Drug-related emergency department visits: external validation of an assessment tool in a general emergency department population.

BACKGROUND: The process of identifying drug-related hospitalisations is subjective and time-consuming. Assessment tool for identifying hospital admissions related to medications (AT-HARM10) was developed to simplify and objectify this process. AT-HARM10 has not previously been externally validated, thus the predictive precision of the tool is uncertain. AIM: To externally validate AT-HARM10 in adult patients admitted to the emergency department (ED). METHOD: This retrospective cross-sectional study investigated 402 patients admitted to the ED, Diakonhjemmet Hospital, Oslo, Norway. A trained 5th-year pharmacy student used AT-HARM10 to assess all patients and to classify their ED visits as possibly or unlikely drug-related. Assessment of the same patients by an interdisciplinary expert panel acted as the gold standard. The external validation was conducted by comparing AT-HARM10 classifications with the gold standard. RESULTS: According to AT-HARM10 assessments, 169 (42%) patients had a possible drug-related ED visit. Calculated sensitivity and specificity values were 95% and 71%, respectively. Further, positive and negative predictive values were 46% and 98%, respectively. Adverse effects/over-treatment and suboptimal treatment were the issues most frequently overestimated by AT-HARM10 compared with the gold standard. CONCLUSION: AT-HARM10 identifies drug-related ED visits with high sensitivity. However, the low positive predictive value indicates that further review of ED visits classified as possible drug-related by AT-HARM10 is necessary. AT-HARM10 can serve as a useful first-step screening that efficiently identifies unlikely drug-related ED visits, thus only a smaller proportion of the patients need to be reviewed by an interdisciplinary expert panel.

Leaving Against Medical Advice: Current Problems and Plausible Solutions.

Leave against medical advice (LAMA) is defined as 'a decision to leave the hospital before the treating physician recommends discharge', and is associated with higher rates of readmission, longer subsequent hospitalization, and worse health outcomes. In addition to this, they also contribute to poor healthcare resource utilization. We conducted a single-center audit to establish patient demographics and contributing factors of patients leaving against medical advice from our emergency department (ED). We benchmarked our data against locally available clinical policy guidelines. We interrogated our electronic health record system (known as Salamtak®), which is a Cerner-based platform (Cerner Corporation, Kansas City, MO 64138) for patients who signed LAMA from ED from 2018 to 2023. We selected a convenience pilot sample of 120 subjects. Based on a literature review, we identified patient demographics (age, gender, nationality, socioeconomic status, marital status, religion), possible contributing factors (time of attendance, insurance status, length of ED stay), and patient outcomes (reattendances within 1 week and mortality) to evaluate. Based on locally available guidance, we formulated six criteria to audit with a standard set at 100% for each. A team of emergency medicine residents collected data that was anonymized on an Excel spreadsheet (Microsoft Excel, Microsoft Corporation. (2018). Basic descriptive statistics were used to collate results. About 93 patients (77.5%) were 16 years and above, and 27 patients (22.5%) were below 16 years. There was a slight preponderance of males (64 patients, 53.3%) than females (56 patients, 46.6%). The majority of LAMA cases presented in the evening and night (97 patients, 80.8%). About 57 (47.5%) patients had an ED length of stay of 3 hours or more. The average ED length of stay for these patients was 3.4 hours. About 73 patients (60.3%) were insured. Out of 120 patients, only 12 (10%) had a mental capacity assessment documented. The commonest reason for signing LAMA was a social reason in 45 (37.5%) cases. In the remaining cases, the causes were a combination of family, financial, waiting, or other/undocumented reasons). When faced with a decision to LAMA, the involvement of a Public Relationship Officer (PRO) was only documented to be consulted in seven (5.8%) cases. About 14 cases were re-attended within 1 week (11.6%) and no mortalities were reported in any of the reattendances. LAMA is a not-so-rare phenomenon often occurring in EDs, and often a cause of trepidation for healthcare workers. Treating this as an aberrant behavior on the part of the patient, or laying the responsibility for this action on the healthcare provider is primitive, counter-productive, and not patient-centric. Familiarity with local guidelines around this contentious area is essential. Revised nomenclature like 'premature discharge' may be less stigmatizing for the patient. Where possible, a harm reduction approach should be used and frontline healthcare workers must be prepared with an escalation plan. In the United Arab Emirates, familiarity with Wadeema's Law as a child protection measure is essential.

Emergency department workforces' experiences and perceptions of well-being from an international perspective: a scoping review.

OBJECTIVES: To identify and present the available evidence regarding workforce well-being in the emergency department. DESIGN: Scoping review. SETTING: The emergency department (ED). DATA SOURCES: CINAHL, MEDLINE, APA PsycINFO and Web of Science were searched with no publication time parameters. The reference lists of articles selected for full-text review were also screened for additional papers. ELIGIBILITY CRITERIA FOR STUDY SELECTION: All peer-reviewed, empirical papers were included if: (1) participants included staff-based full-time in the ED, (2) ED workforce well-being was a key component of the research, (3) English language was available and (4) the main focus was not burnout or other mental illness-related variables. RESULTS: The search identified 6109 papers and 34 papers were included in the review. Most papers used a quantitative or mixed methods survey design, with very limited evidence using in-depth qualitative methods to explore ED workforce well-being. Interventions accounted for 41% of reviewed studies. Findings highlighted pressing issues with ED workforce well-being, contributed to by a range of interpersonal, organisational and individual challenges (eg, high workloads, lack of support). However, the limited evidence base, tenuous conceptualisations and links to well-being in existing literature mean that the findings were neither consistent nor conclusive. CONCLUSIONS: This scoping review highlights the need for more high-quality research to be conducted, particularly using qualitative methods and the development of a working definition of ED workforce well-being.

No Association between SARS-CoV-2 Infection and Quality of Life 6- and 12-Months After Infection.

OBJECTIVE: To assess the association between SARS-CoV-2 infection and long-term quality of life (QoL). METHODS: Prospective cohort study with 6- and 12-month follow-up conducted in 14 Canadian institutions. Children tested for SARS-CoV-2 between August 2020 and February 2022 were eligible. QoL was measured using PedsQLTM-4.0, overall health status scores 6- and 12-months after testing. RESULTS: Among SARS-CoV-2 positive and negative participants eligible for long-term follow-up, 74.8% (505/675) and 71.8% (1106/1541) at 6- and 59.0% (727/1233) and 68.1% (2520/3699) at 12-months, completed follow-up, respectively. Mean ± SD PedsQL™ scores did not differ between positive and negative groups; difference: -0.86 (95%CI: -2.33, 0.61) at 6- and -0.48 (95%CI: -1.6, 0.64) at 12-months, respectively. SARS-CoV-2 test-positivity was associated with higher social subscale scores. Although in bivariate analysis, overall health status at 6-month was higher among SARS-CoV-2 cases [difference: 2.16 (95%CI: 0.80, 3.53)], after adjustment for co-variates, SARS-CoV-2 infection was not independently associated with total PedsQL™ or overall health status at either time point. Parental perception of recovery did not differ based on SARS-CoV-2 test-status at either time point. CONCLUSIONS: SARS-CoV-2 infection was not associated with QoL, overall health status, or parental perception of recovery 6- and 12-months following infection. CLINICAL TRIAL REGISTRATION (IF ANY): N/A.

Trauma nursing competency in the emergency department: a concept analysis.

OBJECTIVES: Despite numerous published concept analyses of nursing competency, the specific understanding of trauma nursing competency in emergency departments remains limited, with no clear definition. This study aimed to clarify the definitions and attributes of trauma nursing competencies in emergency departments. DESIGN: Walker and Avant's method was used to clarify the concept of trauma nursing competency in emergency departments. DATA SOURCES: PubMed, EMBASE, CINAHL and RISS were searched from inception to 23 April 2023. ELIGIBILITY CRITERIA: Relevant studies that included combinations of the terms 'nurse', 'nursing', 'emergency', 'trauma', 'competency', 'capability' and 'skill' were selected. We restricted the literature search to English and Korean full-text publications, with no limit on the publication period; grey literature was excluded. DATA EXTRACTION AND SYNTHESIS: This study uses defining attributes, antecedents and consequences extracted through data analysis. To aid comprehension of the model, related and contrary cases of the concept were created, and empirical referents were defined. RESULTS: After excluding duplicates, irrelevant studies, incomplete texts and articles unrelated to the context and study population, 15 of the initial 927 studies were included. Five additional studies were added after a manual search of the references. The final concept analysis therefore included 20 studies. The attributes of trauma nursing competency for emergency nurses included 'rapid initial assessments considering injury mechanisms', 'priority determinations based on degrees of urgency and severity', 'clinical knowledge of trauma nursing', 'skills of trauma nursing', 'interprofessional teamwork' and 'emotional care'. CONCLUSIONS: The concept analysis revealed that it is possible to promote the enhancement and development of trauma nursing competency in emergency departments across various contexts, such as clinical practice, education, research and organisational settings. This could ultimately improve trauma nursing quality and treatment outcomes.

Impact of Spatial Separation for Respiratory Patients on Emergency Department Flow Process Intervals and Length of Stay.

BACKGROUND: Spatial separation in emergency departments (ED) is empirically practised as part of transmission-based precaution. Despite its potential benefits in segregating potentially infectious patients, the effects of spatial separation on patient flow remains uncertain. AIM: To explore the impact of spatial separation on ED patient flow and identify specific clinical factors and flow process intervals (FPI) influencing ED length-of-stay (EDLOS). METHODS: This was a retrospective study of data extracted from patients' electronic medical records from January 1 to March 31, 2022 conducted at the ED of a tertiary hospital in Kuala Lumpur, Malaysia. During this period, patients were separated into respiratory areas (RA) and non-respiratory areas (NRA) based on Centers for Disease Control and Prevention recommendations. The study obtained ethics approval from the institution's ethics board. FINDINGS: A total of 1,054 patients were included in the study, 275 allocated to RA and 779 to NRA. Patients in RA had a significantly longer median EDLOS compared to in NRA (9 hours 29 minutes versus 7 hours 6 minutes, p<0.001, d=0.41). A lower proportion of patients in RA achieved an EDLOS ≤8 hours compared to NRA (41.8% versus 58.3%, p<0.001). Independent factors affecting EDLOS were triage category, re-triaging, hypertension, performing biomedical imaging, medical, surgical, and critical care consultations, and disposition plan. Bottlenecks significantly prolonging EDLOS were decision-to-departure, ultrasound interval and referral-to-consultation. CONCLUSION: Spatial separation prolongs FPI and EDLOS. Addressing inpatient access block and streamlining specialty review and biomedical imaging processes may reduce RA EDLOS.

Multicentre, retrospective cohort study protocol to identify racial and ethnic differences in acute kidney injuries in children and adolescents with diabetic ketoacidosis.

INTRODUCTION: Approximately 40% of children with diabetic ketoacidosis (DKA) develop acute kidney injury (AKI), which increases the risk of chronic kidney damage. At present, there is limited knowledge of racial or ethnic differences in diabetes-related kidney injury in children with diabetes. Understanding whether such differences exist will provide a foundation for addressing disparities in diabetes care that may continue into adulthood. Further, it is currently unclear which children are at risk to develop worsening or sustained DKA-related AKI. The primary aim is to determine whether race and ethnicity are associated with DKA-related AKI. The secondary aim is to determine factors associated with sustained AKI in children with DKA. METHODS AND ANALYSIS: This retrospective, multicentre, cross-sectional study of children with type 1 or type 2 diabetes with DKA will be conducted through the Paediatric Emergency Medicine Collaborative Research Committee. Children aged 2-18 years who were treated in a participating emergency department between 1 January 2020 and 31 December 2023 will be included. Children with non-ketotic hyperglycaemic-hyperosmolar state or who were transferred from an outside facility will be excluded. The relevant predictor is race and ethnicity. The primary outcome is the presence of AKI, defined by Kidney Disease: Improving Global Outcomes criteria. The secondary outcome is 'sustained' AKI, defined as having AKI ≥48 hours, unresolved AKI at last creatinine measurement or need for renal replacement therapy. Statistical inference of the associations between predictors (ie, race and ethnicity) and outcomes (ie, AKI and sustained AKI) will use random effects regression models, accounting for hospital variation and clustering. ETHICS AND DISSEMINATION: The Institutional Review Board of Children's Minnesota approved this study. 12 additional sites have obtained institutional review board approval, and all sites will obtain local approval prior to participation. Results will be presented at local or national conferences and for publication in peer-reviewed journals.

Protocol for Improving Care by FAster risk-STratification through use of high sensitivity point-of-care troponin in patients presenting with possible acute coronary syndrome in the EmeRgency department (ICare-FASTER): a stepped-wedge cluster randomised quality improvement initiative.

INTRODUCTION: Clinical assessment in emergency departments (EDs) for possible acute myocardial infarction (AMI) requires at least one cardiac troponin (cTn) blood test. The turn-around time from blood draw to posting results in the clinical portal for central laboratory analysers is ~1-2 hours. New generation, high-sensitivity, point-of-care cardiac troponin I (POC-cTnI) assays use whole blood on a bedside (or near bedside) analyser that provides a rapid (8 min) result. This may expedite clinical decision-making and reduce length of stay. Our purpose is to determine if utilisation of a POC-cTnI testing reduces ED length of stay. We also aim to establish an optimised implementation process for the amended clinical pathway. METHODS AND ANALYSIS: This quality improvement initiative has a pragmatic multihospital stepped-wedge cross-sectional cluster randomised design. Consecutive patients presenting to the ED with symptoms suggestive of possible AMI and having a cTn test will be included. Clusters (comprising one or two hospitals each) will change from their usual-care pathway to an amended pathway using POC-cTnI-the 'intervention'. The dates of change will be randomised. Changes occur at 1 month intervals, with a minimum 2 month 'run-in' period. The intervention pathway will use a POC-cTnI measurement as an alternate to the laboratory-based cTn measurement. Clinical decision-making steps and logic will otherwise remain unchanged. The POC-cTnI is the Siemens (Erlangen Germany) Atellica VTLi high-sensitivity cTnI assay. The primary outcome is ED length of stay. The safety outcome is cardiac death or AMI within 30 days for patients discharged directly from the ED. ETHICS AND DISSEMINATION: Ethics approval has been granted by the New Zealand Southern Health and Disability Ethics Committee, reference 21/STH/9. Results will be published in a peer-reviewed journal. Lay and academic presentations will be made. Maori-specific results will be disseminated to Maori stakeholders. TRIAL REGISTRATION NUMBER: ACTRN12619001189112.

Identifying Interventions to Improve Diagnostic Safety in Emergency Departments: Protocol for a Participatory Design Study.

BACKGROUND: Emergency departments (EDs) are complex and fast-paced clinical settings where a diagnosis is made in a time-, information-, and resource-constrained context. Thus, it is predisposed to suboptimal diagnostic outcomes, leading to errors and subsequent patient harm. Arriving at a timely and accurate diagnosis is an activity that occurs after an effective collaboration between the patient or caregiver and the clinical team within the ED. Interventions such as novel sociotechnical solutions are needed to mitigate errors and risks. OBJECTIVE: This study aims to identify challenges that frontline ED health care providers and patients face in the ED diagnostic process and involve them in co-designing technological interventions to enhance diagnostic excellence. METHODS: We will conduct separate sessions with ED health care providers and patients, respectively, to assess various design ideas and use a participatory design (PD) approach for technological interventions to improve ED diagnostic safety. In the sessions, various intervention ideas will be presented to participants through storyboards. Based on a preliminary interview study with ED patients and health care providers, we created intervention storyboards that illustrate different care contexts in which ED health care providers or patients experience challenges and show how each intervention would address the specific challenge. By facilitating participant group discussion, we will reveal the overlap between the needs of the design research team observed during fieldwork and the needs perceived by target users (ie, participants) in their own experience to gain their perspectives and assessment on each idea. After the group discussions, participants will rank the ideas and co-design to improve our interventions. Data sources will include audio and video recordings, design sketches, and ratings of intervention design ideas from PD sessions. The University of Michigan Institutional Review Board approved this study. This foundational work will help identify the needs and challenges of key stakeholders in the ED diagnostic process and develop initial design ideas, specifically focusing on sociotechnological ideas for patient-, health care provider-, and system-level interventions for improving patient safety in EDs. RESULTS: The recruitment of participants for ED health care providers and patients is complete. We are currently preparing for PD sessions. The first results from design sessions with health care providers will be reported in fall 2024. CONCLUSIONS: The study findings will provide unique insights for designing sociotechnological interventions to support ED diagnostic processes. By inviting frontline health care providers and patients into the design process, we anticipate obtaining unique insights into the ED diagnostic process and designing novel sociotechnical interventions to enhance patient safety. Based on this study's collected data and intervention ideas, we will develop prototypes of multilevel interventions that can be tested and subsequently implemented for patients, health care providers, or hospitals as a system. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55357.

Trends in severity of work-related traumatic injury and musculoskeletal disorder, Ontario 2004-2017.

OBJECTIVES: Traumatic injury surveillance can be enhanced by describing injury severity trends. This study reports trends in work-related injury severity for males and females over the period 2004-2017 in Ontario, Canada. METHODS: A weighted measure of workers' compensation benefit expenditures was used to define injury severity, obtained from the linkage of workers' compensation claims to emergency department (ED) records where the main injury or illness was attributed to work. Denominator counts were obtained from Statistics Canada's Labor Force Survey. Trends in the annual incidence of injury, classified as low, moderate, or high severity, were examined using regression modeling, stratified by age and sex. RESULTS: Over a 14-year observation period, there were 1,636,866 ED records included in the analyses. Overall, 57.6% of occupational injury records were classified as low severity, 29.5% as moderate severity, and 12.8% as high severity conditions. There was an increase in the incidence of high severity injuries among females (annual percent change (APC): 1.52%; 95% CI: 0.77, 2.28), while the incidence of low and moderate severity injuries generally declined for males and females. Among females, injuries attributed to animate mechanical forces and assault increased as causes of low, moderate, and high severity injuries. The incidence of concussion increased for both males (APC: 10.51%; 95% CI: 8.18, 12.88) and females (APC: 16.37%; 95% CI: 13.37, 19.45). CONCLUSION: The incidence of severe work-related injuries increased among females in Ontario between 2004 and 2017. The methods applied in this surveillance study of traumatic injury severity are plausibly generalizable to applications in other jurisdictions.

Patient flow modeling and simulation to study HAI incidence in an Emergency Department.

Healthcare-associated infections (HAIs), or nosocomial infections, refer to patients getting new infections while getting treatment for an existing condition in a healthcare facility. HAI poses a significant challenge in healthcare delivery that results in higher rates of mortality and morbidity as well as a longer duration of hospital stay. While the real cause of HAI in a hospital varies widely and in most cases untraceable, it is popularly believed that patient flow in a hospital-which hospital units patients visit and where they spend the most time since their admission into the hospital-can trace back to HAI incidence in the hospital. Based on this observation, we, in this paper, model and simulate patient flow in an emergency department of a hospital and then utilize the developed model to study HAI incidence therein. We obtain (a) a flowchart of patient movement (admission to discharge) and (b) anonymous patient data from University Health Medical Center for a duration of 11 months (Aug 2022-June 2023). Based on these data, we develop and validate the patient flow model. Our model captures patient movement in different areas of a typical emergency department, such as triage, waiting room, and minor procedure rooms. We employ the discrete-event simulation (DES) technique to model patient flow and associated HAI infections using the simulation software, Anylogic. Our simulation results show that the rates of HAI incidence are proportional to both the specific areas patients occupy and the duration of their stay. By utilizing our model, hospital administrators and infection control teams can implement targeted strategies to reduce the incidence of HAI and enhance patient safety, ultimately leading to improved healthcare outcomes and more efficient resource allocation.

A Quality Improvement Project to Measure and Improve the Quality of Below-Knee Ankle Cast Application in Emergency Departments.

Background Ankle fractures are very common injuries seen in an emergency setting. Initial management involves the application of below-knee plaster casts. At our local trauma meetings, we have observed that below-knee casts are often applied incorrectly which can result in suboptimal outcomes for patients and increase the burden on plaster room services if re-application is required. This quality improvement project aimed to assess the quality of below-knee cast applications for ankle fractures in two local district general hospitals (DGHs). Methodology We performed a closed-loop audit utilising a retrospective analysis of patients who underwent casting for unstable ankle fractures. Two audit cycles were completed over a 90-day period across two DGHs. Working within our local orthopaedic unit, we created a targeted, multi-disciplinary educational programme led by experienced plaster technicians. Between audit cycles, we organised a single interactive session with specialist nurses in the urgent treatment centre (UTC) of our DGH while a second DGH did the same with junior doctors working in the emergency department. Both sessions demonstrated correct casting techniques and discussed the importance of a neutral ankle position for optimal patient recovery. Our audit criteria were based on AO Foundation guidance, which states that the ankle should be immobilised in a neutral plantigrade position. All patients with an unstable ankle fracture requiring immobilisation in a below-knee cast were included in the audit. We measured the angle of plantarflexion from neutral, with 90° representing a neutral angle. The angle between the axis of the tibia and the sole of the foot was measured and judged to be within an acceptable range if it was between 80° and 100°, representing a stable ankle position. The audit findings were presented in our local audit meeting. Results In our first audit cycle, we collected data from 65 patients across both sites (N = 32 for DGH 1 and N = 33 for DGH 2). The mean angle was 108.5° and 18 of the 65 (27.7%) patients had angles of ankle plantarflexion that were in the acceptable range (80°-100°). Following the intervention, we again collected data from 61 patients across both sites (N = 28 for DGH 1 and N = 33 for DGH 2). The mean angle was 106.2° and 23 of the 61 (37.7%) patients had an acceptable angle of ankle plantarflexion (80°-100°). Both of our outcome measures showed an improvement but were not statistically significant. The hospital that provided an educational session for the doctors showed an improvement in acceptable ankle casts of 3% while the hospital which provided an educational session for the UTC team improved by 22%. Conclusions We demonstrated a quantifiable approach to assess and improve the quality of below-knee cast application for ankle fractures via a single intervention that would be easily reproducible in other hospitals. We suggest further studies to investigate below-knee cast application quality and its association with patient outcomes as our data and other preliminary sources suggest that current standards are unsatisfactory.

Patient experience of emergency department triage: An integrative review.

BACKGROUND: Emergency department (ED) triage is often patients' first contact with a health service and a critical point for patient experience. This review aimed to understand patient experience of ED triage and the waiting room. METHODS: A systematic six-stage approach guided the integrative review. Medline, CINAHL, EmCare, Scopus, ProQuest, Cochrane Library, and JBI database were systematically searched for primary research published between 2000-2022 that reported patient experience of ED triage and/or waiting room. Quality was assessed using established critical appraisal tools. Data were analysed for descriptive statistics and themes using the constant comparison method. RESULTS: Twenty-nine articles were included. Studies were mostly observational (n = 17), conducted at a single site (n = 23), and involved low-moderate acuity patients (n = 13). Nine interventions were identified. Five themes emerged: 'the who, what and how of triage', 'the patient as a person', 'to know or not to know', 'the waiting game', and 'to leave or not to leave'. CONCLUSION: Wait times, initiation of assessment and treatment, information provision and interactions with triage staff appeared to have the most impact on patient experience, though patients' desires for each varied. A person-centred approach to triage is recommended.

Multidimensional frailty in elderly emergency department patients: unveiling the prevalence and significance of social frailty.

PURPOSE: This study aimed to assess the prevalence and factors of physical, psychological, and social frailty among older adults in the emergency department, comparing these data with community population to understand emergency setting manifestations. METHODS: Conducted at the Emergency Department of National Taiwan University BioMedical Park Hospital, this prospective observational cohort study enrolled older adult patients over a three-month period. Frailty assessments included the Study of Osteoporotic Fractures scale for physical frailty, the Tilburg Frailty Indicator for psychological frailty, and the Makizako Social Frailty Index for social frailty. Data analysis involved a multivariable logistic model to determine the risk factors associated with each frailty type. RESULTS: Out of 991 older adult individuals seeking medical care, 207 participated in the study. The study found high prevalence rates of frailty: 46.38% for physical, 41.06% for psychological, and 48.79% for social frailty. Risk factors for frailty included older age and a history of falls. Interestingly, the prevalence of social frailty was notably higher than physical and psychological frailty. Gender and polypharmacy showed no significant association with any frailty type. CONCLUSION: This research reveals high physical, psychological, and social frailty among older ED patients, especially noting social frailty's prevalence. It highlights the importance for emergency care to adopt holistic care strategies that address older adults' multifaceted health challenges, suggesting a paradigm shift in current healthcare practices to better cater to the multifaceted needs of this vulnerable population.

RéSUMé: OBJECTIFS: Cette étude visait à évaluer la prévalence et les facteurs de la fragilité physique, psychologique et sociale chez les personnes âgées au service des urgences, en comparant ces données avec la population communautaire pour comprendre les manifestations en situation d'urgence. MéTHODES: Menée au service des urgences de l'hôpital BioMedical Park de l'Université nationale de Taiwan, cette étude prospective de cohorte observationnelle a recruté des patients adultes âgés sur une période de trois mois. Les évaluations de la fragilité comprenaient l'échelle de l'étude des fractures ostéoporotiques pour la fragilité physique, l'indicateur de la fragilité psychologique de Tilburg et l'indice de fragilité sociale de Makizako pour la fragilité sociale. L'analyse des données comportait un modèle logistique multivarié pour déterminer les facteurs de risque associés à chaque type de fragilité. RéSULTATS: Sur 991 personnes âgées ayant besoin de soins médicaux, 207 ont participé à l'étude. L'étude a révélé des taux de prévalence élevés de la fragilité : 46,38% pour le physique, 41,06% pour le psychologique et 48,79% pour la fragilité sociale. Les facteurs de risque de fragilité comprenaient un âge avancé et des antécédents de chute. Fait intéressant, la prévalence de la fragilité sociale était nettement plus élevée que la fragilité physique et psychologique. Le genre et la polypharmacie n'ont montré aucune association significative avec aucun type de fragilité. CONCLUSION: Cette recherche révèle une grande fragilité physique, psychologique et sociale chez les patients âgés aux urgences, en particulier la prévalence de la fragilité sociale. Il souligne l'importance pour les soins d'urgence d'adopter des stratégies de soins holistiques qui répondent aux défis de santé multiformes des personnes âgées, suggérant un changement de paradigme dans les pratiques de soins de santé actuelles pour mieux répondre aux besoins multiformes de cette population vulnérable.

Emergency Physicians' Knowledge, Attitudes, and Practices Related to Psychiatric Emergencies in Makkah's General Hospitals in Saudi Arabia: A Cross-Sectional Study.

Purpose: This study aims to assess the knowledge, attitudes, and practices of emergency physicians (EPs) related to psychiatric emergencies (PEs) in Makkah's general hospitals. Sample and Methods: This study was an observational cross-sectional study using an online survey distributed to 138 EPs in the emergency departments (EDs) of six public hospitals in Makkah City, Saudi Arabia, between March 15 and May 1, 2023. A convenience sample was used for data collection. The questionnaire was developed after related surveys in the literature were reviewed. Results: 59.9% of the physicians were aged 20-30 years. Most (68.8%) worked in hospitals that had psychiatric facilities. Regarding knowledge, only 30% of the emergency doctors were considered knowledgeable: the majority could identify PEs (79.7%), perform mental status examinations (71.0%), distinguish physical and mental symptoms (66.7%), and communicate with psychiatric patients (58.0%). However, only 52.9% could initiate management plans by prescribing psychiatric medication to patients. In relation to attitude, most physicians disagreed with the idea that healthcare practitioners do not need to advocate for psychiatric patients (67.4%), but many (62.3%) assumed that they do not have the responsibility to manage psychiatric patients, and they felt that conducting psychiatric evaluations in public hospitals is challenging because of the busy environment there. As regards practice, mentally ill patients (60.9%) were managed or referred by practices, and 56.5% of the EPs advised these patients upon discharge. Conclusion: The study showed that EPs have positive attitudes toward psychiatric patients, but their knowledge varied based on age, occupation levels, and years of experience. There were significant knowledge gaps, particularly regarding effective communication with psychiatric patients. Additionally, many EPs manage psychiatric patients without being aware of the psychiatric resources in their hospital. Improving medical school curricula and postgraduate training can enhance care. However, more research in this field is needed.

Head-and-neck Cancer in the Emergency Department: A Contemporary Review of Common Presentations and Management.

Head-and-neck cancer (HNC) can present with life.threatening symptoms in the emergency department. Patients can sometimes be misdiagnosed with pulmonary disease due to similar signs and symptoms, ultimately leading to delayed diagnosis and potentially devastating consequences. Reasons for this include lack of awareness of patient risk factors and knowledge of the myriad of presenting complaints in the disease process among physicians working in primary care and in the emergency department. This article explores the contemporary risk factors and common presenting symptoms and discusses initial management for a patient with potential head-and-neck malignancy. Emergency presentations of HNC are wide ranging and can overlap with common respiratory pathologies. Clinician awareness of this can assist the team in deciding what appropriate examination and investigations are required to reduce the risk of delaying diagnosis and further treatment.

Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation.

BACKGROUND: Addressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100 million (US$130 million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context. METHODS: We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interviews) and quantitative data (time series analyses of attendances, reattendances, hospital admissions, length of stay) based on previous research using a purposive sample of 13 GP-ED service models (3 inside-integrated, 4 inside-parallel service, 3 outside-onsite and 3 with no GPs) in England and Wales. We used realist methodology to understand the relationship between contexts, mechanisms and outcomes to develop programme theories about how and why different GP-ED service models work. RESULTS: GP-ED service models are complex, with variation in scope and scale of the service, influenced by individual, departmental and external factors. Quantitative data were of variable quality: overall, no reduction in attendances and waiting times, a mixed picture for hospital admissions and length of hospital stay. Our programme theories describe how the GP-ED service models operate: inside the ED, integrated with patient flow and general ED demand, with a wider GP role than usual primary care; outside the ED, addressing primary care demand with an experienced streaming nurse facilitating the 'right patients' are streamed to the GP; or within the ED as a parallel service with most variability in the level of integration and GP role. CONCLUSION: GP-ED services are complex . Our programme theories inform recommendations on how services could be modified in particular contexts to address local demand, or whether alternative healthcare services should be considered.