Reasons for non-urgent presentations to the emergency department in Saudi Arabia

Background The majority of patients who attend emergency departments (EDs) in Saudi Arabia have non-urgent problems, resulting in overcrowding, excessive waiting times and delayed care for more acutely ill patients. The purpose of this research was to examine the reasons for non-urgent visits to a Saudi ED and factors associated with patient perceptions of urgency. Methods We administered a survey to 350 consecutively presenting Canadian Triage and Acuity Scale (CTAS) IV or V adult patients at a large tertiary ED in Riyadh region, Saudi Arabia, during 25 days of data collection in March 2013. Results Over half of the sample usually visited the ED to access healthcare. The most common reasons for attending the ED were not having a regular healthcare provider (63%), being able to receive care on the same day (62%), and the convenience of and access to medical care 24/7 (62%). Approximately two-thirds of CTAS V patients and one-third of CTAS IV patients believed their condition was more urgent than their triage nurse rating. Conclusion Multiple factors influence non-urgent visits to the ED in the Saudi context including insufficient community awareness of the role of the ED and perceived lack of access to primary healthcare services.

The Implications of Activity Based Funding for Emergency Departments : A Comprehensive Literature Review

Executive Summary Emergency Departments (EDs) locally, nationally and internationally are becoming increasingly busy. Within this context, it can be challenging to deliver a health service that is safe, of high quality and cost-effective. Whilst various models are described within the literature that aim to measure ED ‘work’ or ‘activity’, they are often not linked to a measure of costs to provide such activity. It is important for hospital and ED managers to understand and apply this link so that optimal staffing and financial resourcing can be justifiably sought. This research is timely given that Australia has moved towards a national Activity Based Funding (ABF) model for ED activity. ABF is believed to increase transparency of care and fairness (i.e. equal work receives equal pay). ABF involves a person-, performance- or activity-based payment system, and thus a move away from historical “block payment” models that do not incentivise efficiency and quality. The aim of the Statewide Workforce and Activity-Based Funding Modelling Project in Queensland Emergency Departments (SWAMPED) is to identify and describe best practice Emergency Department (ED) workforce models within the current context of ED funding that operates under an ABF model. The study is comprised of five distinct phases. This monograph (Phase 1) comprises a systematic review of the literature that was completed in June 2013. The remaining phases include a detailed survey of Queensland hospital EDs’ resource levels, activity and operational models of care, development of new resource models, development of a user-friendly modelling interface for ED mangers, and production of a final report that identifies policy implications. The anticipated deliverable outcome of this research is the development of an ABF based Emergency Workforce Modelling Tool that will enable ED managers to profile both their workforce and operational models of care. Additionally, the tool will assist with the ability to more accurately inform adequate staffing numbers required in the future, inform planning of expected expenditures and be used for standardisation and benchmarking across similar EDs. Summary of the Findings Within the remit of this review of the literature, the main findings include: 1. EDs are becoming busier and more congested Rising demand, barriers to ED throughput and transitions of care all contribute to ED congestion. In addition requests by organisational managers and the community require continued broadening of the scope of services required of the ED and further increases in demand. As the population live longer with more lifestyle diseases their propensity to require ED care continues to grow. 2. Various models of care within EDs exist Models often vary to account for site specific characteritics to suit staffing profile, ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Existing and new models implemented within EDs often depend on the target outcome requiring change. Generally this is focussed on addressing issues at the input, throughput or output areas of the ED. Even with models targeting similar demographic or illness, the structure and process elements underpinning the model can vary, which can impact on outcomes and variance to the patient and carer experience between and within EDs. Major models of care to manage throughput inefficiencies include: A. Workforce Models of Care focus on the appropriate level of staffing for a given workload to provide prompt, timely and clinically effective patient care within an emergency care setting. The studies reviewed suggest that the early involvement of senior medical decision maker and/or specialised nursing roles such as Emergency Nurse Practitioners and Clinical Initiatives Nurse, primary contact or extended scope Allied Health Practitioners can facilitate patient flow and improve key indicators such as length of stay and reducing the number of those who did not wait to be seen amongst others. B. Operational Models of Care within EDs focus on mechanisms for streaming (e.g. fast-tracking) or otherwise grouping patient care based on acuity and complexity to assist with minimising any throughput inefficiencies. While studies support the positive impact of these models in general, it appears that they are most effective when they are adequately resourced. 3. Various methods of measuring ED activity exist Measuring ED activity requires careful consideration of models of care and staffing profile. Measuring activity requires the ability to account for factors including: patient census, acuity, LOS, intensity of intervention, department skill-mix plus an adjustment for non-patient care time. 4. Gaps in the literature Continued ED growth calls for new and innovative care delivery models that are safe, clinically effective and cost effective. New roles and stand-alone service delivery models are often evaluated in isolation without considering the global and economic impact on staffing profiles. Whilst various models of accounting for and measuring health care activity exist, costing studies and cost effectiveness studies are lacking for EDs making accurate and reliable assessments of care models difficult. There is a necessity to further understand, refine and account for measures of ED complexity that define a workload upon which resources and appropriate staffing determinations can be made into the future. There is also a need for continued monitoring and comprehensive evaluation of newly implemented workforce modelling tools. This research acknowledges those gaps and aims to: • Undertake a comprehensive and integrated whole of department workforce profiling exercise relative to resources in the context of ABF. • Inform workforce requirements based on traditional quantitative markers (e.g. volume and acuity) combined with qualitative elements of ED models of care; • Develop a comprehensive and validated workforce calculation tool that can be used to better inform or at least guide workforce requirements in a more transparent manner.

Extreme temperatures and paediatric emergency department admissions

Background Children are particularly vulnerable to the effects of extreme temperatures. Objective To examine the relationship between extreme temperatures and paediatric emergency department admissions (EDAs) in Brisbane, Australia, during 2003–2009. Methods A quasi-Poisson generalised linear model combined with a distributed lag non-linear model was used to examine the relationships between extreme temperatures and age-, gender- and cause-specific paediatric EDAs, while controlling for air pollution, relative humidity, day of the week, influenza epidemics, public holiday, season and long-term trends. The model residuals were checked to identify whether there was an added effect due to heat waves or cold spells. Results There were 131 249 EDAs among children during the study period. Both high (RR=1.27; 95% CI 1.12 to 1.44) and low (RR=1.81; 95% CI 1.66 to 1.97) temperatures were significantly associated with an increase in paediatric EDAs in Brisbane. Male children were more vulnerable to temperature effects. Children aged 0–4 years were more vulnerable to heat effects and children aged 10–14 years were more sensitive to both hot and cold effects. High temperatures had a significant impact on several paediatric diseases, including intestinal infectious diseases, respiratory diseases, endocrine, nutritional and metabolic diseases, nervous system diseases and chronic lower respiratory diseases. Low temperatures were significantly associated with intestinal infectious diseases, respiratory diseases and endocrine, nutritional and metabolic diseases. An added effect of heat waves on childhood chronic lower respiratory diseases was seen, but no added effect of cold spells was found. Conclusions As climate change continues, children are at particular risk of a variety of diseases which might be triggered by extremely high temperatures. This study suggests that preventing the effects of extreme temperature on children with respiratory diseases might reduce the number of EDAs.

Pulmonary embolism in the emergency department : a Singaporean nursing case review

Introduction The presentation of pulmonary embolism to the emergency department (ED) can prove challenging because of the myriad of potential disease processes that mimic its signs and symptoms. The incidence of pulmonary embolism and indeed the mortality associated with it is relatively high. Early diagnosis and treatment is crucial in off-setting the potential deleterious effects associated with this condition. The aim of this article is to present a nursing case review of a patient presenting to the ED with a diagnosis of pulmonary embolism. Method We chose to use a case review to highlight the nursing and medical care that was provided for a patient who presented to the emergency department acutely with dyspnoea, chest pain and pyrexia. The use of case reviews are useful in reporting unusual or rare cases and this format is typically seen more in medicine than in nursing. They can naturally take one of two formats—a single case report or a series of case reports; in this case we opted to report on a single case. Discussion The gentleman in question was an ambulance admissionto the ED with a three day history of chest pain, shortness of breath and one episode of syncope which brought him to the ED. Over the course of his admission a variety of treatment modalities were used successfully to alleviate the problem. More notable from a nursing perspective was the use of diagnostic tools as an interpretation to guide his care and provide a platform from which a deeper understanding and appreciation of the intricacies the critically ill patient often presents. Conclusion We found the use of case review very enlightening in understanding the disease process and the decision-making that accompanies this. Whilst our patient was successfully rehabilitated home, we learnt a lot from the experience which has been most beneficial in supporting our understanding of pulmonary embolism.

Use of hospital emergency departments by immigrants from non-English speaking backgrounds in Queensland

This study aimed to examine the use of hospital emergency departments and to investigate the level of satisfaction with the emergency department service among patients from a non-English-speaking background compared to those of patients from an English-speaking background in Queensland. The findings of this study might inform health professionals and policy planners to develop educational interventions and policies to ensure equitable use of emergency services among the populations.

Constrained control design for dynamic positioning of marine vehicles with control allocation

In this paper, we address the control design problem of positioning of over-actuated marine vehicles with control allocation. The proposed design is based on a combined position and velocity loops in a multi-variable anti-windup implementation together with a control allocation mapping. The vehicle modelling is considered with appropriate simplifications related to low-speed manoeuvring hydrodynamics and vehicle symmetry. The control design is considered together with a control allocation mapping. We derive analytical tuning rules based on requirements of closed-loop stability and performance. The anti- windup implementation of the controller is obtained by mapping the actuator-force constraint set into a constraint set for the generalized forces. This approach ensures that actuation capacity is not violated by constraining the generalized control forces; thus, the control allocation is simplified since it can be formulated as an unconstrained problem. The mapping can also be modified on-line based on actuator availability to provide actuator-failure accommodation. We provide a proof of the closed-loop stability and illustrate the performance using simulation scenarios for an open-frame underwater vehicle.

A survey of control allocation methods for underwater vehicles

A control allocation system implements a function that maps the desired control forces generated by the vehicle motion controller into the commands of the different actuators. In this article, a survey of control allocation methods for over-actuated underwater vehicles is presented. The methods are applicable for both surface vessels and underwater vehicles. The paper presents a survey of control allocation methods with focus on mathematical representation and solvability of thruster allocation problems. The paper is useful for university students and engineers who want to get an overview of state-of-the art control allocation methods as well as advance methods to solve more complex problems.

The impact of heatwaves on emergency department visits in Brisbane, Australia : a time series study

Introduction The acute health effects of heatwaves in a subtropical climate and their impact on emergency departments (ED) are not well known. The purpose of this study is to examine overt heat-related presentations to EDs associated with heatwaves in Brisbane. Methods Data were obtained for the summer seasons (December to February) from 2000-2012. Heatwave events were defined as two or more successive days with daily maximum temperature >=34[degree sign]C (HWD1) or >=37[degree sign]C (HWD2). Poisson generalised additive model was used to assess the effect of heatwaves on heat-related visits (International Classification of Diseases (ICD) 10 codes T67 and X30; ICD 9 codes 992 and E900.0). Results Overall, 628 cases presented for heat-related illnesses. The presentations significantly increased on heatwave days based on HWD1 (relative risk (RR) = 4.9, 95% confidence interval (CI): 3.8, 6.3) and HWD2 (RR = 18.5, 95% CI: 12.0, 28.4). The RRs in different age groups ranged between 3-9.2 (HWD1) and 7.5-37.5 (HWD2). High acuity visits significantly increased based on HWD1 (RR = 4.7, 95% CI: 2.3, 9.6) and HWD2 (RR = 81.7, 95% CI: 21.5, 310.0). Average length of stay in ED significantly increased by >1 hour (HWD1) and >2 hours (HWD2). Conclusions Heatwaves significantly increase ED visits and workload even in a subtropical climate. The degree of impact is directly related to the extent of temperature increases and varies by socio-demographic characteristics of the patients. Heatwave action plans should be tailored according to the population needs and level of vulnerability. EDs should have plans to increase their surge capacity during heatwaves.

Port-Hamiltonian control of fully actuated underwater vehicles

This chapter presents a novel control strategy for trajectory tracking of underwater marine vehicles that are designed using port-Hamiltonian theory. A model for neutrally buoyant underwater vehicles is formulated as a PHS, and then the tracking controller is designed for the horizontal plane-surge, sway and yaw. The control design is done by formulating the error dynamics as a set-point regulation port-Hamiltonian control problem. The control design is formulated in two steps. In the first step, a static-feedback tracking controller is designed, and the second step integral action is added. The global asymptotic stability of the closed loop system is proved and the performance of the controller is illustrated using a model of an open-frame offshore underwater vehicle.

Emergency powers and pandemics : federalism and the management of public health emergencies in Australia

Under the International Health Regulations 2005 Australia is obliged to develop a domestic framework designed to equip it to respond to public health emergencies. The legislative arrangements for the declaration of a public health emergency in Australia are complex, vary across state jurisdictions and intersect with other emergency powers. The task of harmonising laws and other arrangements within a federal system poses both challenges and opportunities for flexibility and choice. This article argues that Australia's current multi-strand and multi-level response provides a coordinated framework which also accommodates desirable levels of flexibility and choice.

Energy-based motion control of marine vehicles using interconnection and damping assignment passivity-based control : a survey

This paper reviews some recent results in motion control of marine vehicles using a technique called Interconnection and Damping Assignment Passivity-based Control (IDA-PBC). This approach to motion control exploits the fact that vehicle dynamics can be described in terms of energy storage, distribution, and dissipation, and that the stable equilibrium points of mechanical systems are those at which the potential energy attains a minima. The control forces are used to transform the closed-loop dynamics into a port-controlled Hamiltonian system with dissipation. This is achieved by shaping the energy-storing characteristics of the system, modifying its interconnection structure (how the energy is distributed), and injecting damping. The end result is that the closed-loop system presents a stable equilibrium (hopefully global) at the desired operating point. By forcing the closed-loop dynamics into a Hamiltonian form, the resulting total energy function of the system serves as a Lyapunov function that can be used to demonstrate stability. We consider the tracking and regulation of fully actuated unmanned underwater vehicles, its extension to under-actuated slender vehicles, and also manifold regulation of under-actuated surface vessels. The paper is concluded with an outlook on future research.

Energy-based positioning control of underactuated vehicles using manifold regulation

In this paper, we consider the problem of position regulation of a class of underactuated rigid-body vehicles that operate within a gravitational field and have fully-actuated attitude. The control objective is to regulate the vehicle position to a manifold of dimension equal to the underactuation degree. We address the problem using Port-Hamiltonian theory, and reduce the associated matching PDEs to a set of algebraic equations using a kinematic identity. The resulting method for control design is constructive. The point within the manifold to which the position is regulated is determined by the action of the potential field and the geometry of the manifold. We illustrate the performance of the controller for an unmanned aerial vehicle with underactuation degree two-a quadrotor helicopter.

Expanding Emergency Department capacity : a multisite study

Objectives: To i) identify predictors of admission, and ii) describe outcomes for patients who arrived via ambulance to three Australian public Emergency Departments (EDs), before and after the opening of 41 additional ED beds within the area. Methods: A retrospective, comparative, cohort study using deterministically linked health data collected between 3 September 2006 and 2 September 2008. Data included ambulance offload delay, time to see doctor, ED length of stay (ED LOS), admission requirement, access block, hospital length of stay and in-hospital mortality. Logistic regression analysis was undertaken to identify predictors of hospital admission. Results: One third of all 286,037 ED presentations were via ambulance (n= 79,196) and 40.3% required admission. After increasing emergency capacity, the only outcome measure to improve was in-hospital mortality. Ambulance offload delay, time to see doctor, ED length of stay (ED LOS), admission requirement, access block, hospital length of stay did not improve. Strong predictors of admission before and after increased capacity included: age over 65 years, Australian Triage Scale (ATS) category 1-3, diagnoses of circulatory or respiratory conditions and ED LOS > 4 hours. With additional capacity the odds ratios for these predictors increased for age >65 and ED LOS > 4 hours and decreased for triage category and ED diagnoses. Conclusions: Expanding ED capacity from 81 to 122 beds within a health service area impacted favourably on mortality outcomes but not on time-related service outcomes such as ambulance offload time, time to see doctor and ED LOS. To improve all service outcomes, when altering (increasing/decreasing) ED bed numbers, the whole healthcare system needs to be considered.

Manoeuvring control of fully-actuated marine vehicles : a Port-Hamiltonian system approach to tracking

This paper presents a novel control strategy for trajectory tracking of marine vehicles manoeuvring at low speed. The model of the marine vehicle is formulated as a Port-Hamiltonian system, and the tracking controller is designed using energy shaping and damping assignment. The controller guarantees global asymptotic stability and includes integral action for output variables with relative degree greater than one.

Comparison of high sensitivity troponin T and I assays in the diagnosis of non-ST elevation acute myocardial infarction in emergency patients with chest pain

Objectives: Concentrations of troponin measured with high sensitivity troponin assays are raised in a number of emergency department (ED) patients; however many are not diagnosed with acute myocardial infarction (AMI). Clinical comparisons between the early use (2 h after presentation) of high sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) assays for the diagnosis of AMI have not been reported. Design and methods: Early (0 h and 2 h) hs-cTnT and hs-cTnI assay results in 1571 ED patients with potential acute coronary syndrome (ACS) without ST elevation on electrocardiograph (ECG) were evaluated. The primary outcome was diagnosis of index MI adjudicated by cardiologists using the local cTnI assay results taken ≥6 h after presentation, ECGs and clinical information. Stored samples were later analysed with hs-cTnT and hs-cTnI assays. Results: The ROC analysis for AMI (204 patients; 13.0%) for hs-cTnT and hs-cTnI after 2 h was 0.95 (95% CI: 0.94–0.97) and 0.98 (95% CI: 0.97–0.99) respectively. The sensitivity, specificity, PLR, and NLR of hs-cTnT and hs-cTnI for AMI after 2 h were 94.1% (95% CI: 90.0–96.6) and 95.6% (95% CI: 91.8–97.7), 79.0% (95% CI: 76.8–81.1) and 92.5% (95% CI: 90.9–93.7), 4.48 (95% CI: 4.02–5.00) and 12.86 (95% CI: 10.51–15.31), and 0.07 (95% CI: 0.04–0.13) and 0.05 (95% CI:0.03–0.09) respectively. Conclusions: Exclusion of AMI 2 h after presentation in emergency patients with possible ACS can be achieved using hs-cTnT or hs-cTnI assays. Significant differences in specificity of these assays are relevant and if using the hs-cTnT assay, further clinical assessment in a larger proportion of patients would be required.