Taking care of the most vulnerable : a descriptive study of patients with 12 attendances or more at a Swiss university hospital emergency department in 2009

Introduction: Patients who repeatedly attend the Emergency Department (ED) often have a distinct and complex vulnerability profile that includes poor somatic, psychological, and social indicators. This profile has an impact on the patients' well-being as well as on hospital costs. The objective of the study was to specify the characteristics of hyper users (HU) and explore the connection with ED care and hospital costs. Methods: The study sample comprised all adult patients with 12 or more attendances at the ED of the Lausanne University Hospital in 2009. The data were collected by retrospectively searching internal databases to identify the patients concerned and then analysing the profiles of these patients. Information gathered included demographic, somatic, psychological, at-risk behaviour, and social indicators, and health system consumption including costs. Results: In 2009, 23 patients (0.1%) attended 12 times or more (425 attendances, 0.8%). The average age was about 43 years, 60.9% were female, and 47.8% single. Of these 95.7% had basic insurance, 87.0% had a general practitioner, and 30.4% were under legal guardianship. The majority attended in the evening or at night (67.1%), and almost one quarter of these attendances resulted in inpatient treatment (24.0%). Most HU had attended the ED in previous years too (95.7% in 2008). The most prevalent diagnoses concerned 'mental disorders' (87.0%). About 30.4% of patients had attempted suicide (all were female patients). Other frequent diagnoses concerned 'trauma' (65.2%), and the 'digestive' and the 'nervous system' (each 56.5%). At-risk behaviour such as severe alcohol consumption (34.8%), or excessive use of medicines (26.1%) was very frequent, and some patients used illicit drugs (21.7%). There was only a weak association between the number of ED attendances and the resulting costs. However, a reduction of one outpatient visit per patient would have decreased ED outpatient costs by 8.5%. Conclusions: HU often have a particularly vulnerable profile. Mental problems are prevalent among them, as are at-risk behaviour and severe somatic conditions. The complexity of the patients' profiles demands specific care that cannot be guaranteed within an everyday ED routine. The use of an interdisciplinary case management team might be a promising approach in diminishing the number of attendances and the associated costs, although the profiles of HU are such that they probably cannot completely give up ED attendance.

Computing infinite plans for LTL goals using a classical planner

Classical planning has been notably successful in synthesizing finite plans to achieve states where propositional goals hold. In the last few years, classical planning has also been extended to incorporate temporally extended goals, expressed in temporal logics such as LTL, to impose restrictions on the state sequences generated by finite plans. In this work, we take the next step and consider the computation of infinite plans for achieving arbitrary LTL goals. We show that infinite plans can also be obtained efficiently by calling a classical planner once over a classical planning encoding that represents and extends the composition of the planningdomain and the B¨uchi automaton representingthe goal. This compilation scheme has been implemented and a number of experiments are reported.

Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system.

OBJECTIVES: The objectives were to identify the social and medical factors associated with emergency department (ED) frequent use and to determine if frequent users were more likely to have a combination of these factors in a universal health insurance system. METHODS: This was a retrospective chart review case-control study comparing randomized samples of frequent users and nonfrequent users at the Lausanne University Hospital, Switzerland. The authors defined frequent users as patients with four or more ED visits within the previous 12 months. Adult patients who visited the ED between April 2008 and March 2009 (study period) were included, and patients leaving the ED without medical discharge were excluded. For each patient, the first ED electronic record within the study period was considered for data extraction. Along with basic demographics, variables of interest included social (employment or housing status) and medical (ED primary diagnosis) characteristics. Significant social and medical factors were used to construct a logistic regression model, to determine factors associated with frequent ED use. In addition, comparison of the combination of social and medical factors was examined. RESULTS: A total of 359 of 1,591 frequent and 360 of 34,263 nonfrequent users were selected. Frequent users accounted for less than a 20th of all ED patients (4.4%), but for 12.1% of all visits (5,813 of 48,117), with a maximum of 73 ED visits. No difference in terms of age or sex occurred, but more frequent users had a nationality other than Swiss or European (n = 117 [32.6%] vs. n = 83 [23.1%], p = 0.003). Adjusted multivariate analysis showed that social and specific medical vulnerability factors most increased the risk of frequent ED use: being under guardianship (adjusted odds ratio [OR] = 15.8; 95% confidence interval [CI] = 1.7 to 147.3), living closer to the ED (adjusted OR = 4.6; 95% CI = 2.8 to 7.6), being uninsured (adjusted OR = 2.5; 95% CI = 1.1 to 5.8), being unemployed or dependent on government welfare (adjusted OR = 2.1; 95% CI = 1.3 to 3.4), the number of psychiatric hospitalizations (adjusted OR = 4.6; 95% CI = 1.5 to 14.1), and the use of five or more clinical departments over 12 months (adjusted OR = 4.5; 95% CI = 2.5 to 8.1). Having two of four social factors increased the odds of frequent ED use (adjusted = OR 5.4; 95% CI = 2.9 to 9.9), and similar results were found for medical factors (adjusted OR = 7.9; 95% CI = 4.6 to 13.4). A combination of social and medical factors was markedly associated with ED frequent use, as frequent users were 10 times more likely to have three of them (on a total of eight factors; 95% CI = 5.1 to 19.6). CONCLUSIONS: Frequent users accounted for a moderate proportion of visits at the Lausanne ED. Social and medical vulnerability factors were associated with frequent ED use. In addition, frequent users were more likely to have both social and medical vulnerabilities than were other patients. Case management strategies might address the vulnerability factors of frequent users to prevent inequities in health care and related costs.

Protect Iowa Health, 2005

The Iowa Department of Public Health works with local, state and federal partners in developing plans and creating systems to increase the state’s ability to respond to bioterrorism, infectious disease outbreaks and other public health emergencies.

Iowa Homeland Security & Emergency Management Division Performance Report, FY 2005

Agency Performance Report

Théâtre de la guerre en Afrique, comprenant les régences d'Alger, de Tunis, Tripoli et de l'empire du Maroc : Avec plans détaillés de la baie et des fortifications de la ville d'Alger et de ses environs, d'après les meilleurs matériaux qu'on a pu se procurer sur ce pays / drefsé par Frémin géographe

Échelle(s) : [ca 1:5 085 000], 30 myriamètres [= 5,9 cm]

Plan de la ville de Marseille : de ses faubourgs et bastides : Avec les plans détaillés de son lazaret, principaux monuments, édifices et endroits remarquables, donnant tous les changements qui ont eu lieu jusqu'à l'année 1839 / Vicq, grav. édit.

Échelle(s) : [ca 1:7 150], échelle de 600 mètres [= 8,4 cm]

Itinéraire de Bône à Constantine et marche de l'armée expéditionnaire en novembre 1836 : Sous les ordres de M. le Maréchal Clausel, avec les plans Drean, Nechmeya et Guelma / Dessiné par Ginoux ; Toulon, Lith[ographe] Imbert

Échelle(s) : [ca 1:226 000], 1 Lieue de poste [= 1,9 cm]

Proclamation of Disaster Emergency, Octber 2000

Proclamation of Disaster Emergency by Governor Vilsack, October 2000

Report on Special Investigation of the Linn County Emergency Management Agency, For the Period July 1, 2003 through April 21, 2006

County Audit Report - Special Investigation