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BackgroundThe physician in triage (PIT) strategy was implemented in the emergency department (ED) of the Soroka University Medical Center (SUMC) to improve overcrowding and waiting time. Our objective in the current study was to assess the impact of the PIT strategy on door-to-balloon time for the treatment of acute ST-elevation myocardial infarction (STEMI).MethodsThe PIT programme began on January 2016, working weekdays between 8:00 and 23:00 hours. We included patients who visited the ED and were diagnosed with STEMI, from November 2014 to February 2018. The primary outcome was improvement in door-to-balloon (D2B) time <90 min between the preintervention and postintervention period. The analysis included a comparison between the two time periods using univariate tests, a time trend analysis illustrated by the locally weighted scatterplot smoothing curves and a regression analysis using generalised estimating equation models. To determine the impact of the PIT, as opposed to other changes in the department, we stratified the population arriving after January 2016 to patients arriving during PIT hours versus patients arriving on weekends and at nights (23:00–8:00 hours).ResultsIn all, 415 patients met all the inclusion criteria of which 237 (57.1%) visited on weekdays 8:00–23:00 hours. The per cent of patients with D2B <90 min was 13.9% higher for postintervention versus preintervention visits (p=0.006). D2B time was significantly shorter by 9 min for postintervention visits (p=0.001). In the postintervention period, patients arriving between 8:00 and 23:00 hours on weekdays were more likely to have D2B <90 min than those arriving nights and weekends; 90/146 (61.6%) vs 47.2% (51/108), respectively, p=0.02. ORs for D2B <90 min was 2.04 (95% CI 1.06 to 3.91) for weekday visits, and 1.90 (0.88 to 4.12) for weekend and night visits.ConclusionThe PIT model in SUMC is associated with D2B reduction for patients with STEMI. To achieve further reduction, both targeted interventions should be performed and PIT strategy should be applied for full time, including nights and weekends.

ObjectiveIt is often asserted that the crowding phenomenon in emergency departments (ED) can be explained by an increase in visits considered as non-urgent. The aim of our study was to quantify the increase in ED visit rates and to determine whether this increase was explained by non-severe visit types.MethodsThis observational study covers all ED visits between 2002 and 2015 by adult inhabitants of the Midi-Pyrénées region in France. Their characteristics were collected from the emergency visit summaries. We modelled the visit rates per year using linear regression models, and an increase was considered significant when the 95% CIs did not include zero. The severity of the patients’ condition during ED visit was determined through the ‘Clinical Classification of Emergency’ score. Non-severe visits were those where the patient was stable, and the physician deemed no intervention necessary. Intermediate-severity visits concerned patients who were stable but requiring diagnostic or therapeutic procedures.ResultsThe 37 studied EDs managed >7 million visits between 2002 and 2015. There was an average increase of +4.83 (95% CI 4.33 to 5.32) visits per 1000 inhabitants each year. The increase in non-severe visit types was +0.88 (95% CI 0.42 to 1.34) per 1000 inhabitants, while the increase in intermediate-severity visit types was +3.26 (95% CI 2.62 to 3.91) per 1000 inhabitants. This increase affected all age groups and all sexes.DiscussionIt appears that the increase in ED use is not based on an increase in non-severe visit types, with a greater impact of intermediate-severity visit types requiring diagnostic or therapeutic procedures in ED.

BackgroundFor several years, EDs in the UK NHS have faced considerable increases in attendance rates. Walk-in centres (WiCs) and minor injuries units (MIUs) have been suggested as solutions. We aimed to investigate the associations between practice and practice population characteristics with ED attendance rates or combined ED/WiC/MIU attendance, and the associations between WiC/MIU and ED attendance.MethodsWe used general practice-level data including 7462 English practices in 2012/2013 and present adjusted regression coefficients from linear multivariable analysis for relationships between patients' emergency attendance rates and practice characteristics.ResultsEvery percentage-point increase in patients reporting inability to make an appointment was associated with an increase in emergency attendance by 0.36 (95% CI 0.06 to 0.66) per 1000 population. Percentage-point increases in patients unable to speak to a general practitioner (GP)/nurse within two workdays and patients able to speak often to their preferred GP were associated with increased emergency attendance/1000 population by 0.23 (95% CI 0.05 to 0.42) and 0.10 (95% CI 0.00 to 0.19), respectively. Practices in areas encompassing several towns (conurbations) had higher attendance than rural practices, as did practices with more non-UK-qualified GPs. Practice population characteristics associated with increased emergency attendance included higher unemployment rates, higher percentage of UK whites and lower male life expectancy, which showed stronger associations than practice characteristics. Furthermore, higher MIU or WiC attendance rates were associated with lower ED attendance rates.ConclusionsImproving availability of appointments and opportunities to speak a GP/nurse at short notice might reduce ED attendance. Establishing MIUs and WiCs might also reduce ED attendance.

BackgroundA small proportion of patients referred to as ‘frequent attenders’ account for a large proportion of hospital activity such as ED attendances and admissions. There is a lack of recent, national estimates of the volume of frequent ED attenders. We aimed to estimate the volume and age distribution of frequent ED attenders in English hospitals.MethodWe included all attendances at all major EDs across England in the financial year 2016–2017. Patients who attended three times or more were classified as frequent attenders. We used a logistic regression model to predict the odds of being a frequent attender by age group.Results14 829 519 attendances were made by 10 062 847 patients who attended at least once. 73.5% of ED attenders attended once and accounted for 49.8% of the total ED attendances. 9.5% of ED attenders attended three times or more; they accounted for 27.1% of the ED attendances. While only 1.2% attended six times or more, their contribution was 7.6% of the total attendances. Infants and adults aged over 80 years were significantly more likely to be frequent attenders than adults aged 30–59 years (OR=2.11, 95% CI 2.09 to 2.13, OR=2.22, 95% CI 2.20 to 2.23, respectively). The likelihood of hospital admission rose steeply with the number of attendances a patient had.ConclusionOne in 10 patients attending the ED are frequent attenders and account for over a quarter of attendances. Emergency care systems should consider better ways of reorganising health services to meet the needs of patients who attend EDs frequently.

This report analyses the impact of reverse triage, as described by Kelen, to rapidly assess the need for continuing inpatient care and to expedite patient discharge to create surge capacity for disaster victims. The Royal Darwin Hospital was asked to take up to 30 casualties suffering from blast injuries from a boat carrying asylum seekers that had exploded 840 km west of Darwin. The hospital was full, with a backlog of cases awaiting admission in the emergency department. The Disaster Response Team convened at 10:00 to develop the surge capacity to admit up to 30 casualties. By 14:00, 56 beds (16% of capacity) were predicted to be available by 18:00. The special circumstances of a disaster enabled staff to suspend their usual activities and place a priority on triaging inpatients' suitability for discharge. The External Disaster Plan was activated and response protocols were followed. Normal elective activity was suspended. Multidisciplinary teams immediately assessed patients and completed the necessary clinical and administrative requirements to discharge them quickly. As per the Plan there was increased use of community care options: respite nursing home beds and community nursing services. Through a combination of cancellation of all planned admissions, discharging 19 patients at least 1 day earlier than planned and discharging all patients earlier in the day surge capacity was made available in Royal Darwin Hospital to accommodate blast victims. Notably, reverse triage resulted in no increase in clinical risk with only one patient who was discharged early returning for further treatment.

For many of us in emergency medicine, rising to the challenge of the COVID-19 crisis will be the single most exciting and challenging episode of our careers. Lessons have been learnt on how to make quick and effective changes without being hindered by the normal restraints of bureaucracy. Changes that would normally have taken months to years to implement have been successfully introduced over a period of several weeks. Although we have managed these changes largely by command and control, compassionate leadership has identified leaders within our team and paved the way for the future. This article covers the preparation and changes made in response to COVID-19 in a London teaching hospital.

ObjectiveEvidence favours centralisation of emergency care for specific conditions, but it remains unclear whether broader implementation improves outcomes and efficiency. Routine healthcare data examined consolidation of three district general hospitals with mixed medical admission units (MAU) into a single high-volume site directing patients from the ED to specialty wards with consultant presence from 08:00 to 20:00.MethodsConsecutive unscheduled adult index admissions from matching postcode areas were identified retrospectively in Hospital Episode Statistics over a 3-year period: precentralisation baseline (from 16 June 2014 to 15 June 2015; n=18 586), year 1 postcentralisation (from 16 June 2015 to 15 June 2016; n=16 126) and year 2 postcentralisation (from 16 June 2016 to 15 June 2017; n=17 727). Logistic regression including key demographic covariates compared baseline with year 1 and year 2 probabilities of mortality and daily discharge until day 60 after admission and readmission within 60 days of discharge.ResultsRelative to baseline, admission postcentralisation was associated with favourable OR (95% CI) for day 60 mortality (year 1: 0.95 (0.88 to 1.02), p=0.18; year 2: 0.94 (0.91 to 0.97), p<0.01), mainly among patients aged 80+ years (year 1: 0.88 (0.79 to 0.97); year 2: 0.91 (0.87 to 0.96)). The probability of being discharged alive on any day since admission increased (year 1: 1.07 (1.04 to 1.10), p<0.01; year 2: 1.04 (1.02 to 1.05), p<0.01) and the risk of readmission decreased (year 1: 0.90 (0.87 to 0.94), p<0.01; year 2: 0.92 (0.90 to 0.94), p<0.01).ConclusionA centralised site providing early specialist care was associated with improved short-term outcomes and efficiency relative to lower volume ED admitting to MAU, particularly for older patients.

IntroductionThere is uncertainty about the best way to measure emergency department crowding. We have previously developed a consensus-based measure of crowding, the International Crowding Measure in Emergency Departments (ICMED). We aimed to obtain pilot data to evaluate the ability of a shortened form of the ICMED, the sICMED, to predict senior emergency department clinicians’ concerns about crowding and danger compared with a very well-studied measure of emergency department crowding, the National Emergency Department Overcrowding Score (NEDOCS).MethodsWe collected real-time observations of the sICMED and NEDOCS and compared these with clinicians’ perceptions of crowding and danger on a visual analogue scale. Data were collected in four emergency departments in the East of England. Associations were explored using simple regression, random intercept models and models accounting for correlation between adjacent time points.ResultsWe conducted 82 h of observation in 10 observation sets. Naive modelling suggested strong associations between sICMED and NEDOCS and clinician perceptions of crowding and danger. Further modelling showed that, due to clustering, the association between sICMED and danger persisted, but the association between these two measures and perception of crowding was no longer statistically significant.ConclusionsBoth sICMED and NEDOCS can be collected easily in a variety of English hospitals. Further studies are required but initial results suggest both scores may have potential use for assessing crowding variation at long timescales, but are less sensitive to hour-by-hour variation. Correlation in time is an important methodological consideration which, if ignored, may lead to erroneous conclusions. Future studies should account for such correlation in both design and analysis.

BackgroundThe specialty of emergency medicine (EM) is new in most African countries, where emergency medicine registrar (residency) programmes (EMRPs) are at different stages of evolution and little is known about the programmes. Identifying and describing these EMRPs will facilitate planning for sustainability, collaborative efforts and curriculum development for existing and future programmes. Our objective was to identify and provide an overview of existing EMRPs in Africa and their applicant requirements, faculty characteristics and plans for sustainability.MethodsWe conducted a descriptive cross-sectional survey of Africa’s EMRPs between January and December 2017, identifying programmes through an online search supplemented by discussions with African EM leaders. Leaders of all identified African EMRPs were invited to participate. Data were collected prospectively using a structured survey and are summarised with descriptive statistics.ResultsWe identified 15 programmes in 12 countries and received survey responses from 11 programmes in 10 countries. Eight of the responding EMRPs began in 2010 or later. Only 36% of the EMRPs offer a 3-year programme. Women make up an average of 33% of faculty. Only 40% of EMRPs require faculty to be EM specialists. In smaller samples that reported the relevant data, 67% (4/6) of EMRPs have EM specialists who trained in that EMRP programme making up more than half of their faculty; 57% of Africa’s 288 EMRP graduates to date are men; and an average of 39% of EMRP graduates stay on as faculty for 78% (7/9) of EMRPs.ConclusionEMRPs currently produce most of their own EM faculty. Almost equal proportions of men and women have graduated from a predominantly >3-year training programme. Graduates have a variety of opportunities in academia and private practice. Future assessments may wish to focus on the evolution of these programme’ curricula, faculty composition and graduates’ career options.

ObjectivesTo determine whether the impact of a thoracic CT scan on community-acquired pneumonia (CAP) diagnosis and patient management varies according to emergency physician’s experience (≤10 vs >10 years).MethodsEarly thoracic CT Scan for Community-Acquired Pneumonia at the Emergency Department is an interventional study conducted from November 2011 to January 2013 in four French emergency departments, and included suspected patients with CAP. We analysed changes in emergency physician CAP diagnosis classification levels before and after CT scan; and their agreement with an adjudication committee. We performed univariate analysis to determine the factors associated with modifying the diagnosis classification level to be consistent with the radiologist’s CT scan interpretation.Results319 suspected patients with CAP and 136 emergency physicians (75% less experienced with ≤10 years, 25% with >10 years of experience) were included. The percentage of patients whose classification was modified to become consistent with CT scan radiologist’s interpretation was higher among less-experienced than experienced emergency physicians (54.2% vs 40.2%; p=0.02). In univariate analysis, less emergency physician experience was the only factor associated with changing a classification to be consistent with the CT scan radiologist’s interpretation (OR 1.77, 95% CI 1.01 to 3.10, p=0.04). After CT scan, the agreement between emergency physicians and adjudication committee was moderate for less-experienced emergency physicians and slight for experienced emergency physicians (k=0.457 and k=0.196, respectively). After CT scan, less-experienced emergency physicians modified patient management significantly more than experienced emergency physicians (36.1% vs 21.7%, p=0.01).ConclusionsIn clinical practice, less-experienced emergency physicians were more likely to accurately modify their CAP diagnosis and patient management based on thoracic CT scan than more experienced emergency physicians.Trial registration numberNCT01574066