Unscheduled Emergency Department Revisits Within 48 Hours of Discharge.

This study aimed to analyze early revisits (within 48 hours of discharge) in an Emergency Department. Among the 178,295 visits, 11,686 were revisits, resulting in a rate of 6.55% (95%CI 6.43-6.67). A total of 1,410 revisits required hospitalization, and 252 were due to preventable errors (17.87%). These errors were mainly related to an inadequate therapeutic plan at discharge (47.22%), an incomplete diagnostic process (29.37%), and misdiagnoses (13.10%). These findings represent a technology-enabled clinical audit tool. Electronic Healthcare Records have the potential to: provide quality metrics of hospital performance, help to keep revisit rates updated (assessment through a real-time dashboard), and improve clinical management (by transparency initiatives about errors, and a supportive learning environment regarding lessons learned).

[Clinical characteristics and care times in a chest pain unit of the emergency department of an argentine center]. / Características clínicas y tiempos de atención en una unidad de dolor torácico del servicio de emergencias de un centro argentino.

Objectives: . To report the frequency of precordial pain, describe clinical characteristics, and care times. Methods: . Retrospective descriptive study that included consultations in the Chest Pain Unit in 2021 in the emergency department of a private hospital in Argentina. Results: There were 1469 admissions for chest pain, yielding a frequency of 1.09% (95%CI 1.04-1.15). They were 52% men, mean age 62 years (SD ±15); 48% had hypertension and 32% dyslipidemia. The median time to initial ECG was 4.3 min (ICR 2.5-7.5); and 26 min (ICR 14-46) to medical evaluation. A total of 206 (14%) were hospitalized with a median of 3 days, 76% were admitted to a closed unit, 9% required non-invasive ventilation/mechanical ventilaction and in-hospital mortality was 2.9%. Those hospitalized presented shorter delay time to medical attention (p<0.01), and greater performance of complementary studies (p<0.01), with no differences in time to ECG (p=0.22). Conclusions: Care times were within the stipulated standards, being an important indicator of quality. Nursing was crucial, taking care of the correct triage, ECG on admission, and guaranteeing care until medical evaluation.

Efecto de la inactivación de las órdenes múltiples para solicitud de estudios complementarios en una central de emergencias.

Introducción. La plantilla de órdenes múltiples es una herramienta informática que podría producir consecuencias inadvertidas pese a sus innumerables beneficios. Nos propusimos explorar el efecto de su inactivación sobre las solicitudes de estudios complementarios y los costos asociados. Métodos. Corte transversal en la Central de Emergencias de Adultos del Hospital Italiano de Buenos Aires, que incluyó muestra consecutiva de consultas pre-intervención (Enero-Febrero 2020) y post-intervención (2021). Mediante el uso de bases secundarias, las variables incluidas fueron los débitos administrativos y sus respectivos precios de facturación. Resultados. Hubo 27.671 consultas en 2020 con una mediana de valor total de 474$, y 20.819 con 1.639$ en 2021. Tras el análisis restringido al área de consultorios de moderada complejidad (excluyendo consultas por COVID-19), se encontró: una disminución en la mediana del número de prácticas por consulta (mediana de 11 vs 10, p=0,001), una disminución en la solicitud de al menos una práctica de laboratorio (45% versus 39%, p=0,001), sin encontrar cambios significativos en costos globales (mediana 1.419$ vs 1.081$; p=0,122) ni en costos específicos de laboratorio (mediana 1.071$ vs 1.089$, p=0,710). Conclusión. Pese a la inflación interanual, se logró una reducción significativa en el número de prácticas y se mantuvieron los costos globales por consulta. Estos hallazgos demuestran la efectividad de la intervención, pero serán necesarias medidas educativas que apunten al recordatorio de los potenciales daños en la sobreutilización, y los costos sanitarios de los estudios innecesarios.

Effect of computerized physician order entry inactivation to order complementary studies in an emergency department / [Efecto de la inactivación de las órdenes múltiples para solicitud de estudios complementarios en una central de emergencias.]

Introduction: The computerized provider order entry (CPOE) is a computing tool that could lead to unintended consequences despite its myriad benefits. We aimed to explore the effect of its inactivation on requests for complementary studies and the associated costs. Methods: Cross sectional study at the Emergency Department of Hospital Italiano de Buenos Aires, which included a consecutive sample of pre-intervention (January-February 2020) and post-intervention (2021) consultations. Using secondary bases, the variables included were administrative debits and their respective billing prices. Results: There were 27,671 consultations in 2020 with a total median value of $474, and 20,819 with $1,639 in 2021. After the analysis restricted to the area of ​​moderately complex clinics (excluding COVID-19 consultations), the following was found: a decrease in the median number of practices per consultation (median of 11 vs. 10, p=0.001), a decrease in the request for at least one laboratory practice (45% vs. 39%, p=0.001), without finding significant changes in global costs (median $1,419 vs. $1,081; p=0.122) or in specific laboratory costs (median $1,071 vs. $1,089, p=0.710). Conclusion: Despite inflation, a significant reduction in the number of practices was achieved and overall costs per consultation were maintained. These findings demonstrate the effectiveness of the intervention, but an educational intervention aimed at reminding the potential harm of overuse and the health costs of unnecessary studies will be necessary.

Introducción: La plantilla de órdenes múltiples es una herramienta informática que podría producir consecuencias inadvertidas pese a sus innumerables beneficios. Nos propusimos explorar el efecto de su inactivación sobre las solicitudes de estudios complementarios y los costos asociados. Métodos: Corte transversal en la Central de Emergencias de Adultos del Hospital Italiano de Buenos Aires, que incluyó muestra consecutiva de consultas pre-intervención (Enero-Febrero 2020) y post-intervención (2021). Mediante el uso de bases secundarias, las variables incluidas fueron los débitos administrativos y sus respectivos precios de facturación. Resultados: Hubo 27.671 consultas en 2020 con una mediana de valor total de 474$, y 20.819 con 1.639$ en 2021. Tras el análisis restringido al área de consultorios de moderada complejidad (excluyendo consultas por COVID-19), se encontró: una disminución en la mediana del número de prácticas por consulta (mediana de 11 vs 10, p=0,001), una disminución en la solicitud de al menos una práctica de laboratorio (45% versus 39%, p=0,001), sin encontrar cambios significativos en costos globales (mediana 1.419$ vs 1.081$; p=0,122) ni en costos específicos de laboratorio (mediana 1.071$ vs 1.089$, p=0,710). Conclusión: Pese a la inflación interanual, se logró una reducción significativa en el número de prácticas y se mantuvieron los costos globales por consulta. Estos hallazgos demuestran la efectividad de la intervención, pero serán necesarias medidas educativas que apunten al recordatorio de los potenciales daños en la sobreutilización, y los costos sanitarios de los estudios innecesarios.

[Participatory Action Research on perceptions, concerns and needs of health professionals in an emergency department from Argentina]. / Investigación-Acción Participativa sobre percepciones, preocupaciones y necesidades de los profesionales de salud en una central de emergencias de Argentina.

INTRODUCTION: To explore perceptions, concerns and needs of healthcare professionals in an emergency department (ED) from Argentina. METHODS: Participatory action research, coordinated and carried out by ED healthcare professionals, which included physicians, nurses and administrative staff who actively engaged in both data collection and analysis. Mixed methodologies were used: documentary analysis of complaints and written claims by patients, 10 individual interviews, and two reflective focus groups of 10 healthcare professionals (who differed in occupation, seniority and experience, including residents in training). RESULTS: The topics that emerged were work factors that lead to errors and threaten patient-centered clinical encounters: work overload and lack of time, the overuse of resources for defensive medicine purposes and technology that replaces physical contact. Healthcare professionals reported episodes of aggression by patients or their families, when long waits and structural insufficiencies (such as lack of beds, saturation of the waiting room, discomfort) threaten patience and tolerance. From these insights, improvements were generated in various areas of the ED. CONCLUSIONS: The identification of problems by the ED stakeholders l was a relevant approach that led to a process of collective management change, promoted reflection and raised awareness, allowing the identification of areas for improvement, design strategies and concrete feasible proposals.

OBJETIVO: Explorar las percepciones, preocupaciones y necesidades del personal de salud en una Central de Emergencias de Adultos (CEA) de Argentina. Métodos: Investigación o acción participativa, coordinada y ejecutada por el propio personal de la CEA, que incluyó médicos/as, personal de enfermería y administrativo/as para participar activamente en la recolección de información y en el análisis. Se utilizaron metodologías mixtas: análisis documental de quejas y reclamaciones escritas por parte de los pacientes, 10 entrevistas individuales y 2 grupos focales reflexivos con 10 integrantes del personal de salud (de diferente cargo y antigüedad, y residentes en formación). RESULTADOS: Los tópicos emergentes fueron factores laborales que inducen al error y atentan contra el encuentro clínico centrado en la persona: la sobrecarga y la falta de tiempo, la sobreutilización de recursos por medicina defensiva y la tecnología que reemplaza el contacto físico. El personal de salud manifestó episodios de agresiones de pacientes o sus familiares, cuando las largas esperas y las insuficiencias estructurales (como falta de camas, saturación de sala de espera, incomodidad) atentan contra la paciencia y la tolerancia. A partir de esta reflexión se generaron mejoras en diversas áreas de la CEA. CONCLUSIONES: La identificación de las problemáticas realizadas por los propios actores de la CEA resultó un método pertinente para generar un proceso de cambio de gestión colectiva, promover la reflexión y concientizar, permitir identificar áreas de mejora, diseñar estrategias y propuestas concretas.

Can CPOE Based on Electronic Order Sets Cause Unintended Consequences (Expensive and Unnecessary Tests) at the Emergency Department?

Computerized Provider Order Entry (CPOE) systems may cause unintended consequences. This study aimed to describe the on-going system for CPOE order sets, and to explore an economic evaluation at the Emergency Department. First, we developed a costs dashboard which showed us the significant and excessive use of medical tests per consultation. We identified the top 10 most widely used and most expensive tests. Additionally we noticed that the labs seemed to continually increase. Then, we found that 27% of the consultations have at least one item of laboratory practice between January and February 2020, and this represents more than 80% of the consultation costs. Health care spending has reached epic proportions globally. We think that it is time to rethink effective strategies. Maybe it is time to deactivate/remove electronic order sets (EOSs) and the functionality to develop and create their own "private" order sets, in order to eliminate waste and inefficiencies.

Evaluation of Telehealth Service for COVID-19 Outpatients: A Dashboard to Measure Healthcare Quality and Safety.

Due to the COVID-19 pandemic, changes and improvements regarding the organization have been made to adapt quickly at the Emergency Department (ED) of the Hospital Italiano de Buenos Aires, Argentina. This article describes the design, implementation, and use of an electronic dashboard which provided monitoring of patients discharged home, during follow-up with telehealth. It was useful to access essential information to organize and coordinate professional work and patients' surveillance, providing highly relevant data in real-time as proxy variables for quality and safety during home isolation. The implemented tool innovated in the integration of technologies within a real context. The information management was crucial to optimize services and decision-making, as well to guarantee safety for healthcare workers and patients.

Impact of COVID-19 Pandemic on Telehealth and In-Person Visits: Implications from an Emergency Department in Argentina.

Since Argentina's government declared a national emergency to combat the COVID-19 pandemic with a lockdown status, it has produced consequences on the healthcare system. We aimed to quantify the effect on the Emergency Department (ED) visits at Hospital Italiano de Buenos Aires. Our electronic health data showed that ED in-person visits declined 46% during the COVID-19 pandemic, from an overall of 176,370 visits during 2019 to 95,421 visits during 2020. Simultaneously, there was a telehealth visits boom when mandatory quarantine began (March 20, 2020): from a median of 12 daily in February 2020 to a median of 338 daily in April 2020; reaching a maximum daily peak of 1,132 on March 26 2020. For a while, teleconsultations replaced ED visits. Then, when face-to-face visits began to increase, teleconsultations began to decrease slowly, as the phenomenon reversed.

Infecciones respiratorias superiores virales en una central de emergencias: estudio de cohorte retrospectiva / Upper respiratory tract infection on an Emergency Department: retrospective cohort

Estimar la frecuencia de cuadro de vías aéreas superiores (CVAS) como motivo de consulta no programada, describir el proceso de atención y explorar la variación tras la implementación de una nueva estrategia de gestión para la atención, así como el efecto en los indicadores de calidad y seguridad de atención. Cohorte retrospectiva que incluyó consultas por CVAS entre 01/01/2015 y 31/12/2016 de Demanda Espontánea (consultas de baja complejidad de la Central de Emergencia de Adultos), en el Hospital Italiano de Buenos Aires. La prevalencia global del período 2015-2016 resultó 12,01% (21.581/179.597). La intervención múltiple, resultó efectiva en términos de disminución de estudios complementarios (19% antes y 17% después con p=0,001), disminución de laboratorios (9% antes y 8% después con p=0,009), y reducción del tiempo de atención (media de 51 minutos antes y 42 minutos después, con p=0,001). No hubo diferencias significativas en la incidencia acumulada de reconsultas a los 7 días (12,72% antes y 13,11% después con p=0,400) ni en la tasa de internaciones a los 7 días (0,42% antes y 0,38% después con p=0,651) desde la consulta índice (primer consulta en guardia). En un sistema sobresaturado, se requiere fortalecer los sistemas de atención primaria que conforman la puerta de entrada de la salud para garantizar la correcta utilización de los recursos disponibles, la solicitud de estudios apropiados y la indicación correcta de antibióticos. Muchas lecciones aprendidas facilitaron la organización y la reestructuración necesarias durante la pandemia COVID-19 (AU)

To estimate upper respiratory tract infection (URTI) frequency as a reason for unscheduled consultation, to describe the care process and to explore the variation after the implementation of a new management strategy for care, as well as the effect on quality and security indicators of care. Retrospective cohort which included consecutive consultations by URTI between 01/01/2015 and 12/31/2016 for ambulatory clinic (low complexity consultations at the Emergency Department), at the Hospital Italiano de Buenos Aires. The prevalence for the period 2015-2016 was 12.01% (21,581/179,597). The multiple intervention was effective in terms of reduction of complementary studies (19% before and 17% after; p =0.001), reduction of laboratories (9% before and 8% after; p=0.009), and reduction of attention time (mean of 51 minutes before and 42 minutes after; p=0.001). During the follow up, there were no significant differences in the cumulative incidence of reconsultations at 7 days (12.72% before and 13.11% after; p=0.400) or in the rate of hospitalizations at 7 days (0.42% before and 0.38% after; p=0.651) from the index consultation. In an overcrowded system, it is necessary to strengthen the primary care systems that make up the gateway to health to guarantee the correct use of available resources, the request for appropriate studies and the correct indication of antibiotics. Many lessons learned facilitated the organization and restructuring of the Emergency Department needed during the COVID-19 pandemic (AU)

[Analysis of Crowding in an Adult Emergency Department of a tertiary university hospital]. / Descripción de las características del fenómeno Crowding en la Central de Emergencia de Adultos, en un hospital universitario de alta complejidad: estudio de cohorte retrospectiva.

BACKGROUND: Crowding in Emergency Departments (ED), results from the imbalance between the simultaneous demand for health care and the ability of the system to respond. The NEDOCS scale (National Emergency Department Crowding Scale) measures the degree of crowding in an ED. AIM: To describe ED Crowding characteristics, using the NEDOCS scale, in an Argentinean hospital. MATERIAL AND METHODS: A retrospective cohort study was conducted with all adult patient consultations between July 2013 and July 2014 at the ED of Hospital Italiano de Buenos Aires. We included all hours in the analysis period (365 days x 24 h = 8,760). The NEDOCS value was calculated for each hour using an automatic algorithm and was quantified in a six points score. Levels 4 (overcrowded), 5 (severely overcrowded) and 6 (dangerously overcrowded) were defined as overcrowding. Contour plots analysis was applied to identify patterns. RESULTS: During the study period, 124,758 visits to the ED were registered. Overcrowding was present in 57.7% (5,055) of the analyzed hours. A predominance of scores between four and five was observed between 10:00 and 24:00 hours. The months with predominance of overcrowding were June, July and August (southern winter). CONCLUSIONS: The calculation of the NEDOCS score and the analysis of its temporal distribution are highly relevant to identify opportunities for improvement and to develop mechanisms to prevent the highest categories of overcrowding.

Descripción de las características del fenómeno Crowding en la Central de Emergencia de Adultos, en un hospital universitario de alta complejidad: estudio de cohorte retrospectiva / Analysis of Crowding in an Adult Emergency Department of a tertiary university hospital

Background: Crowding in Emergency Departments (ED), results from the imbalance between the simultaneous demand for health care and the ability of the system to respond. The NEDOCS scale (National Emergency Department Crowding Scale) measures the degree of crowding in an ED. Aim: To describe ED Crowding characteristics, using the NEDOCS scale, in an Argentinean hospital. Material and Methods: A retrospective cohort study was conducted with all adult patient consultations between July 2013 and July 2014 at the ED of Hospital Italiano de Buenos Aires. We included all hours in the analysis period (365 days x 24 h = 8,760). The NEDOCS value was calculated for each hour using an automatic algorithm and was quantified in a six points score. Levels 4 (overcrowded), 5 (severely overcrowded) and 6 (dangerously overcrowded) were defined as overcrowding. Contour plots analysis was applied to identify patterns. Results: During the study period, 124,758 visits to the ED were registered. Overcrowding was present in 57.7% (5,055) of the analyzed hours. A predominance of scores between four and five was observed between 10:00 and 24:00 hours. The months with predominance of overcrowding were June, July and August (southern winter). Conclusions: The calculation of the NEDOCS score and the analysis of its temporal distribution are highly relevant to identify opportunities for improvement and to develop mechanisms to prevent the highest categories of overcrowding.