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  • 1. Berg, Lena M
    et al.
    Ehrenberg, Anna
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Florin, Jan
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karonlinska institutet.
    Östergren, Jan
    Discacciati, Andrea
    Göransson, Katarina E
    Associations between crowding and ten-day mortality among patients allocated lower triage acuity levels without need of acute hospital care on departure from the emergency department2019Inngår i: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 74, nr 3, s. 345-356Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    STUDY OBJECTIVE: We describe the association between emergency department (ED) crowding and 10-day mortality for patients triaged to lower acuity levels at ED arrival and without need of acute hospital care on ED departure.

    METHODS: This was a registry study based on ED visits with all patients aged 18 years or older, with triage acuity levels 3 to 5, and without need of acute hospital care on ED departure during 2009 to 2016 (n=705,699). The sample was divided into patients surviving (n=705,076) or dying (n=623) within 10 days. Variables concerning patient characteristics and measures of ED crowding (mean length of stay and ED occupancy ratio) were extracted from the hospital's electronic health records. ED length of stay per ED visit was estimated by the average length of stay for all patients who presented to the ED during the same day and shift and with the same acuity level. The 10-day mortality after ED discharge was used as the outcome measure. Multivariable logistic regression analyses were conducted.

    RESULTS: The 10-day mortality rate was 0.09% (n=623). The event group had larger proportions of patients aged 80 years or older (51.4% versus 7.7%) and triaged with acuity level 3 (63.3% versus 35.6%), and greater comorbidity (age-combined Charlson comorbidity index median interquartile range 6 versus 0). We observed an increased 10-day mortality for patients with a mean ED length of stay greater than or equal to 8 hours versus less than 2 hours (adjusted odds ratio 5.86; 95% confidence interval [CI] 2.15 to 15.94) and for elevated ED occupancy ratio. Adjusted odds ratios for ED occupancy ratio quartiles 2, 3, and 4 versus quartile 1 were 1.48 (95% CI 1.14 to 1.92), 1.63 (95% CI 1.24 to 2.14), and 1.53 (95% CI 1.15 to 2.03), respectively.

    CONCLUSION: Patients assigned to lower triage acuity levels when arriving to the ED and without need of acute hospital care on departure from the ED had higher 10-day mortality when the mean ED length of stay exceeded 8 hours and when ED occupancy ratio increased.

  • 2.
    Ekström, Andreas
    et al.
    Department of Clinical Science and Education, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Kurland, Lisa
    Department of Clinical Science and Education, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Farrokhnia, Nasim
    Department of Clinical Science and Education, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Castrén, Maaret
    Department of Clinical Science and Education, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden.
    Nordberg, Martin
    Department of Clinical Science and Education, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Forecasting emergency department visits using internet data2015Inngår i: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 65, nr 4, s. 436-442.e1Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    STUDY OBJECTIVE: Using Internet data to forecast emergency department (ED) visits might enable a model that reflects behavioral trends and thereby be a valid tool for health care providers with which to allocate resources and prevent crowding. The aim of this study is to investigate whether Web site visits to a regional medical Web site, the Stockholm Health Care Guide, a proxy for the general public's concern of their health, could be used to predict the ED attendance for the coming day.

    METHODS: In a retrospective, observational, cross-sectional study, a model for forecasting the daily number of ED visits was derived and validated. The model was derived through regression analysis, using visits to the Stockholm Health Care Guide Web site between 6 pm and midnight and day of the week as independent variables. Web site visits were measured with Google Analytics. The number of visits to the ED within the region was retrieved from the Stockholm County Council administrative database. All types of ED visits (including adult, pediatric, and gynecologic) were included. The period of August 13, 2011, to August 12, 2012, was used as a training set for the model. The hourly variation of visits was analyzed for both Web site and the ED visits to determine the interval of hours to be used for the prediction. The model was validated with mean absolute percentage error for August 13, 2012, to October 31, 2012.

    RESULTS: The correlation between the number of Web site visits between 6 pm and midnight and ED visits the coming day was significant (r=0.77; P<.001). The best forecasting results for ED visits were achieved for the entire county, with a mean absolute percentage error of 4.8%. The result for the individual hospitals ranged between mean absolute percentage error 5.2% and 13.1%.

    CONCLUSION: Web site visits may be used in this fashion to predict attendance to the ED. The model works both for the entire region and for individual hospitals. The possibility of using Internet data to predict ED visits is promising.

  • 3.
    Herlitz, Johan
    et al.
    [external].
    Ekström, L
    Wennerblom, B
    Axelsson, Å
    Bång, A
    Holmberg, S
    Prognosis among survivors of prehospital cardiac arrest1995Inngår i: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 25, nr 1, s. 58-63Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    STUDY OBJECTIVE: To describe the prognosis in consecutive patients discharged from hospital after prehospital cardiac arrest. PATIENTS: All patients in the community of Göteborg who were discharged from hospital after out-of-hospital cardiac arrest between 1981 and 1991. RESULTS: Two hundred forty-three patients were discharged from hospital during the observation period, of whom 80% initially experienced ventricular fibrillation. Among patients discharged, 21% died during the first year; after 10 years, 82% had died. Age, sex, previous history of cardiovascular disease, circumstances at the time of cardiac arrest, complications during hospitalization, and discharge medications were assessed as predictors of 1-year mortality. Independent predictors of death during follow-up were history of myocardial infarction (P < .001), no prescription of beta-blockers at discharge (P < .01), age (P < .05), and cerebral performance category (CPC) at discharge (P < .05). CONCLUSION: Among patients who survived out-of-hospital cardiac arrest, one of five died during the first year and one of five survived 10 years after discharge. Prognosis was associated with a history of myocardial infarction, prescription of beta-blockers at discharge, age, and CPC at discharge.

  • 4.
    Holden, Richard J.
    KTH, Skolan för teknik och hälsa (STH), Ergonomi.
    Lean Thinking in Emergency Departments: A Critical Review2011Inngår i: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 57, nr 3, s. 265-278Artikkel, forskningsoversikt (Fagfellevurdert)
    Abstract [en]

    Emergency departments (EDs) face problems with crowding, delays, cost containment, and patient safety. To address these and other problems, EDs increasingly implement an approach called Lean thinking. This study critically reviewed 18 articles describing the implementation of Lean in 15 EDs in the United States, Australia, and Canada. An analytic framework based on human factors engineering and occupational research generated 6 core questions about the effects of Lean on ED work structures and processes, patient care, and employees, as well as the factors on which Lean's success is contingent. The review revealed numerous ED process changes, often involving separate patient streams, accompanied by structural changes such as new technologies, communication systems, staffing changes, and the reorganization of physical space. Patient care usually improved after implementation of Lean, with many EDs reporting decreases in length of stay, waiting times, and proportion of patients leaving the ED without being seen. Few null or negative patient care effects were reported, and studies typically did not report patient quality or safety outcomes beyond patient satisfaction. The effects of Lean on employees were rarely discussed or measured systematically, but there were some indications of positive effects on employees and organizational culture. Success factors included employee involvement, management support, and preparedness for change. Despite some methodological, practical, and theoretic concerns, Lean appears to offer significant improvement opportunities. Many questions remain about Lean's effects on patient health and employees and how Lean can be best implemented in health care.

  • 5. Isbister, Geoffrey K.
    et al.
    Friberg, Lena E.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Farmaceutiska fakulteten, Institutionen för farmaceutisk biovetenskap.
    Stokes, Barrie
    Buckley, Nicholas A.
    Lee, Christopher
    Gunja, Naren
    Brown, Simon G.
    MacDonald, Ellen
    Graudins, Andis
    Holdgate, Anna
    Duffull, Stephen B.
    Activated charcoal decreases the risk of QT prolongation after citalopram overdose2007Inngår i: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 50, nr 5, s. 593-600Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Study objective: We determine whether single-dose activated charcoal (SDAC) administration after citalopram overdose reduces the proportion of patients developing abnormal QT prolongation. Methods: Data were collected retrospectively for citalopram overdose patients presenting to 8 emergency departments. Demographics, dose, coingested drugs, SDAC administration, and serial ECGs were extracted from medical records. The primary outcome was the proportion of patients who had an observed QT,RR combination at any time above an abnormal threshold, established as a predictor of torsade de pointes. We compared the proportion of patients with QT prolongation who received or did not receive SDAC. These data were analyzed within a Bayesian framework, using probabilities of abnormal QT,RR combinations with and without derived from a previous single-center study. WinBUGS was used to generate posterior estimates and credible intervals of the relative risk by combining the prior probabilities and the study data. Results: SDAC was administered on average 2.1 hours (range, 0.5 to 6.25 hours) after ingestion in 48 of 254 admissions, and abnormal QT,RR combinations occurred in 2 cases (4.2%), compared with 23 of 206 (11.2%) cases not receiving SDAC. There did not appear to be any clinically important difference in age, sex, dose, and cardiotoxic coingestants between the 2 groups. No cases of torsade de pointes occurred. The estimated relative risk of having an abnormal QT,RR combination for SDAC compared to no SDAC was 0.28 (0.06 to 0.70) (median with 2.5% and 97.5% credible limits). The probability that the relative risk was less than 1.0 was 0.99, which can be interpreted as very strong evidence in favor of a beneficial effect of SDAC. The absolute risk difference was estimated as 7.5% and the median number needed to treat as 13.3. Conclusion: SDAC may be effective in reducing the risk of a prolonged QT in patients after citalopram overdose. Current trends toward nonuse of activated charcoal should be evaluated to determine whether patients poisoned by specific agents may benefit from activated charcoal administration.

  • 6.
    Ljung, Lina
    et al.
    Karolinska Inst, Dept Clin Sci & Educ, Sodersjukhuset, Stockholm, Sweden;Soder Sjukhuset, Dept Cardiol, Stockholm, Sweden.
    Lindahl, Bertil
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för medicinska vetenskaper, Kardiologi. Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Uppsala kliniska forskningscentrum (UCR).
    Eggers, Kai M.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för medicinska vetenskaper.
    Frick, Mats
    Karolinska Inst, Dept Clin Sci & Educ, Sodersjukhuset, Stockholm, Sweden;Soder Sjukhuset, Dept Cardiol, Stockholm, Sweden.
    Linder, Rikard
    Karolinska Inst, Dept Clin Sci, Danderyd Univ Hosp, Stockholm, Sweden.
    Löfmark, Henrik B.
    Karolinska Inst, Dept Clin Sci, Danderyd Univ Hosp, Stockholm, Sweden.
    Martinsson, Arne
    Capio St Gorans Hosp, Dept Emergency Med, Stockholm, Sweden.
    Melki, Dina
    Karolinska Univ Hosp, Heart & Vasc Theme, Stockholm, Sweden.
    Sarkar, Nondita
    Karolinska Inst, Dept Med, Stockholm, Sweden;Karolinska Univ Hosp, Heart & Vasc Theme, Stockholm, Sweden.
    Svensson, Per
    Karolinska Inst, Dept Med, Stockholm, Sweden;Karolinska Univ Hosp Solna, Funct Area Emergency Med, Stockholm, Sweden.
    Jernberg, Tomas
    Karolinska Inst, Dept Clin Sci, Danderyd Univ Hosp, Stockholm, Sweden.
    A Rule-Out Strategy Based on High-Sensitivity Troponin and HEART Score Reduces Hospital Admissions2019Inngår i: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 73, nr 5, s. 491-499Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Study objective: We evaluate whether a combination of a 1-hour high-sensitivity cardiac troponin algorithm and History, ECG, Age, Risk Factors, and Troponin (HEART) score reduces admission rate (primary outcome) and affects time to discharge, health care-related costs, and 30-day outcome (secondary outcomes) in patients with symptoms suggestive of an acute coronary syndrome.

    Methods: This prospective observational multicenter study was conducted before (2013 to 2014) and after (2015 to 2016) implementation of a strategy including level of high-sensitivity cardiac troponin T or I at 0 and 1 hour, combined with the HEART score. Patients with a nonelevated baseline high-sensitivity cardiac troponin level, a 1-hour change in high-sensitivity cardiac troponin T level less than 3 ng/L, or high-sensitivity cardiac troponin I level less than 6 ng/L and a HEART score less than or equal to 3 were considered to be ruled out of having acute coronary syndrome. A logistic regression analysis was performed to adjust for differences in baseline characteristics.

    Results: A total of 1,233 patients were included at 6 centers. There were no differences in regard to median age (64 versus 63 years) and proportion of men (57% versus 54%) between the periods. After introduction of the new strategy, the admission rate decreased from 59% to 33% (risk ratio 0.55 [95% confidence interval {CI} 0.48 to 0.63]; odds ratio 0.33 [95% CI 0.26 to 0.42]; adjusted odds ratio 0.33 [95% CI 0.25 to 0.42]). The median hospital stay was reduced from 23.2 to 4.7 hours (95% CI of difference -20.4 to -11.4); median health care-related costs, from $1,748 to $1,079 (95% CI of difference -$953 to -$391). The number of clinical events was very low.

    Conclusion: In this before-after study, clinical implementation of a 1-hour high-sensitivity cardiac troponin algorithm combined with the HEART score was associated with a reduction in admission rate and health care burden, with very low rates of adverse clinical events.

  • 7.
    Mokhtari, Arash
    et al.
    Skane Univ Hosp, Dept Internal & Emergency Med, Lund, Sweden.;Skane Univ Hosp, Dept Cardiol, Lund, Sweden.;Lund Univ, Dept Clin Sci, Lund, Sweden..
    Lindahl, Bengt
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för medicinska vetenskaper, Kardiologi. Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Uppsala kliniska forskningscentrum (UCR).
    Smith, J. Gustav
    Skane Univ Hosp, Dept Cardiol, Lund, Sweden.;Lund Univ, Dept Clin Sci, Lund, Sweden..
    Holzmann, Martin J.
    Karolinska Univ Hosp, Dept Emergency Med, Huddinge, Sweden.;Karolinska Inst, Dept Internal Med, Stockholm, Sweden..
    Khoshnood, Ardavan
    Skane Univ Hosp, Dept Internal & Emergency Med, Lund, Sweden.;Lund Univ, Dept Clin Sci, Lund, Sweden..
    Ekelund, Ulf
    Skane Univ Hosp, Dept Internal & Emergency Med, Lund, Sweden.;Lund Univ, Dept Clin Sci, Lund, Sweden..
    Diagnostic Accuracy of High-Sensitivity Cardiac Troponin T at Presentation Combined With History and ECG for Ruling Out Major Adverse Cardiac Events2016Inngår i: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 68, nr 6, s. 649-658Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Study objective: We evaluate the diagnostic accuracy of a high-sensitivity cardiac troponin T (hs-cTnT) level less than 5 ng/L or less than or equal to 14 ng/L at emergency department (ED) presentation, combined with the emergency physician's assessment of history and ECG, for ruling out major adverse cardiac events within 30 days.

    Methods: This prospective observational study enrolled consecutive ED chest pain patients. Emergency physicians' assessments of patient history and ECG were collected. The primay outcome was 30-day major adverse cardiac events, defined as acute myocardial infarction, unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of cardiac or unknown cause.

    Results: A total of 1,138 patients were included in the final analysis. The combination of hs-cTnT less than 5 ng/L, a nonischemic ECG result, and a nonhigh risk history was present for 29.2% of all patients and had a sensitivity of 99.2% (95% confidence interval [CI] 95.6% to 100%), negative predictive value (NPV) of 99.7% (95% CI 98.3% to 100%), and a negative likelihood ratio of 0.02 (95% CI 0 to 0.17) for 30-day major adverse cardiac events. The same combination with hs-cTnT less than or equal to 14 ng/L was present in 66.7% of the patients and had a sensitivity of 92% (95% CI 85.8% to 96.1%), NPV of 98.7% (95% CI 97.6% to 99.4%), and negative likelihood ratio of 0.11 (95% CI 0.06 to 0.20).

    Conclusion: A single hs-cTnT result of less than 5 ng/L at ED presentation when combined with a nonischemic ECG result and a nonhigh risk history identified 29% of chest pain patients at a very low risk of 30-day major adverse cardiac events. A similar strategy with hs-cTnT less than or equal to 14 ng/L was associated with a higher miss rate.

  • 8.
    Mueller, Christian
    et al.
    Univ Basel Hosp, Dept Cardiol, Basel, Switzerland.;Univ Basel Hosp, Cardiovasc Res Inst Basel, Basel, Switzerland..
    Giannitsis, Evangelos
    Univ Heidelberg Hosp, Heidelberg, Germany..
    Christ, Michael
    Paracelsus Med Univ, Gen Hosp, Dept Emergency & Crit Care Med, Nurnberg, Germany..
    Ordonez-Llanos, Jorge
    Inst Invest Biomed St Pau, Dept Clin Biochem, Barcelona, Spain..
    deFilippi, Christopher
    Univ Maryland, Sch Med, Dept Med, Baltimore, MD 21201 USA..
    McCord, James
    Henry Ford Heart & Vasc Inst, Henry Ford Hlth Syst, Detroit, MI USA..
    Body, Richard
    Cent Manchester Univ Hosp NHS Fdn Trust, Manchester, Lancs, England..
    Panteghini, Mauro
    Univ Milan, Sch Med, Dept Biomed & Clin Sci Luigi Sacco, Milan, Italy..
    Jernberg, Tomas
    Karolinska Inst, Dept Med, Huddinge, Sweden..
    Plebani, Mario
    Univ Hosp Padova, Dept Lab Med, Padua, Italy..
    Verschuren, Franck
    Clin Univ St Luc, Dept Acute Med, Brussels, Belgium.;Catholic Univ Louvain, Brussels, Belgium..
    French, John
    Liverpool Hosp, Liverpool, NSW, Australia.;Univ New S Wales, Liverpool, NSW, Australia..
    Christenson, Robert
    Univ Maryland, Sch Med, Dept Pathol, Baltimore, MD 21201 USA..
    Weiser, Silvia
    Roche Diagnost Germany, Penzberg, Germany..
    Bendig, Garnet
    Roche Diagnost Germany, Penzberg, Germany..
    Dilba, Peter
    Roche Diagnost Germany, Penzberg, Germany..
    Lindahl, Bertil
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för medicinska vetenskaper, Kardiologi. Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Uppsala kliniska forskningscentrum (UCR).
    Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T2016Inngår i: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 68, nr 1, s. 76-87Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Study objective: We aim to prospectively validate the diagnostic accuracy of the recently developed 0-h/1-h algorithm, using high-sensitivity cardiac troponin T (hs-cTnT) for the early rule-out and rule-in of acute myocardial infarction. Methods: We enrolled patients presenting with suspected acute myocardial infarction and recent (<6 hours) onset of symptoms to the emergency department in a global multicenter diagnostic study. Hs-cTnT (Roche Diagnostics) and sensitive cardiac troponin I (Siemens Healthcare) were measured at presentation and after 1 hour, 2 hours, and 4 to 14 hours in a central laboratory. Patient triage according to the predefined hs-cTnT 0-hour/1-hour algorithm (hs-cTnT beloow 12 ng/L and Delta 1 hour below 3 ng/L to rule out; hs-cTnT at least 52 ng/L r Delta 1 hour at least 5 ng/L to rule in; remaining patients to the "observational zone") was compared against a centrally adjudicated final diagnosis by 2 independent cardiologists (reference standard). The final diagnosis was based on all available information, including coronary angiography and echocardiography results, follow-up data, and serial measurements of sensitive cardiac troponin I, whereas adjudicators remained blinded to hs-cTnT. Results: Among 1,282 patients enrolled, acute myocardial infarction was the final diagnosis for 213 (16.6%) patients. Applying the hs-cTnT 0-hour/1-hour algorithm, 813 (63.4%) patients were classified as rule out, 184 (14.4%) were classified as rule in, and 285 (22.2%) were triaged to the observational zone. This resulted in a negative predictive value and sensitivity for acute myocardial infarction of 99.1% (95% confidence interval [CI] 98.2% to 99.7%) and 96.7% (95% CI 93.4% to 98.7%) in the rule-out zone (7 patients with false-negative results), a positive predictive value and specificity for acute myocardial infarction of 77.2% (95% CI 70.4% to 83.0%) and 96.1% (95% CI 94.7% to 97.2%) in the rule-in zone, and a prevalence of acute myocardial infarction of 22.5% in the observational zone. Conclusion: The hs-cTnT 0-hour/1-hour algorithm performs well for early rule-out and rule-in of acute myocardial infarction.

  • 9.
    Mueller, Christian
    et al.
    Univ Basel Hosp, Dept Cardiol, CH-4031 Basel, Switzerland.;Univ Basel Hosp, Cardiovasc Res Inst Basel, CH-4031 Basel, Switzerland..
    Giannitsis, Evangelos
    Univ Heidelberg Hosp, Heidelberg, Germany..
    Lindahl, Bertil
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för medicinska vetenskaper, Kardiologi. Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Uppsala kliniska forskningscentrum (UCR).
    Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T Reply2016Inngår i: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 67, nr 6, s. 794-795Artikkel i tidsskrift (Fagfellevurdert)
  • 10.
    Postma, Jeroen
    et al.
    Erasmus University, Netherlands.
    Zuiderent-Jerak, Teun
    Linköpings universitet, Institutionen för tema, Tema teknik och social förändring. Linköpings universitet, Filosofiska fakulteten.
    Beyond Volume Indicators and Centralization: Toward a Broad Perspective on Policy for Improving Quality of Emergency Care2017Inngår i: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 69, nr 6, s. 689-697Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Study objective: Policymakers increasingly regard centralization of emergency care as a useful measure to improve quality. However, the clinical studies that are used to justify centralization, arguing that volume indicators are a good proxy for quality of care (practice makes perfect), have significant shortcomings. In light of the introduction of a new centralization policy in the Netherlands, we show that the use of volume indicators in emergency care is problematic and does not do justice to the daily care provided in emergency departments (EDs). Methods: We conducted an ethnographic study in 3 EDs, a primary care facility, and an ambulance call center in the Netherlands, including 109 hours of observation, more than 30 ethnographic interviews with professionals and managers, and 5 semistructured follow-up interviews. Results: We argue that emergency care is a complex, multilayered practice and distinguish 4 different repertoires: acute and complex care, uncertain diagnostics, basic care, and physical, social, and mental care. A repertoire entails a definition of what good care is, what professional skills are needed, and how emergency care should be organized. Conclusion: The first repertoire of acute and complex care might benefit from centralization. The other 3 repertoires, however, equally deserve attention but are made invisible in policies that focus on the first repertoire and extrapolate the idea of centralization to emergency care as a whole. Emergency care research and policies should take all repertoires into account and pay more attention to alternative measures and indicators beyond volume, eg, patient satisfaction, professional expertise, and collaboration between EDs and other facilities.

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