Why do walk-in patients prefer a busy urban emergency department during office hours? A pilot survey of 200 consecutive patients from Switzerland

In Switzerland, more and more patients go directly to the emergency department, bypassing general practitioners. However, a mixture of non-urgent walk-in patients and acute emergencies in the same emergency department can inevitably make it more difficult to provide genuine emergencies with rapid treatment, leading to deterioration in the quality of emergency services, and tending to increase on-floor mortality and morbidity, together with higher overall costs.

Performance Modeling Of Reconfigurable Distributed Systems Based On The Opensparc Fpga Board And The Sirc Communication Framewor

This thesis explores system performance for reconfigurable distributed systems and provides an analytical model for determining throughput of theoretical systems based on the OpenSPARC FPGA Board and the SIRC Communication Framework. This model was developed by studying a small set of variables that together determine a system¿s throughput. The importance of this model is in assisting system designers to make decisions as to whether or not to commit to designing a reconfigurable distributed system based on the estimated performance and hardware costs. Because custom hardware design and distributed system design are both time consuming and costly, it is important for designers to make decisions regarding system feasibility early in the development cycle. Based on experimental data the model presented in this paper shows a close fit with less than 10% experimental error on average. The model is limited to a certain range of problems, but it can still be used given those limitations and also provides a foundation for further development of modeling reconfigurable distributed systems.

SCIENTIFIC MANAGEMENT SYSTEMS AS ENFRAMING OR EMPOWERING: HOW LEAN AND SIX SIGMA DEFINE TECHNICAL COMMUNICATION

In this project, I examine current forms of scientific management systems, Lean and Six Sigma, as they relate to technical communication. With the goal of breaking work up into standardized processes in order to cut costs and increase efficiency, Lean, Six Sigma and Lean Six Sigma hybrid systems are increasingly applied beyond manufacturing operations to service and other types of organizational work, including technical communication. By consulting scholarship from fields such as business, management, and engineering, and analyzing government Lean Six Sigma documentation, I investigate how these systems influence technical communication knowledge and practice in the workplace. I draw out the consequences of system-generated power structures as they affect knowledge work, like technical communication practice, when it is reduced to process. In pointing out the problems these systems have in managing knowledge work, I also ask how technical communication might shape them.

Evaluation of the benefit of emergency vaccination in a foot-and-mouth disease free country with low livestock density

Foot-and-mouth disease (FMD) is highly contagious and one of the most economically devastating diseases of cloven-hoofed animals. Scientific-based preparedness about how to best control the disease in a previously FMD-free country is therefore essential for veterinary services. The present study used a spatial, stochastic epidemic simulation model to compare the effectiveness of emergency vaccination with conventional (non-vaccination) control measures in Switzerland, a low-livestock density country. Model results revealed that emergency vaccination with a radius of 3 km or 10 km around infected premises (IP) did not significantly reduce either the cumulative herd incidence or epidemic duration if started in a small epidemic situation where the number of IPs is still low. However, in a situation where the epidemic has become extensive, both the cumulative herd incidence and epidemic duration are reduced significantly if vaccination were implemented with a radius of 10 km around IPs. The effect of different levels of conventional strategy measures was also explored for the non-vaccination strategy. It was found that a lower compliance level of farmers for movement restrictions and delayed culling of IPs significantly increased both the cumulative IP incidence and epidemic duration. Contingency management should therefore focus mainly on improving conventional strategies, by increasing disease awareness and communication with stakeholders and preparedness of culling teams in countries with a livestock structure similar to Switzerland; however, emergency vaccination should be considered if there are reasons to believe that the epidemic may become extensive, such as when disease detection has been delayed and many IPs are discovered at the beginning of the epidemic.

Persuasive email messages for patient communication.

To improve health and reduce costs, we need to encourage patients to make better health care decisions. Since email is widely available, it may be useful for patient-directed interventions. However, we know little about how the contents of an email message can influence a health-related decision. We propose a model to understand how patients may process persuasive email messages.

Risk, outcomes, and cost of emergency center visits in cancer patients

Cancer is a chronic disease that often necessitates recurrent hospitalizations, a costly pattern of medical care utilization. In chronically ill patients, most readmissions are for treatment of the same condition that caused the preceding hospitalization. There is concern that rather than reducing costs, earlier discharge may shift costs from the initial hospitalization to emergency center visits. ^ This is the first descriptive study to measure the incidence of emergency center visits (ECVs) after hospitalization at The University of M. D. Anderson Cancer Center (UTMDACC), to identify the risk factors for and outcomes of these ECVs, and to compare 30-day all-cause mortality and costs for episodes of care with and without ECVs. ^ We identified all hospitalizations at UTMDACC with admission dates from September 1, 1993 through August 31, 1997 which met inclusion criteria. Data were electronically obtained primarily from UTMDACC's institutional database. Demographic factors, clinical factors, duration of the index hospitalization, method of payment for care, and year of hospitalization study were variables determined for each hospitalization. ^ The overall incidence of ECVs was 18%. Forty-five percent of ECVs resulted in hospital readmission (8% of all hospitalizations). In 1% of ECVs the patient died in the emergency center, and for the remaining 54% of ECVs the patient was discharged home. Risk factors for ECVs were marital status, type of index hospitalization, cancer type, and duration of the index hospitalization. The overall 30-day all-cause mortality rate was 8.6% for hospitalizations with an ECV and 5.3% for those without an ECV. In all subgroups, the 30-day all-cause mortality rate was higher for groups with ECVs than for those without ECVs. The most important factor increasing cost was having an ECV. In all patient subgroups, the cost per episode of care with an ECV was at least 1.9 times the cost per episode without an ECV. ^ The higher costs and poorer outcomes of episodes of care with ECVs and hospital readmissions suggest that interventions to avoid these ECVs or mitigate their costs are needed. Further research is needed to improve understanding of the methodological issues involved in relation to health care issues for cancer patients. ^

Optimizing Triage and Hospitalization in Adult General Medical Emergency Patients. The Triage Project

Background: Patients presenting to the emergency department (ED) currently face inacceptable delays in initial treatment, and long, costly hospital stays due to suboptimal initial triage and site-of-care decisions. Accurate ED triage should focus not only on initial treatment priority, but also on prediction of medical risk and nursing needs to improve site-of-care decisions and to simplify early discharge management. Different triage scores have been proposed, such as the Manchester triage system (MTS). Yet, these scores focus only on treatment priority, have suboptimal performance and lack validation in the Swiss health care system. Because the MTS will be introduced into clinical routine at the Kantonsspital Aarau, we propose a large prospective cohort study to optimize initial patient triage. Specifically, the aim of this trial is to derive a three-part triage algorithm to better predict (a) treatment priority; (b) medical risk and thus need for in-hospital treatment; (c) post-acute care needs of patients at the most proximal time point of ED admission. Methods/design: Prospective, observational, multicenter, multi-national cohort study. We will include all consecutive medical patients seeking ED care into this observational registry. There will be no exclusions except for non-adult and non-medical patients. Vital signs will be recorded and left over blood samples will be stored for later batch analysis of blood markers. Upon ED admission, the post-acute care discharge score (PACD) will be recorded. Attending ED physicians will adjudicate triage priority based on all available results at the time of ED discharge to the medical ward. Patients will be reassessed daily during the hospital course for medical stability and readiness for discharge from the nurses and if involved social workers perspective. To assess outcomes, data from electronic medical records will be used and all patients will be contacted 30 days after hospital admission to assess vital and functional status, re-hospitalization, satisfaction with care and quality of life measures. We aim to include between 5000 and 7000 patients over one year of recruitment to derive the three-part triage algorithm. The respective main endpoints were defined as (a) initial triage priority (high vs. low priority) adjudicated by the attending ED physician at ED discharge, (b) adverse 30 day outcome (death or intensive care unit admission) within 30 days following ED admission to assess patients risk and thus need for in-hospital treatment and (c) post acute care needs after hospital discharge, defined as transfer of patients to a post-acute care institution, for early recognition and planning of post-acute care needs. Other outcomes are time to first physician contact, time to initiation of adequate medical therapy, time to social worker involvement, length of hospital stay, reasons fordischarge delays, patient’s satisfaction with care, overall hospital costs and patients care needs after returning home. Discussion: Using a reliable initial triage system for estimating initial treatment priority, need for in-hospital treatment and post-acute care needs is an innovative and persuasive approach for a more targeted and efficient management of medical patients in the ED. The proposed interdisciplinary , multi-national project has unprecedented potential to improve initial triage decisions and optimize resource allocation to the sickest patients from admission to discharge. The algorithms derived in this study will be compared in a later randomized controlled trial against a usual care control group in terms of resource use, length of hospital stay, overall costs and patient’s outcomes in terms of mortality, re-hospitalization, quality of life and satisfaction with care.

Cost-effectiveness of peer role play and standardized patients in undergraduate communication training.

BACKGROUND The few studies directly comparing the methodological approach of peer role play (RP) and standardized patients (SP) for the delivery of communication skills all suggest that both methods are effective. In this study we calculated the costs of both methods (given comparable outcomes) and are the first to generate a differential cost-effectiveness analysis of both methods. METHODS Medical students in their prefinal year were randomly assigned to one of two groups receiving communication training in Pediatrics either with RP (N = 34) or 19 individually trained SP (N = 35). In an OSCE with standardized patients using the Calgary-Cambridge Referenced Observation Guide both groups achieved comparable high scores (results published). In this study, corresponding costs were assessed as man-hours resulting from hours of work of SP and tutors. A cost-effectiveness analysis was performed. RESULTS Cost-effectiveness analysis revealed a major advantage for RP as compared to SP (112 vs. 172 man hours; cost effectiveness ratio .74 vs. .45) at comparable performance levels after training with both methods. CONCLUSIONS While both peer role play and training with standardized patients have their value in medical curricula, RP has a major advantage in terms of cost-effectiveness. This could be taken into account in future decisions.

Spine radiography in the evaluation of back and neck pain in an orthopaedic emergency clinic

BACKGROUND AND OBJECTIVES Despite the recommendations of national and international societies for the treatment of patients with acute neck and back pain, still too many radiologic examinations were performed. The purpose of this study was to analyze and optimize diagnostics and treatment of patients with acute back pain. METHODS The medical records of 484 patients presented to the emergency clinic with acute neck or back pain were analyzed for clinical history, physical examination, radiographic findings and therapy. RESULTS Radiographs of the lumbar, cervical, or thoracic spine were performed in 338 cases (70%). Radiographs were normal in 142 patients (42%) and degenerative changes were identified in 123 patients (36%). Only 2 patients (0.4%) had radiographic findings that had direct therapeutic relevance: 1 patient with metastatic disease and 1 patient with posttraumatic C1-C2 instability. For most patients without sensorimotor deficits and absent specific indications for radiography (“red flags”), therapy was not affected by the results of radiography. CONCLUSIONS Plain radiography of the spine was unnecessary in most patients initially evaluated with non-specific acute back pain and does not improve the clinical outcome. The implementation of national and international guidelines is a slow process, but helps to reduce costs and to protect patients from unnecessary ionizing radiation exposure.

Biomarker-guided personalised emergency medicine for all - hope for another hype?

Polymorbid patients, diverse diagnostic and therapeutic options, more complex hospital structures, financial incentives, benchmarking, as well as perceptional and societal changes put pressure on medical doctors, specifically if medical errors surface. This is particularly true for the emergency department setting, where patients face delayed or erroneous initial diagnostic or therapeutic measures and costly hospital stays due to sub-optimal triage. A "biomarker" is any laboratory tool with the potential better to detect and characterise diseases, to simplify complex clinical algorithms and to improve clinical problem solving in routine care. They must be embedded in clinical algorithms to complement and not replace basic medical skills. Unselected ordering of laboratory tests and shortcomings in test performance and interpretation contribute to diagnostic errors. Test results may be ambiguous with false positive or false negative results and generate unnecessary harm and costs. Laboratory tests should only be ordered, if results have clinical consequences. In studies, we must move beyond the observational reporting and meta-analysing of diagnostic accuracies for biomarkers. Instead, specific cut-off ranges should be proposed and intervention studies conducted to prove outcome relevant impacts on patient care. The focus of this review is to exemplify the appropriate use of selected laboratory tests in the emergency setting for which randomised-controlled intervention studies have proven clinical benefit. Herein, we focus on initial patient triage and allocation of treatment opportunities in patients with cardiorespiratory diseases in the emergency department. The following five biomarkers will be discussed: proadrenomedullin for prognostic triage assessment and site-of-care decisions, cardiac troponin for acute myocardial infarction, natriuretic peptides for acute heart failure, D-dimers for venous thromboembolism, C-reactive protein as a marker of inflammation, and procalcitonin for antibiotic stewardship in infections of the respiratory tract and sepsis. For these markers we provide an overview on physiopathology, historical evolution of evidence, strengths and limitations for a rational implementation into clinical algorithms. We critically discuss results from key intervention trials that led to their use in clinical routine and potential future indications. The rational for the use of all these biomarkers, first, tackle diagnostic ambiguity and consecutive defensive medicine, second, delayed and sub-optimal therapeutic decisions, and third, prognostic uncertainty with misguided triage and site-of-care decisions all contributing to the waste of our limited health care resources. A multifaceted approach for a more targeted management of medical patients from emergency admission to discharge including biomarkers, will translate into better resource use, shorter length of hospital stay, reduced overall costs, improved patients satisfaction and outcomes in terms of mortality and re-hospitalisation. Hopefully, the concepts outlined in this review will help the reader to improve their diagnostic skills and become more parsimonious laboratory test requesters.

Factors associated with hospital admission of elder cardiovascular patients in an emergency center

Context. Healthcare utilization of elder cardiovascular patients in United States will increase in near future, due to an aging population. This trend could burden urban emergency centers, which have become a source of primary care. ^ Objective. The objective of this study was to determine the association of age, gender, ethnicity, insurance and other presenting variables on hospital admission in an emergency center for elder cardiovascular patients. ^ Design, setting and participants. An anonymous retrospective review of emergency center patient login records of an urban emergency center in the years 2004 and 2005 was conducted. Elder patients (age ≥ 65 years) with cardiovascular disease (ICD91 390-459) were included. Multivariate logistic regression analysis was used to identify independent factors for hospital admission. Four major cardiovascular reasons for hospitalisation – ischemic heart disease, heart failure, hypertensive disorders and stroke were analysed separately. ^ Results. The number of elder patients in the emergency center is increasing, the most common reason for their visit was hypertension. Majority (59%) of the 12,306 elder patients were female. Forty five percent were uninsured and 1,973 patients had cardiovascular disease. Older age (OR 1.10; CI 1.02-1.19) was associated with a marginal increase in hospital admission in elder stroke patients. Elder females compared to elder males were more likely to be hospitalised for ischemic heart disease (OR 2.71; CI 1.22-6.00) and heart failure (OR 1.58; CI 1.001-2.52). Furthermore, insured elder heart failure patients (OR 0.54; CI 0.31-0.93) and elder African American heart failure patients (OR 0.32; CI 0.13-0.75) were less likely to be hospitalised. Ambulance use was associated with greater hospital admissions in elder cardiovascular patients studied, except for stroke. ^ Conclusion. Appropriate health care distribution policies are needed for elder patients, particularly elder females, uninsured, and racial/ethnic minorities. These findings could help triage nurse evaluations in emergency centers to identify patients who were more likely to be hospitalised to offer urgent care and schedule appointments in primary care clinics. In addition, health care plans could be formulated to improve elder primary care, decrease overcrowding in emergency centers, and decrease elder healthcare costs in the future. ^

Emergency department usage patterns among residents of Hardin, Jefferson, and Orange Counties in southeast Texas

Emergency departments (EDs) have been called the net below the safety net due to their long history of providing care to the uninsured and others lacking access to the healthcare system. In past years, those with Medicaid and, more recently, those with Medicare, are also utilizing the ED as a medical home for routine primary care. There are many reasons for this but the costs to the community have become increasingly burdensome. ^ To evaluate how often the ED is being utilized for primary care, we applied a standardized tool, the New York University Algorithm, to over 43,000 ED visits when no hospitalization was required made by Hardin, Jefferson, and Orange County residents over a 12 month period. We compared our results to Harris County, where studies using the same framework have been performed, and found that sizeable segments of the population in both areas are utilizing the ED for non-emergent primary care that could be treated in a more cost-effective community setting. ^ We also analyzed our dataset for visit-specific characteristics. We found evidence of two possible health care disparities: (1) Blacks had a higher rate of primary care-related ED visits in relation to their percentage of the population when compared to other racial/ethnic groups; and (2) when form of payment is considered, the uninsured were more likely to have a primary care-related ED visit than any other group. These findings suggest a lack of community-based primary care services for the medically needy in Southeast Texas. ^ We believe that studies such as this are warranted elsewhere in Texas as well. We plan to present our findings to local policy makers, who should find this information helpful in identifying gaps in the safety net and assist them in better allocating scarce community resources. ^

Debriefing after resuscitations in a pediatric emergency department

Multiple guidelines recommend debriefing of actual resuscitations to improve clinical performance. We implemented a novel standardized debriefing program using a Debriefing In Situ Conversation after Emergent Resuscitations Now (DISCERN) tool. Following the development of the evidence-based DISCERN tool, we conducted an observational study of all resuscitations (intubation, CPR, and/or defibrillation) at a pediatric emergency department (ED) over one year. Resuscitation interventions, patient survival, and physician team leader characteristics were analyzed as predictors for debriefing. Each debriefing's participants, time duration, and content were recorded. Thematic content of debriefings was categorized by framework approach into Team Emergency Assessment Measure (TEAM) elements. There were 241 resuscitations and 63 (26%) debriefings. A higher proportion of debriefings occurred after CPR (p<0.001) or ED death (p<0.001). Debriefing participants always included an attending and nurse; the median number of staff roles present was six. Median interval (from resuscitation end to start of debriefing) & debriefing durations were 33 (IQR 15,67) and 10 minutes (IQR 5,12), respectively. Common TEAM themes included co-operation/coordination (30%), communication (22%), and situational awareness (15%). Stated reasons for not debriefing included: unnecessary (78%), time constraints (19%), or other reasons (3%). Debriefings with the DISCERN tool usually involved higher acuity resuscitations, involved most of the indicated personnel, and lasted less than 10 minutes. This qualitative tool could be adapted to other settings. Future studies are needed to evaluate for potential impacts on education, quality improvement programming, and staff emotional well-being.^

The impact of communication and cultural diversity in utilizing dental services among Saudi Arabian students in U.S.A.

Objectives: The purpose of this study is to understand the perceived effects of patient-dental staff communication and cultural diversity on the utilization of dental services in the U.S. by Saudi Arabian students who live in the U.S. and enrolled into the King Abdullah Scholarship program. Methods: The study design was an analytical cross-sectional study. Data for this study was obtained from the Saudi Dental Servicers Utilization Survey, a voluntary internet survey available online for one month through Facebook. Ordered logistic regression analyses and multinomial logistic regression analyses were used to measure the relationships between patient-dental staff communication and cultural diversity on the utilization of dental services. Results: Eight hundred and forty-seven responses were analyzed for this study. Overall, the majority of Saudi students reported having excellent communication experience with dental providers in the U.S. More than 58% of respondents reported at least one regular dental visit last year. Factors that influenced the use of regular dental care were: dentist's explanation of treatment plan, response of dental staff to patient's needs, respectful and polite dental staff, dental staff kindness, availability of up-to-date equipment, and overall communication with dentist. However, the utilization of emergency dental care was not associated with any measurement of patient-dental provider communication. Overall future utilization of dental care is associated with all aspects of patient-dental staff communication measured in this survey. Furthermore, more utilization of regular dental care was related to respondent's perception of the importance of trustworthiness dental staff and the importance of a dentist's reputation was only marginally associated. Respondent's perception of dentist's reputation was associated with more use of emergency dental services. Respondents are more likely to anticipate using dental care in the future if they perceived trustworthiness dental staff, and the dentist's reputation as influencing factors to their usage of dental services. Conclusions: Patient-dental staff communication was partially associated with utilization of regular dental care, not associated with utilization of emergency dental care, and broadly associated with anticipated future utilization of dental care. In addition, trustworthy dental staff, and a dentist's reputation were considered to be strong influencing factors towards utilization of dental services.^

The value of cultural assets. Maintenance Costs and economic sustainability at heritage

Under the 12th International Conference on Building Materials and Components is inserted this communication related to the field of management of those assets that constitute the Spanish Cultural Heritage and maintenance. This work is related to the field of management of those assets that constitute the Spanish Cultural Heritage which share an artistic or historical background. The conservation and maintenance become a social demand necessary for the preservation of public values, requiring the investment of necessary resources. The legal protection involves a number of obligations and rights to ensure the conservation and heritage protection. The duty of maintenance and upkeep exceeds the useful life the property that must endure more for their cultural value for its usability. The establishment of the necessary conditions to prevent deterioration and precise in order to fulfill its social function, seeking to prolong the life of the asset, preserving their physical integrity and its ability to convey the values protected. This obligation implies a substantial financial effort to the holder of the property, either public or private entity, addressing a problem of economic sustainability. Economic exploitation, with the aim of contributing to their well-maintained, is sometimes the best way to get resources. The work will include different lines of research with the following objectives. - Establishment of processes for assessing total costs over the building life cycle (LCC), during the planning stages or maintenance budgets to determine the most advantageous operating system. - Relationship between the value of property and maintenance costs, and establishing a sensitivity analysis.