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Introduction: 80 % of Americans wish to die somewhere other than a hospital, and hospice is an essential resource for providing such care. The emergency department (ED) is an important location for identifying patients with end-of-life care needs and providing access to hospice. The objective of this study was to analyze a quality improvement (QI) program designed to increase the number of patients referred directly to hospice from the ED, without the need for an observation stay and without access to in-hospital hospice., Methods: We implemented a QI program in September 2021 consisting of three components: (1) clarification and streamlining of referral workflows, (2) staff/provider education on hospice and workflows, and (3) electronic medical record (EMR) tools to facilitate hospice transitions. The primary outcome was the change in monthly ED-to-hospice cases pre- and post-implementation. We also calculated the monthly incidence rate of ED-to-hospice transfers. The secondary outcome was ED length of stay (LOS)., Results: 202 patients completed ED-to-hospice transfers from January 1, 2019 to February 29, 2024. 98 patients transitioned from the ED to hospice before QI implementation, and 104 patients transitioned after implementation. We observed a slight but insignificant increase in the mean monthly ED-to-hospice cases from 3.16 patients per month pre-implementation to 3.47 patients per month post-implementation (P = 0.46). We found no significant difference in the monthly incidence rate of ED-to-hospice cases before and after implementation (P = 0.78). ED LOS was unaffected (P = 0.21)., Conclusion: In this largest study to date on direct ED-to-hospice discharges, a QI program focused on workflow optimization, education, and EMR modification was insufficient to significantly impact ED-to-hospice discharges. Future efforts to increase hospice transitions from the ED should investigate methods to improve patient identification, the impact of in-hospital hospice programs, and coordination with hospital and community teams to support home-based care for those desiring to remain there., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: People detained in short-term police custody often have complex health conditions that may necessitate emergency care, yet little is known about their management in EDs. The present study aimed to understand ED doctors' experiences and perceptions regarding the appropriateness and management of detainee transfers from police watch-houses to the EDs., Methods: A qualitative descriptive study, using semi-structured interviews undertaken with ED doctors working in five purposively sampled EDs across Queensland, Australia. Data were analysed using inductive content analysis., Results: Fifteen ED specialists and trainees participated. Participants reported that their overarching approach was to provide equitable care for watch-house detainees, as they would for any patient. This equitable approach needed to be responsive to complicating factors common to this population, including presence of police guards; restraints; complexity (physical/mental/social) of presentation; reliance on police to transport; ED doctors' often limited understanding of the watch-house environment; justice processes and uncertain legal disposition; communication with the watch-house; and detainees misreporting symptoms. Thresholds for assessment and treatment of detainees were contextualised to the needs of the patient, ED environment, and imperatives of other relevant agencies (e.g. police). Participants often relied on existing strategies to deliver quality care despite challenges, but also identified a need for additional strategies, including education for ED staff; improved communication with watch-houses; standardised paperwork; extended models of watch-house healthcare; and integrated medical records., Conclusions: Providing equitable healthcare to patients transported from watch-houses to the EDs is challenging but essential. Numerous opportunities exist to enhance the delivery of optimal care for this underserved population., (© 2024 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for Emergency Medicine.)

Background and Objectives: Older adults residing in residential aged care facilities (RACFs) often experience substandard transitions to emergency departments (EDs) through rationed and delayed ED care. We aimed to identify research describing interventions to improve transitions from RACFs to EDs., Research Design and Methods: In our scoping review, we included English language articles that (a) examined an intervention to improve transitions from RACF to EDs; and (b) focused on older adults (≥65 years). We employed content analysis. Dy et al.'s Care Transitions Framework was used to assess the contextualization of interventions and measurement of implementation success., Results: Interventions in 28 studies included geriatric assessment or outreach services (n = 7), standardized documentation forms (n = 6), models of care to improve transitions from RACFs to EDs (n = 6), telehealth services (n = 3), nurse-led care coordination programs (n = 2), acute-care geriatric departments (n = 2), an extended paramedicine program (n = 1), and a web-based referral system (n = 1). Many studies (n = 17) did not define what "improvement" entailed and instead assessed documentation strategies and distal outcomes (e.g., hospital admission rates, length of stay). Few authors reported how they contextualized interventions to align with care environments and/or evaluated implementation success. Few studies included clinician perspectives and no study examined resident- or family/friend caregiver-reported outcomes., Discussion and Implications: Mixed or nonsignificant results prevent us from recommending (or discouraging) any interventions. Given the complexity of these transitions and the need to create sustainable improvement strategies, future research should describe strategies used to embed innovations in care contexts and to measure both implementation and intervention success., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Objective: This quality improvement project was a collaborative effort with Penn Medicine's emergency department (ED) and oncology nurse navigators (ONNs). The goal of the project was to streamline patient transitions from the ED to the outpatient oncology clinic by developing a standardized referral process. The main objectives were to simplify and automate the referral process using the electronic medical record, improve multidisciplinary communication across the care continuum, ensure timely follow-up, and address barriers to oncology care., Methods: The ED providers placed a consult to ONNs. The ONNs reached out to the patient within 48 hours of the consult. They maintained a database of patient referrals and collected information such as patient demographics, reason for referral, insurance, and patient outcomes., Results: The ED providers referred 204 patients to the ONNs from April 2022 to September 2023. The development of a standardized referral process from the ED to the outpatient oncology clinic proved successful. Of the patients referred, the ONNs facilitated 98 cancer diagnoses and 80 of those patients are receiving oncology care at Penn Medicine. The median time to the patient's first appointments was seven days, diagnosis was 15 days, and treatment initiation occurred within 32 days., Conclusion: The project team achieved their goal of facilitating timely access to oncology care, ensuring continuity, and addressing patient-specific barriers., Implications for Nursing Practice: This quality improvement initiative highlights the ONNs' role in enhancing access and equity in cancer care delivery. The success of the project underscores the ONN's expertise and leadership in addressing healthcare disparities in oncology care. Collaboratively, the teams created a new referral workflow improving care transitions from the ED to the outpatient oncology clinic. The project sets a precedent for optimizing patient care transitions, demonstrating the positive impact of ONNs as key members of the multidisciplinary healthcare team., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Katie Fanslau reports a relationship with Oncology Nursing Society that includes: writer. Margaret Rummel reports a relationship with Academy of Oncology Nurse & Patient Navigators: various committees. Megan Roy reports a relationship with AstraZeneca: speakers bureau. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Emergency general surgery conditions are common, require urgent surgical evaluation, and are associated with high mortality and costs. Although appropriate interhospital transfers are critical to successful emergency general surgery care, the performance of emergency general surgery transfer systems remains unclear. We aimed to describe emergency general surgery transfer patterns and identify factors associated with potentially avoidable transfers., Methods: We performed a retrospective cohort study of emergency general surgery episodes in 8 US states using the 2016 Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases and the American Hospital Association Annual Surveys. We identified Emergency Department-to-Inpatient and Inpatient-to-Inpatient interhospital emergency general surgery transfers. Potentially avoidable transfers were defined as discharge within 72 hours after transfer without undergoing any procedure or operation at the destination hospital. We examined transfer incidence and characteristics. We performed multilevel regression examining patient-level and hospital-level factors associated with potentially avoidable transfers., Results: Of 514,410 adult emergency general surgery episodes, 26,281 (5.1%) involved interhospital transfers (Emergency Department-to-Inpatient: 65.0%, Inpatient-to-Inpatient: 35.1%). Over 1 in 4 transfers were potentially avoidable (7,188, 27.4%), with the majority occurring from the emergency department. Factors associated with increased odds of potentially avoidable transfers included self-pay (versus government insurance, odds ratio: 1.26, 95% confidence interval: 1.09-1.45, P = .002), level 1 trauma centers (versus non-trauma centers, odds ratio: 1.24, 95% confidence interval: 1.05-1.47, P = .01), and critical access hospitals (versus non-critical access, odds ratio: 1.30, 95% confidence interval: 1.15-1.47, P < .001). Hospital-level factors (size, trauma center, ownership, critical access, location) accounted for 36.1% of potentially avoidable transfers variability., Conclusion: Over 1 in 4 emergency general surgery transfers are potentially avoidable. Understanding factors associated with potentially avoidable transfers can guide research, quality improvement, and infrastructure development to optimize emergency general surgery care., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: We aimed to determine the incidence, nature of and predisposing factors for risk events (REs) that occur during the intrahospital transport of patients from the ED., Methods: We undertook a prospective, observational study of intrahospital patient transports from a single ED between 30 January and 20 March 2020. An investigator attended each transport and recorded any RE on a specifically designed data collection document. An RE was any mishap, even if not foreseen, that had the potential to cause the patient harm. A patient equipment number was assigned based on the number of pieces of equipment required during the transport. Poisson regression generated incidence rate ratios (IRRs) and determined risk factors for REs., Results: Of 738 transports, 289 (39.1%, 95% CI 35.6% to 42.8%) had at least one RE. The total of 521 REs comprised 125 patient-related, 279 device-related and 117 line/catheter-related REs. The most common included trolley collisions (n=142), intravenous fluid line catching/tangling (n=93), agitation/aggression events (n=31) and cardiac monitoring issues (n=31). Thirty-four (6.5%) REs resulted in an undesirable patient outcome, most commonly distress and pain. Predisposing factors for REs included an equipment number ≥3 (IRR 5.68, 95% CI 3.95 to 8.17), transport to a general ward (IRR 2.68, 95% CI 2.12 to 3.39), hypertension (IRR 1.93, 95% CI 1.07 to 3.50), an abnormal temperature and a GCS<14., Conclusions: REs are common in transport of patients from the ED and can result in undesirable patient outcomes. Adequate pre-transfer preparation, especially securing equipment and lines, would result in a reduced risk., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Despite large-scale quality improvement initiatives, substantial proportions of patients with ST-elevation myocardial infarction (STEMI) transferred to percutaneous coronary intervention centers do not receive percutaneous coronary intervention within the recommended 120 minutes. We sought to examine the contributory role of emergency medical services (EMS) activation relative to percutaneous coronary intervention center activation in the timeliness of care for patients transferred with STEMI., Methods: We conducted a retrospective analysis of interfacility transfers from emergency departments (ED) to a single percutaneous coronary intervention center between 2011-2014. We included emergency department (ED) patients transferred to the percutaneous coronary intervention center and excluded scene transfers and those given fibrinolytics. We calculated descriptive statistics and used multivariable linear regression to model the association of variables with ED time intervals (arrival to electrocardiogram [ECG], ECG-to-EMS activation, and ECG-to-STEMI alert) adjusting for patient age, gender, mode of arrival, weekday hour presentation, facility transfers in the past year, and transferring facility distance., Results: We identified 159 patients who met inclusion criteria. Subjects were a mean of 59 years old (standard deviation 13), 22% female, and 93% White; 59% arrived by private vehicle, and 24% presented after weekday hours. EDs transferred a median of 9 STEMIs (interquartile range [IQR] 3, 15) in the past year and a median of 65 miles (IQR 35, 90) from the percutaneous coronary intervention center. Median ED length of stay was 65 minutes (IQR 51, 85). Among component intervals, arrival to ECG was 6%, ECG-to-EMS activation 32%, and ECG-to-STEMI alert was 49% of overall ED length of stay. Only 18% of transfers had EMS activation earlier than STEMI alert. ECG-to-EMS activation was shorter in EDs achieving length of stay ≤60 minutes compared to those >60 minutes (12 vs 31 minutes, P<0.001). Multivariable modeling showed that after-hours presentation was associated with longer ECG-to-EMS activation (adjusted relative risk [RR] 1.05, P<0.001). Female gender (adjusted RR 0.81, P<0.001), prior facility transfers (adjusted RR 0.84, P<0.001), and initial ambulance presentation (adjusted RR 0.93, P = 0.02) were associated with shorter ECG-to-EMS activation., Conclusion: In STEMI transfers, faster EMS activation was more likely to achieve a shorter ED length of stay than a rapid, percutaneous coronary intervention center STEMI alert. Large-scale quality improvement efforts such as the American Heart Association's Mission Lifeline that were designed to regionalize STEMI have improved the timeliness of reperfusion, but major gaps, particularly in interfacility transfers, remain. While the transferring EDs are recognized as the primary source of delay during interfacility STEMI transfers, the contributions to delays at transferring EDs remain poorly understood.

Introduction: Patients with spontaneous intracranial hemorrhage (sICH) are associated with high mortality and require early neurosurgical interventions. At our academic referral center, the neurocritical care unit (NCCU) receives patients directly from referring facilities. However, when no NCCU bed is immediately available, patients are initially admitted to the critical care resuscitation unit (CCRU). We hypothesized that the CCRU expedites transfer of sICH patients and facilitates timely external ventricular drain (EVD) placement comparable to the NCCU., Methods: This is a pre-post study of adult patients transferred with sICH and EVD placement. Patients admitted between January 2011-July 2013 (2011 Control) were compared with patients admitted either to the CCRU or the NCCU (2013 Control) between August 2013-September 2015. The primary outcome was time interval from arrival at any intensive care units (ICU) to time of EVD placement (ARR-EVD). Secondary outcomes included time interval from emergency department transfer request to arrival, and in-hospital mortality. We assessed clinical association by multivariable logistic regressions., Results: We analyzed 259 sICH patients who received EVDs: 123 (48%) CCRU; 81 (31%) 2011 Control; and 55 (21%) in the 2013 Control. The groups had similar characteristics, age, disease severity, and mortality. Median ARR-EVD time was 170 minutes [106-311] for CCRU patients; 241 minutes [152-490] (p < 0.01) for 2011 Control; and 210 minutes [139-574], p = 0.28) for 2013 Control. Median transfer request-arrival time for CCRU patients was significantly less than both control groups. Multivariable logistic regression showed each minute delay in ARR-EVD was associated with 0.03% increased likelihood of death (odds ratio 1.0003, 95% confidence interval, 1.0001-1.006, p = 0.043)., Conclusion: Patients admitted to the CCRU had shorter transfer times when compared to patients admitted directly to other ICUs. Compared to the specialty NCCU, the CCRU had similar time interval from arrival to EVD placement. A resuscitation unit like the CCRU can complement the specialty unit NCCU in caring for patients with sICH who require EVDs.

Background: Pediatric emergency department (PED) overcrowding and prolonged boarding times (admission order to PED departure) decrease quality of care. Timely transfer of patients from the PED to inpatient units is a key driver that relieves overcrowding. In 2015, PED boarding time at our hospital was 10% longer than the national benchmark. We described a resident-led quality-improvement initiative to decrease PED mean boarding times by 10% (from 173 to 156 minutes) within 6 months among general pediatric admissions., Methods: We applied Plan-Do-Study-Act (PDSA) methodology. PDSA 1 (October 2016) interventions were bundled to include streamlined mobile communications, biweekly educational presentations, and reminder signs. PDSA 2 (August 2017) provided alternative workflows for senior residents. Outcomes were mean PED boarding times for general pediatrics admissions. The proportion of PICU transfers within 12 hours of admission served as a balancing measure. Statistical process control charts were used to analyze boarding times and PICU transfer rates., Results: Leading up to PDSA 1, monthly mean boarding times decreased from 173 to 145 minutes and were sustained throughout the study period and up to 1 year after study completion. The X-bar chart demonstrated a shift with 57 consecutive months of mean boarding times below the preintervention mean. There were no changes in PICU transfer rates within 12 hours of admission., Conculsions: Resident-led quality improvement efforts, including education and streamlined workflow, significantly improved PED boarding time without causing harm to patients., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Background and Objectives: High-quality cardiopulmonary resuscitation (CPR) increases the likelihood of survival of pediatric out-of-hospital cardiac arrest (OHCA). Maintenance of high-quality CPR during transition of care between prehospital and pediatric emergency department (PED) providers is challenging. Our objective for this initiative was to minimize pauses in compressions, in alignment with American Heart Association recommendations, for patients with OHCA during the handoffs from prehospital to PED providers. We aimed to decrease interruptions in compressions during the first 2 minutes of PED care from 17 seconds (baseline data) to 10 seconds over 12 months. Our secondary aims were to decrease the length of the longest pause in compressions to <10 seconds and eliminate encounters in which time to defibrillator pad placement was >120 seconds., Methods: Our multidisciplinary team outlined our theory for improvement and designed interventions aimed at key drivers. Interventions included specific roles and responsibilities, CPR handoff choreography, and empowerment of frontline providers. Data were abstracted from video recordings of patients with OHCA receiving manual CPR on arrival., Results: We analyzed 33 encounters between March 2018 and July 2019. We decreased total interruptions from 17 to 12 seconds during the first 2 minutes and decreased the time of the longest single pause from 14 to 7 seconds. We saw a decrease in variability of time to defibrillator pad placement., Conclusions: Implementation of a quality improvement initiative involving CPR transition choreography resulted in decreased interruptions in compressions and decreased variability of time to defibrillator pad placement., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

After admission to emergency department (ED), patients with critical illnesses are transferred to intensive care unit (ICU) due to unexpected clinical deterioration occurrence. Identifying such unplanned ICU transfers is urgently needed for medical physicians to achieve two-fold goals: improving critical care quality and preventing mortality. A priority task is to understand the crucial rationale behind diagnosis results of individual patients during stay in ED, which helps prepare for an early transfer to ICU. Most existing prediction studies were based on univariate analysis or multiple logistic regression to provide one-size-fit-all results. However, patient condition varying from case to case may not be accurately examined by such a simplistic judgment. In this study, we present a new decision tool using a mathematical optimization approach aiming to automatically discover rules associating diagnostic features with high-risk outcome (i.e., unplanned transfers) in different deterioration scenarios. We consider four mutually exclusive patient subgroups based on the principal reasons of ED visits: infections, cardiovascular/respiratory diseases, gastrointestinal diseases, and neurological/other diseases at a suburban teaching hospital. The analysis results demonstrate significant rules associated with unplanned transfer outcome for each subgroups and also show comparable prediction accuracy (>70%) compared to state-of-the-art machine learning methods while providing easy-to-interpret symptom-outcome information., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: There have been claims that Delayed Transfers of Care (DTOCs) of inpatients to home or a less acute setting are related to Emergency Department (ED) crowding. In particular DTOCs were associated with breaches of the UK 4-hour waiting time target in a previously published analysis. However, the analysis has major limitations by not adjusting for the longitudinal trend of the data. The aim of this work is to investigate whether the proposition that DTOCs impact the 4-hour target requires further research., Method: Estimation of an association between two or more variables that are measured over time requires specialised statistical methods. In this study, we performed two separate analyses. First, we created two sets of artificial data with no correlation. We then added an upward trend over time and again assessed for correlation. Second, we reproduced the simple linear regression of the original study using NHS England open data of English trusts between 2010 and 2016, assessing correlation of numbers of DTOCs and ED breaches of the 4-hour target. We then reanalysed the same data using standard time series methods to remove the trend before estimating an association., Results: After introducing upward trends into the uncorrelated artificial data the correlation between the two data sets increased (R 2 =0.00 to 0.51 respectively). We found strong evidence of longitudinal trends within the NHS data of ED breaches and DTOCs. After removal of the trends the R 2 reduced from 0.50 to 0.01., Conclusion: Our reanalysis found weak correlation between numbers of DTOCs and ED 4-hour target breaches. Our study does not indicate that there is no relationship between 4-hour target and DTOCs, it highlights that statistically robust evidence for this relationship does not currently exist. Further work is required to understand the relationship between breaches of the 4-hour target and numbers of DTOCs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Objective: To evaluate the quality of the care transition for patients with chronic non-communicable diseases discharged from the emergency department to home., Method: A cross-sectional observational and epidemiological study conducted at an emergency department in the South of Brazil with 117 patients and 81 caregivers. The Care Transitions Measure was applied by phone to collect data. A descriptive and analytical statistical analysis was performed., Results: The quality of the care transition's total score was close to satisfactory (69.5). The "Self-Management Training" factor had the highest score (70.6), while "Understanding medications" had the lowest (68.3). Items related to understanding medications and confidence in carrying out care after discharge obtained lower scores., Conclusions: A moderate quality of the care transition was evidenced, as well as the need to adopt strategies to improve the emergency department discharge process and the continuity of the care of patients with chronic diseases.

Introduction: Patients with end-stage liver disease are at risk for clinical deterioration, often requiring hospital admissions while awaiting transplantation. Nurses observed that many patients were or became unstable soon after arrival, requiring transfers to the medical intensive care unit., Objective: To explore the incidence, timing, and factors associated with unplanned intensive care transfers., Design: We conducted a quality improvement project using plan-do-study-act methods to explore administrative data from adult patients admitted to the hepatology service's medical-surgical unit. Chi-square and t -tests were used to examine associations between demographic, clinical, and temporal factors and unplanned transfers. Data were analyzed at the hospital encounter level., Results: Unplanned transfers occurred in 8.6% of 1418 encounters. The number of transfers during these encounters ranged from 1 to 6. Most unplanned transfers (65.9%) occurred during the evening shift. On average, there was a 4.2-hour delay to the transfer. Fifty-one percent of these encounters required support from clinicians outside the unit while waiting for a bed. Factors associated with unplanned intensive care unit transfer were male sex ( P = .02), self-referral to the emergency department ( P < .001), and lower initial mean Rothman Index ( P < .001)., Discussion: Results validated nurses' concerns about the patients' severity of illnesses at the time of admission and frequent need for transfer to intensive care soon after admission. We now have actionable data that are being used by leaders to assess unit admission criteria and develop operating budgets for human and material resources needed to care for this challenging population.

Objective: Every year, emergency medical services agencies transport approximately 150,000 pediatric patients between hospitals. During these transitions of care, patient safety may be affected and contribute to adverse events when important clinical information is missing, incomplete, or inaccurate. Written interfacility transfer policies are one way to standardize procedures and facilitate communication between the hospitals leading to improved patient safety and satisfaction for children and families., Methods: We assessed the presence and components of written interfacility transfer guidelines and agreements for pediatric patients via a survey sent to US hospital emergency department (ED) nurse managers during 2010 and 2013., Results: Although there was an increase in the presence of written interfacility transfer guidelines and agreements, a third of hospitals did not have either by 2013, and only 50% had guidelines with all recommended pediatric components. Hospitals with medium and low ED pediatric patient volumes were less likely to have written guidelines or agreements compared with hospitals with high volume. Hospitals with advanced pediatric resources, such as a pediatric emergency care coordinator or EDs designated approved for pediatrics, were more likely to have guidelines or agreements than less resourced hospitals., Conclusions: Although there was improvement over time, opportunities exist for increasing the presence of written interfacility transfer guidelines as well as agreements for pediatric patients. Further studies are needed to demonstrate whether improved delivery of patient care is associated with the presence of written interfacility transfer guidelines and agreements and to identify other elements in the process to ensure optimal pediatric patient care.

Acute heart failure (AHF) represents a relevant burden for emergency departments worldwide. AHF patients have markedly worse long-term outcomes than patients with other acute cardiac diseases (e.g. acute coronary syndromes); mortality or readmissions rates at 3 months approximate 33%, whereas 1-year mortality from index discharge ranges from 25% to 50%.The multiplicity of healthcare professionals acting across the care pathway of AHF patients represents a critical factor, which generates the need for integrating the different expertise and competence of general practitioners, emergency physicians, cardiologists, internists, and intensive care physicians to focus on care goals able to improve clinical outcomes.This consensus document results from the cooperation of the scientific societies representing the different healthcare professionals involved in the care of AHF patients and describes shared strategies and pathways aimed at ensuring both high quality care and better outcomes. The document describes the patient journey from symptom onset to the clinical suspicion of AHF and home management or referral to emergency care and transportation to the hospital, through the clinical diagnostic pathway in the emergency department, acute treatment, risk stratification and discharge from the emergency department to ordinary wards or home. The document analyzes the potential role of a cardiology fast-track and Observation Units and the transition to outpatient care by general practitioners and specialist heart failure clinics.The increasing care burden and complex problems generated by AHF are unlikely to be solved without an integrated multidisciplinary approach. Efficient networking among emergency departments, intensive care units, ordinary wards and primary care settings is crucial to achieve better outcomes. Thanks to the joint effort of qualified scientific societies, this document aims to achieve this goal through an integrated, shared and applicable pathway that will contribute to a homogeneous care management of AHF patients across the country.

Background: During the transfer of patients, both ambulance and hospital emergency service professionals need to exchange necessary, precise, and complete information for an effective handover. Some factors threaten a quality handover such as excessive caseload, patients with multiple comorbidities, limited past medical history, and frequent interruptions., Purpose: To explore the viewpoint of nurses on their experience of patient handovers, describing the essential aspects of the process and areas for improvement, and establishing standardized elements for an effective handover., Methods: A qualitative research method was used., Results: Nurses identified the need to standardize the patient transfer process by a written record to support the verbal handover and to transmit patient information adequately, in a timely manner, and in a space free of interruptions, in order to increase patient safety., Conclusions: An organized method does not exist. The quality of handovers could be enhanced by improvements in communication and standardizing the process.

Background: Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable., Methods: Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract., Results: Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital., Conclusions: The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient's autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.

Aim: Neonatal endotracheal intubation is a challenging procedure during transport. The aim of this study was to evaluate the effectiveness of the emergency intubation guidelines followed by our Neonatal Emergency Transport Service (NETS)., Methods: Our transport intubation guidelines follows a weight-based nomogram for nasal intubation, and the tube position is clinically verified after intubation, while the postintubation chest X-ray is postponed to Neonatal Intensive Care Unit (NICU) admission. Data on postnatal age, weight and tube insertion depth were obtained from the online NETS clinical database, and the postintubation chest X-ray images were assessed., Results: During the study period, 161 newborn infants were nasally intubated during transport, and received a postintubation radiograph at NICU admission. A total of 130 neonates (80.7%) had the endotracheal tube (ETT) correctly positioned between T1 and T2 vertebrae, while 12 (7.5%) was at C7 vertebrae level and 19 (11.8%) at T3. No patients had ETT tip positioned at T4 vertebrae level or below. No adverse events related to intubation were observed., Conclusion: Our intubation procedure showed a good reliability and safety in neonatal critical care transport, although chest X-ray to confirm the tube placement is postponed to NICU arrival. Based on our results, we suggest a revised version of weight-based nomogram for nasal intubation., (©2018 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Introduction: Transitions of patient care during physicians' change of shift introduce the potential for critical information to be missed or distorted, resulting in possible morbidity. The Joint Commission, the Accreditation Council for Graduate Medical Education, and the Society of Hospital Medicine jointly encourage a structured format for patient care sign-out. This study's objective was to examine the impact of a standardized checklist on the quality of emergency medicine (EM) resident physicians' patient-care transition at shift change., Methods: Investigators developed a standardized sign-out checklist for EM residents to complete prior to sign out. This checklist included topics of diagnoses, patient-care tasks to do, patient disposition, admission team, and patient code status. Two EM attending physicians, the incoming and departing, assessed the quality of transitions of care at this shift change using a standardized assessment form. This form also assessed overall quality of sign-out using a visual analog scale (VAS), based on a 10-centimeter scale. For two months, we collected initial, status quo data (pre-checklist [PCL] cohort) followed by two months of residents using the checklist (post-checklist [CL] cohort)., Results: We collected data for 77 days (July 1, 2015 - November 11, 2015), 38 days of status quo sign-out followed by 39 days of checklist utilization, comprised of 1,245 attending assessments. Global assessment of sign-out for the CL was 8 compared to 7.5 for the PCL. Aspects of transition of care that implementation of the sign-out checklist impacted included the following (reported as a frequency): "To Do" (PCL 84.3%, CL 97.8%); "Disposition" (PCL 97.2%, CL 99.4%); "Admit Team" (67.1%, CL 76.2%); and "Attending Add" (PCL 23.4%, CL 11.3%)., Conclusion: Implementation of a sign-out checklist enhanced EM resident physician transition of care at shift end by increasing the frequency of discussion of critical tasks remaining for patient care, disposition status, and subjective assessment of quality of sign-out., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Background: Miscommunication during patient transfers is a leading cause of medical errors. Inpatient standardization of handoff communication has been associated with reduced medical errors, but less is known about best practices for handoffs from referring providers to the emergency department (ED). The study aims were to identify (1) stakeholder perceptions of current handoff processes and (2) key handoff elements and strategies to optimize patient care on transfer., Methods: A mixed-methods needs assessment study was conducted at a tertiary care children's hospital with a communication center that receives verbal handoff via telephone from referring providers and provides written summary to the ED. ED, primary care providers, and communication center staff were surveyed to understand perceptions of handoff processes and ideal handoff elements. Focus groups were conducted to refine concepts. Descriptive statistics, chi-square analysis, and qualitative content analysis were used to analyze responses., Results: The survey response rate was 129/152 providers (85%). Forty-two percent of respondents described the quality of the handoff process as "very good" or "excellent"; 43% reported miscommunication occurring "sometimes" or "frequently." Within the I-PASS framework-Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver-respondents identified 10 key elements to obtain through a receiver-driven process to optimize care on transfer. Free-text responses revealed a perceived need to standardize communication., Conclusion: A minority of providers perceived handoff quality between outpatient practices and the ED as "very good" or "excellent"; almost half perceived regular miscommunication. A receiver-driven process is a novel approach that may help ensure standardized communication of key handoff elements in this context., (Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Older adults may be at risk of adverse outcomes after emergency department (ED) visits due to ineffective transitions of care. Semi-structured interviews were employed to identify and categorize reasons for ED use and problems that occur during transition from the ED back to home among 14 residents of low-income senior housing. Qualitative thematic and descriptive analyses were used. Ambulance use, timely ED use or a wait-and-see approach, and lack of health-care provider contact before ED visit were emergent themes. Delayed medication receipt, no current medication list, and medication knowledge gaps were identified. Lack of a personal health record, follow-up care instruction, and worsening symptoms education emerged as transition problems from ED to home. After an ED visit, education opportunities exist around seeing primary care providers for nonurgent conditions, follow-up care, medications, and worsening condition symptoms. Timely receipt of discharge medications and medication education may improve medication-related transition problems.

Background: Multifaceted interventions driven by the needs of patients and providers can help move evidence into practice more rapidly. This study engaged both patients and primary care providers (PCPs) to help design novel opinion leader (OL)-based interventions for patients with acute asthma seen in emergency departments (EDs)., Methods: A mixed methods design was employed. In phase I, we invited convenience samples of patients with asthma presenting to the ED and PCPs to participate in a survey. Perceptions with respect to: a) an ideal OL-profile for asthma guidance; and b) content, style and delivery methods of OL-based interventions in acute asthma directed from the ED were collected. In phase II, we conducted focus groups to further explore preferences and expectations for such interventions with attention to barriers and facilitators for implementation., Results: Overall, 54 patients completed the survey; 39% preferred receiving guidance from a respirologist, 44% during their ED visit and 56% through individual discussions. In addition, 55% expressed interest in having PCP follow-up within a week of ED discharge. A respirologist was identified as the ideal OL-profile by 59% of the 39 responding PCPs. All expressed interest in receiving notification of their patients' ED presentation, most within a week and including diagnosis and ED/post ED-treatment. Personalized, guideline-based, recommendations were considered to be the ideal content by the majority; 39% requested this guidance through a pamphlet faxed to their offices. In the focus groups, patients and PCPs recognized the importance of health professional liaisons in transitions in care; patient anxiety and PCP time constraints were identified as potential barriers for ED-educational information uptake and proper post-ED follow-up, respectively., Conclusions: Engaging patients and PCPs yielded actionable information to tailor OL-based multifaceted interventions for acute asthma in the ED. We identified potential facilitators for the implementation of such interventions (e.g., patient interaction with alternative health care professionals who could facilitate transitions in asthma care between the ED and the primary care setting), and for the provision of post discharge self-management education (e.g., consideration of the first week of ED discharge as a practical time frame for this intervention). Prioritization of identified barriers (e.g., lack of PCP involvement) could be addressed by the identification of potential early adopters in practice environments (e.g., clinicians with special interest in asthma).

Background: Urgent care centers (UCCs) can offer a cheap alternative to emergency departments (EDs) for some patients with acute complaints. However, if patients who initially present to a UCC are unnecessarily transferred to an ED, those patients may suffer undue financial harm. The group of patients transferred from UCCs to EDs have never previously been studied., Objectives: The primary objective of this study was to determine the fraction of transfers from a UCC to an ED that were unnecessary. We also assessed the frequency with which these patients were discharged from the ED, and tried to determine which groups of patients were most likely to be unnecessarily transferred., Methods: This was a retrospective chart review performed on patients transferred from UCCs to our ED. If the transferred patient had no advanced imaging tests, advanced procedures, or specialty consultations in the ED, and was not admitted, we considered the transfer to be unnecessary. Patients were stratified by age (adult vs. pediatric) and type of insurance., Results: We identified 3232 patients who were transferred from UCCs to our ED over a 1-year period. Among those, 1159 (35.9%; 95% confidence interval [CI] 34.2-37.5%) met our criteria as unnecessary, and 2075 (64.2%; 95% CI 62.5-65.8%) were discharged from the ED. Notably, pediatric patients were more likely than adult patients to be unnecessarily transferred. Patients without medical insurance were not more likely to be transferred than those with private insurance., Conclusion: Most patients transferred to our ED from a UCC were discharged, and many transfers were unnecessary, especially those involving pediatric patients. These transfers may represent an economic burden to our society., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: With emerging global payment structures, medical systems need to understand longer-term impacts of care transition strategies., Objective: To determine the effect of a care transition program using patient navigators (PNs) on health service utilization among high-risk safety-net patients over a 180-day period., Design: Randomized controlled trial conducted October 2011 through April 2013., Participants: Patients admitted to the general medicine service with ≥1 readmission risk factor: (1) age ≥ 60; (2) in-network inpatient admission within prior 6 months; (3) index length of stay ≥ 3 days; or (4) admission diagnosis of heart failure or (5) chronic obstructive pulmonary disease. The analytic sample included 739 intervention patients, 1182 controls., Interventions: Through hospital visits and 30 days of post-discharge telephone outreach, PNs provided coaching and assistance with medications, appointments, transportation, communication with primary care, and self-care., Main Measures: Primary outcomes: (1) hospital-based utilization, a composite of ED visits and hospital admissions; (2) hospital admissions; (3) ED visits; and (4) outpatient visits. We evaluated outcomes following an index discharge, stratified by patient age (≥ 60 and < 60 years), using a 180-day time frame divided into six 30-day periods., Key Results: The PN program produced starkly different outcomes by patient age. Among older PN patients, hospital-based utilization was consistently lower than controls, producing an 18.7% cumulative decrease at 180 days (p = 0.038); outpatient visits increased in the critical first 30-day period (p = 0.006). Among younger PN patients, hospital-based utilization was 31.7% (p = 0.038) higher at 180 days, largely reflecting sharply higher utilization in the initial 30 days (p = 0.002), with non-significant changes thereafter; outpatient visits experienced no significant changes., Conclusions: A PN program serving high-risk safety-net patients differentially impacted patients based on age, and among younger patients, outcomes varied over time. Our findings highlight the importance for future research to evaluate care transition programs among different subpopulations and over longer time periods.

Objective: Current guidelines do not address the disposition of patients with mild traumatic brain injury (TBI) and resultant intracranial hemorrhage (ICH). Emergency medicine clinicians working in hospitals without neurosurgery coverage typically transfer patients with both to a trauma center with neurosurgery capability. Evidence is accruing which demonstrates that the risk of neurologic decompensation depends on the type of ICH and as a result, not every patient may need to be transferred. The purpose of this study was to identify risk factors for admission among patients with mild TBI and ICH who were transferred from a community hospital to the emergency department (ED) of a Level 1 trauma center., Methods: Study subjects were patients ≥18years of age who were transferred from a community hospital to the ED of an urban, academic Level 1 trauma center between April 1, 2015 and March 31, 2016, and with an isolated traumatic ICH. Patients who had an epidural hematoma, were deemed to require a trauma center's level of service, were found to have non-traumatic ICHs, or had a Glasgow Coma Scale of <13 were excluded. Using a multivariable logistic regression model, we sought to determine patient factors and Computed Tomography (CT) findings which were associated with admission (to the floor, intensive care unit, or operating room with neurosurgery) of the Level 1 trauma center., Results: 644 transferred patients were identified; 205 remained eligible after exclusion criteria. Presence of warfarin (odds ratio [OR] 4.09, 95% Confidence Interval [CI] 1.64, 10.25, p=0.0026) and a subdural hematoma (SDH) ≥1 cm (OR 6.28, 95% CI 1.24, 31.71, p=0.0263) were independently statistically significant factors predicting admission. Age, sex, GCS, presence of neurologic deficit, aspirin use, clopidogrel use, SDH <1 cm, IPH, and SAH were each independently not significant predictive factors of an admission., Conclusions: After controlling for factors, transferred patients with mild TBI with a SDH ≥1 cm or on warfarin have a higher odds ratio of requiring inpatient admission to a Level 1 trauma center. While these patients may require admission, there may be opportunities to develop and study a low risk traumatic intracranial hemorrhage protocol, which keeps a subgroup of patients with a mild TBI and resultant ICH at community hospitals with access to a nearby Level 1 trauma center., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Theoretical frameworks and models based on behaviour change theories are increasingly used in the development of implementation interventions. Development of an implementation intervention is often based on the available evidence base and practical issues, i.e. feasibility and acceptability. The aim of this study was to describe the development of an implementation intervention for the T 3 Trial (Triage, Treatment and Transfer of patients with stroke in emergency departments (EDs)) using theory to recommend behaviour change techniques (BCTs) and drawing on the research evidence base and practical issues of feasibility and acceptability., Methods: A stepped method for developing complex interventions based on theory, evidence and practical issues was adapted using the following steps: (1) Who needs to do what, differently? (2) Using a theoretical framework, which barriers and enablers need to be addressed? (3) Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? A researcher panel was convened to review the list of BCTs recommended for use and to identify the most feasible and acceptable techniques to adopt., Results: Seventy-six barriers were reported by hospital staff who attended the workshops (step 1: thirteen TDF domains likely to influence the implementation of the T 3 Trial clinical intervention were identified by the researchers; step 2: the researcher panellists then selected one third of the BCTs recommended for use as appropriate for the clinical context of the ED and, using the enabler workshop data, devised enabling strategies for each of the selected BCTs; and step 3: the final implementation intervention consisted of 27 BCTs)., Conclusions: The TDF was successfully applied in all steps of developing an implementation intervention for the T 3 Trial clinical intervention. The use of researcher panel opinion was an essential part of the BCT selection process to incorporate both research evidence and expert judgment. It is recommended that this stepped approach (theory, evidence and practical issues of feasibility and acceptability) is used to develop highly reportable implementation interventions. The classifying of BCTs using recognised implementation intervention components will facilitate generalisability and sharing across different conditions and clinical settings.

Background and Purpose: The American Heart Association/American Stroke Association and Department of Health Stroke Coverdell Program convened a stakeholder meeting in upstate NY to develop recommendations to enhance stroke systems for acute large vessel occlusion., Methods: Prehospital, hospital, and Department of Health leadership were invited (n=157). Participants provided goals/concerns and developed recommendations for prehospital triage and interfacility transport, rating each using a 3-level impact (A [high], B, and C [low]) and implementation feasibility (1 [high], 2, and 3 [low]) scale. Six weeks later, participants finalized recommendations., Results: Seventy-one stakeholders (45% of invitees) attended. Six themes around goals/concerns emerged: (1) emergency medical services capacity, (2) validated prehospital screening tools, (3) facility capability, (4) triage/transport guidelines, (5) data capture/feedback tools, and (6) facility competition. In response, high-impact (level A) prehospital recommendations, stratified by implementation feasibility, were (1) use of online medical control for triage (6%); (2) regional transportation strategy (31%), standardized emergency medical services checklists (18%), quality metrics (14%), standardized prehospital screening tools (13%), and feedback for performance improvement (7%); and (3) smartphone application algorithm for screening/decision-making (6%) and ambulance-based telemedicine (6%). Level A interfacility transfer recommendations were (1) standardized transfer process (32%)/timing goals (16%)/regionalized systems (11%), performance metrics (11%), image sharing capabilities (7%); (2) provider education (9%) and stroke toolbox (5%); and (3) interfacility telemedicine (7%) and feedback (2%)., Conclusions: The methods used and recommendations generated provide models for stroke system enhancement. Implementation may vary based on geographic need/capacity and be contingent on establishing standard care practices. Further research is needed to establish optimal implementation strategies., (© 2017 American Heart Association, Inc.)

Background: Poor communication causes fragmented care. Studies of transitions of care within a hospital and on discharge suggest significant communication deficits. Communication during transfers between hospitals has not been well studied. We assessed the written communication provided during interhospital transfers of emergency general surgery patients. We hypothesized that patients are transferred with incomplete documentation from referring facilities., Methods: We performed a retrospective review of written communication provided during interhospital transfers to our emergency department (ED) from referring EDs for emergency general surgical evaluation between January 1, 2014 and January 1, 2016. Elements of written communication were abstracted from referring facility documents scanned into the medical record using a standardized abstraction protocol. Descriptive statistics summarized the information communicated., Results: A total of 129 patients met inclusion criteria. 87.6% (n = 113) of charts contained referring hospital documents. 42.5% (n = 48) were missing history and physicals. Diagnoses were missing in 9.7% (n = 11). Ninety-one computed tomography scans were performed; among 70 with reads, final reads were absent for 70.0% (n = 49). 45 ultrasounds and x-rays were performed; among 27 with reads, final reads were missing for 80.0% (n = 36). Reasons for transfer were missing in 18.6% (n = 21). Referring hospital physicians outside the ED were consulted in 32.7% (n = 37); consultants' notes were absent in 89.2% (n = 33). In 12.4% (n = 14), referring documents arrived after the patient's ED arrival and were not part of the original documentation provided., Conclusions: This study documents that information important to patient care is often missing in the written communication provided during interhospital transfers. This gap affords a foundation for standardizing provider communication during interhospital transfers., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Patients admitted to a psychiatric hospital commonly suffer from comorbid medical problems which sometimes require urgent medical attention. Twenty-two percent of emergency medical transfers from the Institute of Mental Health (IMH) to the emergency rooms of general hospitals were preventable and could be managed at IMH itself. We undertook a quality improvement project to understand the reasons behind such preventable referrals and implemented changes to address this., Methods: Using the model for improvement, we deconstructed our processes and analysed root causes for such preventable referrals. Thereafter changes were implemented with Plan-Do-Study-Act (PDSA) cycles to analyse their outcomes., Results: During the 6-month study period, we achieved a 100% reduction in preventable referrals through strategies aimed at reducing pressure on our on-call physicians in the making of medical decisions, maximising usage of our medical resources, constant education and raising awareness of this issue., Conclusions: Reducing preventable transfer of inpatients from a psychiatric hospital to the emergency departments of general hospitals is a worthwhile endeavour. Such initiatives optimise use of healthcare resources, improve patient care and increase satisfaction.

Background: Quality improvement methodology was applied to study sporadic reports that patients with asthma were not given bronchodilator treatments or assessed within an appropriate time frame when they were admitted from the emergency department to the medical ward. The goal was to increase the number of patients who had an interval between emergency department assessment/bronchodilator treatment and medical ward assessment/treatment of <120 min., Methods: A flow chart diagram, a fishbone diagram, data collection, intervention implementation, and data monitoring and analysis were used in this study. Data were collected on a pre-test of change cohort of 227 subjects with asthma from January 2013 to March 2014. A test of change adding a Q2H respiratory therapist assessment and as needed bronchodilator treatment order while the subject was in the emergency department was implemented during May of 2014. These data were compared with a post-test of change cohort of 278 subjects with asthma from May 2014 to July 2015. Data collection for both cohorts included the time from the last assessment/bronchodilator treatment in the emergency department to emergency department discharge, the time from emergency department discharge to assessment/treatment in the medical ward, and the sum of these 2 time periods. Mean times (minutes) were noted, and comparisons were made using 2-tailed independent t tests with significance set at P < .05. Mean monthly times were also compared in process control charts., Results: There was a 124% increase noted in the percentage of subjects who received bronchodilator treatment within 120 min, a 53% increase within 180 min, and a 19% increase within 240 min. The interval time between treatments decreased 21%., Conclusions: Through quality improvement methodology, the group was able to significantly decrease the time between the last assessment/bronchodilator treatment in the emergency department and the first assessment/treatment in the medical ward for subjects with asthma. Moreover, improvement was seen in all studied parameters despite similar volumes in emergency department visits., (Copyright © 2016 by Daedalus Enterprises.)

Purpose: To describe the epidemiology of pediatric burn patients seen in U.S. emergency departments (EDs) and to determine factors associated with inter-facility transfer., Methods: We analyzed data from the 2012 Nationwide Emergency Department Sample. Current American Burn Association (ABA) Guidelines were used to identify children <18 who met criteria for referral to burn centers. Burn patient admission volume was used as a proxy for burn expertise. Logistic models were fitted to examine the odds of transfer from low volume hospitals., Results: In 2012, there were an estimated 126,742 (95% CI: 116,104-137,380) pediatric burn ED visits in the U.S. Of the 69,003 (54.4%) meeting referral criteria, 83.2% were in low volume hospitals. Only 8.2% of patients meeting criteria were transferred from low volume hospitals. Of the 52,604 (95% CI: 48,433-56,775) not transferred, 98.3% were treated and released and 1.7% were admitted without transfer; 54.7% of burns involved hands., Conclusions: Over 90% of pediatric burn ED patients meet ABA burn referral criteria but are not transferred from low volume hospitals. Perhaps a portion of the 92% of patients currently receiving definitive care in low volume hospitals are under-referred and would have improved clinical outcomes if transferred at the time of presentation., Competing Interests: All authors have no conflicts of interest to declare., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: The Dutch Major Incident Hospital (MIH) is a standby, highly prepared, 200-bed hospital strictly reserved to provide immediate, large-scale, and emergency care for victims of disasters and major incidents. It has long-standing experience training for various major incident scenarios, including functioning as a back-up facility for the Netherlands. In 1995, the MIH had experience with overtaking an evacuated hospital when that hospital was threatened by flooding. In November 2014, an exercise was performed to transfer an evacuating hospital to the MIH. The scenario again became reality when a neighbouring hospital had to evacuate in September 2015. This article evaluates the events and compares the exercise to the real events in order to further optimise future training., Methods: All three events were analysed using the Protocol for Reports from Major Accidents and Disasters, a standardised protocol to evaluate medical responses to a major incident., Results: During the 2014 exercise, 72 patients were received, compared with 143 and 70, respectively, in the real events in 1995 and 2015. Personnel from the evacuating hospitals accompanied the patients and continued working in the MIH. The patient surge differed on all three occasions. The information technology (IT) systems proved to be more prone to fail during the real event, and legal implications to have staff from another hospital work in the MIH had to be put in protocol during the deployment. The acute phase was comparable in all three events, and performance was good. However, the exercise did not last long enough to analyse the implications on multiday care, as experienced during a multiday deployment., Conclusion: Large-scale major incident exercises are a great benchmark for the medical response in the acute phase of relief. The MIH was shown to be highly prepared to admit an entire evacuating hospital or large groups of patients in such a scenario. Experiences from the past, combined with regular training that closely resembles reality, guarantee the level of preparedness. Key differences between a true deployment and an exercise are the inability to train multiple days, and in our experience, a successful operation of IT systems in test environments does not guarantee their successful use during live events., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Purpose of Review: Standards for capnography inside operating theatres in high and middle-income countries are well recognized and implemented. This review examines recent standards and recommendations for the use of capnography outside the operating room and their rationale and development., Recent Findings: The landmark publication of the Royal College of Anaesthetists and Difficult Airway Society's National Audit Project 4 report provided compelling evidence of airway deaths and a significant patient harm occurring outside the operating room, particularly in ICUs and to a lesser extent in emergency departments. Up to 74% of these ICU deaths could have been prevented by capnography. This provided a serious wake up call for relevant clinicians. As a result, there have recently been new standards published for the use of capnography in these and other areas of the hospital. Waveform capnography can also reflect cardiac output, as the 2015 resuscitation guidelines emphasized. Work still needs to be done on implementing all of these new standards., Summary: Established standards for using capnography within the operating theatre have significantly improved patient safety and it is hoped that the recent publication of new but similar capnography standards for application outside the operating theatre will do the same there. The reasons for the current low levels of implementation of some of these standards outside the operating room are worthy of further research.

Background: Testicular torsion (TT) remains one of the most common urological emergencies. The length of time from onset of symptoms to detorsion and degree of spermatic cord twisting are usually the most important factors for testicular damage. Therefore early presentation, accurate diagnosis, and prompt treatment are important factors for optimizing the testicular salvage rate. While delay in seeking medical attention is a common cause of testicular loss in pediatric patients with testicular torsion, delays in diagnosis and treatment can be preventable causes of testicular loss., Objective: In this study, we aimed to develop a standardized process to improve the patient flow from the Emergency Room (ER) to Operating Room (OR) for TT patients in an academic children's hospital., Study Design: Thirty consecutive pediatric patients with acute testicular torsion between November 2013 and July 2014 served as the control group. A scrotal pain checklist was implemented in July 2014, and 30 consecutive patients from July 2014 until April 2015 served as the study group. Perioperative parameters including times, ultrasound (US) findings, and surgical results were reviewed., Results: The mean ages of the control group and the study group were similar (12.3 ± 4.9 years and 11.5 ± 5 years, respectively) (p = 0.575). ER arrival to OR time, triage completion to OR time, and scrotal US to OR time were significantly decreased in the study group (p < 0.001) (Table). Although triage time and ER arrival to scrotal US times were decreased in the study group, the differences were not significant (p = 0.071, p = 0.112, respectively)., Discussion: Utilizing scoring tools during the triage of patients with scrotal pain can help identify high-risk patients earlier and prevent unnecessary use of resources in an ER serving a large pediatric population. Limitations of this pilot study include the limited number of patients and the potential for the Hawthorne effect (staff awareness of the study). Additionally, we did not examine scrotal pain checklist scores for other acute scrotal diseases. This study focused on a quality improvement process for TT patients, in order to reduce ER to OR times., Conclusion: A standardized process with use of a scrotal pain checklist and prompt communication between the ER, Urology, and Radiology teams led to significantly reduced times from the ER to the OR. Standardized processes for pediatric patients with testicular torsion may help to improve testicular survival rates., (Copyright © 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Appropriate use of emergency departments (EDs) is a focus of national healthcare reform efforts, and patients requiring hospital admission account for a substantial proportion of ED utilization. Despite this, little attention has been paid to evaluating direct admission to the hospital as an alternative to hospital admissions beginning in the ED. In this Perspective, we discuss the role of hospital medicine in the changing epidemiology of hospital admissions, the potential risks and benefits of direct admission to the hospital, and the need for research to evaluate the safety and effectiveness of this admission approach. We propose that transitions of care research and quality improvement, historically focused on hospital-to-home transitions, be expanded to address transitions into the hospital., (© 2015 Society of Hospital Medicine.)

Objective: To reduce transfer time of critically ill patients from the emergency department (ED) to the medical intensive care unit (MICU)., Design: A prospective, observational study assessing preimplementation and postimplementation of quality improvement interventions in a tertiary academic medical center., Interventions: A team of frontline health care professional including ED, MICU, and supporting services using the clinical microsystems approach mapped out existing practice patterns, determined causes for delays, and used the Plan-Do-Study-Act to test changes. Measurements and Main Results The team identified multiple issues that contributed to delays. These included poor coordination between transport services, respiratory therapy, and nursing in transferring patients from the ED as well delays in identification and transfer of stable MICU patients. These interventions reduced transfer time from 4.2 (3.4-5.7) hours to 2.2 (1.4-3.1) hours (median [interquartile range]; P<.001). Hospital length of stay decreased from 9.9±9 to 8.3±7 days (P<.03)., Conclusion: A team made up of frontline health care professionals using a structured quality improvement process and implementing multifaceted, multistage interventions, reduced transfer delays, and length of stay. Added benefits included engagement among members of the 2 microsystems and a more cohesive approach to patient care., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background and Objective: Appropriate patient placement at the time of admission to avoid unplanned transfers to the ICU and codes outside of the ICU is an important safety goal for many institutions. The objective of this study was to determine if the overall rate of unplanned ICU transfers within 12 hours of admission to the inpatient medical/surgical unit was higher for direct admissions compared with emergency department (ED) admissions., Methods: This was a retrospective cohort study of all unplanned ICU transfers within 12 hours of admission to an inpatient unit at a tertiary care children's hospital from January 2010 to December 2012. Proportions of preventable unplanned transfers from the ED and from direct admission were calculated and compared., Results: Over the study period, there were a total of 46,998 admissions; 279 unplanned ICU transfers occurred during the study period of which 101 (36%) were preventable. Preventable unplanned transfers from each portal of entry were calculated and compared with the total number of admissions from those portals. The portals of entry evaluated included admissions from our internal ED versus all outside facility transfers. The rates of early unplanned transfer (per 1000 admissions) by portal of entry were 3.50 for direct admissions and 3.18 for ED. There was no difference between direct admissions and ED admissions resulting in preventable unplanned transfers to the ICU (P=.64)., Conclusions: Rates of unplanned ICU transfers within 12 hours of admission to an inpatient unit are not higher for direct admissions compared with ED admissions. Further studies are required to determine clinical risk factors associated with unplanned ICU transfer after admission, thus allowing for more accurate initial patient placement., (Copyright © 2015 by the American Academy of Pediatrics.)

Objective: Time spent in the emergency department (ED) before admission to hospital is often considered an important key performance indicator (KPI). Throughout Australia and New Zealand, there is no standard definition of 'time of admission' for patients admitted through the ED. By using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database, the aim was to determine the differing methods used to define hospital admission time and assess how these impact on the calculation of time spent in the ED before admission to an intensive care unit (ICU)., Methods: Between March and December of 2010, 61 hospitals were contacted directly. Decision methods for determining time of admission to the ED were matched to 67,787 patient records. Univariate and multivariate analyses were conducted to assess the relationship between decision method and the reported time spent in the ED., Results: Four mechanisms of recording time of admission were identified, with time of triage being the most common (28/61 hospitals). Reported median time spent in the ED varied from 2.5 (IQR 0.83-5.35) to 5.1 h (2.82-8.68), depending on the decision method. After adjusting for illness severity, hospital type and location, decision method remained a significant factor in determining measurement of ED length of stay., Conclusions: Different methods are used in Australia and New Zealand to define admission time to hospital. Professional bodies, hospitals and jurisdictions should ensure standardisation of definitions for appropriate interpretation of KPIs as well as for the interpretation of studies assessing the impact of admission time to ICU from the ED. WHAT IS KNOWN ABOUT THE TOPIC?: There are standards for the maximum time spent in the ED internationally, but these standards vary greatly across Australia. The definition of such a standard is critically important not only to patient care, but also in the assessment of hospital outcomes. Key performance indicators rely on quality data to improve decision-making. WHAT DOES THIS PAPER ADD?: This paper quantifies the variability of times measured and analyses why the variability exists. It also discusses the impact of this variability on assessment of outcomes and provides suggestions to improve standardisation. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: This paper provides a clearer view on standards regarding length of stay in the ICU, highlighting the importance of key performance indicators, as well as the quality of data that underlies them. This will lead to significant changes in the way we standardise and interpret data regarding length of stay.

Background: Residents of long-term care facilities have a high risk of acute care admission. Estimates of the frequency of inappropriate transfers vary substantially throughout the studies and various assessment tools have been used. The purpose of this study is to systematically review and describe the internationally existing assessment tools used for determining appropriateness of hospital admissions among long-term care residents., Method: Systematic review of the literature of two databases (PubMed and CINAHL®). The search covered seven languages and the period between January 2000 and December 2012. All quantitative studies were included if any assessment tool for appropriateness of hospital and/or emergency department admission of long-term care residents was used. Two pairs of independent researchers extracted the data., Results: Twenty-nine articles were included, covering study periods between 1991 and 2009. The proportion of admissions considered as inappropriate ranged from 2% to 77%. Throughout the studies, 16 different assessment tools were used; all were based on expert opinion to some extent; six also took into account published literature or interpretation of patient data. Variation between tools depended on the concepts studied, format and application, and aspects evaluated. Overall, the assessment tools covered six aspects: specific medical diagnoses (assessed by n = 8 tools), acuteness/severity of symptoms (n = 7), residents' characteristics prior to admission (n = 6), residents' or families' wishes (n = 3), existence of a care plan (n = 1), and availability or requirement of resources (n = 10). Most tools judged appropriateness based on one fulfilled item; five tools judged appropriateness based on a balance of aspects. Five tools covered only one of these aspects and only six considered four or more aspects. Little information was available on the psychometric properties of the tools., Conclusions: Most assessment tools are not comprehensive and do not take into account residents' individual aspects, such as characteristics of residents prior to admission and wishes of residents or families. The generalizability of the existing tools is unknown. Further research is needed to develop a tool that is evidence-based, comprehensive and generalizable to different regions or countries in order to assess the appropriateness of hospital admissions among long-term care residents.

We know that errors related to consent, capacity and substitute decision-making can lead to transfers from long-term care to hospital that seniors do not want and cannot benefit from. Three ethics quality improvement projects were launched to minimize errors in decision-making to work towards providing care residents want and can benefit from. We learned that there is a systemic barrier, namely the level-of-care form that undermines the efforts made by long-term care staff to meet their ethical and legal obligations. Because of the use of these forms, residents can receive treatment that they do not want or could not benefit from, including transfer to hospital., (Copyright © 2014 Longwoods Publishing.)

We reviewed telehealth consultations for acute paediatric patients presenting at rural sites in the Mackay district in 2012. Patient data and outcomes were collected prospectively, and a survey of the referring clinicians was undertaken. Thirty four patient consultations were conducted via telehealth with 14 referring clinicians. Most of the referrals were for respiratory illnesses, including bronchiolitis. We received feedback surveys for 16 consultations (57% response rate). In 47% of the cases, the paediatric team felt that transfer was avoided by using teleconsultation. In 80% of consultations, the referring clinicians felt that video consultation was more effective than telephone alone. In 30% of cases, the referring clinicians felt that the patient would have been transferred to higher facility in the absence of the telehealth facility. Clinicians thought that almost all consultations had educational value and reduced their anxiety in dealing with acute paediatric problems. There were no adverse outcomes or delayed transfers of patients staying at their rural sites. We recommend that telehealth consultation occur for all enquiries about acute paediatric patients at rural sites, especially if transfer of the patient is being considered.

Background: Emergency access targets have been implemented Australia-wide following recent retrospective cohort studies linking emergency department (ED) overcrowding and excess mortality., Aim: To examine the impact of ED access targets on the characteristics and health service utilisation of general medicine (GM) inpatients at the Royal Melbourne Hospital., Methods: A retrospective cohort study was conducted on all patient episodes admitted from ED to GM units from January 2009 to December 2012 (n = 15562), compared in two cohorts for 24 months before (n = 7393) and after (n = 8169) the implementation of the '4-h rule'. The main outcome measures were age, comorbidity, clinical urgency at presentation (Australasian Triage Score), ED and inpatient length of stay, diagnosis at discharge, and in-hospital complications., Results: After the implementation of the '4-h rule', there was an increased proportion of younger patients aged ≤50 years (7.7-9.1%), urgent Australasian Triage Scale 3 (45.6-49.7%) and semi-urgent Australasian Triage Scale 4 (21.8-27.6%) patients admitted to GM. On average, GM patients had fewer comorbid conditions (proportion with Charlson score ≥6 decreased from 14.2% to 11.9%), and higher proportions (21.8-24.7%) were admitted for less than 48 h., Conclusion: Implementation of a 4-h access target has been associated with changes to the characteristics of patients admitted to GM, including higher proportions of younger patients, with fewer comorbid conditions and lower clinical urgency at presentation, although the latter may be explained by a coincidental change in the way that ED patients were triaged, as well as a greater number of these patients presenting to ED overall., (© 2013 The Authors; Internal Medicine Journal © 2013 Royal Australasian College of Physicians.)

Aim: If developing policies to optimize quality acute care within residential aged care facilities (RACF) is a goal, understanding the factors that influence the decision to transfer a resident from RACF to hospital emergency departments is important. The aim of the present study was to review the published literature pertaining to transfer decisions., Methods: We carried out a systematic review of the qualitative literature to ascertain key influences on transfer decisions amongst three key stakeholder groups - residents, their family and carers., Results: From 11 papers we found two themes encompassing seven domains of influence. Transfers are influenced by an expectation or goal of improved resident clinical or quality of life outcomes - these are domains within the "resident dominant" theme. However, transfers also occur where there is no expectation of resident benefit. These domains, such as inadequate facility resourcing and care planning, are categorized within the "resident subordinate" theme., Conclusion: Transfer decisions are often influenced by considerations beyond expected benefit to the individual resident. Conceptualizing influences on transfer decisions within this framework might assist clinicians and policy makers in the design and delivery of services for RACF residents., (© 2013 Japan Geriatrics Society.)

Introduction: This study aims to determine the source of communication gaps in history of present illness (HPI), medical history, and advanced directives in nursing home (NH) patients transferred to the emergency department (ED). We also attempt to determine if these gaps create differences in patient turnaround time (TAT), disposition decision, or diagnostic testing., Methods: A convenience sample of patients transferred from NHs to a level 1 community trauma center was enrolled by the physicians caring for them. The physicians assessed the adequacy and source of the history for each patient. The patient's chart was then retrospectively reviewed to determine disposition, ED TAT, and diagnostic tests ordered., Results: One hundred patients were enrolled. Physicians found that NH paperwork contained adequate HPI 35% of the time. Patients could provide their own HPI 28% of the time. In 32% of patients, adequate HPI could not be obtained from the patient, NH paperwork, or NH personnel. Comparing patients in whom adequate HPI was available (n = 68) to those in whom HPI was not available (n = 32), there was no difference in TAT (146 vs 173 minutes, P = .22), admissions (60% vs 66%, P = .66), or diagnostic testing (P = .89-1.0)., Conclusion: Emergency department physicians often do not have adequate HPI in patients transferred from NHs. The absence of adequate information does not affect patient TAT, disposition decision, or ED diagnostic testing., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Emergency department (ED) overcrowding is a threat to patient safety and public health. Availability of specialty consultation to the ED may contribute to overcrowding. We implemented a novel intervention using education, goal setting and real-time performance feedback to improve time to admission for patients referred to general internal medicine (GIM)., Methods: Using a time-series design, we examined the effects of a quality improvement intervention on ED wait-times in an academic medical centre. The multifaceted approach included a didactic session for GIM housestaff on medicine triage principles and methods; setting a goal to have disposition decisions and, where appropriate, admission order within 4 h of consultation request; and providing personal data feedback on their performance on this metric to GIM housestaff during their rotation on the inpatient teaching service over a 1-year period. We compared time from consultation request to disposition decision and overall ED length of stay (LOS) for all patients referred to GIM during the intervention period (February 2011-February 2012) with data from the control period (January 2010-January 2011)., Results: Mean time from GIM consultation request to admission order entry decreased by 92 min (SD, 5, p<0.05) from 321min in the control period to 229 min in the intervention period. Overall ED LOS for GIM patients decreased by 59 min (SD, 14, p<0.05) for admitted patients from 1022 min in the control period to 963 min in the intervention period, and by 40 min (SD, 13, p<0.05) for all patients referred to GIM. GIM staffing and patient characteristics remained stable across the two periods., Discussion: ED throughput for admitted medical patients improved with a quality improvement initiative involving education, goal setting and performance feedback.

Background: Primary percutaneous coronary intervention (PCI) is the preferred management for patients with acute ST-segment elevation myocardial infarction (STEMI) if performed in a timely manner by experienced providers. Patients can access a PCI facility by three routes: prehospital STEMI diagnosis by emergency medical services (EMS) and direct transport by EMS to a PCI facility (EMS-PCI); visit to a hospital emergency department (ED) followed by referral to an on-site PCI facility (ED-PCI); or transfer from the ED to a PCI facility in another hospital (ED-transfer-PCI)., Aims: To assess the implementation rate in France of the guidelines recommending that STEMI patients be transported by EMS to a PCI facility and to compare the times between symptom onset and PCI for these three routes., Methods: We used the results of the pilot testing of a national quality indicator programme on STEMI in 64 hospitals, providing data on patient characteristics, referral route and symptom-onset-to-needle time. We compared delays for each route in a Cox proportional-hazard model., Results: In a population of 1217 patients, median symptom-onset-to-needle time was 186minutes (Q1 133; Q3 292) for the EMS-PCI route, 237minutes (Q1 165; Q3 368) for the ED-PCI route and 305minutes (Q1 230; Q3 570) for the ED-transfer-PCI route. A total of 70.8% of patients were transported by EMS as recommended. After adjustment for age, symptom onset period (weekends/nights) and history of cardiovascular disease, the EMS-PCI route was associated with the shortest symptom-onset-to-needle times. The hazard ratio was 0.71 [0.59-0.86] for the ED-PCI route and 0.67 [0.52-0.86] for the ED-transfer-PCI route., Conclusion: STEMI patients receive prompter care after prehospital diagnosis and direct transport to a PCI facility by EMS than by visiting a hospital ED. Use of this referral route should be further encouraged in France as approximately one-third of STEMI patients are still presenting directly to the ED., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Introduction: The primary goal of this investigation was to develop a simulation model to evaluate the various internal and external factors affecting patient flow and crowding in the emergency department (ED). In addition, a few recommendations are proposed to reconfigure the patient flow to improve ED capacity while maintaining service quality., Methods: In this research, we present a simulation study conducted in the ED at the "S Hospital" located in Seoul. Based on patient flow data and process analysis, a simulation model of patient throughput in the ED has been developed. We evaluated simulations of diverting the specific patient load in the light of our proposed recommendations to a separately managed area named as the ED load relief area (ED-LRA) and analyzing potential effects on overall length of stay (LOS) and waiting time (WT)., Results: What-if analyses have been proposed to identify key issues and investigate the improvements as per our proposed recommendations. The simulation results suggest that specific patient load diversion is needed to ensure desired outcomes. With the diversion of specific patient load to ED-LRA, there is a reduction of 40.60% in mean LOS and 42.5% in WT with improved resource utilization. As a result, opening of an ED-LRA is justified., Conclusions: Real-world systems are often too intricate for analytical models and often too expensive to trial with directly. Simulation models allow the modeling of this intricacy and enable experimentation to make inferences about how the actual system might perform. Our simulation study modeled that diverting the specific patient load to ED-LRA produced an improvement in overall ED's LOS and WT.