Engorgement des centres d'urgences: une raison légitime de refuser l'accès aux patients non urgents [Emergency department overcrowding: a legitimate reason to refuse access to urgent care for non-urgent patients?].

Non-urgent cases represent 30-40% of all ED consults; they contribute to overcrowding of emergency departments (ED), which could be reduced if they were denied emergency care. However, no triage instrument has demonstrated a high enough degree of accuracy to safely rule out serious medical conditions: patients suffering from life-threatening emergencies have been inappropriately denied care. Insurance companies have instituted financial penalties to discourage the use of ED as a source of non-urgent care, but this practice mainly restricts access for the underprivileged. More recent data suggest that in fact most patients consult for appropriate urgent reasons, or have no alternate access to urgent care. The safe reduction of overcrowding requires a reform of the healthcare system based on patients' needs rather than access barriers.

Understanding disparities in emergency department visits for asthma

Asthma is the most common chronic disorder in childhood, affecting an estimated 6.2 million children under 18 years (1). The purpose of this study was to look at individual- and community-level characteristics simultaneously to examine and explain the factors that contribute to the use of emergency department services by children 18 years old or less and to determine if there was an association between air quality and ED visits in the same population, from 2005-2007 in Houston/Harris County. Data were collected from the Houston Safety Net Hospital Emergency Department Use Study and the 2000 US Census. Bivariate and multivariate logistic regression models and mixed effects models were used to analyze data that was collected during the study period.^ There were 704,902 ED visits made by children 18 and younger, who were living in Houston from January 1, 2005 to December 31, 2007. Of those, 19,098 had a primary discharge diagnosis of asthma. Asthma ED visits varied by season, with proportions of ED visits for asthma highest from September-December. African-American children were 2.6 (95% CI, 2.43-2.66) times more likely to have an ED visit for asthma compared to White children. Poverty, single parent headed households, and younger age all a greater likelihood of having gone to the ED for asthma treatment. Compared to Whites living in lightly-monitored pollution areas, African-Americans and Hispanics living in heavily monitored areas were 1.15 (95% CI, 1.04-1.28) times more likely to have an ED visit for asthma.^ Race and poverty seem to account for a large portion of the disparities in ED use found among children. This was true even after accounting for multiple individual- and community-level variables. These results suggest that racial disparities in asthma continue to pose risks for African American children, and they point to the need for additional research into potential explanations and remedies. Programs to reduce inappropriate ED use must be sensitive to an array of complex socioeconomic issues within minority and income populations. ^

Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study

Background There has been considerable publicity regarding population ageing and hospital emergency department (ED) overcrowding. Our study aims to investigate impact of one intervention piloted in Queensland Australia, the Hospital in the Nursing Home (HiNH) program, on reducing ED and hospital attendances from residential aged care facilities (RACFs). Methods A quasi-experimental study was conducted at an intervention hospital undertaking the program and a control hospital with normal practice. Routine Queensland health information system data were extracted for analysis. Results Significant reductions in the number of ED presentations per 1000 RACF beds (rate ratio (95 % CI): 0.78 (0.67–0.92); p = 0.002), number of hospital admissions per 1000 RACF beds (0.62 (0.50–0.76); p < 0.0001), and number of hospital admissions per 100 ED presentations (0.61 (0.43–0.85); p = 0.004) were noticed in the experimental hospital after the intervention; while there were no significant differences between intervention and control hospitals before the intervention. Pre-test and post-test comparison in the intervention hospital also presented significant decreases in ED presentation rate (0.75 (0.65–0.86); p < 0.0001) and hospital admission rate per RACF bed (0.66 (0.54–0.79); p < 0.0001), and a non-significant reduction in hospital admission rate per ED presentation (0.82 (0.61–1.11); p = 0.196). Conclusions Hospital in the Nursing Home program could be effective in reducing ED presentations and hospital admissions from RACF residents. Implementation of the program across a variety of settings is preferred to fully assess the ongoing benefits for patients and any possible cost-savings.

Change to costs and lengths of stay in the emergency department and the Brisbane protocol: An observational study

- Objective To compare health service cost and length of stay between a traditional and an accelerated diagnostic approach to assess acute coronary syndromes (ACS) among patients who presented to the emergency department (ED) of a large tertiary hospital in Australia. - Design, setting and participants This historically controlled study analysed data collected from two independent patient cohorts presenting to the ED with potential ACS. The first cohort of 938 patients was recruited in 2008–2010, and these patients were assessed using the traditional diagnostic approach detailed in the national guideline. The second cohort of 921 patients was recruited in 2011–2013 and was assessed with the accelerated diagnostic approach named the Brisbane protocol. The Brisbane protocol applied early serial troponin testing for patients at 0 and 2 h after presentation to ED, in comparison with 0 and 6 h testing in traditional assessment process. The Brisbane protocol also defined a low-risk group of patients in whom no objective testing was performed. A decision tree model was used to compare the expected cost and length of stay in hospital between two approaches. Probabilistic sensitivity analysis was used to account for model uncertainty. - Results Compared with the traditional diagnostic approach, the Brisbane protocol was associated with reduced expected cost of $1229 (95% CI −$1266 to $5122) and reduced expected length of stay of 26 h (95% CI −14 to 136 h). The Brisbane protocol allowed physicians to discharge a higher proportion of low-risk and intermediate-risk patients from ED within 4 h (72% vs 51%). Results from sensitivity analysis suggested the Brisbane protocol had a high chance of being cost-saving and time-saving. - Conclusions This study provides some evidence of cost savings from a decision to adopt the Brisbane protocol. Benefits would arise for the hospital and for patients and their families.

Emergency department crowding: prioritising quantified crowding measures using a Delphi study.

AimsEmergency department (ED) crowding has been associated with a number of negative health outcomes, including unnecessary deaths, increased waiting times and a decrease in care quality. Despite the seriousness of this issue, there is little agreement on appropriate crowding measures to assess crowding effects on ED operations. The objective of this study was to prioritise a list of quantified crowding measures that would assess the current state of a department.MethodsA three round Delphi study was conducted via email and an Internet based survey tool. The panel consisted of 40 professionals who had exposure to and expertise in crowding. Participants submitted quantified crowding measures which, through three rounds, were evaluated and ranked to assess participant agreement for inclusion.ResultsThe panel identified 27 measures of which eight (29.6%) reached consensus at the end of the study. These measures comprised: (1) ability of ambulances to offload; (2) patients who leave without being seen or treated; (3) time until triage; (4) ED occupancy rate; (5) patients' total length of stay in the ED; (6) time to see a physician; (7) ED boarding time; and (8) number of patients boarding in the ED.ConclusionsThis study resulted in the identification of eight quantified crowding measures, which present a comprehensive view of how crowding is affecting ED operations, and highlighted areas of concern. These quantified measures have the potential to make a considerable contribution to decision making by ED management and to provide a basis for learning across different departments.

Emergency department triage revisited

Triage is a process that is critical to the effective management of modern emergency departments. Triage systems aim, not only to ensure clinical justice for the patient, but also to provide an effective tool for departmental organisation, monitoring and evaluation. Over the last 20 years, triage systems have been standardised in a number of countries and efforts made to ensure consistency of application. However, the ongoing crowding of emergency departments resulting from access block and increased demand has led to calls for a review of systems of triage. In addition, international variance in triage systems limits the capacity for benchmarking. The aim of this paper is to provide a critical review of the literature pertaining to emergency department triage in order to inform the direction for future research. While education, guidelines and algorithms have been shown to reduce triage variation, there remains significant inconsistency in triage assessment arising from the diversity of factors determining the urgency of any individual patient. It is timely to accept this diversity, what is agreed, and what may be agreeable. It is time to develop and test an International Triage Scale (ITS) which is supported by an international collaborative approach towards a triage research agenda. This agenda would seek to further develop application and moderating tools and to utilise the scales for international benchmarking and research programmes.

Evaluating the effect of a patient education brochure on patients’ expectations and satisfaction with emergency department service

Introduction: The purpose of this study was to assess the capacity of a written intervention, in this case a patient information brochure, to improve patient satisfaction during an Emergency Department (ED) visit. For the purpose of measuring the effect of the intervention the ED journey was conceptualised as a series of distinct areas of service comprising waiting time, service by the triage nurse, care from doctors and nurses and information giving Background of study: Research into patient satisfaction has become a widespread activity endorsed by both governments and hospital administrations. The literature on ED patient satisfaction has consistently indicated three primary areas of patient dissatisfaction: waiting time, nursing care and communication. Recent developments in the literature on patient satisfaction studies however have highlighted the relationship between patients. expectations of a service encounter and their consequent assessment of the experience as dissatisfying or satisfying. Disconfirmation theory posits that the degree to which expectations are confirmed will affect subsequent levels of satisfaction. The conceptual framework utilised in this study is Coye.s (2004) model of disconfirmation. Coye while reiterating satisfaction is a consequence of the degree expectations are either confirmed or disconfirmed also posits that expectations can be modified by interventions. Coye.s work conceptualises these interventions as intra encounter experiences (cues) which function to adjust expectations. Coye suggests some cues are unintended and may have a negative impact which also reinforces the value of planned cues intended to meet or exceed consumer expectations. Consequently the brochure can be characterized as a potentially positive cue, encouraging the patient to understand processes and to orient them in what can be a confronting environment. Only a limited number of studies have examined the effect of written interventions within an ED. No studies could be located which have tested the effect of ED interventions using a conceptual framework which relates the effect of the degree to which expectations are confirmed or disconfirmed in terms of satisfaction with services. Method: Two studies were conducted. Study One used qualitative methods to explore patients. expectations of the ED from the perspective of both patients and health care professionals. Study One was used in part to direct the development of the intervention (brochure) in Study Two. The brochure was an intervention designed to modify patients. expectations thus increasing their satisfaction with the provision of ED service. As there was no existing tools to measure ED patients. expectations and satisfaction a new tool was also developed based on the findings and the literature of Study One. Study Two used a non-randomised, quasi-experimental approach using a non-equivalent post-test only comparison group design used to investigate the effect of the patient education brochure (Stommel and Wills, 2004). The brochure was disseminated to one of two study groups (the intervention group). The effect of the brochure was assessed by comparing the data obtained from both the intervention and control group. These two groups consisted of 150 participants each. It was expected that any differences in the relevant domains selected for examination would indicate the effect of the brochure both on expectation and potentially satisfaction. Results: Study One revealed several areas of common ground between patients and nurses in terms of relevant content for the written intervention, including the need for information on the triage system and waiting times. Areas of difference were also found with patients emphasizing communication issues, whereas focus group members expressed concern that patients were often unable to assimilate verbal information. The findings suggested the potential utility of written material to reinforce verbal communication particularly in terms of the triage process and other ED protocols. This material was synthesized within the final version of the written intervention. Overall the results of Study Two indicated no significant differences between the two groups. The intervention group did indicate a significant number of participants who viewed the brochure of having changed their expectations. The effect of the brochure may have been obscured by a lack of parity between the two groups as the control group presented with statistically significantly higher levels of acuity and experienced significantly shorter waiting times. In terms of disconfirmation theory this would suggest expectations that had been met or exceeded. The results confirmed the correlation of expectations with satisfaction. Several domains also indicated age as a significant predictor with older patients tending to score higher satisfaction results. Other significant predictors of satisfaction established were waiting time and care from nurses, reinforcing the combination of efficient service and positive interpersonal experiences as being valued by patients. Conclusions: Information presented in written form appears to benefit a significant number of ED users in terms of orientation and explaining systems and procedures. The degree to which these effects may interact with other dimensions of satisfaction however is likely to be limited. Waiting time and interpersonal behaviours from staff also provide influential cues in determining satisfaction. Written material is likely to be one element in a series of coordinated strategies to improve patient satisfaction during periods of peak demand.

Implementing an emergency department patient admission predictive tool : insights from practice

Purpose: This paper aims to show that identification of expectations and software functional requirements via consultation with potential users is an integral component of the development of an emergency department patient admissions prediction tool. ---------- Design/methodology/approach: Thematic analysis of semi-structured interviews with 14 key health staff delivered rich data regarding existing practice and future needs. Participants included emergency department staff, bed managers, nurse unit managers, directors of nursing, and personnel from health administration. ---------- Findings: Participants contributed contextual insights on the current system of admissions, revealing a culture of crisis, imbued with misplayed communication. Their expectations and requirements of a potential predictive tool provided strategic data that moderated the development of the Emergency Department Patient Admissions Prediction Tool, based on their insistence that it feature availability, reliability and relevance. In order to deliver these stipulations, participants stressed that it should be incorporated, validated, defined and timely. ---------- Research limitations/implications: Participants were envisaging a concept and use of a tool that was somewhat hypothetical. However, further research will evaluate the tool in practice. ---------- Practical implications: Participants' unsolicited recommendations regarding implementation will not only inform a subsequent phase of the tool evaluation, but are eminently applicable to any process of implementation in a healthcare setting. ---------- Originality/value: The consultative process engaged clinicians and the paper delivers an insider view of an overburdened system, rather than an outsider's observations.

Quality of child abuse information in emergency department injury surveillance data : linking hospital and child welfare data

Emergency departments (EDs) are often the first point of contact with an abused child. Despite legal mandate, the reporting of definite or suspected abusive injury to child safety authorities by ED clinicians varies due to a number of factors including training, access to child safety professionals, departmental culture and a fear of ‘getting it wrong’. This study examined the quality of documentation and coding of child abuse captured by ED based injury surveillance data and ED medical records in the state of Queensland and the concordance of these data with child welfare records. A retrospective medical record review was used to examine the clinical documentation of almost 1000 injured children included in the Queensland Injury Surveillance Unit database (QISU) from 10 hospitals in urban and rural centres. Independent experts re-coded the records based on their review of the notes. A data linkage methodology was then used to link these records with records in the state government’s child welfare database. Cases were sampled from three sub-groups according to the surveillance intent codes: Maltreatment by parent, Undetermined and Unintentional injury. Only 0.1% of cases coded as unintentional injury were recoded to maltreatment by parent, while 1.2% of cases coded as maltreatment by parent were reclassified as unintentional and 5% of cases where the intent was undetermined by the triage nurse were recoded as maltreatment by parent. Quality of documentation varied across type of hospital (tertiary referral centre, children’s, urban, regional and remote). Concordance of health data with child welfare data varied across patient subgroups. Outcomes from this research will guide initiatives to improve the quality of intentional child injury surveillance systems.

Barriers to information transfer for multi-trauma patients upon discharge from the Emergency Department in a tertiary level hospital

Purpose: Communication is integral to effective trauma care provision. This presentation will report on barriers to meaningful information transfer for multi-trauma patients upon discharge from the Emergency Department (ED) to the care areas of Intensive Care Unit, High Dependency Unit, and Perioperative Services. This is an ongoing study at one tertiary level hospital in Queensland. Method: This is a multi-phase, mixed method study. In Phase 1 data were collected about information transfer. This Phase was initially informed by a comprehensive literature review, then via focus groups, chart audit, staff survey and review of national and international trauma forms. Results: The barriers identified related to nursing handover, documented information, time inefficiency, patient complexity and stability and time of transfer. Specifically this included differences in staff expectations and variation in the nursing handover processes, no agreed minimum dataset of information handed over, missing, illegible or difficult to find information in documentation (both medical and nursing), low compliance with some forms used for documentation. Handover of these patients is complex with information coming from many sources, dealing with issues is more difficult for these patients when transferred out of hours. Conclusions and further directions: This study investigated the current communication processes and standards of information transfer to identify barriers and issues. The barriers identified were the structure used for documentation, processes used (e.g. handover), patient acuity and time. This information is informing the development, implementation and evaluation of strategies to ameliorate the issues identified.

The development of chronic cough in children following presentation to a tertiary paediatric emergency department with acute respiratory illness : study protocol for a prospective cohort study

Background Acute respiratory illness, a leading cause of cough in children, accounts for a substantial proportion of childhood morbidity and mortality worldwide. In some children acute cough progresses to chronic cough (> 4 weeks duration), impacting on morbidity and decreasing quality of life. Despite the importance of chronic cough as a cause of substantial childhood morbidity and associated economic, family and social costs, data on the prevalence, predictors, aetiology and natural history of the symptom are scarce. This study aims to comprehensively describe the epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children presenting to a tertiary paediatric emergency department. Methods/design A prospective cohort study of children aged <15 years attending the Royal Children's Hospital Emergency Department, Brisbane, for a respiratory illness that includes parent reported cough (wet or dry) as a symptom. The primary objective is to determine the prevalence and predictors of chronic cough (>= 4 weeks duration) post presentation with acute respiratory illness. Demographic, epidemiological, risk factor, microbiological and clinical data are completed at enrolment. Subjects complete daily cough dairies and weekly follow-up contacts for 28(+/-3) days to ascertain cough persistence. Children who continue to cough for 28 days post enrolment are referred to a paediatric respiratory physician for review. Primary analysis will be the proportion of children with persistent cough at day 28(+/-3). Multivariate analyses will be performed to evaluate variables independently associated with chronic cough at day 28(+/-3). Discussion Our protocol will be the first to comprehensively describe the natural history, epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children. The results will contribute to studies leading to the development of evidence-based clinical guidelines to improve the early detection and management of chronic cough in children during and after acute respiratory illness.

A needle in a haystack : the use of routinely collected emergency department injury surveillance data to help identify physical child abuse

A retrospective, descriptive analysis of a sample of children under 18 years presenting to a hospital emergency department (ED) for treatment of an injury was conducted. The aim was to explore characteristics and identify differences between children assigned abuse codes and children assigned unintentional injury codes using an injury surveillance database. Only 0.1% of children had been assigned the abuse code and 3.9% a code indicating possible abuse. Children between 2-5 years formed the largest proportion of those coded to abuse. Superficial injury and bruising were the most common types of injury seen in children in the abuse group and the possible abuse group (26.9% and 18.8% respectively), whereas those with unintentional injury were most likely to present with open wounds (18.4%). This study demonstrates that routinely collected injury surveillance data can be a useful source of information for describing injury characteristics in children assigned abuse codes compared to those assigned no abuse codes.