A systematic review of triage-related interventions to improve patient flow in emergency departments

Background Overcrowding in emergency departments is a worldwide problem. A systematic literature review was undertaken to scientifically explore which interventions improve patient flow in emergency departments. Methods A systematic literature search for flow processes in emergency departments was followed by assessment of relevance and methodological quality of each individual study fulfilling the inclusion criteria. Studies were excluded if they did not present data on waiting time, length of stay, patients leaving the emergency department without being seen or other flow parameters based on a nonselected material of patients. Only studies with a control group, either in a randomized controlled trial or in an observational study with historical controls, were included. For each intervention, the level of scientific evidence was rated according to the GRADE system, launched by a WHO-supported working group. Results The interventions were grouped into streaming, fast track, team triage, point-of-care testing (performing laboratory analysis in the emergency department), and nurse-requested x-ray. Thirty-three studies, including over 800,000 patients in total, were included. Scientific evidence on the effect of fast track on waiting time, length of stay, and left without being seen was moderately strong. The effect of team triage on left without being seen was relatively strong, but the evidence for all other interventions was limited or insufficient. Conclusions Introducing fast track for patients with less severe symptoms results in shorter waiting time, shorter length of stay, and fewer patients leaving without being seen. Team triage, with a physician in the team, will probably result in shorter waiting time and shorter length of stay and most likely in fewer patients leaving without being seen. There is only limited scientific evidence that streaming of patients into different tracks, performing laboratory analysis in the emergency department or having nurses to request certain x-rays results in shorter waiting time and length of stay.

Constructive alignment in Computer Engineering and Informatics departments at Dalarna University : An empirical investigation

Background: Constructive alignment (CA) is a pedagogical approach that emphasizes the alignment between the intended learning outcomes (ILOs), teaching and learning activities (TLAs) and assessment tasks (ATs) as well as creation of a teaching/learning environment where students will be able to actively create their knowledge. Objectives: This paper aims at investigating the extent of constructively-aligned courses in Computer Engineering and Informatics department at Dalarna University, Sweden. This study is based on empirical observations of teacher’s perceptions of implementation of CA in their courses. Methods: Ten teachers (5 from each department) were asked to fill a paper-based questionnaire, which included a number of questions related to issues of implementing CA in courses. Results: Responses to the items of the questionnaire were mixed. Teachers clearly state the ILOs in their courses and try to align the TLAs and ATs to the ILOs. Computer Engineering teachers do not explicitly communicate the ILOs to the students as compared to Informatics teachers. In addition, Computer Engineering teachers stated that their students are less active in learning activities as compared to Informatics teachers. When asked about their subjective ratings of teaching methods all teachers stated that their current teaching is teacher-centered but they try to shift the focus of activity from them to the students. Conclusions: From teachers’ perspectives, the courses are partially constructively-aligned. Their courses are “aligned”, i.e. ILOs, TLAs and ATs are aligned to each other but they are not “constructive” since, according to them, there was a low student engagement in learning activities, especially in Computer Engineering department.

Analysis of quality indicators of central sterile supply departments at accredited public hospitals

O objetivo do estudo foi descrever e analisar os indicadores de qualidade de Centros de Material e Esterilização de hospitais públicos acreditados do Estado de São Paulo e sua gestão pelos responsáveis do setor. Trata-se de um estudo de casos múltiplos, onde são apresentados os dados interligados de três hospitais acreditados num relatório de casos cruzados. Os dados foram coletados por entrevista semiestruturada com o responsável e por visita técnica com análise documental. Os resultados constatam a dificuldade dos responsáveis em pontuar os indicadores específicos do setor e os referidos foram os de produção e pesquisa de satisfação do cliente que não retratam a qualidade efetiva do serviço, pois são fragmentados, sem consolidação de resultados na busca de melhorias, o que sugere baixa especificidade e baixa sensibilidade dos critérios da Organização Nacional de Acreditação à realidade deste setor.

A Study of Interdisciplinary Research Needs: Results from Input of Faculty in Six Engineering Departments in Prioritizing Serial Subscriptions

Baldwin, Virginia (2003) "A Study of Interdisciplinary Research Needs: Results from Input of Faculty in Six Engineering Departments in Prioritizing Serial Subscriptions," American Society for Engineering Education Conference, June 23, 2003, Nashville, TN,

Describing some of the Dimensions that comprise the Profile of the Faculty Staff of Statistics Departments in Brazil

Statistics is a required course in virtually all undergraduate programs in Brazilian universities. In addition, undergraduate programs in Statistics are offered in many public universities. However, despite the importance of this science, there are no systematic studies in the national literature regarding the characterization of the faculty staff, which is responsible for the teaching of statistics in the country. In this context, this paper presents a description of the faculty members of undergraduate courses in Statistics. This description was based on a descriptive sample, related to aspects of their education and scientific production. A prediction of future demand for PhDs in Statistics to fill the vacancies is also provided based on the retirement of faculty members in undergraduate courses in Statistics in the country.

Outcome and patients' satisfaction after functional treatment of acute lateral ankle injuries at emergency departments versus family doctor offices

BACKGROUND: In some Western countries, more and more patients seek initial treatment even for minor injuries at emergency units of hospitals. The initial evaluation and treatment as well as aftercare of these patients require large amounts of personnel and logistical resources, which are limited and costly, especially if compared to treatment by a general practitioner. In this study, we investigated whether outsourcing from our level 1 trauma center to a general practitioner has an influence on patient satisfaction and compliance. METHODS: This prospective, randomized study, included n = 100 patients who suffered from a lateral ankle ligament injury grade I-II (16, 17). After radiological exclusion of osseous lesions, the patients received early functional treatment and were shown physical therapy exercises to be done at home, without immobilization or the use of stabilizing ortheses. The patients were randomly assigned into two groups of 50 patients each: Group A (ER): Follow-up and final examination in the hospital's emergency unit. Group B (GP): Follow-up by general practitioner, final examination at hospital's emergency unit. The patients were surveyed regarding their satisfaction with the treatment and outcome of the treatment. RESULTS: Female and male patients were equally represented in both groups. The age of the patients ranged from 16 - 64 years, with a mean age of 34 years (ER) and 35 years (GP). 98% (n = 98) of all patients were satisfied with their treatment, and 93% (n = 93) were satisfied with the outcome. For these parameters no significant difference between the two groups could be noted (p = 0.7406 and 0.7631 respectively). 39% of all patients acquired stabilizing ortheses like ankle braces (Aircast, Malleoloc etc.) on their own initiative. There was a not significant tendency for more self-acquired ortheses in the group treated by general practicioners (p = 0,2669). CONCLUSION: Patients who first present at the ER with a lateral ankle ligament injury grade I-II can be referred to a general practitioner for follow-up treatment without affecting patient satisfaction regarding treatment and treatment outcome.

Quality in emergency departments: a study on 3,285,440 admissions

INTRODUCTION: A multi-centre study has been conducted, during 2005, by means of a questionnaire posted on the Italian Society of Emergency Medicine (SIMEU) web page. Our intention was to carry out an organisational and functional analysis of Italian Emergency Departments (ED) in order to pick out some macro-indicators of the activities performed. Participation was good, in that 69 ED (3,285,440 admissions to emergency services) responded to the questionnaire. METHODS: The study was based on 18 questions: 3 regarding the personnel of the ED, 2 regarding organisational and functional aspects, 5 on the activity of the ED, 7 on triage and 1 on the assessment of the quality perceived by the users of the ED. RESULTS AND CONCLUSION: The replies revealed that 91.30% of the ED were equipped with data-processing software, which, in 96.83% of cases, tracked the entire itinerary of the patient. About 48,000 patients/year used the ED: 76.72% were discharged and 18.31% were hospitalised. Observation Units were active in 81.16% of the ED examined. Triage programmes were in place in 92.75% of ED: in 75.81% of these, triage was performed throughout the entire itinerary of the patient; in 16.13% it was performed only symptom-based, and in 8.06% only on-call. Of the patients arriving at the ED, 24.19% were assigned a non-urgent triage code, 60.01% a urgent code, 14.30% a emergent code and 1.49% a life-threatening code. Waiting times were: 52.39 min for non-urgent patients, 40.26 min for urgent, 12.08 for emergent, and 1.19 for life-threatening patients.

State of Emergency Medicine in Switzerland: a national profile of emergency departments in 2006

BACKGROUND Emergency departments (EDs) are an essential component of any developed health care system. There is, however, no national description of EDs in Switzerland. Our objective was to establish the number and location of EDs, patient visits and flow, medical staff and organization, and capabilities in 2006, as a benchmark before emergency medicine became a subspecialty in Switzerland. METHODS In 2007, we started to create an inventory of all hospital-based EDs with a preliminary list from the Swiss Society of Emergency and Rescue Medicine that was improved with input from ED physicians nationwide. EDs were eligible if they offered acute care 24 h per day, 7 days per week. Our goal was to have 2006 data from at least 80% of all EDs. The survey was initiated in 2007 and the 80% threshold reached in 2012. RESULTS In 2006, Switzerland had a total of 138 hospital-based EDs. The number of ED visits was 1.475 million visits or 20 visits per 100 inhabitants. The median number of visits was 8,806 per year; 25% of EDs admitted 5,000 patients or less, 31% 5,001-10,000 patients, 26% 10,001-20,000 patients, and 17% >20,000 patients per year. Crowding was reported by 84% of EDs with >20,000 visits/year. Residents with limited experience provided care for 77% of visits. Imaging was not immediately available for all patients: standard X-ray within 15 min (70%), non-contrast head CT scan within 15 min (38%), and focused sonography for trauma (70%); 67% of EDs had an intensive care unit within the hospital, and 87% had an operating room always available. CONCLUSIONS Swiss EDs were significant providers of health care in 2006. Crowding, physicians with limited experience, and the heterogeneity of emergency care capabilities were likely threats to the ubiquitous and consistent delivery of quality emergency care, particularly for time-sensitive conditions. Our survey establishes a benchmark to better understand future improvements in Swiss emergency care.

Can geriatric approaches support the care of old patients in emergency departments? A review from a Swiss ED

In the coming decades, old patients will account for an increasing proportion of emergency department (ED) visits. During or after their stay in the ED, they more frequently suffer adverse outcomes than younger patients. There is evidence that specific age-centred approaches improve the outcomes. We therefore reviewed specific conditions needing particular attention in older ED patients, such as cognitive disorders and delirium, impaired mobility and falls, as well as problems related to the activities of daily living, disability, poly-pharmacy, adverse drug effects, co-morbidity and atypical presentation. We also propose steps to further improve the quality of care in older ED patients by using appropriate age-centred management.

Patient Safety Alert : A new way to share patient safety information among departments and units

Communication : If there is one topic that comes up over and over again as we discuss ways to make John Dempsey Hospital the safest hospital, it is “communication.” In fact, several of the 2006 and 2007 National Patient Safety Goals are centered around improving the effectiveness of communication among caregivers. There are many ways of doing this, and we have implemented several already. These include handoffs, medication reconciliation, “SBAR,” etc. On page two, we will talk in more detail about hand-offs and the use of “SBAR.”

A model for use by local public health departments to evaluate pandemic influenza plans

The events of the 1990's and early 2000's demonstrated the need for effective planning and response to natural and man-made disasters. One of those potential natural disasters is pandemic flu. Once defined, the CDC stated that program, or plan, effectiveness is improved through the process of program evaluation. (Centers for Disease Control and Prevention, 1999) Program evaluation should be accomplished not only periodically, but in the course of routine administration of the program. (Centers for Disease Control and Prevention, 1999) Accomplishing this task for a "rare, but significant event" is challenging. (Herbold, John R., PhD., 2008) To address this challenge, the RAND Corporation (under contract to the CDC) developed the "Facilitated Look-Backs" approach that was tested and validated at the state level. (Aledort et al., 2006).^ Nevertheless, no comprehensive and generally applicable pandemic influenza program evaluation tool or model is readily found for use at the local public health department level. This project developed such a model based on the "Facilitated Look-Backs" approach developed by RAND Corporation. (Aledort et al., 2006) Modifications to the RAND model included stakeholder additions, inclusion of all six CDC program evaluation steps, and suggestions for incorporating pandemic flu response plans in seasonal flu management implementation. Feedback on the model was then obtained from three LPHD's—one rural, one suburban, and one urban. These recommendations were incorporated into the final model. Feedback from the sites also supported the assumption that this model promotes the effective and efficient evaluation of both pandemic flu and seasonal flu response by reducing redundant evaluations of pandemic flu plans, seasonal flu plans, and funding requirement accountability. Site feedback also demonstrated that the model is comprehensive and flexible, so it can be adapted and applied to different LPHD needs and settings. It also stimulates evaluation of the major issues associated with pandemic flu planning. ^ The next phase in evaluating this model should be to apply it in a program evaluation of one or more LPHD's seasonal flu response that incorporates pandemic flu response plans.^

America's state health departments and the enhancement of health communication through podcasting

Perhaps it was foreshadowing the influence emerging technologies would have on health when the term "podcast" beat out "bird flu" for the 2005 word of the year, an honor given by The New Oxford American Dictionary. From medical school courses to medical journal summaries, podcasting has found a niche in the health field and with studies showing a high proportion of people using the Internet to seek health information, it is imperative that the online information be accurate and easily accessible. With the responsibility of health departments to reach out to their respective communities with effective health communication strategies, this study assessed the proportion of 50 states' and the District of Columbia's health departments utilizing podcasting as a tool for health communication. Additionally, to assess any trends, the prevalence of podcasting was compared to select state demographic characteristics (age, sex, and median income), the organization of the health department (freestanding or super-agency), and the respective United Health Foundation 2007 health ranking. ^ Prevalence data were collected from each state health department's website to find evidence of podcasting to any extent. If a podcast was present, characteristics including creator, release frequency, and transcript were further assessed. The study found that 51% (26/51) of all health departments were utilizing podcasts in some capacity and almost 20% (5/26) of these had created their own podcasts. The most common use of podcasting was to link to outside podcast resources, most notably, the Centers for Disease Control's podcast series. No significant associations were found between the state-specific variables and the podcasting outcomes; however, higher percentages of young adults in some states suggest potential podcasting opportunities for targeting these known podcast users with age-specific health messages. Another recommendation is a future assessment of local health departments' use of podcasting as their smaller, more defined target audiences may be a more efficient use of podcasting as a health communication tool. Additionally, there is a need for evaluations of podcasts' overall effectiveness as a health communication tool to (1) reach a target audience; and (2) convey a specific health message. In conclusion, the findings from this project illuminate the extent of podcast influence in states' and the District of Columbia's health departments as a health communication tool; however evaluations of effectiveness are imperative for future studies.^