IntroductionThe Royal College of Emergency Medicine highlights poor flow through hospitals as a major challenge to improving emergency department flow. We describe the effect of several hospital-wide flow interventions on Yeovil District Hospital’s emergency department flow.MethodsDuring 2016, a design science research study addressed several areas disproportionally contributing to exit block within Yeovil District Hospital. In this follow-up study, we used a retrospective, before/after design, to describe the effect of these interventions on the ED. We used the Royal College of Emergency Medicine’s clinical quality indicators (4-hour standard, time to decision-maker, 7-day unplanned reattendance, left without being seen, ambulatory patient care and patient experience). Pearson correlation coefficient (r) was used to compare variables. Wilcoxon signed-rank test was used to compare performance before and after the intervention.ResultsYeovil District Hospital emergency department was attended by 160 373 patients between August 2015 and October 2018. Mean monthly attendance was 4112 (±342) patients, mean age was 43 (±28) years with equal male/female split (49/51%). The 4-hour standard made a recovery from 92% to 97% (p=0.01) that did not correlate with a recovery in national data (r=0.09); this despite rising attendances both at Yeovil and nationally (r=0.75). All clinical quality indicators improved significantly (except unplanned reattendance and patient feedback which improved but not significantly).DiscussionThe positive effect on emergency department clinical quality indicators reveals the beneficial impact of improving in-patient flow. Qualitative research is needed to better understand facilitators and barriers to flow improvement work.
HYPOTHESIS: Idiopathic and allergic rhinitics have similar mucosal mast cell and IgE+ cell distribution. INTRODUCTION: The pathophysiology of idiopathic rhinitis (IR) is unknown but patients differ from those with allergic rhinitis (AR) in that they do not express IgE. Our study is novel because we investigated: (1) three study groups chosen prospectively using strict selection criteria over a 4-year period; and (2) mast cell and IgE+ cell counts were on full-thickness, full-length inferior turbinate mucosa. METHODS: Patient groups: allergic (n = 17); idiopathic: (n = 16); and normal controls (n = 9). Immunohistochemistry: mast cell and IgE+ cell detection using anti-mast cell tryptase and anti-IgE antibodies with an avidin-biotin (peroxidase) complex on paraffin processed tissue. Morphometry: sections were divided into three strata comprising an epithelial layer and two submucosal layers. Statistics: Mann-Whitney non-parametric analysis. alpha = 0.05, beta = 0.2. RESULTS: The power of the study was 89%. Mast cells (P = 0.03) and IgE+ cells (P < 0.05) were significantly increased in the epithelium of idiopahtic and allergic rhinitis mucosa compared to the normal control. More IgE+ cells were counted in the AR and IR groups compared to the controls in all three strata. CONCLUSION: Mast cells and IgE+ cells are involved in the pahtophysiology of IR. We propose that IR may be a variant form of AR involving a localized IgE-mediated inflammatory response.
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