Articles: emergency-department.
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ABSTRACTObjective:Emergency department (ED) overcrowding in Canada is an ongoing problem resulting in prolonged wait times, service declines, increased patient suffering, and adverse patient outcomes. We explored the relationship between socioeconomic status (SES) and ED use in Canada's universal health care system to improve our understanding of the nature of ED users to both improve health care to the most deprived populations and reduce ED patient input. Methods:This retrospective study took information from the National Ambulatory Care Reporting System (NACRS) database for all ED visits in Ontario between April 1, 2003, and March 31, 2010. ⋯ Conclusion:Social determinants of health clearly impact ED use patterns. People of the lowest SES use ED services disproportionately more than other socioeconomic groups. Focused health system planning and policy development directed at optimizing health services for the lowest SES populations are essential to changing ED use patterns and may be one method of decreasing ED overcrowding.
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ABSTRACTObjectives:1) To assess temporal patterns in historical patient arrival rates in an emergency department (ED) to determine the appropriate number of shift schedules in an acute care area and a fast-track clinic and 2) to determine whether physician scheduling can be improved by aligning physician productivity with patient arrivals using an optimization planning model. Methods:Historical data were statistically analyzed to determine whether the number of patients arriving at the ED varied by weekday, weekend, or holiday weekend. Poisson-based generalized additive models were used to develop models of patient arrival rate throughout the day. ⋯ Results:Statistical modelling found that patient arrival rates were different for acute care versus fast-track clinics; the patterns in arrivals followed essentially the same daily pattern in the acute care area; and arrival patterns differed on weekdays versus weekends in the fast-track clinic. The planning model reduced the unmet patient demand (i.e., the average number of patients arriving at the ED beyond the average physician productivity) by 19%, 39%, and 69% for the three scenarios examined. Conclusions:The planning model improved the shift schedules by aligning physician productivity with patient arrivals at the ED.
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ABSTRACTObjectives:Current guidelines emphasize that emergency department (ED) patients at low risk for potential ischemic chest pain cannot be discharged without extensive investigations or hospitalization to minimize the risk of missing acute coronary syndrome (ACS). We sought to derive and validate a prediction rule that permitted 20 to 30% of ED patients without ACS safely to be discharged within 2 hours without further provocative cardiac testing. Methods:This prospective cohort study enrolled 1,669 chest pain patients in two blocks in 2000-2003 (development cohort) and 2006 (validation cohort). ⋯ The validation of the rule was limited by the lack of consistency in data capture, incomplete follow-up, and lack of evaluation of the accuracy, comfort, and clinical sensibility of this clinical decision rule. Conclusion:The Vancouver Chest Pain Rule may identify a cohort of ED chest pain patients who can be safely discharged within 2 hours without provocative cardiac testing. Further validation across other centres with consistent application and comprehensive and uniform follow-up of all eligible and enrolled patients, in addition to measuring and reporting the accuracy of and comfort level with applying the rule and the clinical sensibility, should be completed prior to adoption and implementation.
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ABSTRACTAnti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a recently described and underdiagnosed entity that typically affects young, previously healthy individuals. Patients usually present in phases, which may include refractory seizures, psychosis, unresponsiveness, and autonomic instability. The diagnosis of anti-NMDAR encephalitis is challenging; however, prompt diagnosis and early treatment can lead to complete recovery. ⋯ It is essential to consider this diagnosis in suspicious emergency department presentations, particularly young patients who present with altered mental status, psychosis, or new-onset seizure activity when other obvious causes are ruled out. Emergency physicians should discuss the possibility of empirical intravenous immunoglobulin administration with neurology consultants if anti-NMDAR encephalitis is suspected. We describe the case of a 20-year-old man with anti-NMDAR encephalitis who presented to the emergency department with status epilepticus.
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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. ⋯ 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.