Bland-Altman analysis for determining the coincidence between two methods for measuring emergency department crowding: visual analogue scale versus national emergency department overcrowding scale / 中华急诊医学杂志

Objective To establish a practicable and easily mastered emergency department overcrowding (EDO) assessment system suitable for domestic ED setting by determining the validity and usefulness of the national emergency department over-crowding study (NEDOCS) tool in a 2000-bed tertiary care academic institution in China in comparison with visual analogue scale (VAS) in order to address the worldwide grave concern of EDO.Methods In a period of 6 months,data of subjective and objective EDO assessed simultaneously three times a day (1:00,9:00,17:00) were collected.The data were analyzed by using Bland-altmann method and Kappa test to determine the coincidence between VAS and NEDOCS assessments.Results The VAS-p value evaluated by physicians was significantly lower than VAS-n value evaluated by nurses [(6.49 ± 1.82) vs.(7.12 ± 1.78),P ＜ 0.01].The reliability analysis showed that Kappa value was as low as 0.112 (P ＜0.01) suggesting there was a great discrepancy between VAS-p value and VAS-n value.VAS-m (average value of VAS-p and VAS-n) was taken for comparing different evaluation systems.The significant correlation was found between the VAS-m and NEDOCS (r =0.7l4,P ＜0.01).However,the Bland-Altman plot showed the 95％ limit of coincidence was in an extensive range (-32.47 to 71.42) suggesting discrepancy existed between two methods.Conclusions The present study suggested there was a significant discrepancy between the two subjective assessments of ED crowding (VAS-p vs.VAS-n).There might be a fatal flaw existed in the assumptions of the original VAS method for EDO measurement.Using the Bland-Altman plot analysis,the results showed that NEDOCS did not authentically reflect the staff' s sense of overcrowding in the ED.It is very important and urgent to establish an objective and effective EDO evaluation system for ED management.

Healthcare policy and healthcare utilization behavior to improve hospital infection control after the Middle East respiratory syndrome outbreak

The recent outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) infections in South Korea in May 2015 revealed that the Korean healthcare system and hospitals are highly vulnerable to hospital-spread infections. In a short period of time, MERS-CoV infection spread widely across Korea due to the unique characteristics of the Korean healthcare system including 1) hospitals with limited infection control capabilities, 2) a heavy dependency on private caregivers due to a nursing shortage, 3) emergency department overcrowding, and 4) healthcare-related patient behaviour such as hospital shopping. To prevent future outbreaks of emerging infectious diseases similar to MERS-CoV, the Korean healthcare system should be reformed and healthcare-related patient behaviour must change. To improve the performance of hospital infection control, the National Health Insurance service should pay more for hospital infection control services and cover private patient rooms when medically necessary, including for infectious disease patients. To reduce risks of hospital infection related to private caregiving, the nurse staffing level should be increased and hospitals should take full responsibility for inpatient nursing care. To reduce hospital shopping, the National Health Insurance service should introduce a differential fee schedule which pays more when primary care providers care for patients with common conditions and tertiary care providers care for patients with severe conditions. To incentivize patients for appropriate health care use, lower patient out-of-pocket payments should be combined with a differential provider fee schedule.

Optimal Use of Emergency Services

The growth of emergency services in Singapore over years in terms of volume and complexity is relentless. In the pre-hospital environment, ambulance call volumes have more than doubled from 62,095 in 1997 to 142,549 cases in 2012. The use of emergency ambulances services should be commensurate with the timeframe of which the medical condition is deteriorating or the potential for sudden catastrophic outcomes. Activation of the EAS ambulance for STEMIs and strokes help to reduce the D2B time and time to thrombolysis. Patients at risk of AMI or stroke often fail to recognise the symptoms and hence fail to activate the EMS system. Physicians do have a role to identify those at risk to educate them to achieve better outcomes. Good documentation of positive and significant negative findings and relevant tests provides a baseline to expedite patient assessment at the ED. An understanding of the available ED resources as well as the access to services, especially when subspecialty consultation is needed, helps to improve the appropriateness of referrals.

Optimal Use of Emergency Services

The growth of emergency services in Singapore over years in terms of volume and complexity is relentless. In the pre-hospital environment, ambulance call volumes have more than doubled from 62,095 in 1997 to 142,549 cases in 2012. The use of emergency ambulances services should be commensurate with the timeframe of which the medical condition is deteriorating or the potential for sudden catastrophic outcomes. Activation of the EAS ambulance for STEMIs and strokes help to reduce the D2B time and time to thrombolysis. Patients at risk of AMI or stroke often fail to recognise the symptoms and hence fail to activate the EMS system. Physicians do have a role to identify those at risk to educate them to achieve better outcomes. Good documentation of positive and significant negative findings and relevant tests provides a baseline to expedite patient assessment at the ED. An understanding of the available ED resources as well as the access to services, especially when subspecialty consultation is needed, helps to improve the appropriateness of referrals.