropriate visits were Hispanics and Medicaid recipients. Patients and physicians have differing opinions of the urgency of a visit and of how soon medical treatment is required. To decrease the frequency of inappropriate use of emergency departments, educational efforts should be focused on the subgroups with high rates of such use.     

Disaggregating the Power Generation Sector for Input‐Output Life Cycle Assessment

The electric power industry plays a critical role in the economy and the environment, and it is important to examine the economic, environmental, and policy implications of current and future power generation scenarios. However, the tools that exist to perform the life cycle assessments are either too complex or too aggregated to be useful for these types of activities. In this work, we build upon the framework of existing input‐output (I‐O) models by adding data about the electric power industry and disaggregating this single sector into additional sectors, each representing a specific portion of electric power industry operations. For each of these disaggregated sectors, we create a process‐specific supply chain and a set of emission factors that allow calculation of the environmental effects of that sector's output. This new model allows a much better fit for scenarios requiring more specificity than is possible with the current I‐O model.     

Triage: a working solution to overcrowding in the emergency department

Recently, emergency departments across the continent have become crowded with patients requiring non-urgent care. To alleviate this situation at The Hospital for Sick Children in Toronto, receptionists in the emergency department direct patients requiring urgent care to the emergency room and those requiring non-urgent care to a screening clinic (triage). During a two-month period, 13,551 patients visited the emergency department. The triage receptionist sent 8368 patients to the emergency room and 5183 to the screening clinic. About 45% of patients visiting the emergency room had suffered accidents and injuries, and 19% had respiratory illness; 15% of patient visits resulted in admission to hospital. In contrast to this, 49% of patients sent to the screening clinic had respiratory illness and 18% had infective disease; less than 1% of patients needed hospitalization.     

Effect of Supervised Students' Involvement on Diagnostic Accuracy in Hospitalized Medical Patients �� A Prospective Controlled Study

Background

During internships most medical students engage in history taking and physical examination during evaluation of hospitalized patients. However, the students'' ability for pattern recognition is not as developed as in medical experts and complete history taking is often not repeated by an expert, so important clues may be missed. On the other hand, students'' history taking is usually more extensive than experts'' history taking and medical students discuss their findings with a Supervisor. Thus the effect of student involvement on diagnostic accuracy is unclear. We therefore compared the diagnostic accuracy for patients in the medical emergency department with and without student involvement in the evaluation process.

Methodology/Principal Findings

Patients in the medical emergency department were assigned to evaluation by either a supervised medical student or an emergency department physician. We only included patients who were admitted to our hospital and subsequently cared for by another medical team on the ward. We compared the working diagnosis from the emergency department with the discharge diagnosis. A total of 310 patients included in the study were cared for by 41 medical students and 21 emergency department physicians. The working diagnosis was changed in 22% of the patients evaluated by physicians evaluation and in 10% of the patients evaluated by supervised medical students (p = .006). There was no difference in the expenditures for diagnostic procedures, length of stay in the emergency department or patient comorbidity complexity level.

Conclusion/Significance

Involvement of closely supervised medical students in the evaluation process of hospitalized medical patients leads to an improved diagnostic accuracy compared to evaluation by an emergency department physician alone.     

A numerical method of evaluating and categorizing hospital emergency departments.

The capabilities of individual hospital emergency departments participating in an emergency medical services system must be evaluated as the first step im improving the services in the region. By means of a weighted point-scoring method, personnel, facilities, equipment and organization can be assessed and the department categorized. This not only provides an evaluation of the present status of the department but also sets standards for improvement. Categorization provides the basis for regionalization of services, whereby each department has a defined responsibility to provide treatment of specified sophistication.     

Confirmation of death.

A working party set up to study the problems surrounding the confirmation of death investigated current practice by means of a questionnaire sent to a random sample of accident and emergency departments in district general hospitals. Of the 38 replying, 24 said that bodies were examined in the ambulance, four in the accident and emergency department, and 10 in both. Answers to the other questions also suggest that the present procedures are in general unsatisfactory, and some dissatisfaction was expressed by departments. The individuals and organisations consulted were unanimous that confirmation of death should not be carried out in the ambulance. A change of practice would, however, create practical problems. The working party recommends therefore that the standard practice should be for all bodies to be properly examined by a doctor in the accident and emergency department, and that funds should be made available for any building alterations and increase in staff made necessary by such changes.     

Improving the efficiency of a hospital emergency department: a simulation study with indirectly imputed service-time distributions

This paper presents a case study which uses simulation to analyze patient flows in a hospital emergency department in Hong Kong. We first analyze the impact of the enhancements made to the system after the relocation of the Emergency Department. After that, we developed a simulation model (using ARENA) to capture all the key relevant processes of the department. When developing the simulation model, we faced the challenge that the data kept by the Emergency Department were incomplete so that the service-time distributions were not directly obtainable. We propose a simulation–optimization approach (integrating simulation with meta-heuristics) to obtain a good set of estimate of input parameters of our simulation model. Using the simulation model, we evaluated the impact of possible changes to the system by running different scenarios. This provides a tool for the operations manager in the Emergency Department to “foresee” the impact on the daily operations when making possible changes (such as, adjusting staffing levels or shift times), and consequently make much better decisions.     

Frequency of emergency room visits for childhood asthma in Ottawa, Canada: the role of weather

The aim of this study was to evaluate associations between meteorological conditions and the number of emergency department visits for asthma in a childrens hospital in Ottawa, Canada. A case-crossover study design was used. Hospital emergency department visits for asthma between 1992 and 2000 were identified based on patients presenting complaints. We obtained hourly measures for the following meteorological variables: wind speed, temperature, atmospheric pressure, relative humidity, and visibility. Particular emphasis was placed on exploring the association between asthma visits and fog, thunderstorms, snow, and liquid and freezing forms of precipitation. In total, there were 18,970 asthma visits among children between 2 and 15 years of age. The number of visits and weather characteristics were grouped into 6 h case and control intervals. The occurrence of fog or liquid precipitation was associated with an increased number of asthma visits, while snow was associated with a reduced number (P<0.05). Stratified analyses by season found no association in any of the four calendar intervals between the number of asthma visits and visibility, change in relative humidity and change in temperature. In contrast, summertime thunderstorm activity was associated with an odds ratio of 1.35 (95% CI=1.02–1.77) relative to summer periods with no activity. Models that incorporate calendar and meteorological data may help emergency departments to more efficiently allocate resources needed to treat children presenting with respiratory distress.     

Primary care for nontraumatic illness at the emergency department and the family physician's office.

A total of 1117 visits by patients to two hospital emergency departments and 15 family physicians'' offices for nontraumatic complaints over two 2-week periods were studied. Patients visiting the two settings fell into two distinct subgroups, and they appeared to select where to seek care by the acuteness and duration of the complaint. Several highly significant differences were noted between the two groups: those who visited an emergency department had complaints of shorter duration, underwent more investigations (which more often gave abnormal results), were more likely to undergo investigation for mental symptoms, had more consultations, received counselling and drug therapy less often (but intramuscular injections more often), were admitted to hospital more often, returned for further care for the same complaint less often, complied with disposal instructions less often, were more likely to receive fewer than 5 days'' care and were less likely to receive more than 31 days'' care; those without a family physician more often received additional care (were referred, admitted or asked to return).     

Provision of first contact care out of hours in four urban areas in England.

In a typical two week period in 1984 in three urban areas with general practitioner deputising services roughly 40% of first contact patient encounters out of hours were with hospital accident and emergency departments, and only a quarter were with general practitioner deputising services, although 47%, 64%, and 97% of general practitioners in the areas had permission to use such services. Roughly a third only of the encounters were with the practices themselves, and even fewer occurred overnight (11 pm-7 am). In a fourth urban area where 68% of general practitioners formed an out of hours cooperative rota a third of the encounters were with the accident and emergency department and half (more overnight) were with the rota. The presence of a woman principal in a practice and large partnerships of four principals or more were associated with an increased proportion of encounters with the practice itself. Undue prominence may have been given to the role of deputising services in out of hours care. Paradoxically, the use of general practitioner cooperatives may result in even less personal care being given by the patient''s own practice.     

Atención de pacientes adultos con crisis epilépticas en servicios de urgencias (Registro ACESUR). Diferencias en función de la edad ≥ 75 años

ObjectivesTo determine whether there are differences in the profile and in the care of adult patients with epileptic seizures in emergency department according to age ≥ 75 years, and if this is independently associated with results in the emergency department and 30 days after discharge.Material and methodsACESUR is a multicentre, prospective, observational cohort multipurpose register that was carried out in 2017. The distribution of the variables corresponding to the clinical presentation and care according to age ≥ 75 years were compared. Subsequently, logistic regression models were performed with the objective of evaluating the effect of age ≥ 75 years on the outcome variables.ResultsA total of 541 (81.5%) cases younger than 75 years were analysed compared to 123 adult patients (18.5%) of ≥ 75 years or more. In the group of long-lived it was observed significantly greater probability of dependence, co-morbidity, polypharmacy, a previous visit to the hospital emergency department, arrived by ambulance, first seizures and a symptomatic aetiopathogenic classification. In the multivariate analysis, after adjusting for the above variables, it is observed that age > 75 years is associated independently with a higher incidence of specific supplementary tests (OR: 2.31; 95% CI: 1.21-4.44), but not pharmacological intervention (OR: 1.63; 95% CI: 0.96-2.80), or hospitalisation or extended stay in emergency departments (OR: 1.56; 95% CI: 0.94-2.59). On adjusting for all previous variables, age > 75 years is associated with lower incidence of adverse events at 30 days (OR: 0.43; 95% CI: 0.25-0.77).ConclusionsIn the ACESUR Registry, differences in clinical presentation and in the care of patients with seizures in emergency departments were identified when comparing those patients > 75 years with those < 75 years. Age ≥ 75 years is not independently associated with a higher incidence of intervention in emergency departments, or with more adverse outcomes at 30 days after discharge.