Prevalence of morphine use and time to initial analgesia in an Australian emergency department.

OBJECTIVE: To explore the association of morphine use with factors influencing time to initial analgesia (T-A). METHODS: A retrospective cohort review was conducted. Morphine data were collected from a register for restricted drugs located in the ED. T-A was the time interval between triage and signing out of morphine's first dose. Statistical analyses were performed to determine the association between morphine use and patient volume. RESULTS: In total, 8% of ED attendees received at least one dose of morphine sulphate in the ED. Prevalence of morphine use significantly (P < 0.05) varied by patient's age, Australasian Triage Scale category, time of arrival and type of illness. The median time of T-A was 79 min (95% CI 71-85) with substantially longer (median 107 min) for those who arrived during the afternoon and triaged as less urgent (median 127 min). Patients who arrived late at night (median 47 min), triaged as immediately/imminently life-threatening (median 58 min) and diagnosed as renal colic (median 27 min) or fractures/injuries (median 67 min) were more likely to receive i.v. morphine faster than other patients. The findings confirmed that large volume of patients in ED was associated with longer T-A. Patient volume in the ED showed a significant positive association with T-A (r = 0.568, 32% variation explained, P < 0.01). CONCLUSION: T-A is an important indicator of the quality of ED services. Severity of illness and patient volume were significant factors associated with extended T-A. Strategies for improving pain management in the complex ED environment are discussed.

A population follow-up study of patients who left an emergency department without being seen by a medical officer.

OBJECTIVES: To describe the population of emergency department patients who leave without being seen by a medical officer, to investigate the circumstances of their visit and to ascertain whether they subsequently receive alternative medical care. METHODS: A follow-up study was conducted of patients who were initially triaged, but left without being seen by a medical officer between July 2003 and October 2003 in a tertiary referral hospital emergency department in Sydney, Australia. Emergency Department Information System data were reviewed for population demographics, presenting complaints and acuity rating of patients. Follow-up telephone interviews were conducted within 7 days after the patient left the emergency department. RESULTS: During the study period, 8.6% (1272 of 14 741) of the emergency department patients left without seeing a doctor and 35.9% (457 of 1272) of these patients who walks out were contacted for follow-up. The results from bivariate and multivariate analyses showed that walkout rates significantly varied by sociodemographic and clinical characteristics of the patients. Young patients aged 0-29 years, and those with longer waiting time for triage and triaged as "less urgent" were more likely to walk out than others. Overcrowding in the emergency department had a significant association with walkout of patients. Prolonged waiting time was the most common reason for leaving emergency departments without being seen by a doctor. Only 12.7% (58 of 457) of the walkout patients revisited emergency departments within 7 days of their departure and of those who were subsequently admitted following their return to hospital accounted for 5.0% (23 of 457). Of the follow-up patients, 39.4% felt angry about their emergency department experiences. CONCLUSIONS: The number of patients who leave an emergency department without seeing a doctor is strongly correlated with waiting time for medical review. Achieving shorter emergency department waiting times is central to reducing the numbers of people leaving without being seen. The rate of patients who leave without being seen is also strongly correlated with triage category. These findings highlight the importance of accurate triaging, as this clearly influences waiting time. It is also likely that there are patients who benefit from the reassurance of the triage assessment, and therefore feel less urgency for medical review. These may be cases where immediate medical review is not essential. This area should be further explored. These results are important for planning and staffing health services. Decision makers should identify and target factors to minimise walkouts from public hospital emergency departments.

Factors associated with walkout of patients from New South Wales hospital emergency departments, Australia.

OBJECTIVE: To explore the association between daily patient numbers, sociodemographic, clinical and system characteristics and walkout rates of patients from New South Wales (NSW) public hospital ED (without seeing a medical officer). METHODS: This was a secondary analysis of the NSW Emergency Department Data Collection, between 1 January 1999 and 31 December 2001, with a total of 4 356 323 ED attendances. Bivariate and multiple logistic regression analyses were performed to explore the relationship of walkout from ED and explanatory variables. RESULTS: About 5.7% of the patients attending in NSW public hospital ED left without seeing a doctor. The results from bivariate and multivariate analyses revealed that walkout rates significantly varied by sociodemographic and clinical characteristics of the patients. Patient groups that more likely to walk out were those aged 15-44 years, from a non-English-speaking background, Aboriginal, with lower socioeconomic status, with no private health insurance coverage and longer waiting times for triage. Patient volume in the ED showed a significant positive association with walkout rates. CONCLUSIONS: After adjusting for triage category (urgency of presentation) and triage time, patients from lower socioeconomic backgrounds and those without private health insurance coverage were more likely to leave ED without treatment. These results have important implications for Health Services. Future strategies aimed at minimizing walkouts from public hospital ED should prioritize and target factors identified in the present study.

Access block in NSW hospitals, 1999-2001: does the definition matter?

OBJECTIVES: To estimate the magnitude of access block and its trend over time in New South Wales hospitals, using different definitions of access block, and to explore its association with clinical and non-clinical factors. DESIGN AND SETTING: An epidemiological study using the Emergency Department Information System datasets (1 January 1999 to 31 December 2001) from a sample of 55 NSW hospitals. MAIN OUTCOME MEASURES: Prevalence of access block measured by four different definitions; strength of association between access block, type of hospital, year of presentation, mode and time of arrival, triage category (an indicator of urgency), age and sex. RESULTS: Rates of access block (for all four definitions) increased between 1999 and 2001 by 1%-2% per year. There were increases across all regions of NSW, but urban regions in particular. Patients presenting to Principal Referral hospitals and those who arrived at night were more likely to experience access block. After adjusting for triage category and year of presentation, the mode of arrival, time of arrival, type of hospital, age and sex were significantly associated with access block. CONCLUSIONS: Access block continues to increase across NSW, whatever the definition used. We recommend that hospitals in NSW and Australia move to the use of one standard definition of access block, as our study suggests there is no significant additional information emerging from the use of multiple definitions.