Clinician consensus on "Inappropriate" presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland.

BACKGROUND: Utilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the "appropriateness" of attendances to the ED in Ireland. METHODS: The Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels. RESULTS: The National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered "inappropriate" (k = 0.341; p < 0.001). For attendances deemed "appropriate" the admission rate was 47% compared to 0% for "inappropriate" attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites. CONCLUSIONS: Multidisciplinary clinicians agree that "inappropriate" use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.

Are we there yet?' Distance to definitive care for Irish patients in the Better Data, Better Planning (BDBP) study.

BACKGROUND: Residing long distances from definitive care compromises patient safety and, in rural Ireland, travel distance to health care can be substantial, particularly in light of national General Practitioner (GP) shortages and hospital reconfigurations. The aim of this research is to describe the profile of patients attending Irish Emergency Departments (EDs) in terms of distance from GP care and definitive care in the ED. METHOD: The 'Better Data, Better Planning' (BDBP) census was a multi-centre, cross-sectional study of n=5 urban and rural EDs in Ireland throughout 2020. At each site, all adults presenting over a 24-h census period were eligible for inclusion. Data were collected on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED, with analysis in SPSS. RESULTS: For n=306 participants, median distance to a GP was 3 km (range 1-100 km) and median distance to the ED was 15 km (range 1-160km). Most participants (n=167, 58%) lived within 5 km of their GP and within 10 km of the ED (n=114, 38%). However, 8% of patients lived ≥15 km from their GP and 9% of patients lived ≥50 km from their nearest ED. Patients living >50 km from the ED were more likely to be transported by Ambulance (p<0.05). CONCLUSIONS: Proximity to health services, by geographical location, is poorer in rural regions, so it's important that these patients have equity of access to definitive care. Therefore, expansion of alternative care pathways in the community and additional resourcing of the National Ambulance Service with enhanced aeromedical support is essential in the future.

The impact of COVID-19 on an Irish Emergency Department (ED): a cross-sectional study exploring the factors influencing ED utilisation prior to and during the pandemic from the patient perspective.

BACKGROUND: The collateral damage of SARS-CoV-2 is a serious concern in the Emergency Medicine (EM) community, specifically in relation to delayed care increasing morbidity and mortality in attendances unrelated to COVID-19. The objectives of this study are to describe the profile of patients attending an Irish ED prior to, and during the pandemic, and to investigate the factors influencing ED utilisation in this cohort. METHODS: This was a cross-sectional study with recruitment at three time-points prior to the onset of COVID-19 in December 2019 (n = 47) and February 2020 (n = 57) and post-Lockdown 1 in July 2020 (n = 70). At each time-point all adults presenting over a 24 h period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. Data analysis was performed in SPSS and included descriptive and inferential statistics. RESULTS: The demographic and clinical profile of patients across time-points was comparable in terms of age (p = 0.904), gender (p = 0.584) and presenting complaint (p = 0.556). Median length of stay in the ED decreased from 7.25 h (IQR 4.18-11.22) in February to 3.86 h (IQR 0.41-9.14) in July (p ≤ 0.005) and differences were observed in disposition (p ≤ 0.001). COVID-19 influenced decision to attend the ED for 31% of patients with 9% delaying presentation. Post-lockdown, patients were less likely to attend the ED for reassurance (p ≤ 0.005), for a second opinion (p ≤ 0.005) or to see a specialist (p ≤ 0.05). CONCLUSIONS: Demographic and clinical presentations of ED patients prior to the first COVID-19 lockdown and during the reopening phase were comparable, however, COVID-19 significantly impacted health-seeking behaviour and operational metrics in the ED at this phase of the pandemic. These findings provide useful information for hospitals with regard to pandemic preparedness and also have wider implications for planning of future health service delivery.

The "better data, better planning" census: a cross-sectional, multi-centre study investigating the factors influencing patient attendance at the emergency department in Ireland.

BACKGROUND: Internationally Emergency Department (ED) crowding is a significant health services delivery issue posing a major risk to population health. ED crowding affects both the quality and access of health services and is associated with poorer patient outcomes and increased mortality rates. In Ireland the practising of "Corridor Medicine" and "Trolley Crises" have become prevalent. The objectives of this study are to describe the demographic and clinical profile of patients attending regional EDs and to investigate the factors influencing ED utilisation in Ireland. METHODS: This was a multi-centre, cross-sectional study and recruitment occurred at a selection of urban and rural EDs (n = 5) in Ireland throughout 2020. At each site all adults presenting over a 24 h census period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. RESULTS: Demographics differed significantly between ED sites in terms of age (p ≤ 0.05), socioeconomic status (p ≤ 0.001), and proximity of health services (p ≤ 0.001). Prior to ED attendance 64% of participants accessed community health services. Most participants (70%) believed the ED was the "best place" for emergency care or attended due to lack of awareness of other services (30%). Musculoskeletal injuries were the most common reason for presentation to the ED in this study (24%) and almost a third of patients (31%) reported presenting to the ED for an x-ray or scan. CONCLUSIONS: This study has identified regional and socioeconomic differences in the drivers of ED presentations and factors influencing ED attendance in Ireland from the patient perspective. Improved awareness of, and provision of alternative care pathways could potentially decrease ED attendances, which would be important in the context of reducing ED crowding during the COVID-19 pandemic. New strategies for integration of acute care in the community must acknowledge and plan for these issues as a universal approach is unlikely to be implemented successfully due to regional factors.

Out-of-hospital cardiac arrest in countries of the Gulf Cooperation Council: a scoping review.

BACKGROUND: Published data are lacking on response to and outcomes of out-of-hospital cardiac arrest in the Middle East. What data there are have not been comprehensively analysed. AIMS: This study aimed to assess the characteristics of people with out-of-hospital cardiac arrest in Gulf Cooperation Council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates) and the response to and outcomes of such incidents. METHODS: This was a scoping review of published and grey literature on out-of-hospital cardiac arrest in GCC countries from 1990 to June 2019. Studies in English and Arabic were eligible for inclusion. MEDLINE, CINAHL, Web of Science and EMBASE were searched as well as relevant non-indexed journals. Google searches were also done. References of included studies were scanned for relevant articles. Experts on the subject in the region were consulted. RESULTS: Of 647 citations retrieved, 24 studies were included for data extraction and analysis. No literature was identified for Bahrain. People with out-of-hospital cardiac arrest in the region were younger, predominantly male and had more comorbidity than reported in other regions of the world. Use of emergency medical services was low across the GCC countries, as was bystander cardiopulmonary resuscitation, return of spontaneous circulation and survival to discharge. CONCLUSIONS: A coordinated effort to address out-of-hospital cardiac arrest, including the generation of research, is lacking within and among GCC countries. Establishment of lead agencies responsible for developing and coordinating strategies to address out-of-hospital cardiac arrest, such as community response, public education and reporting databases, is recommended.

Policy of free GP care for children under 6 years: The impact on emergency department attendance.

Universal health coverage (UHC) aims to improve child health. Ireland, the only country in the European Union without universal access to primary care, introduced general practitioner (GP) care at no charge for children aged under six in 2015. This paper aims to evaluate the impact of this policy on attendance at the emergency department (ED). A difference-in-difference (DiD) analysis was applied to visit records of 367,000 paediatric patients at five hospitals over a period of five years, with treatment and control differentiated by age. DiD was also used to assess if GP referrals and the severity of presentations altered as a consequence of this policy. While existing research estimates that this policy increased attendance by children aged under six at general practice by over 25%, this policy did not lead to a reduction in ED attendance. Hospital level effects on attendance varied from no impact to increased attendance by children aged under six of 28.9%. While increased GP referrals, particularly for injury and medical reasons, indicated more patients presented to their GP prior to ED attendance, walk-ins without referral did not decrease. Attendance increased at both regional hospitals, which also had the highest proportion of GP referred visits. While the marginal probability of a visit being GP referred increased at four of the five hospitals in this study, only in two of these can the entire effect be attributed to the introduction of this policy (effects 1.4 and 1.8 percentage points). Previous unmet need, capacity constraints in general practice, regional variability in the GP to population ratio, restricted hours of access to GPs, coupled with faster access to diagnostics in the ED setting, may explain variability in the effect and why the expected reduction in ED attendances did not occur.

The impact of the COVID-19 pandemic on child health and the provision of Care in Paediatric Emergency Departments: a qualitative study of frontline emergency care staff.

BACKGROUND: The COVID-19 pandemic and subsequent public health guidance to reduce the spread of the disease have wide-reaching implications for children's health and wellbeing. Furthermore, paediatric emergency departments (EDs) have rapidly adapted provision of care in response to the pandemic. This qualitative study utilized insight from multidisciplinary frontline staff to understand 1) the changes in paediatric emergency healthcare utilization during COVID-19 2) the experiences of working within the restructured health system. METHODS: Fifteen semi-structured interviews were conducted with frontline staff working in two paediatric EDs and two mixed adult and children EDs. Participants included emergency medicine clinicians (n = 5), nursing managerial staff (n = 6), social workers (n = 2) and nursing staff (n = 2). Thematic Analysis (TA) was applied to the data to identify key themes. RESULTS: The pandemic and public health restrictions have had an adverse impact on children's health and psychosocial wellbeing, compounded by difficulty in accessing primary and community services. The impact may have been more acute for children with disabilities and chronic health conditions and has raised child protection issues for vulnerable children. EDs have shown innovation and agility in the structural and operational changes they have implemented to continue to deliver care to children, however resource limitations and other challenges must be addressed to ensure high quality care delivery and protect the wellbeing of those tasked with delivering this care. CONCLUSIONS: The spread of COVID-19 and subsequent policies to address the pandemic has had wide-reaching implications for children's health and wellbeing. The interruption to health and social care services is manifesting in myriad ways in the ED, such as a rise in psychosocial presentations. As the pandemic continues to progress, policy makers and service providers must ensure the continued provision of essential health and social services, including targeted responses for those with existing conditions.

Parental Hesitancy and Concerns around Accessing Paediatric Unscheduled Healthcare during COVID-19: A Cross-Sectional Survey.

A decrease in attendance at emergency departments among paediatric populations has been reported during the Coronavirus Disease 2019 (COVID-19) pandemic. The present study sought to understand parents' hesitancy and concerns around accessing healthcare during the pandemic using a cross-sectional survey of parents of children under the age of 16 (N = 1044) in Ireland. Multinomial and logistic regression analyses were used to determine the factors that influenced avoidance and hesitancy. In total, 34% of participants stated that their child required healthcare during the pandemic, of whom 22% decided against seeking healthcare. Parents who reported being much more hesitant about accessing healthcare were more likely to report mild-moderate (Relative Risk Ratio (RRR) = 2.31, CI: 1.54-3.47) and severe-extremely severe stress (RRR: 3.37, CI: 1.81-6.27). Parents who understood government advice to mean avoiding health services were more likely to be hesitant to attend (RRR: 1.71, CI; 1.10-2.67). These effects held when restrictions were beginning to be lifted. Higher levels of stress were associated with a parent believing that the government advice meant that they should not attend health services (OR: 1.66, CI: 1.14-2.41). Public health messaging must ensure parents are reassured on the accessibility and safety of paediatric healthcare services as this public health emergency continues.

Assessing the Impact of COVID-19 Public Health Stages on Paediatric Emergency Attendance.

This study outlines the impact of COVID-19 on paediatric emergency department (ED) utilisation and assesses the extent of healthcare avoidance during each stage of the public health response strategy. Records from five EDs and one urgent care centre in Ireland, representing approximately 48% of national annual public paediatric ED attendances, are analysed to determine changes in characteristics of attendance during the three month period following the first reported COVID-19 case in Ireland, with reference to specific national public health stages. ED attendance reduced by 27-62% across all categories of diagnosis in the Delay phase and remained significantly below prior year levels as the country began Phase One of Reopening, with an incident rate ratio (IRR) of 0.58. The decrease was predominantly attributable to reduced attendance for injury and viral/viral induced conditions resulting from changed living conditions imposed by the public health response. However, attendance for complex chronic conditions also reduced and had yet to return to pre-COVID levels as reopening began. Attendances referred by general practitioners (GPs) dropped by 13 percentage points in the Delay phase and remained at that level. While changes in living conditions explain much of the decrease in overall attendance and in GP referrals, reduced attendance for complex chronic conditions may indicate avoidance behaviour and continued surveillance is necessary.

CUPID COVID-19: emergency department attendance by paediatric patients during COVID-19 - project protocol.

Background: Measures introduced to delay the spread of COVID-19 may result in avoidance of emergency departments (EDs) for non-COVID related illness. Clinicians and medical representative bodies such as the Irish Association for Emergency Medicine (IAEM) have expressed concern that some patients may not seek timely urgent medical intervention. Evidence from previous epidemics found that hospital avoidance during outbreaks of MERS and SARS was common. While ED attendance returned to normal following SARS and MERS, both outbreaks lasted 2-3 months. As the COVID-19 pandemic is forecast to extend into 2021, little is known about the impact COVID-19 will have on paediatric attendance at EDs as the pandemic evolves. Aims: This project aims to assess the impact of COVID-19 on paediatric emergency healthcare utilisation, to understand how the health seeking behaviour of parents may have altered due to the pandemic, and to identify how any barriers to accessing care can be removed.   Methods: Administrative data records from five EDs across Ireland and one Urgent Care Centre will be analysed to identify temporal trends in attendances for emergency care. Qualitative inquiry will be utilised to capture the experience of staff providing emergency healthcare to paediatric patients during COVID-19, and their feedback on identified trends will inform the interpretation of findings. A cross-sectional survey of parents will capture experiences, concerns and decision-making on accessing healthcare for their children during the pandemic. Results and Conclusion: This information will help decision makers respond rapidly to meet the clinical needs of paediatric patients as the circumstances of the pandemic unfold and reduce the disruption to normal paediatric ED services during the onset of COVID-19. As the health of a child can deteriorate more rapidly than that of an adult, any delay in seeking care for an acutely ill child may have serious consequences.

Implementation of an ST-Segment Elevation Myocardial Infarction Bypass Protocol in the Northern United Arab Emirates.

OBJECTIVE: The aim was to evaluate the translation of an ST-segment elevation myocardial infarction (STEMI) bypass protocol to the outcomes of patients with acute coronary syndrome in the Emirate of Ras al-Khaimah in the United Arab Emirates (UAE). METHODS: A prospective cohort study was conducted, which included all patients who had a prehospital 12-lead electrocardiogram (ECG) performed by ambulance crews. Analysis of those who were identified as having STEMI and who subsequently underwent percutaneous coronary intervention (PCI) was performed. RESULTS: A total of 152 patients had a 12-lead ECG performed during the pilot study period (February 24, 2016-August 31, 2016) with 118 included for analysis. Mean patient age was 52 years. There were 87 male (74%) and 31 female (26%) patients. Twenty-nine patients suffered a STEMI, and data were available for 11 who underwent PCI. There was no mortality, and no major adverse cardiac events were reported. The median door-to-balloon (D2B) time was 73 min (range 48-124), and 81% of patients had a D2B time < 90 min. Discharge data were available for six patients: All were discharged home with no impediments to rehabilitation. CONCLUSION: This pilot study has demonstrated agreement with the existing literature surrounding prehospital ECG and PCI activation in an unstudied STEMI population and in a novel clinical setting. It has demonstrated a D2B time of < 90 min in over 80% of STEMI patients, and a faster mean D2B time than self-presentations (mean 77 min vs. 113 min), with no associated mortality or major adverse cardiac events.

A profile of out-of-hospital cardiac arrests in Northern Emirates, United Arab Emirates.

OBJECTIVES: To report the characteristics of out-of-hospital cardiac arrest patients and their outcomes in the emirates of Sharjah, Ras-al-Khaimah, Umm Al-Quwain, Fujairah, and Ajman in the United Arab Emirates (collectively known as the Northern Emirates). Methods: This is a prospective descriptive cohort study of out-of-hospital cardiac arrest incidents transported by the national ambulance crews between February 2014 and March 2015 in the Northern Emirates. Results: A total of 384 patients were enrolled in this study. Male victims of out-of-hospital cardiac arrest represented 76% of the participants. The mean age of the study population was 50.9 years. An over-all prehospital return of spontaneous circulation rate of 3.1% was documented, as well as a 30% rate of bystander cardiopulmonary resuscitation being performed. Public access defibrillators were applied in 0.5% of cases. Data is presented according to Utstein reporting criteria. Conclusion: Baseline data for out-of-hospital cardiac arrest was established for the first time in the Northern Emirates of the United Arab Emirates. A low survival rate for out-of-hospital cardiac arrest, low rates of bystander cardiopulmonary resuscitation, and low public access defibrillator use were discovered. Although low by comparison to established western systems results are similar to other systems in the region. Determining the baseline data presented in this study is essential in recommending and implementing strategies to reduce mortality from out-of-hospital cardiac arrest.

Out of hospital adult cardiac arrests in a university hospital in Central Saudi Arabia.

[No Abstract available].

Development of key performance indicators for prehospital emergency care.

INTRODUCTION: Key performance indicators (KPIs) are used to monitor and evaluate critical areas of clinical and support functions that influence patient outcome. Traditional prehospital emergency care performance monitoring has focused solely on response time metrics. The landscape of emergency care delivery in Ireland is in the process of significant national reconfiguration. The development of KPIs is therefore considered one of the key priorities in prehospital research. AIMS: The aim of this study was to develop a suite of KPIs for prehospital emergency care in Ireland. METHODS: A systematic literature review of prehospital care performance measurement was undertaken followed by a three-round Delphi consensus process facilitated by a broad-based multidisciplinary group of panellists. The consensus process was conducted between June 2012 and October 2013. Each candidate indicator on the Delphi survey questionnaire was rated using a 5-point Likert-type rating scale. Agreement was defined as at least 70% of responders rating an indicator as 'agree' or 'strongly agree' on the rating scale. Data were analysed using descriptive statistics. Sensitivity of the ratings was examined for robustness by bootstrapping the original sample. RESULTS: Of the 78 citations identified by the systematic review, 5 relevant publications were used to select candidate indicators for the Delphi round 1 questionnaire. Response rates in Delphi rounds 1 and 2 were 89% and 83%, respectively. Following the consensus development conference, 101 KPIs reached consensus. Based on the Donabedian framework for quality-of-care indicators, 7 of the KPIs which reached agreement were structure KPIs, 74 were process KPIs and 20 were outcome KPIs. The highest ranked indicator was a process KPI ('Direct transport of ST-elevation myocardial infarction patients to a primary percutaneous intervention (PCI)-capable facility for ECG to PCI time <90 min'). CONCLUSION: Improving the quality of prehospital care requires the development and implementation of performance measurement using scientifically valid and reliable KPIs. Employing a Delphi panel of key multidisciplinary Emergency Medical Service stakeholders, it was feasible to develop a suite of 101 KPIs for performance monitoring of prehospital emergency care in Ireland. This suite of KPIs may contribute to a framework for achieving safer, better care in the prehospital environment.

The use of propofol for procedural sedation in emergency departments.

BACKGROUND: There is increasing evidence that propofol is efficacious and safe for procedural sedation (PS) in the emergency department (ED) setting. However, propofol has a narrow therapeutic window and lacks of a reversal agent. The aim of this review was to cohere the evidence base regarding the efficacy and safety profile of propofol when used in the ED setting for PS. OBJECTIVES: To identify and evaluate all randomized controlled trials (RCTs) comparing propofol with alternative drugs (benzodiazepines, barbiturates, etomidate and ketamine) used in the ED setting for PS. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9), MEDLINE (1950 to September week 2 2013) and EMBASE (1980 to week 2 2013). We searched the Current Controlled Trials metaRegister of Clinical Trials (compiled by Current Science) (September 2013). We checked the reference lists of trials and contacted trial authors. We imposed no language restriction. We re-ran the search in February 2015. We will deal with the one study awaiting classification when we update the review. SELECTION CRITERIA: RCTs comparing propofol to alternative drugs (benzodiazepines, barbiturates, etomidate and ketamine) used in the ED setting for PS in participants of all ages. DATA COLLECTION AND ANALYSIS: Two authors independently performed data extraction. Two authors performed trial quality assessment. We used mean difference (MD), odds ratio (OR) and 95% confidence intervals (CI) to measure effect sizes. Two authors independently assessed and rated the methodological quality of each trial using The Cochrane Collaboration tool for assessing risk of bias. MAIN RESULTS: Ten studies (813 participants) met the inclusion criteria. Two studies only included participants 18 years and younger; six studies only included participants 18 years and older; one study included participants between 16 and 65 years of age and one study included only adults but did not specify the age range. Eight of the included studies had a high risk of bias. The included studies were clinically heterogeneous. We undertook no meta-analysis.The primary outcome measures of this review were: adverse effects (as defined by the study authors) and participant satisfaction (as defined by the study authors). In one study comparing propofol/fentanyl with ketamine/midazolam, delayed adverse reactions (nightmares and behavioural change) were noted in 10% of the ketamine/midazolam group and none in the propofol/fentanyl group. Seven individual studies reported no evidence of a difference in adverse effects between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions. Three individual studies reported no evidence of a difference in pain at the injection site between intravenous propofol and alternative interventions. Four individual studies reported no evidence of a difference in participant satisfaction between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions (ketamine, etomidate, midazolam). All the studies employed propofol without the use of an adjunctive analgesic and all, except one, were small (fewer than 100 participants) studies. The quality of evidence for the adverse effects and participant satisfaction outcomes was very low.Nine included studies (eight comparisons) reported all the secondary outcome measures of the review except mortality. It was not possible to pool the results of the included studies for any of the secondary outcome measures because the comparator interventions were different and the measures were reported in different ways. Seven individual studies reported no evidence of difference in incidence of hypoxia between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions. AUTHORS' CONCLUSIONS: No firm conclusions can be drawn concerning the comparative effects of administering intravenous propofol, with or without an adjunctive analgesic agent, with alternative interventions in participants undergoing PS in the ED setting on adverse effects (including pain at the injection site) and participant satisfaction. The review was limited because no two included studies employed the same comparator interventions, and because the number of participants in eight of the included studies were small (fewer than 100 participants).