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.     

Use of a Hospital Emergency Service by Children and Adolescents for Primary Care

This study was planned to determine the extent to which the emergency service of a large general hospital in Vancouver was providing a primary medical care function for children and adolescents. The data were collected during 14-day study periods in each season of the year. Medical data and physician urgency rating were obtained on all patients. Demographic and socioeconomic data and data pertaining to patterns of medical care were obtained by interview of a one-third sample.The study identified a group of patients receiving primary medical care for non-urgent and non-traumatic conditions. This group resided close to the hospital and had lower socioeconomic indices than the remainder of the patients.The trend to utilize the emergency department for reasons other than the accident and emergency function was confirmed. These findings will be incorporated in the planning of the New Children''s Hospital in Vancouver with the provision of separate facilities for the care of non-urgent attenders.     

Emergency department use at two Hamilton hospitals.

This report compares emergency department use at two urban Hamilton hospitals. One mainly serves lower socioeconomic and industrial groups and the other predominantly suburban residents. Although the groups served are different, the patterns of use at both hospitals were found to be similar. Over one third of visits at both are classified as nonurgent. The urban industrial hospital has higher proportions of visits that are nonurgent, by men and due to trauma. However, other parameters such as arrival time, use of ambulance, proportion admitted, percentage of emergencies, percentage of repeat visits, use of radiology and laboratory facilities and proportions of visits in different categories of presenting complaint were similar at the two hospitals. Similarities in use patterns may be due to universal health insurance, for 90% of users have medical insurance and have family doctors.     

Toward an Understanding of Health Services Use in Women with Binge Eating Disorder

Objectives : This study examined health services use in community samples of 102 white and 60 black women with binge eating disorder (BED), 164 white and 85 black healthy comparison women, and 86 white and 21 black women with a noneating Axis I psychiatric disorder. Research Methods and Procedures : Participants were matched on age, ethnicity, and education and were asked about their use of emergency room visits, outpatient physician visits for medical care, outpatient psychotherapy visits, and days spent in the hospital over the previous 12 months. Total health services use was computed. Results : There were no between‐group differences in outpatient physician visits or inpatient hospital days. Relative to healthy comparison women, women with BED and women with other Axis I disorders had increased total health services use, psychotherapy visits, and emergency department visits. Relative to women with noneating Axis I disorders, women with BED had less use of psychotherapy visits. Although obese white women were more likely to report emergency department visits than obese black women were, nonobese white women were less likely to report emergency department visits than nonobese black women were. Discussion : That health services use by women with BED compared more with that of women with other Axis I disorders than with that of healthy women suggested that BED has clinical significance and is not benign in terms of its impact on the health care system. It appeared, however, that despite the availability of effective treatments, few women with BED received psychotherapy.     

Patterns of local and tourist use of an emergency department.

Illness patterns of local and tourist patients in an emergency department of a medium-sized Ontario city with a single hospital were compared. Frequencies of specific and broad categories of ailments and rates of admission to the hospital were similar in the two groups. However, non-Canadian tourists were admitted to hospital at a much lower rate than Canadian tourists. Rates of visits to the emergency department within certain age categories were remarkably similar, as were rates within the sexes. It is concluded that, in view of the striking similarity in the illness pattern of a group of patients not professionally referred to the hospital and that of local patients, who have potential contact with a more extensive medical network, public attitudes, rather than availability of health professionals, determine the pattern of illness observed in an emergency department.     

Focus: Sex and Gender Health: Patient Preference for Physician Gender in the Emergency Department

Despite historical gender bias against female physicians, few studies have investigated patients’ physician gender preference in the emergency department (ED) setting. We sought to determine if there is an association between ED patient demographics and physician gender preference. We surveyed patients presenting to an ED to determine association between patient demographics and patient physician gender preference for five ED situations: 1) ‘routine’ visit, 2) emergency visit, 3) ‘sensitive’ medical visit, 4) minor surgical/‘procedural’ visit, and 5) ‘bad news’ delivery. A total of 200 ED patients were surveyed. The majority of ED patients reported no physician gender preference for ‘routine’ visits (89.5 percent), ‘emergent’ visits (89 percent), ‘sensitive’ medical visits (59 percent), ‘procedural’ visits (89 percent) or when receiving ‘bad news’ (82 percent). In the setting of ‘routine’ visits and ‘sensitive’ medical visits, there was a propensity for same-sex physician preference.     

The Impact of Heat on an Emergency Department in Italy: Attributable Visits among Children,Adults, and the Elderly during the Warm Season

Introduction

Recent studies suggest that heat is associated with an increase in the number of ambulance calls and emergency department visits. We investigated the association between heat and daily number of emergency department visits at the University Hospital of Verona during the warm seasons 2011–2012 and we assessed the magnitude of the impact in terms of attributable events, focusing on the role of age and triage codification.

Materials and methods

We used a Poisson model to analyse the association between daily number of visits and daily mean apparent temperature, accounting for air pollution level and seasonality. The analyses were stratified by age group and were performed both on the total number of emergency department visits and on the subsample of high-priority visits. Impact estimates were obtained only for this subsample, using a Monte Carlo approach to account for sampling variability. Number of attributable events and attributable community rate were calculated.

Results

We found a positive and immediate association between event occurrence and mean apparent temperatures exceeding a threshold located around 28–29°C. The estimated percent change in the total number of visits per 1°C increase of exposure above the threshold was equal to 3.75 (90% CI: 3.01; 4.49). Focusing only on high-priority visits, the estimated percent change was larger and the greatest effect was among children. We estimated that apparent temperatures above the threshold were responsible for 1177 high-priority visits during the study period. Due to the record high temperatures observed in 2012 in Italy and in Europe, the impact in 2012 was much larger than in 2011, and consisted in 34 high-priority visits every 10000 children, 30 every 10000 people aged 15–64, and 38 every 10000 people aged 65 and over.

Discussion

Our results indicate that heat affects not only the elderly, but also children and non-elderly adults, stressing the need for developing public health preparedness plans for the entire community.     

Higher prevalence of obesity among children with asthma

The aim of this study is to investigate the association between childhood obesity and asthma, and whether this relationship varies by race/ethnicity. For this population-based, cross-sectional study, measured weight and height, and asthma diagnoses were extracted from electronic medical records of 681,122 patients aged 6-19 years who were enrolled in an integrated health plan 2007-2009. Weight class was assigned based on BMI-for-age. Overall, 18.4% of youth had a history of asthma and 10.9% had current asthma. Adjusted odds of current asthma for overweight, moderately obese, and extremely obese youth relative to those of normal weight were 1.22 (95% confidence interval (CI): 1.20, 1.24), 1.37 (95% CI: 1.34, 1.40), and 1.68 (95% CI: 1.64, 1.73), respectively (P trend < 0.001). Black youth are nearly twice as likely (adjusted odds ratio (OR) = 1.93, 95% CI: 1.89, 1.99), and Hispanic youth are 25% less likely (adjusted OR = 0.75, 95% CI: 0.74, 0.77), to have current asthma than to non-Hispanic white youth. However, the relationship between BMI and asthma was strongest in Hispanic and weakest in black youth. Among youth with asthma, increasing body mass was associated with more frequent ambulatory and emergency department visits, as well as increased inhaled and oral corticosteroid use. In conclusion, overweight, moderate, and extreme obesity are associated with higher odds of asthma in children and adolescents, although the association varies widely with race/ethnicity. Increasing BMI among youth with asthma is associated with higher consumption of corticosteroids and emergency department visits.     

Frequent Users of Hospital Emergency Departments in Korea Characterized by Claims Data from the National Health Insurance: A Cross Sectional Study

The Korean National Health Insurance, which provides universal coverage for the entire Korean population, is now facing financial instability. Frequent emergency department (ED) users may represent a medically vulnerable population who could benefit from interventions that both improve care and lower costs. To understand the nature of frequent ED users in Korea, we analyzed claims data from a population-based national representative sample. We performed both bivariate and multivariable analyses to investigate the association between patient characteristics and frequent ED use (4+ ED visits in a year) using claims data of a 1% random sample of the Korean population, collected in 2009. Among 156,246 total ED users, 4,835 (3.1%) were frequent ED users. These patients accounted for 14% of 209,326 total ED visits and 17.2% of $76,253,784 total medical expenses generated from all ED visits in the 1% data sample. Frequent ED users tended to be older, male, and of lower socio-economic status compared with occasional ED users (p < 0.001 for each). Moreover, frequent ED users had longer stays in the hospital when admitted, higher probability of undergoing an operative procedure, and increased mortality. Among 8,425 primary diagnoses, alcohol-related complaints and schizophrenia showed the strongest positive correlation with the number of ED visits. Among the frequent ED users, mortality and annual outpatient department visits were significantly lower in the alcohol-related patient subgroup compared with other frequent ED users; furthermore, the rate was even lower than that for non-frequent ED users. Our findings suggest that expanding mental health and alcohol treatment programs may be a reasonable strategy to decrease the dependence of these patients on the ED.     

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.     

Which patients are likely to die in an accident and emergency department?

Four hundred and eighty-eight deaths occurring in an accident and emergency department over five years were analysed. Their causes were categorised as medical, surgical, or traumatic. Medical causes accounted for 87% of the deaths, of which 60% were from cardiac conditions. Blood loss was an important factor in over half the deaths from surgical and traumatic causes. Lives might have been saved by considering infectious disease in patients with medical conditions and by undertaking more rapid blood transfusion, earlier chest drainage, and lateral cervical spine x rays in appropriate surgical or traumatic cases. The admission to casualty departments of people with terminal neoplasms should be discouraged. The management of medical emergencies should be emphasised when training accident and emergency department staff.     

医疗职业风险要素分析及在薪酬分配中的应用

目的 分析职业风险要素并应用于医师薪酬分配体系中，合理补偿因承担医疗风险带来的健康及经济损失。方法 采用文献法和Delphi法对以往研究进行文献分析提炼要素并征询意见，专家评分法对试点医院各科室职业风险进行评价。结果 职业风险三个要素分别是职业暴露、医疗纠纷及医疗暴力，Delphi专家意见一致。各科室职业风险评价结果中，风险最高的部门是PICU、骨科急诊、外科急诊，最低的是皮肤科门诊、康复科门诊、成人门诊、中医门诊及儿童保健门诊。结论 评分结果与以往职业风险相关的定量研究结果基本一致，职业风险系数可以适度调整科室之间奖金分配。     

Syndromic surveillance for influenzalike illness

Emergency department data are currently being used by several syndromic surveillance systems to identify outbreaks of natural or man-made illnesses, and preliminary results suggest that regular outbreaks might be detected earlier with such data than with traditional reporting. This article summarizes a retrospective study of 5 influenza seasons in Ottawa,Canada; time-series analysis was used to look for an association between consultation to the emergency department for influenzalike illness and the isolation of influenza virus in the community. The population studied included both children and adults consulting to 3 local hospitals. In 4 seasons, visits to the emergency department involving children younger than 5 years consulting mainly for fever and for respiratory symptoms peaked 1 to 4 weeks before the isolation of influenza virus in the community. If monitored regularly for the presence of key symptoms, pediatric hospitals might be efficient and cost-effective sentinels of influenza and of other infectious diseases.     

Self Inflicted Injuries among Children in United States – Estimates from a Nationwide Emergency Department Sample

Objective

The objectives of the current study are to provide nationally representative estimates of hospital based emergency department visits (ED) attributed to self inflicted injuries and attempted suicides among children in United States; and to identify potential methods of such intentional self inflicted injuries and attempted suicides.

Methods

The Nationwide Emergency Department Sample (year 2007) was used. All ED visits occurring among children (aged ≤18 years) with an External Cause of Injury for any of self inflicted injuries were selected. Outcomes examined include hospital ED charges and hospitalization charges. All estimates were projected to national levels.

Results

77,420 visits to hospital based emergency departments were attributed to self inflicted injuries among children (26,045 males and 51,370 females). The average age of the ED visits was 15.7 years. 134 patients died in ED’s (106 males and 28 females) and 93 died in hospitals following in-patient admission (75 males and 18 females). A greater proportion of male ED visits were discharged routinely as opposed to female ED visits (51.1% versus 44%). A greater proportion of male ED visits also died in the emergency departments compared to female visits (0.4% versus 0.05%). 17,965 ED visits necessitated admission into same hospital. The mean charge for each ED visit was $1,874. Self inflicted injuries by poisoning were the most frequently reported sources accounting for close to 70% of all ED visits.

Conclusions

Females comprise a greater proportion of ED visits attributed to self inflicted injuries. 227 children died either in the ED’s or in hospitals. The current study results highlight the burden associated with such injuries among children.     

医院信息化中医疗数据平台的现实应用探讨

目的:了解本地区医院信息化中医疗数据平台的现实应用情况,为推动信息化建设提供参考。方法:以30家我市卫生系统二级以上公立医院(三级医院6家,二级医院24家)为调查对象,调查表内容包括四个部分,包括医院基本情况、信息化部门设置规划情况、资金投入情况和医院数据平台应用情况。结果:有18家医院有信息化发展规划,4家医院信息化发展无规划。医院信息建设资金主要投入方向在硬件,其中二级医院的硬件投入大大超过软件投入,差异有显著性(P<0.05)。同时医疗数据使用平台的效率也不一样,住院病人出入管理系统,门急诊划价收费系统,门急诊药房管理系统使用率排在前三位,使用率最低的为门急诊导医系统。结论:本市医院医疗数据平台的建设大多数还停留在第一个阶段,也是一项复杂的系统工程,要加强信息化工作的组织领导和制定相应的信息化标准规范,建立信息主管制,加大信息化建设的资金投入,真正做到为患者服务。     

Emergency health care use and follow-up among sociodemographic groups of children who visit emergency departments for mental health crises

Background:

Previous studies of differences in mental health care associated with children’s sociodemographic status have focused on access to community care. We examined differences associated with visits to the emergency department.

Methods:

We conducted a 6-year population-based cohort analysis using administrative databases of visits (n = 30 656) by children aged less than 18 years (n = 20 956) in Alberta. We measured differences in the number of visits by socioeconomic and First Nations status using directly standardized rates. We examined time to return to the emergency department using a Cox regression model, and we evaluated time to follow-up with a physician by physician type using a competing risks model.

Results:

First Nations children aged 15–17 years had the highest rate of visits for girls (7047 per 100 000 children) and boys (5787 per 100 000 children); children in the same age group from families not receiving government subsidy had the lowest rates (girls: 2155 per 100 000 children; boys: 1323 per 100 000 children). First Nations children (hazard ratio [HR] 1.64; 95% confidence interval [CI] 1.30–2.05), and children from families receiving government subsidies (HR 1.60, 95% CI 1.30–1.98) had a higher risk of return to an emergency department for mental health care than other children. The longest median time to follow-up with a physician was among First Nations children (79 d; 95% CI 60–91 d); this status predicted longer time to a psychiatrist (HR 0.47, 95% CI 0.32–0.70). Age, sex, diagnosis and clinical acuity also explained post-crisis use of health care.

Interpretation:

More visits to the emergency department for mental health crises were made by First Nations children and children from families receiving a subsidy. Sociodemographics predicted risk of return to the emergency department and follow-up care with a physician.Emergency departments are a critical access point for mental health care for children who have been unable to receive care elsewhere or are in crisis.¹ Care provided in an emergency department can stabilize acute problems and facilitate urgent follow-up for symptom management and family support.^1,2Race, ethnic background and socioeconomic status have been linked to a crisis-oriented care patterns among American children.^3,4 Minority children are less likely than white children to have received mental health treatment before an emergency department visit,^3,4 and uninsured children are less likely to receive an urgent mental health evaluation when needed.⁴ Other studies, however, have shown no relation between sociodemographic status and mental health care,^5,6 and it may be that different health system characteristics (e.g., pay-for-service, insurance coverage, publicly funded care) interact with sociodemographic status to influence how mental health resources are used. Canadian studies are largely absent in this discussion, despite a known relation between lower income and poorer mental health status,⁷ nationwide documentation of disparities faced by Aboriginal children,^8–10 and government-commissioned reviews that highlight deficits in universal access to mental health care.¹¹We undertook the current study to examine whether sociodemographic differences exist in the rates of visits to emergency departments for mental health care and in the use of post-crisis health care services for children in Alberta. Knowledge of whether differences exist for children with mental health needs may help identify children who could benefit from earlier intervention to prevent illness destabilization and children who may be disadvantaged in the period after the emergency department visit. We hypothesized that higher rates of emergency department use, lower rates of follow-up physician visits after the initial emergency department visit, and a longer time to physician follow-up would be observed among First Nations children and children from families receiving government social assistance.     

Organisational Factors Induce Prolonged Emergency Department Length of Stay in Elderly Patients – A Retrospective Cohort Study

Study objective

To assess the association of patient and organisational factors with emergency department length of stay (ED-LOS) in elderly ED patients (226565 years old) and in younger patients (<65 years old).

Methods

A retrospective cohort study of internal medicine patients visiting the emergency department between September 1^st 2010 and August 31^st 2011 was performed. All emergency department visits by internal medicine patients 226565 years old and a random sample of internal medicine patients <65 years old were included. Organisational factors were defined as non-medical factors. ED-LOS is defined as the time between ED arrival and ED discharge or admission. Prolonged ED-LOS is defined as ≥75^th percentile of ED-LOS in the study population, which was 208 minutes.

Results

Data on 1782 emergency department visits by elderly patients and 597 emergency department visits by younger patients were analysed. Prolonged ED-LOS in elderly patients was associated with three organisational factors: >1 consultation during the emergency department visit (odds ratio (OR) 3.2, 95% confidence interval (CI) 2.3–4.3), a higher number of diagnostic tests (OR 1.2, 95% CI 1.16–1.33) and evaluation by a medical student or non-trainee resident compared with a medical specialist (OR 4.2, 95% CI 2.0–8.8 and OR 2.3, 95% CI 1.4–3.9). In younger patients, prolonged ED-LOS was associated with >1 consultation (OR 2.6, 95% CI 1.4–4.6). Factors associated with shorter ED-LOS were arrival during nights or weekends as well as a high urgency level in elderly patients and self-referral in younger patients.

Conclusion

Organisational factors, such as a higher number of consultations and tests in the emergency department and a lower seniority of the physician, were the main aspects associated with prolonged ED-LOS in elderly patients. Optimisation of the organisation and coordination of emergency care is important to accommodate the needs of the continuously growing number of elderly patients in a better way.     

北京市大气细颗粒污染物与老年呼吸系统疾病急诊就医关系的病例交叉研究

目的:探讨北京市大气细颗粒污染物对呼吸系统疾病急诊的影响。方法:收集2013年3月-2014年3月解放军305医院以及西三环的总参军训部北京第八干休所门诊部的临床病例急诊数据、北京市环境监测中心的大气细颗粒污染物和气象条件数据资料,应用病例交叉设计研究方法进行数据分析。结果:在控制气温、相对湿度的影响后,单向回顾性1:1配对病例交叉分析结果显示,滞后0天细颗粒物污染对慢性支气管炎、哮喘、慢性阻塞性肺病急诊影响的OR值最大,细颗粒物日平均浓度每升高10μg/m3,对应的OR值分别为1.032、1.033、1.035。结论:该研究区域内大气细颗粒物污染物浓度升高可以导致呼吸系统疾病相关的慢性支气管炎、哮喘、慢性阻塞性肺病疾病的急诊增加。