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Background Hospital administrators are often challenged with overcrowding at hospitals. The study hospital receives referred patients; however, they have to wait in long queues even for getting registered. This was a cause of concern for hospital administrators. The study was undertaken to find an amicable solution to the queues at registration using Queuing Theory. Method This observational and interventional study was carried out in a tertiary care ophthalmic hospital. In the first phase, data of service time and arrival rate was collected. The queuing model was built using the coefficient of variation (CoV) of the observed times. Server utilization for new patient registration was found to be 1.21 and was 0.63 for revisit patients. Scenario-based simulation carried out using free software for optimal utilization of both types of servers. Recommendations made to combine the registration process and to increase one server were implemented. In the second phase, after one year, patient registration data were collected and compared for the number of patients registered using SPSS 17. Results Number of patients registered within the registration timings increased whereas the number of patients registered after the registration timings decreased significantly at 95% CI with a p-value of less than 0.001. Queues finished early and more number of patients were registered in the same time. Conclusion Using queuing theory, the bottleneck of the systems can be identified. Scenario and software-based simulations provide solutions to the problem of queues. The study is an application of Queuing Theory with a focus on efficient resource utilization. It can be replicated in an organization with limited resources facing the challenge of queues.

Purpose Overcrowding in emergency departments (EDs) is a concerning global problem and has been identified as a national crisis in some countries. Several emergency sorting systems designed successfully in the world. Launched in 2004, a group of branches in south African triage score (SATS) developed. The effectiveness of the case sorting system of SATS was evaluated to reduce the patient's length of stay (LOS) and mortality rate within the ED at Suez Canal University Hospital. Methods The study was designed as an intervention study that included a systematic random sample of patients who presented to the ED in Suez Canal University Hospital. This study was implemented in three phases: pre-intervention phase, 115 patients were assessed by the traditional protocols; intervention phase, a structured training program was provided to the ED staff, including a workshop and lectures; and post-intervention phase, 230 patients were assessed by SATS. All the patients were retriaged 2 h later, calculating the LOS per patient and the mortality. Data was collected and entered using Microsoft Excel software. Collected data from the Triage sheet were analyzed using the SPSS software program version 22.0. Results The LOS in the ED was about 183.78 min before the intervention; while after the training program and the application of SATS, it was reduced to 51.39 min. About 15.7% of the patients died before the intervention; however, after the intervention the ratio decreased to 10.7% deaths. Conclusion SATS is better at assessing patients without missing important data. Additionally, it resulted in a decrease in the LOS and reduction in the mortality rate compared to the traditional protocol.

COVID-19 has affected over 170 countries around the world. Alarming rate has increased with the increase of infected cases and death rates. Whereas, the World Health Organization (WHO) had declared the COVID-19 virus as a pandemic on 11th March 2020. Preparations were made to face the spread of COVID-19, as predicting the most probable risk areas by using spatial models. Prediction spatial models of COVID-19 risk areas can help the governmental authorities to generate sustainable strategies and set up suitable protocols to control the pandemic. This research presents an attempt of a potential spatial prediction modeling of COVID-19 risk areas in Cairo governorate-Egypt. Four indicator models (demographic, residential, environmental and topographic) were developed using geomatics technology based on the guidelines of the UN-habitat sustainable development goals (SDGs) target (11 & 3). Five predicted scenarios were generated for the most pandemic probability areas by the integration of the four indicator models. The results showed that there are common areas in all scenarios for highly COVID-19 pandemic risk areas. These common risk areas were found in (El Marag, El Salam, Ain Shams, El Mataria, El Gammaleya, Manshiat Nasser, El Mosky, Bolak, Hadaak El Koba, and El Sharbeya) districts. The hotspots zones are characterized by overcrowding, high population density and economic activities, large family size, poor infrastructure service and low rate of education. Moreover, it was noticed that crowding points resulted in traffic density and air pollution, which may affect the pandemic spread. The accuracy assessment results displayed that, the environmental predicted scenario was more consistent with the official data of the Egyptian Ministry of Health and Population) MOHP), while the residential one was less convenient. The result of this study supports the health sector by predicting the hot spots areas. The present study is aimed to develop a proactive plan to confront the pandemic before spreading in the Cairo governorate-Egypt. Also, the proposed prediction model can be an effective aid for decision-makers across the world working on containment strategies to minimize the spread of Coronavirus.

Introduction The surge of SARS-CoV-2-virus infected (COVID-19) patients presenting to New York City (NYC) hospitals quickly overwhelmed and outnumbered the available acute care and intensive care resources in NYC in early March 2020. Upon the arrival of military medical assets to the Javits Convention Center in NYC, the planned mission to care for non-SARS-CoV-2 patients was immediately changed to manage patients with (SARS-CoV-2)COVID-19 and their comorbid conditions. Healthcare professionals from every branch of the uniformed services, augmented by state and local resources, staffed the Javits New York Medical Station (JNYMS) from April 2020. Methods The data review reported aggregated summary statistics and participant observations collected by N.Y. State and U.S. military officials. Results During the 28 days of patient intake at the JNYMS, 1,095 SARS-CoV-2-positive patients were transferred from NYC hospitals to the JNYMS. At its peak, the JNYMS accepted 119 patients in a single day, had a maximum census of 453, and had a peak intensive care unit census of 35. The median length of stay was 4.6 days (interquartile range: 3.1-6.9 days). A total of 103 patients were transferred back to local hospitals, and there were 6 deaths, with an overall mortality rate of 0.6% (95% CI, 0.3-1.2). Discussion and Conclusions This is the first report of the care provided at the JNYMS. Within 2 weeks, this multi-agency effort was able to mobilize to care for over 1,000 SARS-CoV-2 patients with varying degrees of illness in a 1-month period. This was the largest field hospital mobilization in the U.S. medical history in response to a non-wartime pandemic. Its success with huge patient throughput including disposition and low mortality relieved critical overcrowding and supply deficiencies throughout NYC hospitals. The downstream impact likely saved additional hundreds of lives and reduced stress on the system during this healthcare crisis.

Objectives Wait time for emergency care is a quality measure that affects clinical outcomes and patient satisfaction. It is unknown if there is racial/ethnic variability in this quality measure in pediatric emergency departments (PEDs). We aim to determine whether racial/ethnic differences exist in wait times for children presenting to PEDs and examine between-site and within-site differences. Methods We conducted a retrospective cohort study for PED encounters in 2016 using the Pediatric Emergency Care Applied Research Network Registry, an aggregated deidentified electronic health registry comprising 7 PEDs. Patient encounters were included among all patients 18 years or younger at the time of the ED visit. We evaluated differences in emergency department wait time (time from arrival to first medical evaluation) considering patient race/ethnicity as the exposure. Results Of 448,563 visits, median wait time was 35 minutes (interquartile range, 17-71 minutes). Compared with non-Hispanic White (NHW) children, non-Hispanic Black (NHB), Hispanic, and other race children waited 27%, 33%, and 12% longer, respectively. These differences were attenuated after adjusting for triage acuity level, mode of arrival, sex, age, insurance, time of day, and month [adjusted median wait time ratios (95% confidence intervals): 1.11 (1.10-1.12) for NHB, 1.12 (1.11-1.13) for Hispanic, and 1.05 (1.03-1.06) for other race children compared with NHW children]. Differences in wait time for NHB and other race children were no longer significant after adjusting for clinical site. Fully adjusted median wait times among Hispanic children were longer compared with NHW children [1.04 (1.03-1.05)]. Conclusions In unadjusted analyses, non-White children experienced longer PED wait times than NHW children. After adjusting for illness severity, patient demographics, and overcrowding measures, wait times for NHB and other race children were largely determined by site of care. Hispanic children experienced longer within-site and between-site wait times compared with NHW children. Additional research is needed to understand structures and processes of care contributing to wait time differences between sites that disproportionately impact non-White patients.

Bangladesh is one of the world's strongest emerging economies. This nation is working on improving women's empowerment, with more women entering meaningful employment, and socio-cultural constraints on women's mobility gradually decreasing over time. However, for women in Bangladesh, travel constraints are currently more significant than cultural constraints. Therefore, to sustain the nation's economic growth, challenges to women's mobility must be resolved by developing a gender-inclusive transport system. To achieve this, proper transport planning is necessary. The aim of this research is to understand the significant variables contributing to Bangladeshi women travellers' mode choices. The main contribution of this article is to present an analysis of women's travel issues according to a range of income classes. The methodological approach adopted for this research is the mixed method approach of quantitative (Artificial Neural Network Model (ANN)) and qualitative (workshop discussions) analysis. Overall, Bangladeshi women commuters are vulnerable irrespective of their travel mode. From the discussion workshops we found that even though women face harassment during their daily commute, often they cannot change to another mode due to financial constraints. From the ANN model we found that uncontrolled fares, poor road conditions, lack of comfort, high cost, lack of availability, onboard overcrowding, and lack of safety to be some of the significant travel related issues that need to be improved across all modes. Overall, we conclude that independence and equity have not yet been achieved for the mobility of women in Bangladesh.

Health problems of women experiencing homelessness are driven either from the usual background characteristics of this population, or from the homeless lifestyle. Apart from poverty and unemployment, transition to homelessness is often associated with substance abuse, history of victimization, stress, poor mental health and human immunodeficiency virus (HIV). Water insecurity can undermine bodily hygiene and dental health, posing a greater risk of dehydration and opportunistic infections. Exposure to extreme environmental conditions like heat waves and natural disasters increases morbidity, accelerates aging, and reduces life expectancy. Nutrition-wise, a high prevalence of food insecurity, obesity, and micronutrient deficiencies are apparent due to low diet quality and food waste. Poor hygiene, violence, and overcrowding increase the susceptibility of these women to communicable diseases, including sexually transmitted ones and COVID-19. Furthermore, established cardiovascular disease and diabetes mellitus are often either undertreated or neglected, and their complications are more widespread than in the general population. In addition, lack of medical screening and contraception non-use induce a variety of reproductive health issues. All these health conditions are tightly related to violations of human rights in this population, including the rights to housing, water, food, reproduction, health, work, and no discrimination. Thus, the care provided to women experiencing homelessness should be optimized at a multidimensional level, spanning beyond the provision of a warm bed, to include access to clean water and sanitation, psychological support and stress-coping strategies, disease management and acute health care, food of adequate quality, opportunities for employment and support for any minor dependants.

Military personnel are often subjected to physical exertion, sleep deprivation, deficient diets, overcrowding, and stress. All of these influences are capable of compromising the immune system’s ability to ward off disease-causing bacteria, thus explaining why the historical narrative of war is frequently accompanied by reports of death and suffering due to epidemics of infectious diseases. Historically some of the most common infections included: diarrhoea, dysentery, typhoid fever, gonorrhoea, and streptococcal tonsillitis. The bacteria which cause these diseases are also capable of triggering arthritis. When an arthritic condition is triggered by an infectious microbe it can broadly be referred to as “reactive arthropathy,” of which the spondyloarthritides (SpAs) are of great interest. Since the bacteria associated with these arthritic conditions are responsible for the epidemics which have plagued combatants for centuries, it is reasonable to assume that reactive arthropathy was present in past military populations. This assertion can be tested through a prevalence study of military related skeletal assemblages. To test the methodology and gain preliminary results for this research project, a pilot study was carried out using remains from the 1461 Battle of Towton. The methodology was deemed to be sound and the statistical results, while not significant, were promising.

BackgroundWe investigated the volume and the characteristics of pediatric eye emergency department (PEED) consultations performed at our tertiary eye center during the early months of the COVID-19 pandemic and we compared them to those carried out in the same time interval of the previous three years.MethodsOphthalmic emergency examinations of patients aged ≤18 years old and done during the national COVID-19 lockdown (March 9th, 2020 – May 3rd, 2020) and in the corresponding date range of the previous three years (2017, 2018, and 2019) have been considered and reviewed. The following features were retrieved and analyzed: age, gender, duration and type of accused symptoms, traumatic etiology, and the discharge diagnosis.Results136, 133, and 154 PEED visits have been performed respectively in 2017, 2018, and 2019, while 29 patients presented in 2020. Therefore, the volume of PEED activity decreased by 79.4% (p p = 0.024).ConclusionsPEED activity decreased consistently after the onset of the pandemic and it was mainly attended by those children whose conditions required prompt assistance, reducing the number of patients diagnosed with milder pathologies. At the end of the emergency, better use of PEED could avoid overcrowding and minimize waste, allowing resource optimization for the management of urgent cases.

Introduction While overcrowding of emergency departments was often reported in the recent years, during the early phase of the pandemic, a reduction in patient numbers was seen. The aim of the current study was to describe the orthopedic trauma patient cohort presenting to the emergency department (ED) during the early pandemic period as compared to the cohort from the analogue time period 2019. Materials and methods A single-center case–control study was performed. All the consecutive orthopedic trauma patients > 12 years presenting to the ED were included. Patients in the same time period in 2019 served as the control group. Results Compared to 2019, in 2020, 33% less patients presented in the emergency department. Patients treated in 2020 were significantly older, significantly more often brought to ED by emergency medical services and significantly more often admitted. The number of fractures and diagnoses requiring surgical treatment decreased only slightly and the proportion of these patients among all the patients was significantly higher during the pandemic than in the control period. Furthermore, a higher percentage of polytrauma patients could be found in 2020 as well. Analysis of Manchester Triage System showed significantly less not urgent patients in 2020. Conclusion The present study shows a significant decline in the number of patients treated in the ED during the pandemic period but at the same time almost identical numbers of patients with fractures or diagnoses requiring surgical treatment. In the context of an overall decline in patient numbers, a stronger concentration on level 1 trauma centers seems to be evident during the pandemic.

As mountain tourism rapidly expands in remote landscapes, there is a critical need for improved disaster risk management to ensure the safety of tourists and industry workers, safeguard infrastruct...

Background and aim Since 2014, the annual number of patients entering our emergency department (ED) has increased significantly. These were primarily Internal Medicine (IM) patients, and of these, 25–30% were admitted. The present governmental policy presents a deterrent to adding IM beds for these patients, and Emergency and IM departments cope with ever-increasing number of IM patients. We describe a quality improvement intervention to increase outflow of IM patients from the ED to the IM departments. Methods We conducted a quality improvement intervention at the Shaare Zedek Medical Center from 2014 to 2018. The first stage consisted of an effort to increase morning discharges from the IM departments. The second stage consisted of establishing a process to increase the number of admissions to the IM departments from the ED. Results Implementation of the first stage led to an increased morning discharge rate from a baseline of 2–4 to 18%. The second stage led to an immediate mean (± SD) morning transfer of 35 ± 7 patients to the medical departments (8–12 per department), providing significant relief for the ED. However, the additional workload for the IM departments’ medical and nursing staff led to a rapid decrease in morning discharges, returning to pre-intervention rates. Throughout the period of the new throughput intervention, morning admissions increased from 30 to > 70%, and were sustained. The number of patients in each department increased from 36 to 38 to a new steady state of 42–44, included constant hallway housing, and often midday peaks of 48–50 patients. Mean length of stay did not change. IM physician and nurse dissatisfaction led to increased number of patients being admitted during the evening and night hours and fewer during the morning. Conclusion We describe a quality improvement intervention to improve outflow of medical patients from the ED in the morning hours. The new ED practices had mixed effects. They led to less ED crowding in the morning hours but increased dissatisfaction among the IM department medical and nursing staff due to an increased number of admissions in a limited number of hours. The present governmental reimbursement policy needs to address hospital overcrowding as it relates to limited community healthcare beds and an aging population.

Background Pulmonary embolism (PE) is a common life-threatening medical emergency that needs prompt diagnosis and management. Providing urgent care is a key determinant of quality in the emergency department (ED) and time-based targets have been implemented to reduce length of stay and overcrowding. The study aimed to determine factors that are associated with having a time-to-disposition of less than 4 h in patients with suspected PE who underwent computed tomography pulmonary angiography (CT-PA) to confirm the diagnosis. Methods After obtaining approval from the ethics committee, we conducted a retrospective observational study by examining CT-PA scans that was performed to rule out PE in all adult patients presenting at the ED between January 2018 and December 2019. Demographic information and clinical information, as well as arrival and disposition times were collected from electronic health records. Multivariable regression analysis was used to identify the independent factors associated with meeting the 4-h target in the ED. Results In total, the study involved 232 patients (76 men and 156 women). The median length of stay in the ED was 5.2 h and the 4-h target was achieved in 37% of patients. Multivariable logistic regression analysis revealed that a positive CT-PA scan for PE was independently associated with meeting the four-hour target in the ED (odds ratio [OR]: 2.2; 95% CI: 1.1–4.8). Furthermore, Hemoptysis was the only clinical symptom that served as an independent factor associated with meeting the 4-h target in the ED (OR: 10.4; 95% CI: 1.2–90.8). Conclusion Despite the lower number of staff and higher volume of patients on weekends, patients who presented on weekends had shorter stays and were more likely to meet the 4-h target. Careful clinical assessment, prior to requesting a CT-PA scan, is crucial, since negative CT-PA scans may be associated with failure to meet the 4-h target.

Background Pregnancy can be a stressful time for many women. Australian Indigenous women of childbearing age (18-44 years) have been found to experience high or very high rates of psychological distress. However, few studies have examined the burden of or any associations between stressful life events, social disadvantage and psychological distress for pregnant Indigenous women in Australia. Methods Two hundred sixty-one rural and remote women, pregnant with an Indigenous infant, from New South Wales in Australia were invited to provide data regarding social disadvantage then complete the Kessler-10 and Stressful Life Events surveys via self-report during each trimester of their pregnancy. Descriptive statistics, Pearson's correlations, Mann-Whitney U and Kruskal-Wallis tests were performed to determine the burden of and any associations between the variables of interest. Results High rates of psychological distress were reported by participants with 16.9% scoring severe distress levels during their pregnancy. Participants also reported high rates of stressful life events with almost 25% experiencing the death of a family member or friend, almost 14% living in overcrowded accommodation, 11% having someone close to them jailed and 8% experience separation from their partner, during their pregnancies. Distress was associated with numerous stressful life events (e.g. witnessing violence, a family member in jail and overcrowding) and one aspect of social disadvantage (smoking status). Conclusions Immediate attention needs to focus on the development of interventions to address the high levels of psychological distress and provide appropriate support services during periods of major life events for pregnant Australian Indigenous women.

Introduction: The COVID-19 was the emerging disease caused by SARS-COV 2. Efficient transmission of this disease occurs through droplets and fomites. As COVID-19 has high transmission and hence susceptible household & non-household close contacts are at high risk of developing disease. Study Objectives: 1) To estimate secondary attack rate of COVID-19 among the contacts during the pandemic in Pune city; 2) To identify factors associated with transmission and development of COVID-19 disease. Material & Methods: This was a retrospective cohort study conducted in the month of June 2020. The sample includes 741 contacts of 119 Laboratory confirmed cases for COVID-19, resides in 15 ward offices areas of PuneMunicipal Corporation after written informed consent. A confidential telephonic interview was taken by using a prestructured questionnaire which includes socio demographic data, duration of stay, family background,outcome, type of house, development of symptoms etc. Results: The overall Secondary Attack Rate estimated to be 32.5%, 33.7% among the high risk contacts while 13.3% among the low risk contacts. In this city, 6 wards (40%) out of 15 wards showed SAR of more than 40%.The characteristics of primary cases associated with spread of disease were presence of symptoms and duration between onset of disease and isolation of primary case. The factors significantly affecting SAR were age, comorbidity, no. of family members, type of family, type of house, overcrowding, no. of rooms, bedroom attached with toilet, type of contact & containment zone. Conclusion: Higher SAR was seen in the household contacts. It is necessary to adopt rigorous measures to cut the transmission chain in this area of close contact. How to cite this article: Jagdale GR, Parande MA, Borle PS, Tapare VS, Tambe MP, Wavare S, Hatnapure M, Salunke P, Shinde P, Paunikar A. Secondary Attack Rate among the Contacts of COVID-19 Patients at the Beginning of the Pandemic in Pune City of Western Maharashtra, India. J Commun Dis. 2021;53(3):51-59. DOI: https://doi.org/10.24321/0019.5138.202138

AIM To explore recent workplace violence literature against nurses in Saudi Arabia in terms of prevalence, contributing factors and recommendations for prevention. BACKGROUND Workplace violence in healthcare settings is a growing concern and efforts to provide nurses with optimum protection against workplace violence are challenged by multifaceted contributing factors. METHOD A systematic search strategy was employed to search workplace violence studies in the Saudi context in PubMed, ProQuest and Google Scholar. A narrative analysis was performed on peer-reviewed articles published in English between 2011 and 2021. FINDINGS Issues related to the prevalence of nursing workplace violence before and after the Saudi government's healthcare workers protection act, measurement and monitoring issues, contributing factors and interventions for mitigating workplace violence are explored. CONCLUSION There was inflation of quantitative descriptions of workplace violence on the account of qualitative approaches to understand the phenomenon. Workplace violence has decreased since the introduction of the Saudi government's legislative act in 2018. Overcrowding, miscommunication, and unmet patient needs were the factors most frequently contributing to workplace violence. IMPLICATIONS FOR NURSING MANAGEMENT Healthcare organizations should enhance workplace violence reporting systems and provide interpreters to support international nurses' communication with Saudi patients and families. Nurses need to be trained in workplace violence-related policies and procedures.

BACKGROUND Emergency department (ED) overcrowding has led to longer waits for patients to be seen, treated, and released. This has been coupled with an increased number of patients who leave without ever being seen by an ED provider. Improving patient throughput and decreasing ED patient length of stay while continuing to provide high-quality care is of paramount importance. Optimization of available standing orders for fever, pain, and/or nausea and vomiting at the time of nurse triage may offer an opportunity to improve patient outcomes, decrease time to medication (TTM) administration for ill and injured patients, and decrease length of stay. PATIENTS AND METHODS This was a retrospective cohort patient analysis for patients younger than 18 years of age presenting to the ED before (February 2019) and after (February 2020) an intensive campaign aimed at educating the triage nurses regarding the use of ED standing orders for acetaminophen, ibuprofen, and ondansetron. The investigators sought to evaluate percentage change in nurse triage-initiated (NTI) orders between the 2 time frames. Secondary outcomes evaluated TTM, documented adverse effects, percentage of inappropriate medication administrations, and correlate TTMs to ED discharge. RESULTS The percentage of patients who received an NTI medication was 49% in 2019 and 58% in 2020 (P = 0.257). For NTI orders, TTM initiation decreased in the postintervention group from an average of 45 minutes down to 37.6 minutes. In the overall cohort, TTM administration in the NTI group was a mean of 41.2 minutes compared with 75.9 minutes in the provider-initiated group (P < 0.0001). Length of stay was the same for the NTI versus the provider-initiated group in overall cohort (134.4 vs 142.9, P = 0.4303). No adverse events were identified. CONCLUSIONS Nurse-initiated medication administration at the time of triage offers an opportunity to get patients vital treatment more quickly. Medications administrated earlier in the pediatric ED encounter have a correlation to improved throughput and higher possibility of quicker discharge from the ED. Further research is needed to fully assess the impact of continuing education on improving utilization of triage standing orders and the impact on ED throughput.

Introduction: Emergency departments (EDs) at public hospitals in Vietnam typically face problems with overcrowding, as well as being populated by a wide variety of illnesses, resulting in increasing dissatisfaction from patients. To alleviate these problems, we used the increasingly popular value-stream mapping (VSM) and lean strategy approaches to (1) evaluate the current patient flow in EDs; (2) identify and eliminate the non-valued-added components; and (3) modify the existing process in order to improve waiting times. Methods: Data from a total of 742 patients who presented at the ED of 108 Military Central Hospital in Hanoi, Vietnam, were collected. A VSM was developed where improvement possibilities were identified and attempts to eliminate non-value-added activities were made. A range of issues that were considered as a resource waste were highlighted, which led to a re-design process focusing on prioritizing blood tests and ultrasound procedures. On the administrative side, various measures were considered, including streamlining communication with medical departments, using QR codes for healthcare insurance payments, and efficient management of X-ray and CT scan online results. Results: By implementing a lean approach, the following reductions in delay and waiting time were incurred: (1) pre-operative test results (for patients requiring medical procedures/operations) by 33.3% (from 134.4 to 89.4 min); (2) vascular interventions by 10.4% (from 54.6 to 48.9 min); and (3) admission to other hospital departments by 49.5% (from 118.3 to 59.8 min). Additionally, prior to the implementation of the lean strategy approach, only 22.9% of patients or their proxies (family members or friends), who responded to the survey expressed satisfaction with the ED services. This percentage increased to 76.5% following the curtailment of non-value-added activities. Through statistical inferential test analyses, it can be confidently concluded that applying lean strategy and tools can improve patient flow in public/ general hospital EDs and achieve better staff coordination within the various clinical and administrative hospital departments. To the authors' knowledge, such analysis in a Vietnamese hospital's ED context has not been previously undertaken.

Background Since August 2017, Myanmar nationals from Rakhine state have crossed the border into Bangladesh and settled in Cox’s Bazar, the World’s largest refugee camp. Due to overcrowding, poor sanitation, and hygienic practices they have been under significant health risks including diarrheal diseases. The objective of this study is to determine the viral etiology of acute gastroenteritis (AGE) among forcibly displaced Myanmar nationals (FDMN) and adjacent Bangladeshi local host population (AHP). Methods From April 2018 to April 2019, we collected stool specimens from 764 FDMN and 1159 AHP of all ages. We tested 100 randomly selected specimens from each group for the most common AGE viruses. Results Among 200 diarrhea patients, 55% and 64% of FDMN and AHP patients, respectively, had viral infections; the most common viruses were rotavirus (29% vs 44%), adenovirus (24% vs 31%), and norovirus (14% vs 10%). In both populations, viral infections were significantly higher in children less than 5 years of age, compared with bacterial infections that were higher in patients older than 5 years of age (P ≤ .05). Conclusions Disparities in viral and bacterial prevalence among various age groups warrant careful antibiotic usage, especially in children less than 5 years of age.

Background Expediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States. Methods A prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016–4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin. Results The use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6–100). NPV improved to 100% (95% CI: 92.9–100) when using the EMS and 3-h ED troponin measures. Conclusions EMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway.

BACKGROUND Non-emergent low-back pain (LBP) is one of the most prevalent presenting complaints to the emergency department (ED) and has been shown to contribute to overcrowding in the ED as well as diverting attention away from more serious complaints. There has been an increasing focus in current literature regarding ED admission and opioid prescriptions for general complaints of pain, however, there is limited data concerning the trends over the last decade in ED admissions for non-emergent LBP as well as any subsequent opioid prescriptions by the ED for this complaint. AIM To determine trends in non-emergent ED visits for back pain; annual trends in opioid administration for patients presenting to the ED for back pain; and factors associated with receiving an opioid-based medication for non-emergent LBP in the ED METHODS Patients presenting to the ED for non-emergent LBP from 2010 to 2017 were retrospectively identified from the National Hospital Ambulatory Medical Care Survey database. The “year” variable was transformed to two-year intervals, and a weighted survey analysis was conducted utilizing the weighted variables to generate incidence estimates. Bivariate statistics were used to assess differences in count data, and logistic regression was performed to identify factors associated with patients being discharged from the ED with narcotics. Statistical significance was set to a P value of 0.05. RESULTS Out of a total of 41658475 total ED visits, 3.8% (7726) met our inclusion and exclusion criteria. There was a decrease in the rates of non-emergent back pain to the ED from 4.05% of all cases during 2010 and 2011 to 3.56% during 2016 and 2017. The most common opioids prescribed over the period included hydrocodone-based medications (49.1%) and tramadol-based medications (16.9), with the combination of all other opioid types contributing to 35.7% of total opioids prescribed. Factors significantly associated with being prescribed narcotics included age over 43.84-years-old, higher income, private insurance, the obtainment of radiographic imaging in the ED, and region of the United States (all, P < 0.05). Emergency departments located in the Midwest [odds ratio (OR): 2.42, P < 0.001], South (OR: 2.35, < 0.001), and West (OR: 2.57, P < 0.001) were more likely to prescribe opioid-based medications for non-emergent LBP compared to EDs in the Northeast. CONCLUSION From 2010 to 2017, there was a significant decrease in the number of non-emergent LBP ED visits, as well as a decrease in opioids prescribed at these visits. These findings may be attributed to the increased focus and regulatory guidelines on opioid prescription practices at both the federal and state levels. Since non-emergent LBP is still a highly common ED presentation, conclusions drawn from opioid prescription practices within this cohort is necessary for limiting unnecessary ED opioid prescriptions.

Background Respiratory syncytial virus (RSV) is a major cause of infant deaths. Its epidemiology in low- and middle-income countries is poorly understood. Risk factors associated with RSV-associated infant deaths that occur in community settings are incompletely known. Methods Community deaths for infants aged 4 days to 6 months were identified during a 3-year postmortem RSV prevalence study at the main city morgue in Lusaka, Zambia, where 80% of deaths are registered. This analysis focuses on the subset of deaths for which an abbreviated verbal autopsy was available and intended to sort deaths into respiratory or nonrespiratory causes by clinical adjudication. Posterior nasopharyngeal swab samples were collected within 48 hours of death and tested for RSV using quantitative reverse-transcription polymerase chain reaction. Associations between potential risk factors were determined as relative risks with 95% confidence intervals (CIs). Results We prospectively enrolled 798 community infant deaths with verbal autopsies and RSV laboratory results, of which 62 results were positive. The mean age of the infants was 10 weeks, and 41.4% of them were male. Of all deaths, 44% were attributed to respiratory causes. RSV was detected in 7.8% of the community infants and was significantly associated with respiratory deaths (risk ratio, 4.0 [95% CI, 2.2–7.1]). Compared with older infants, those aged 0–8 weeks had a 2.83 (95% CI, 1.30–6.15) increased risk of dying with RSV. The risk of RSV for the 0–8-week age group increased to 5.24 (1.56–33.14) with adjustment for demographics, parental education, and geography. RSV deaths were increased with domiciliary overcrowding and were concentrated in poor and dense neighborhoods in Lusaka (risk ratio, 2.00 [95% CI, 1.22–3.27]). Conclusion RSV is a significant contributor to community respiratory deaths in this population, particularly in the first 3 months of life and in the more poor and dense parts of Lusaka.

Management of epizootics of exotic companion mammal herds relies on careful observance of animals, proper management and husbandry, adequate nutrition, and stress reduction. Many diseases occur because of the stress of weaning so anticipating this and maximizing sanitation and ventilation, minimizing overcrowding and concurrent disease, and providing enough fiber for herbivores is prudent. Antimicrobial therapy must be carefully considered in the route of administration and the likely risk of enterotoxemia development. Separation of affected animals, rapid diagnostic testing, and implementation of treatment and supportive care minimizes losses during epizootics. Knowledge of potential zoonotic pathogens is important for veterinarians and staff.

Aim To determine whether psychosocial determinants of adverse childhood experiences (ACE), from pregnancy to 2 years old, are associated with severe early childhood caries (S-ECC) in Indigenous children. Design Secondary data analyses from an ECC prevention trial among 344 First Nations mother-child dyads living on- and off-reserve in Ontario and Manitoba, Canada. Stratified (on-/off-reserve) logistic regression, controlling for mother's age and income source, assessed three categories of psychosocial ACE determinants: alcohol/drug misuse, household financial hardship (overcrowding and food insecurity) and emotional/social well-being (Perceived Stress Scale (PSS-14), sense of personal control (SOC), social support, subjective social status). Results Household overcrowding [adjusted odds ratio (AOR) = 1.89 (95% CI: 1.06-3.38)], food insecurity [AOR = 2.86 (1.53-5.34)] and mothers' high perceived stress [AOR = 2.48 (1.40-4.37)] were associated with S-ECC (dmft > 9) for those on-reserve. Maternal SOC had a protective effect for off-reserve children [AOR = 0.17 (0.03-0.95)]. Conclusions Increased efforts to reduce psychosocial ACE determinants are paramount to decreasing Indigenous children's vulnerability to S-ECC.

The care for emergency conditions is an important feature of developed the systems of healthcare. Emergency medicine is the medical specialty dedicated to diagnosis and treatment of unforeseen illness or injuries. Overcrowding of Emergency Room (ER) by non-urgent cases is a problem that should be raised and reasons for that need to be sought. The aim is to identify the prevalence and factors behind non-urgent cases attending to acute care in Riyadh. This is a cross-sectional study which was conducted over a one-year period. Questionnaires were distributed to parents of children ≤14 years attending pediatric emergency room (ER) in multiple hospitals in Riyadh, Saudi Arabia. The sample size was 383 participants recruited using convenience sampling technique. The inclusion criteria comprised of pediatrics ≤14 years attending to ER with urgent cases (level 1, 2 and 3 according to Emergency Severity Index) and minor trauma (contusion, abrasion), sore throat, upper respiratory tract infection (URTI), mild abdominal pain, vomiting alone or diarrhea alone with no sign of dehydration of (level 4 and 5 according to Emergency Severity Index). 383 questionnaires were collected. The sample consisted mostly of females 56%. Upper respiratory tract infection (URTI) was the highest reason for pediatric emergency room visits (55.1%). Only 12.2% have visited primary health care (PHC) prior to emergency room. Most of participants have sources for medical advice other than emergency physicians (80.3%). Results also show that many parents who have brought their kids to emergency lacked the knowledge that their cases could be managed in primary health care (76.2%). In Conclusion, results have shown that many parents choose ER whenever their children have any symptoms. Reasons for that varied between each participant. Many participants are ignorant of the capabilities of PHC centers, and their services. Raising awareness regarding primary health should be the objective to reduce number of non-urgent cases visiting emergency room.

BACKGROUND: Point of care ultrasound (POCUS) is required for use in many instances on a daily basis in the hospital, especially in the emergency department and other specialty treatment areas. While interns play a crucial role in running emergency services in Thailand, the POCUS usage of interns has not been well studied. METHODS: This was a retrospective observational study of the interns who worked at the Department of Emergency Medicine, a tertiary university hospital in Khon Kaen, Thailand between July 2020 and April 2021. The seven questions survey about participants’ experiences performing POCUS examinations was conceived and carried out by the research team. The primary aim of this study is to identify the frequency of POCUS examinations performed by interns in this or any other given rotation. RESULTS: The response rate was 81.25% with the frequency of POCUS examinations per physician coming in at 2.5 per shift. It should be noted that examinations occurred primarily during the morning shift (79%) and were for diagnostic purposes (100%). The highest POCUS use cases (80%) were found to take place for abdominal examinations and the most commonly used POCUS application was the FAST (Focused Assessment with Sonography for Trauma) examination (92%). The confidence level was rated as 3/5. The primary barrier to performing POCUS was lack of knowledge or ultrasound training (47%). CONCLUSIONS: POCUS is often used by interns though less than in some other specialties. The type of POCUS application employed was limited due to lack of training and the primary obstacle for POCUS use in the emergency department was patient overcrowding.

SARS-CoV-2, the cause of COVID-19, has resulted in high mortalities and global socio-economic disruptions. As knowledge of SARS-CoV-2 and COVID-19 evolves, the public requires up to date and appropriate information in order to keep safe in the absence of a proven vaccine. This review of the literature was written to provide the latest information on the virus and the disease. SARS-CoV-2 bears a higher genomic homology to SARS-CoV-1 than MERS-CoV-1. Globally, COVID-19 has caused more than 4.07 million deaths and infected over 188 million people by 16th July, 2021. In Africa, more than 4.5 million and over 106,000 people have been infected and died, respectively. In Kenya, over 191,000 have been infected and 3,746 people have died from COVID-19 by the date. The figure for Kenya is much lower than the over 150,000 deaths from the Spanish flu of 1918-20. SARS-CoV-2 is transmitted through expiratory droplets and direct contact, while faecal and airborne transmission have been documented, but not confirmed. It enters the body through nasal passages, conjunctiva , or mouth. It can survive on bank notes, vinyl plastic, mobile phone, glass, cardboard, cloth fabric and stainless steel for varying periods. At 50% Rh, it can survive on stainless steel, vinyl plastic and glass at 20, 30 and 40oC for 28, 7 days and less than a day, respectively. On cotton fabrics, it can survive for 7, 3 days and less than 24 hr at 20, 30 and 40oC, respectively. Age, late hospitalization, diabetes co-morbidity, obesity, chronic lung disease and hypertension are the major risk factors for COVID-19 mortality. Age and laboratory indicators are predictors of mortality. Vaccines allowed for emergency use include the Oxford/AstraZeneca, Pfizer/Biontech, Moderna, Sinopharm, SINOVAC, Sputnik V and Johnson and Johnson. Although they all have shown high efficacy against the original COVID-19 strains globally, they have lower efficacy against the Brazilian P.1, the UK B.1.1.7, Finnish FIN-796H, the New Jersey/New York B.1.526, the South African B.1.351 and the Indian Delta mutant. Regular hand washing, face masking, avoiding overcrowding, physical distancing, outdoor communing, seeking immediate medical attention and isolating when infected, all can minimize SARS-CoV-2 transmission. Potential infection from frozen foods packaging, frozen foods and food preparation surfaces has been demonstrated. However, good hygiene practices can minimize infection from foods, shopping bags, take-out containers and groceries. Animal foods should not be consumed raw, while groceries require thorough washing with potable water during preparation. Despite concerns posed by the continuing evolution of virulent mutants of SARS-CoV-2, researchers are working to develop effective vaccines in order to eliminate the threat of the virus.

The unprecedented shock triggered by the COVID-19 pandemic has caused significant impact on public transportation services, travel behavior and mode choice preferences. Increasing risk of virus contagion in shared travel modes might result in a systemic shift from public transport to car commute. Such a shift causes increased congestions, emissions with a burden on the existing infrastructure. Given the urgent need of reconsideration of transport in a post-COVID world, this study presents insights into the possible shift from public transport to car commute due to the coronavirus crisis, potential factors influencing the mode shift, with emphasis being also laid on suitable strategies for promoting public transport use in the future world. Based on an online questionnaire survey conducted in India, results of logistic regression model indicate that commuters' socio-economic characteristics such as age, gender and monthly income tend to significantly influence mode switch preferences. In addition, trip characteristics including travel time, overcrowding and hygiene are strongly associated with mode shift preferences from public transport to car use. Commuters' perceptions on several strategies for promoting public transport have also been assessed, which will indeed pave the way for the formulation of post-COVID transport policies. In essence, efforts need to be directed towards restoring users’ confidence and trust by providing a safe, secure and healthy environment to the public transport users.

Emergency department (ED) admissions have been rising over the last decades, especially in countries without any effective gate-keeping functions. Integration of walk-in clinics into the hospital might reduce ED-visits. Over a longer period, however, the additional service of a walk-in clinic might attract even more patients, nullifying an initial decrease in patients for the ED.This study aimed to determine short- and intermediate-term changes after the implementation of a hospital-integrated walk-in clinic. This is an observational study using routinely-collected health data. Study setting was the ED of a large tertiary care hospital in Austria, a country with universal health care and no regulations regarding level of care.ED-visits were compared between before (2015) and after (2017 and 2018) establishment of a hospital-integrated walk-in clinic.Total ED-visits decreased from 87,624 in 2015 to 67,479 in 2017, and 67,871 in 2018 (p 0.001), mainly due to a decrease in non-urgent (ESI 45) cases (45,715 (54.1%) in 2015; 33,142 (51.3%) in 2017; 30,846 (47.5%) in 2018; short term OR non-urgent vs. urgent: 0.89 (95% CI 0.88-0.91); intermediate term OR urgent vs. non-urgent: 0.76 (95% CI 0.78-0.75)). A total of 2611 (13%) (2017) and 1714 (8.5%) (2018) patients were referred back to the ED.After the introduction of the walk-in clinic, ED-visits declined significantly. This remained stable over a two-year period. Reduction in ED-visits was mainly due to low-acuity patients not requiring admission to the hospital.

Background Inpatient treatment is not the most beneficial treatment setting for many patients with psychiatric disorders and overcrowding is a recurrent problem for psychiatric hospitals. Therefore, it is important to develop strategies to limit avoidable inpatient treatment. This study sought to evaluate the impact of an emergency hotline that was developed to better manage psychiatric patients, particularly for identifying those requiring a hospital admission. Methods This pre-post intervention quality improvement study compared changes in the management of psychiatric patients’ admission before and after the introduction of an emergency hotline where a specialist in psychiatry examines all inpatient referral from private practitioners. Main outcomes were the change in proportion of hospital admissions after referral from a private practitioner before and within 3 months after the intervention. Secondary outcomes were the average length of hospital stay, proportion of non-voluntary admission, the time required for triage and the impact of the intervention on treatments’ costs. Fisher’s Exact test was used to test the primary hypothesis of difference in the proportion of hospitalized patients before and after introduction of the emergency hotline. Secondary outcomes were tested with Student’s t-test for continuous variables and Fishers’s Exact test for proportions. Results Among 45 admission requests from private practitioners during the 3 months after introduction of the new emergency hotline, 25 (55.6%) were accepted as inpatient treatment, while 20 (44%) were redirected to more appropriate outpatient treatments. There was a highly significant difference from the baseline period during which all 34 requests were accepted (44% vs 100%, p Conclusion Implementation of an emergency hotline manage by a specialist in psychiatry for admissions to acute psychiatric wards is feasible and simple to use. Importantly, it allows to significantly decrease the proportion of hospitalizations. Additional studies are needed to assess the generalizability of these exploratory results to other health care settings.

GIS technologies allow an analyzis of large data sets at the lowest cost. To date, when forming a network of secondary schools, almost no geographic information systems have been used. GIS plays a special role in the study of transport and walking accessibility to GSEI. The article analyzes the theoretical, methodological and practical problems of using geographic information systems in studies of walking accessibility to general secondary schools of Chernivtsi city territorial community and describes the general secondary education institutions of the studied community. Based on geoinformation systems developed in Open Route Service and QGIS, the areas of the community with the best and worst walking accessibility to secondary schools were identified, which is certainly of great practical importance in creating pivotal institutions, their service zone and overcoming the problem of overcrowding in some schools. The most convenient location of the general secondary education institutions of Chernivtsi city territorial community was observed in the central part of the city, as well as in microdistricts Prospect and Boulevard, where there is a fairly dense arrangement of general secondary education institutions. There are also areas in the community that are outside the 2-kilometer walking accessibility zone and require transportation for students. Such areas are the Shantsi, Tsetsyno and Slobidka and Rohizna microdistricts, which have a cottage type accommodations. In general, most of the community is within walking accessibility. An important aspect of the location of GSEI is the availability indicator, which ranges 0.2 to 0.81. The average rate of accessibility to GSEI in the Chernivtsi city territorial community is 0.65. It should be noted that in the community there is a relevant problem of providing students with places in GSEI in those areas, where today the construction of new residential areas is actively carried out, while educational institutions are not expanding and not being built.

Purpose: Excessive delays and emergency department (ED) overcrowding have become an increasingly major problem for public health worldwide. This study was to assess the key strategies adopted by an ED, at a public hospital in Jeddah, to reduce delays and streamline patient flow. Materials and Methods: This study was a service evaluation for a Saudi patient population of all age-groups who attended the ED of a public hospital for the period between June 2016 and July 2019. The Saudi initiative to reduce the ED visits at the King Abdullah Medical Complex hospital has started on August 7, 2018. The initiative was to apply an urgency transfer policy which outlines the procedures to follow when patients arrive to the ED where they are reviewed based on the Canadian Triage and Acuity Scale (CTAS). Patients with less-urgent conditions (category 4 and 5) are referred to a primary health-care practice (where a family medicine consultant is available). Patients with urgent conditions (category 1–3) are referred to a specialized health-care centre if the service is not currently provided. To test the effectiveness of ED initiative on reducing the overcrowd, data were categorized into before and after the initiative. The bivariate analysis χ2 tests and 2 sample t-tests were run to explore the relationship of gender and age with dependent variable emergency. Results: A total of 233,998 patients were included in this study, 61.8% of them were males and the average age of ED patients were 35.5 ± 18.6 years. The majority of cases were those classified as “less urgent” (CTAS 4), which accounted for 65.4%. Number of ED visits before and after the initiative was 67 and 33%, respectively. ED waiting times after the initiative have statistically significantly decreased across all acuity levels compared to ED waiting times before the initiative. Conclusion and Implication: The findings suggest that the majority of patients arrive to the ED with less-urgent conditions and arrived by walking-in. The number of cases attending the ED significantly decreased following the introduction of the urgency transfer policy. Referral for less-urgent patients to primary health-care centre may be an important front-end operational strategy to relieve congestion.

More than 50 years after the Fair Housing Act was passed in the USA, equitable outcomes in housing remain elusive. Much research on fair housing has focused on access to housing in the renting or buying process and residential segregation patterns. However, analyses typically overlook how families and individuals can maintain stability once they actually secure housing, particularly for renters. Therefore, this research considers renter insecurity, defined by unaffordability, overcrowding, poor physical conditions, and forced moves, as an essential component to understanding and evaluating fair housing. Using this perspective, inequities in housing insecurity are measured among federal fair housing protected classes. Analyses confirm that households historically impacted by discrimination (e.g., Black, female, disabled, and non-native born) experience disproportionately severe and frequent manifestations of housing insecurity. Consequently, it is not enough to ensure equal access to housing without simultaneously requiring equity in long-term housing outcomes. The research concludes with a discussion of the role of social work practice in advancing fair housing, with a particular emphasis on bridging work between individuals and communities and the implications for policy.

Free secondary education remains limited in the developing world, where some 80% of 264 million children currently unable to access secondary education across 65 countries associated with the Global Partnership for Education are based. Despite a 2015 commitment by UN member countries to provide free secondary education by 2030, most countries with prior cost-sharing approaches are yet to achieve this goal. Ghana remains one of the few countries with a prior cost-sharing model to have rolled out ‘fully’ free secondary education. We broach Ghana’s implementation of the policy and seek to explore the critically emergent issues and challenges facing public senior high schools. The generalities of our empirical evidence unveil that high enrolment rates culminated in teacher shortages, increased workload for existing teachers, classroom deficits, overcrowding in class, high rate of indiscipline and inadequate teaching/learning materials. Delay in the supply of funds also exacerbated schools' predicaments, shredding the efficacy of the policy in schools. Unbeknownst to existing studies, free feeding and lodging plagued schools with dissimilar glitches over dining and accommodation facilities. Thus, the explicated intricacies and deep-seated nuances in these results substantiate arguments that the diverse and categorization of schools determined the distinctiveness and uneven magnitude of schools' challenges in implementing the policy. From the mundane to the sublime, the free financing model worsens existing challenges and erupts new kinds marked by diverse variables along day/boarding, rural/urban, resourced/less resourced and north/south lines. Using the systems theory, we combined interviews, observation and documentary analysis from six distinct schools to evaluate challenges in the policy’s implementation in schools.

Purpose The burden of Alzheimer’s dementia greatly impacts patients and their immediate families. Studies on the perspective of caretakers regarding nutrition in patients with Alzheimer’s disease (AD) dementia are lacking. Yet this information is needed to guide clinical care for patients with dementia. The study explored caretakers’ perspective on nutritional challenges faced by patients with Alzheimer’s disease and related Dementias at Butabika National Referral Hospital. Methods We conducted 20 in-depth interviews and 2 focus group discussions with 20 health workers and 16 caregivers, respectively. The focus group discussions and in-depth interviews were audio-recorded and transcribed. Analysis was conducted using a thematic, constant comparative approach with an emphasis on dominant themes. Results Participants had a mean age of 37 in the range (27–44) years. Seventeen (47%) of them were males. Their duration of Care for Dementia to patients was in the range (2–7) years. The highest level of education was a bachelor’s degree and the primary level was the lowest. Thirteen (35%) were married and twenty-three (65%) were not, and they either survived on salaries or wages as a source of income. The key emerging issues were 1) hindrances to nutritional care in dementia, 2). Factors leading to inadequate nutrition among people with dementia and 3). Recommendations to improve nutrition needs. Conclusion Caretakers experience challenges ranging from psychotic manifestations of a patient to hindrances in the provision of nutritional care. A better understanding of their experience is essential for the development of interventions to help the family members, health workers and other care takers promote good nutrition in patients with Alzheimer’s dementia. A clear referral system should be established to prevent overcrowding of patients at a mental national referral hospital to ensure adequate timely nutritional support to those admitted. Capacity building programs should continue to address the knowledge gap in nutritional requirements of patients with Alzheimer’s dementia.

The Covid-19 emergency in prisons is a public health warming due to overcrowding, poor structural conditions,and life promiscuities.Worldwide a lot of prisoners were Sars-CoV-2 positive and in Italy several outbreaks occurred in many prisons.This paper examines, using a clinical audit, a Covid-19 outbreak occurred in an Italian prison during the spring2021.The study showed that the best measures to mitigate the outbreak negative consequences both in prisoners andin the staff are the preventive actions, the hygiene and disinfection of the common detention areas; the reductionof overcrowding; the stop of the working activities during the quarantine period.Only an improvement of living conditions inside the prisons may reduce the risk of infection among inmates.

Background: Among hospitals-related health risks, environmental factors play a key-role; this accounting for different rooms’ specific use, patients’ vulnerability and risk of overcrowding. For these reasons, air control in hospitals and in healthcare facilities in general deserves scientific attention. Objective: Assessing of the quality of indoor air ventilation in critical care department hospitals and its effect on the incidence of hospital acquired infections in order to optimize the ventilation methods in hospitals. Patients and methods: Our study was performed in Egypt by correlating the examined 70 air samples, from the Intensive Care Unit (ICU), Cardiac Care Unit (CCU) and Neonatal Intensive Care Unit (NICU) in one of the General Organization of Teaching Hospitals and Institute, for presence of bacterial and fungal contamination with the concomitant infection of 70 patients admitted in these units during the period from November 2019 to January 2020. Results: We had 59 (84.2%) positive air samples in comparison to 21 (30%) positive endotracheal tube (ETT) fluid culture and 19 (27.1%) positive blood cultures in the completely selected air sampling areas and in the selected patients during the included sampling period. This suggested a strong relation between the contamination between the indoor airs either by bacterial or fungal organisms, and between the concomitant presence of the same organism in the ETT fluid samples and to lesser extent in the blood cultures. Conclusion: This study has fortified the hypothesis that achieving an optimal level of indoor air quality is related to applying the infection control rules, application of approved air filters and strict adherence to hand hygiene.

Background The increasing worldwide demand for ambulance transport may worsen patient prognosis due to a prolonged response time and overcrowding in the emergency department. Triage in the prehospital setting may reduce the demand for ambulance transport by advising low-acuity patients seek non-emergency medical care. In Japan, a five-level triage system that allows emergency medical services (EMS) to triage patients has been implemented since 2014. This study aimed to validate the five-level triage system. Methods We conducted a retrospective cohort study in patients aged ≥16 years who were transported by EMS to a tertiary-care hospital in Japan from April 2018 to June 2018. We used admission to the intensive care unit (ICU) as the primary outcome. Our secondary outcome was overall admission. We conducted multivariable logistic regression analysis to determine the strength of association between triage acuity and admission (ICU and overall). Results A total of 1261 patients were included in the analysis. The odds ratios of ICU admission were 9.62 (95% confidence interval: 5.66–16.3) in Level 1 and 2.93 (95% confidence interval: 1.60–5.38) in Level 2 compared with reference groups composed of Levels 4 and 5. Similar associations were found for triage acuity and overall admission. Conclusions Our study validates the five-level prehospital triage system for patients transported by EMS and demonstrates an association between the triage acuity and ICU admissions.

Accidents are likely to happen at workplaces which requires employees to rush to the hospitals for emergency treatment. Due to increase in population, treating various medical cases has led to longer waiting times at emergency treatment units (ETUs). The reasons being the ambulance divergence, less staff, and reduced management. An approach to decrease overcrowding at ETU can be the application of modern techniques. Machine learning (ML) is the one which is used to find patients with high illness, therefore developing models that can avoid jams at ETU. In this paper, a new ML technique, light GBM (LGBM), is implemented to increase the predictions rate based on data gathered from hospitals of Northern Ireland. In addition, the proposed model is compared to other ML models such as decision tree and gradient boosted machines (GBM). Test results indicate that LGBM is more efficient with an accuracy of 86.07%. Also, the time taken to produce future predictions by LGBM was 12 milliseconds, whereas decision tree and GBM took 16 milliseconds and 20 milliseconds, respectively.

A little more than a hundred years ago, the humanity plunged into the second wave of «the Spanish flu» just like in the spring of 2021 it plunged into the second wave of coronavirus. Despite the significant biological and virological differences between COVID-19 coronavirus and the Spanish flu, already known to us in the second year of the pandemic, the obvious significant similarity in the dynamics of the epidemiological scenarios of both pandemics is striking.It is officially believed that the epidemic in Europe began in the last months of the deadly First World War (1914—1918). Its development and the next catastrophic spread were caused by: unsanitary conditions, poor nutrition, overcrowding in trenches and refugee camps, the demobilization and the return of soldiers home, as also the rapid development of vehicles at the beginning of the 20th century (trains, cars, high-speed ships). The Spanish flu, caused by the H1N1 virus, had several «waves». It is difficult to estimate the exact number of those who had the Spanish flu, but presumably, this is 500—550 million people. About 25 million people died (some studies indicate a figure of 50 or even 100 million). Unfortunately, the mankind quickly forgot about this viral pandemic and consequently was objectively compelled, after a hundred years, to unexpectedly make the same mistake again and introduce quarantine as the only way to limit the further spread of the next viral pandemic of mankind. The Spanish flu significantly influenced all the further development of medicine. While before the deadly pandemic the private medical practice was widespread, in the process of its overcoming, the formation of the modern international health care system took place. In 1919, the International Bureau for Epidemic Control was founded in Vienna.

The geriatric population constitutes a large slice of the population of Western countries and a class of fragile patients, with greater deaths due to COVID-19. The patterns of healthcare utilization change during pandemic disease outbreaks. Identifying the patterns of changes of this particular fragile subpopulation is important for future preparedness and response. Overcrowding in the emergency department (ED) can occur because of the volume of patients waiting to be seen, delays in patient assessment or treatment in the ED, or impediments to leaving the ED once the treatment has been completed. Overcrowding has become a serious and growing issue globally, which represents a serious impediment to healthcare utilization. To estimate the rate of ED visits attributable to the outbreak and guide the planning of strategies for managing ED access or after the outbreak of transmittable respiratory diseases. This observational study was based on a retrospective review of the epidemiological and clinical records of patients aged > 75 years who visited the Foundation IRCCS Policlinic San Matteo during the first wave of COVID-19 outbreak (February 21 to May 1, 2020; pandemic group). The analysis methods included estimation of the changes in the epidemiological and clinical data from the annual baseline data after the start of the COVID-19 pandemic. Outcome measures and analysis: Primary objective is the evaluation of ED admission rate change and ED overcrowding. Secondary objectives are the evaluation of modes of ED access by reason and triage code, access types, clinical outcomes (such as admission and mortality rates). During the pandemic, ED crowding increased dramatically, although the overall number of patients decreased, in the face of a percentage increase in those with high-acuity conditions, because of changes in patient management that have prolonged length of stay (LOS) and increased rates of access block. Overcrowding during the COVID-19 pandemic can be attributed to the Access Block. Access Block solutions are hence required to prevent a recurrence of crowding to any new viral wave or new epidemic in the future. Supplementary Information The online version contains supplementary material available at 10.1007/s11739-021-02732-w.

The paper contributes to unravelling the perceptions of urban commercial drivers regarding their vulnerability to catching the SARS-CoV-2 virus while at work. It further examines how the perception of vulnerability influences personal use of face masks by drivers, as well as on their insistence on appropriate masking behaviour by other persons on-board public transport. Overcrowding and unsanitary conditions in informal public transport in Africa could facilitate the spread of the corona virus. However, the use of face masks, among other enhanced mitigation measures significantly contain and minimize the spread of the virus. Primary data, obtained through surveys at five major public transport terminals in Accra, was analysed and interpreted using the Health Belief Model as an explanatory framework. Results indicate that most drivers have a high vulnerability perception to Covid-19. It further emerged that older drivers, in particular, consistently wore face masks and insisted on other persons in their commercial vehicles to follow suit. Socio-demographic factors, and the need to ensure one’s personal safety and those of loved ones were critical determinants of face mask use among surveyed drivers. The study thus recommends that public awareness campaigns should strategically focus attention on the younger generation of drivers (i.e. 18–39 years) who perceived themselves to be immune to the SARS-CoV-2 virus. Also, the collaborative efforts of state and non-state actors, like the transport operator unions, must be further strengthened if the gains made so far against Covid-19 is to be sustained.

The use of Informal Public Transport (IPT) in Dar es Salaam, Tanzania, has been associated with mobility difficulties, i.e. traffic congestion, unscheduled service and lack of safety and security. The introduction of the Bus Rapid Transit (BRT) system was therefore considered as a powerful intervention for these mobility difficulties. In May 2016, the BRT started operating with exclusive bus lanes and a clear schedule to offer a qualitative, accessible and affordable system. This paper explores changes in travel experiences and perceptions of individuals (local inhabitants) regarding IPT and BRT use in meeting mobility demands before and after implementation of the BRT. Focus group discussions and short questionnaires were conducted before and after BRT to explore changes in mobility experiences among different individuals. Results show that in both periods, the demand for IPT use remained dominant, driven by a low fare, connectivity within a neighbourhood and outside the major road, flexibility and the possibility to commute with goods. The use of BRT was mainly attributed by relief in traffic congestion (when only considering in-bus time) and a lack of options along the corridor. Surprisingly, BRT users also experienced several mobility difficulties after implementation: long waiting time, overcrowding (in-bus and stations), and difficulties to commute with goods, and a lack of safety and security. Peri-urban individuals continued to experience more travel difficulties with both transport systems than individuals in areas adjacent to the BRT because of limited connectivity, congestion and unpaved local roads. For low-income individuals, the BRT was considered as another burden for their livelihoods (higher financial cost) rather than it was expected as a solution towards a high quality, accessible and affordable system. There is a need to integrate public transport with supportive improved local roads to serve multiple destinations.

Mona Faisal Al-Qahtani,1 Fatimah Yahyia Khubrani2 1Department of Public Health, College of Public Health, Imam Abdulrahman Bin Faisal University, Dammam, 31441, Saudi Arabia; 2Quality Control Department, Medical Center, King Fahd University of Petroleum and Mineral, Dhahran, Saudi ArabiaCorrespondence: Mona Faisal Al-QahtaniDepartment of Public Health, College of Public Health, Imam Abdulrahman Bin Faisal University, P.O. Box 2435, Dammam, 31441, Saudi ArabiaEmail malqahtani@iau.edu.saBackground: Emergency department (ED) crowding has been described as the most serious problem that endangers the reliability of healthcare system worldwide. The aim of this study was to explore the possible relationship of ED crowding status and length of stay in patient received care. In addition, association between LOS and other variables in relation to crowding status has been explored.Methods: This is a retrospective cohort analysis study done by using dataset abstracted from Quadra Med Information System of patients visited emergency department of a tertiary university hospital at Eastern Province of Saudi Arabia during the period of January 1st, 2018 to December 30th, 2018. ED occupancy rates were used to define crowding status (as crowding and overcrowding), while the percentage of patient who spent in ED more than 6 hours was used to define the length of stay in ED.Results: There were 53,309 crowded and 57,290 overcrowded presentations in ED. The median length ± interquartile range of the length of stay for low-crowded and high-crowded conditions were 211 ± 606 and 242 ± 659 minutes, respectively. There was a significant association between ED crowding status and length of stay (p < 0.05).Conclusion: The increased patients’ length of stay at ED was associated with crowding status of ED. Therefore, decision-makers at ministry of health should develop and implement measures and interventions to shed light on the causes of crowding, to reduce the crowding at ED, and resolve the problem steamed from such crowding for the purpose of shorten patients’ length of stay at ED.Keywords: emergency department, crowded, length of stay, university hospital

Phenomenon In the United Kingdom (UK) the government has increased the number of places at university to study medicine in England to meet workforce demands. In parallel, there have been growing student numbers in other healthcare professions and new professions whose roles overlap with doctors, such as advanced nurse practitioners and physician associates, have been introduced. These increasing numbers of medical students and other healthcare professions training in the same clinical setting have led to questions about the effect on the student experience. We aimed to investigate the impact of student-student encounters on the learning experience during clinical placements before student numbers increase further. Approach In this investigation medical student perceptions were collected retrospectively at Norwich Medical School, University of East Anglia in the UK, during the 2018/19 academic year following two clinical placements in secondary care settings. Through mandatory online course evaluations, all medical students were asked if their learning had been positively or negatively affected by other students, and how frequently they had certain student-student experiences. Findings Responses from 786 (of 844) medical students (93% response rate) demonstrated that most students felt their learning had been affected in some way by the presence of others while on their secondary care placements. Students experienced both positive and negative impacts of encounters with other students. Final year students tended to report more negative experiences, with first year students reporting more positive. while some students had experienced competition for learning opportunities and lower quality interactions with patients and doctors due to "overcrowding," more students reported benefits from learning from and with other students. However, it also was found that any negative encounters with other students, even if accompanied by positive experiences, detrimentally affected student satisfaction with the placement. Insights This investigation indicates that student-student interactions influence the clinical learning experience of medical students both positively and negatively. Given the overriding influence of negative encounters, the findings suggest a need to maximize the beneficial effects of encountering other students on clinical placements; while protecting against missed or poor-quality learning opportunities due to competition between students, particularly for more senior students. Medical educators need to consider where their clinical attachments are at risk from multiple students being present at the same time and work to alleviate the negative impacts of such student-student encounters, while actively encouraging peer learning experiences between the medical students and collaborative activities between students of different healthcare professions. This is likely to become increasingly important as student numbers in medicine and other healthcare professions continue to grow.

The World Health Organization (WHO) declared the pandemic status of coronavirus disease of 2019 (COVID-19). The necessity for social distancing has prompted states to make policy changes. These policy changes are in line with the policies and recommendations set by the WHO, the Centers for Disease and Control Prevention (CDC), the United States Department of Health and Human Services (HHS), the Centers for Medicare and Medical Services (CMS), the Kaiser Permanente, the National Institutes of Health (NIH), the United States Food and Drug Administration (FDA), and the American Medical Association (AMA). The aim of this study is to discuss and analyze the effectiveness of many organizations in responding to the COVID-19 crisis. Three processes were involved in conducting the narrative review: (1) a search was conducted through the websites of eight organizations (CDC, HHS, CMS, Kaiser Permanente, NIH, WHO, FDA, and AMA), (2) Selection of relevant information related to the responses taken by the eight organizations between January 21, 2020 and April 24, 2020 were included, (3) the information selected from the websites of the eight organizations were recorded, summarized, and integrated in this paper.COVID-19 is a health problem that needs to be approached in a collaborative manner. All eight organizations that have taken action against the further spread of the virus. The different policy changes and/or recommendations from the eight organizations have one common ground and that is the necessity for social distancing. To prevent overcrowding in hospitals and in other healthcare facilities, the organizations have decided to expand telehealth coverage. In Conclusions Health-related and policy-issuing organizations provided policies that are aligned with one another in order to contain the spread of COVID-19.

Aim On August 4, 2020, a massive explosion hit Lebanon’s capital city, Beirut. The aim of this study was to explore the effect of the Beirut blast on the COVID-19 situation in the country. Subject and Methods Data on COVID-19 were retrieved from the Lebanese Ministry of Public Health (LMOPH), where all the COVID-19 positive cases were reported. The study was divided into two periods, considering the incubation period of the COVID-19 virus: (July 27–August 9, 2020) and (August 10–23, 2020). Information obtained included daily number of cases, tests, deaths, hospitalized patients, intensive care unit (ICU) patients, and mode of acquisition (local vs. expat). Daily positivity rates were reported per 100 tests. An independent sample t-test and a Joinpoint regression analysis were used to determine significance. A p value less than 0.05 was considered significant. Results A total of 201,010 tests were conducted during our studied period, with 8993 positive cases, constituting a total positivity rate of 4.5 per 100 tests. Case fatality rate over the studied period was 0.8%. The positivity rate of the period prior to August 10, 2020, was 2.7 per 100 tests, significantly less than that of the period following the explosion, which was 6.4 per 100 tests (p p p Conclusion The port of Beirut explosion resulted in a significant increase in the daily number of positive COVID-19 cases. The aftermath of the explosion, the damage to healthcare facilities, and the overcrowding due to emergency efforts were contributing factors to that increase.

The monthly dapivirine vaginal ring has proven efficacious in reducing HIV incidence in two Phase 3 clinical trials. When considering the potential future availability of the ring to the public, key questions remain about the feasibility of integrating the ring as an HIV prevention intervention into women’s lives. We conducted qualitative mapping interviews (n = 66) among women enrolled in MTN-025/HOPE, an open-label trial conducted in Malawi, South Africa, Uganda and Zimbabwe, to examine how home environments influenced use of the dapivirine vaginal ring. Most women had secure places to store their rings including wardrobes, suitcases, and bags. The primary concerns for ring storage were potential tampering from children or rodents. Household overcrowding limited the privacy some women had which made removal and insertion of vaginal rings challenging. Despite these challenges, ring storage, insertion, and removal was feasible across social and living contexts.

Overcrowding in Malaysian preschools is concerning and can be attributed to inadequate building size and poor planning. Sufficient space for learning activities is crucial for children's development. This study examines and proposes recommendations to improve the overall planning of 26 public Ministry of Education (MOE) preschools in Klang Valley. The Children’s Physical Environment Rating Scale was used to assess planning aspects including building size, indoor activity spaces, classroom enrolment, and modules. Most assessed MOE preschools lacked space and the average quality of overall planning was rated Fair. Recommendations are hoped to promote better planning for public preschools in Malaysia. Keywords: preschool planning; preschool size; preschool overcrowding; children education. eISSN 2514-751X © 2021. The Authors. Published for AMER ABRA by E-International Publishing House, Ltd., UK. This is an open-access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers), ABRA (Association of Behavioural Researchers on Asians/Africans/Arabians) and cE-Bs (Centre for Environment-Behaviour Studies), Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia. DOI: https://doi.org/10.21834/ajebs.v6i18.383

Preliminary Care Unit is the Sri Lankan model of the emergency department in the state health facilities above the level of Base Hospitals in the country. Provision of prompt, quality, and comprehensive patient care without any unnecessary delay, minimizing unnecessary admissions to wards, and reducing the cost of patient management were the objectives of establishing such units. The current study aimed to systematically assess the process of service delivery in the Preliminary Care Unit of District General Hospital, Gampaha. The study was descriptive with both cross-sectional and retrospective components and was conducted in 2019. Study instruments and techniques included are key informant interviews, focus group discussions, the desk review of secondary data, and direct observation. Key informant interviews with the medical officer-in-charge and nursing sister in charge of the unit were conducted by the principal investigator. Two focus group discussions were conducted, with ten randomly selected medical officers and 8 nursing officers with a minimum one-year of work experience at the Preliminary Care Unit. Data gathered from the desk review of the secondary data from the admission book, Bed Head Tickets, and record of monthly statistics of the preliminary care unit using a checklist to ascertain the total number of admissions and their outcome in 2018. All admissions of a randomly selected week of 2018 were studied to assess the age and gender distribution and they were classified into two categories as medical and surgical, according to the admitting doctor’s notes. Direct observation was used to triangulate the data. The major deficiencies of the process of service delivery in the Preliminary Care Unit elicited at the key informant interviews and focus group discussions were overcrowding and excess waiting which were multifactorial in causation. Less organized process flow and inadequate resource availability led to overcrowding and excess waiting.