EMERGENCY MEDICINE IN ISRAEL - THE EVOLUTION OF FROM EMERGENCY ROOM 1990 TO EMERGENCY DEPARTMENT 2040: PERSONAL POINT OF VIEW

INTRODUCTION: In this short review, in honor of Israel's 70th anniversary, more than a hundred years after the establishment of the first and largest HMO in Israel (Kupat Cholim Clalit), the 100th anniversary of Hadassah Hospital in Jerusalem (and its first Emergency Room) and 30 years after the first steps to build real Emergency Medicine (EM) in Israel, we review the short history of EM, its current position here and now, among other aspects of the health system and its vision. Proceeding from the Emergency Room towards the Emergency Department, from unwanted neglected tasks of frustrated physicians to essential clinical profession and from routine technical daily activities to advanced innovative futuristic emergency diagnosis and treatment. The point of view and impression is 100% personal. It is that of one physician who grew up in the system and was actively involved in the development of EM. The author is currently leading "Laniado" ER to be a modern department serving the rapidly growing population of Netanya and it's neighborhood.

The effect of administrative cessation of the use of ipratropium bromide in the treatment of acute asthma attacks in the emergency department.

BACKGROUND: The anticholinergic agent ipratropium bromide has demonstrated effectiveness in the treatment of severe asthma exacerbations. METHODS: We conducted a retrospective quasi-experiment to investigate the clinical consequences on acute asthma patients of the administrative removal of ipratropium bromide from an emergency department (ED) of a large tertiary hospital. We compared the combined negative outcome (hospitalization, length of stay in the ED, hospital readmission within 48 hours or 7 days, intubation, and death) of acute asthma patients, treated in the 12 months preceding (n = 394; Period A) and the 12 months following (n = 334; Period B) the policy change. Multiple imputations based on sequentially improved regressions were performed for missing data on measures of severity. RESULTS: Administration of steroid medications increased from 49.8% to 61.4%; p = .002 from Period A to Period B. There was no statistically significant difference in combined negative outcome between Periods A and B (41.1% and 42.9%, respectively). CONCLUSIONS: An administrative decision to stop the purchase of ipratropium bromide in an ED was followed by an increased use of steroids; adverse consequences did not increase in acute asthmatic patients. In the absence of ipratropium bromide in the ED, steroids may thus serve as an appropriate substitute, an observation that calls for a randomized controlled clinical trial.

Treatment of stable atrial fibrillation in the emergency department: a population-based comparison of electrical direct-current versus pharmacological cardioversion or conservative management.

OBJECTIVE: To compare the success rates and short-term complications of three treatment approaches, pharmacological and direct-current cardioversion (DCC), or 'wait-and-watch' among stable atrial fibrillation (AF) patients in the emergency department (ED). METHODS: All AF-related ED admissions during a 1-year period were retrospectively reviewed, and those meeting criteria of eligibility for immediate cardioversion, based on clinical stability, AF duration and adequacy of anticoagulation, were included. The propensity score approach generalized for the three groups was used to adjust for the observational non-randomized study nature. RESULTS: Among 374 eligible patients, the rate of successful cardioversion was higher in DCC than in pharmacological or wait-and-watch groups (78.2, 59.2 and 37.9% respectively, p < 0.001), with corresponding percentages of patients discharged from ED (52.9, 47.9 and 32.1%, p < 0.01) and respective odds ratios of 6.00, 2.47 and 1, adjusting for seniority of the treating physician, age, gender and patient comorbidities. DCC was 2.43 times more effective than pharmacological treatment in achieving sinus rhythm (95% confidence interval = 1.36-4.33, p = 0.003). Rehospitalization within 14 days due to probable AF-treatment-related complications of home-discharged patients was 3.4%. CONCLUSIONS: DCC was found to be the most effective treatment, with few short-term complications following conversion of stable AF patients to sinus rhythm in the ED.

Civilian doctors in military clinics--outsourcing for better medicine.

OBJECTIVES: To determine whether outsourcing of medical consulting services could improve the quality of medical treatment in military primary care clinics. METHODS: Data were collected prospectively over 2 months in two regular army clinics manned by ordinary army doctors and in two intervention clinics also staffed with senior civilian doctors. The causes for doctor visits, diagnoses, and other patient data were collected. RESULTS: Information was recorded from 4970 soldier visits in the four clinics. Although a prescription of rest days was similar in both types of clinics, the level of tertiary referrals was lower by one-third in the intervention clinics compared to the regular clinics. Surrogate markers for quality of care, such as increased use of planned follow-up and reduced antibiotic use, were significantly better in the intervention clinics, and so was overall patient satisfaction. CONCLUSIONS: Integration of specialist civilian physicians in the military primary care system is highly beneficial and provides better care and saves costs.

Management by constraints: considering patient volume when adding medical staff to the emergency department.

BACKGROUND: The emergency department is one of the hospital's busiest facilities and is frequently described as a bottleneck. Management by constraint is a managerial methodology that helps to focus on the most critical issues by identifying such bottlenecks. Based on this theory, the benefit of adding medical staff may depend on whether or not physician availability is the bottleneck in the system. OBJECTIVE: To formulate a dynamic statistical model to forecast the need for allocating additional medical staff to improve the efficacy of work in the emergency department, taking into account patient volume. METHODS: The daily number of non-trauma admissions to the general ED was assessed for the period 1 January 1992 to 1 December 1995 using the hospital computerized database. The marginal benefit to shortening patient length of stay in the ED by adding a physician during the evening shift was examined for different patient volumes. Data were analyzed with the SAS software package using a Gross Linear Model. RESULTS: The addition of a physician to the ED staff from noon to midnight significantly shortened patient LOS: an average decrease of 6.61 minutes for 80-119 admissions (P < 0.001). However, for less than 80 or more than 120 admissions, adding a physician did not have a significant effect on LOS in the ED. CONCLUSIONS: The dynamic model formulated in this study shows that patient volume determines the effectiveness of investing manpower in the ED. Identifying bottleneck critical factors, as suggested by the theory of constraints, may be useful for planning and coordinating emergency services that operate under stressful and unpredictable conditions. Consideration of patient volume may also provide ED managers with a logical basis for staffing and resource allocation.

Prolapso de la válvula mitral y enfermedad tromboembólica cerebral

Aunque el riesgo absoluto de enfermedad tromboembólica cerebral (ETC) en pacientes con prolapso de válvula mitral (PVM) parece ser muy bajo, todavía existe incertidumbre con relación al verdadero riesgo relativo. Investigaciones futuras en grupos mayores de pacientes serán muy beneficiosas, especialmente para la identificación de los subgrupos de pacientes con PVM y alto riesgo para el desarrollo de episodios tromboembólicos. En este artículo se revisan los posibles mecanismos en la relación casual entre PVM y ETC con énfasis en la detección de los pacientes con mayor riesgo de presentar ETC y las medidas terapéuticas y profilácticas adecuadas.