Emergency Medicine Journal最新文献

Background: Treatment with the 12-hour Scottish and Newcastle Antiemetic Protocol (SNAP) acetylcysteine regimen is associated with decreased length of stay and fewer anaphylactoid reactions in adult patients, and the protocol is now recommended by several UK organisations and used widely. One potential barrier to adoption is concern regarding the potential for variation in protocol performance with patient age. Anecdotally, this has led to slower adoption in paediatric settings.

Methods: Secondary analysis of data from 2212 patients at the Royal Infirmary of Edinburgh, UK, treated with acetylcysteine for paracetamol overdose between 28 September 2013 and 27 September 2017. Patients were grouped into 10-year age ranges to allow comparison of treatment regimen performance across ages. Groups were compared for their rates of anaphylactoid reactions, duration of admission attributable to acetylcysteine infusion and severity of liver injury assessed by biochemical markers.

Results: Patients in all age groups treated with SNAP experienced statistically significant reductions in anaphylactoid reactions. There were no significant differences in the severity of acute liver injury as assessed by biochemical results.

Conclusion: This secondary analysis provides data to support the use of SNAP regardless of patient age and reassure clinicians that there is no evidence of previously unrecognised variation in protocol performance.

Introduction: There is a lack of indicators to guide quality improvement activities in virtual emergency medicine internationally. We developed quality indicators for use across a collaboration of four metropolitan virtual ED (VED) settings in four Australian states. The services deliver ED care directly to patients, in consultation with paramedics, and as virtual care coordination.

Methods: The model of care and use of potential indicators at each site were described using interviews and combined with literature review to develop a set of 27 candidate benchmarking indicators. These were refined using a three-stage Delphi study conducted between November 2022 and May 2023. The first stage used a survey to assess the indicators' feasibility and importance, synonyms and draft definitions. These results were fed back to participants for refinement during discussions and written review of revised indicators and definitions across two subsequent stages.

Results: A definition for VED care was proposed: 'An episode of care between patients and/or care providers, occurring remotely, using any form of communication or information technologies, for conditions that would otherwise result in a physical presentation for emergency care.' Across Delphi rounds 1 and 2, some proposed indicators were removed, and new types of indicators were added. In rounds 2 and 3, 24 and 23 indicators, respectively, were reviewed, and the final indicator set comprised 16 indicators. The majority (15) were readily mapped to the six Institute of Medicine Domains of Quality (efficient (n=2), effective (n=5), equitable (n=2), patient centred (n=2), safe (n=2) and timely (n=2)) and all 16 mapped to the National Quality Forum's telehealth quality indicators (access to care (n=2), effectiveness (n=8), experience (n=4), financial impact/cost (n=2)).

Conclusion: There is enthusiasm for a national benchmarking collaborative across four Australian VED services and states. An identified set of 16 indicators and definitions can be further validated with consumers and piloted.

We approach emergency department delay-related harm as though it were a distinct condition and explore use of an explicit cost-effectiveness threshold as a guide to management. Based on the reported association of delayed emergency admission with short-term mortality, to prevent loss of one quality-adjusted life year per patient harmed in Ireland, annual resources equivalent to 70 additional bed years, or infrastructure funding for 90 new beds, could be considered cost-effective. The additional commitment represents under 1% of annual public acute hospital sector expenditure in Ireland, an OECD member country.

Background: The Psychiatric, Alcohol and Non-Prescription Drug Assessment (PANDA) Unit was opened at St Vincent's Hospital Sydney in 2020 to provide short-stay medical monitoring and care for people presenting to the emergency department with alcohol or other drug intoxication or behavioural disturbance with co-existing general medical, drug and alcohol and/or mental health issues. The aim of this study was to describe the activity of the PANDA Unit across the first 3 years of operation and explore patient experience.

Methods: A mixed methods design was used. A retrospective record review (2020-2023) captured patient demographics, admission characteristics and discharge disposition. Brief, structured interviews were conducted with PANDA patients to explore their admission experience, including the care provided. Interviews were analysed using an inductive approach to develop themes.

Results: 2473 patients had 4108 admissions to PANDA, median 333 (range, 296-396) admissions per quarter. Median patient age was 40 (range, 16-93) years, most (64.5%) were male and 11.2% had 'no-fixed abode' documented. Most admissions were associated with alcohol and stimulant intoxication and/or suicidality. Median PANDA length of stay was 21.2 hours (range, 0.5-883.1); 20% of admissions were >48 hours. Most patients (83.8%) were discharged from PANDA to their usual place of residence, 4.9% self-discharged and 15% were readmitted to PANDA within 28 days of discharge, 56 people were readmitted three or more times. The experiences of interview participants (n=14) regarding the PANDA Unit was described by three key themes: (1) patients receive non-judgemental, whole-person care from a large multidisciplinary team, (2) PANDA provides a transition point to further care and (3) PANDA is a comfortable and busy space.

Conclusions: PANDA provided tailored care in a short-stay context for people presenting to emergency department with complex comorbidities. Its unique model of care addressed barriers to healthcare access, such as stigma and siloed care.

Background: Older patients' attendances at EDs are rising. There are concerns that these individuals have prolonged stays, which have been shown to be associated with adverse clinical outcomes. We assessed the length of stay in older patients in a single ED in Singapore.

Methods: This was an observational retrospective study of ED attendances between 2017 and 2019 at the Singapore General Hospital (SGH) using the SGH ED database. The primary outcome was ED length of stay, with prolonged stay defined as 4 hours or more. The association between age (categorised into 18-44, 45-64, 65-84 and 85+) and length of stay was analysed using a mixed-effects logistic regression adjusting for variables like gender, ethnicity and triage acuity. Associations are expressed as adjusted ORs (AOR) with 95% CI. A subgroup analysis was performed for all considered variables.

Results: 391 171 patients qualified for analysis; median age 57 years (IQR 37-70) and 51.5% male. The median length of stay increased across age categories (age 18-44, 3.53 hours; 45-64, 4.04 hours; 65-84, 4.32 hours; and 85+, 4.46 hours). Using patients aged 18-44 as a reference, the AORs for prolonged length of stay by age group were 45-64 AOR 1.17 (95% CI 1.13 to 1.21), 65-84 AOR 1.26 (95% CI 1.21 to 1.30) and 85+ AOR 1.25 (95% CI 1.18 to 1.31). In the subgroup analysis, there was no association between age and length of stay for patients admitted, having multiple comorbidities, having blood tests or having high acuity scores.

Conclusion: In this Singaporean tertiary hospital, older patients had increased median stays and were more likely to stay in the ED for more than 4 hours. However, this did not apply in some subpopulations. This potentially suggests the need for systematic changes in discharge planning and triaging to reduce prolonged stays and their consequences for older patients.