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Objectives: To evaluate the different internal factors influencing patient flow, effectiveness, and overcrowding in the emergency department (ED), as well as the effects of ED reorganisation on these indicators. Methods: The study compared measurements at regular intervals of three hours of patient arrivals and patient flow between two comparable periods (from 10 February to 2 March) of 1999 and 2000. In between, a structural and staff reorganisation of ED was undertaken. The main reason for each patient remaining in ED was recorded and allocated to one of four groups: (1) factors related to ED itself ; (2) factors related to ED-hospital interrelation; (3) factors related to hospital itself; and (4) factors related to neither ED nor hospital. The study measured the number of patients waiting to be seen and the waiting time to be seen as effectiveness markers, as well as the percentage of time that ED was overcrowded, as judged by numerical and functional criteria. Results: Effectiveness of ED was closely related with some ED related and hospital related factors. After the reorganisation, patients who remained in ED because of hospital related or non-ED-non-hospital related factors decreased. ED reorganisation reduced the number of patients waiting to be seen from 5.8 to 2.5 (p<0.001) and waiting time from 87 to 24 minutes (p<0.001). Before the reorganisation, 31% and 48% of the time was considered to be overcrowded in numerical and functional terms respectively. After the reorganisation, these figures were reduced to 8% and 15% respectively (p<0.001 for both). Conclusions: ED effectiveness and overcrowding are not only determined by external pressure, but also by internal factors. Measurement of patient flow across ED has proved useful in detecting these factors and in being used to plan an ED reorganisation. E mergency department (ED) overcrowding is closely related to a decrease in both subjective patient satisfaction, 1 2 and objective care quality. 3-5 Attendance peaks have frequently been invoked as one of the major reasons for overcrowding, and the "number of arrivals per hour" has been proposed as an explanation for ED performance.6-10 However, this indicator does not take into account the effect of patients who remain in ED because of internal reasons. American studies have demonstrated that measurement of patient flow in ED might be valuable tool to analyse the influence of internal factors on overcrowding. 12Although similar studies have not been conducted, it is conceivable that this methodology would be practical in European countries. In this sense, in a preliminary assessment of the relative effect of external and internal factors performed in Spain, it has been demonstrated that such internal factors are at least (if not more) as important as external factors in determining ED overcrowding.13 However, the question of whether ED patient flow can actually be improved by uncovering ED internal dysfunction or modifying ED structures, has been poorly studied.14 This study was designed in two separate p...

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Lean thinking is a methodology that can improve triage acuity level-3 patient flow in the ED, resulting in better throughput along with reduced waiting time.

We evaluated the effect of oral calcium supplementatIon on blood pressure, calcium metabolism, and msuhn resistance m essential hypertension After receiving a standard diet with 500 mg of calcmm per day durmg a 4-week period, 20 nondiabetic, essential hypertensive patients were randomized in a double-blind fashion to receive oral calcium supplementation (1500 mg of calcium per day) or placebo for 8 weeks At the end of the 4-week period of low-calcium diet and after the 8-week period of intervention, we measured blood pressure (by both office and 24-hour ambulatory blood pressure momtonng), calaum-regulating hormones [urinary hydroxyprohne and serum osteocalcm, parathormone, and l,25(OH)2-vltamm DJ, mtraplatelet free calcium concentration, fasting plasma glucose and insulin levels, and the msuhn-sensitivity index (euglycenuc-hypermsuhnetmc clamp). Compared with patients maintained at low calcium intake, essential hypertensive patients under oral calcium supplementation significantly reduced serum osteocalcm (from 222+1 9 to 17 9220 pg/L, P= 001.5), parathormone (from 4 2020 38 to 3 30?0 36 pmol/L; P= 0003), and 1,25(OH)2-vltarnm D1 (from 98 0211 0 to 61 625 7 pmol/L, P=.OO62) LIkewise, we found a significant reduction m mtraplatelet free calcium concentration (from 35 92 1.2 to 26 520 8 nmol/L; P= 0005) and fastmg plasma msulm levels (from 71 85.5 9 to 64 6?6 2 pmol/L, P= 05) and a significant increase m the msulm-sensitivity index (from 2 8920.77 to 4 0050 95 mg kg-' nun-', P= 0007) None of these parameters were significantly modified m patients maintained at low calcium rntake Office and 24-hour mean values of systolic and dlastohc blood pressure did not change after 8 weeks of oral calcium supplementation or placebo (Hypertension. 1997;29[part 21: 531-536 Essential hypertension IS associated with increased calcium concentration in several cell types 5-7 In animal models with experimental hypertensloqs-10 calcium supplementation leads to a decrease m intracellular calcmm, which IS postulated as one of the mechanisms of the BP fall Furthermore, m black hypertensive patients, it has been reported that high calcium intake prevents the increase m intracellular calcmm promoted by a high salt diet 11Several studies have demonstrated the existence of some degree of msulm resistance and/or hypermsulmemla m patients with essential hypertension and an mverse relation between BP and msulm-mediated glucose disposal.l2,'3 An important relationship IS likely to exist between alterations m intracellular calcium metabolism, insulin resistance, and hypertension 14 There are several From the Hypertension Unit, Departments of Internal Medicine and Nephrology (E P), Hospital Clime, Umverslty of Barcelona, Spam Correspondence to Alejandro de la Sierra, MD, Hypertension Unit, Department of Internal Medicine, Hospital Clime, Vlllarroel 170, 08036-Barcelona, Spam E-mail lserte@mechcma ub es 0 1997 American Heart Assoaatlon, Inc data suggesting that "optimal" levels of intracellular free calcium concentration are necessary fo...

Health authorities must be aware of the hazards of recreational gamma-hydroxybutyrate, and physicians must be cognizant of this recent cause of coma among youths presenting to the emergency departments.

BackgroundEpidemiological evidence suggests a cardioprotective role of α‐linolenic acid (ALA), a plant‐derived ω‐3 fatty acid. It is unclear whether ALA is beneficial in a background of high marine ω‐3 fatty acids (long‐chain n‐3 polyunsaturated fatty acids) intake. In persons at high cardiovascular risk from Spain, a country in which fish consumption is customarily high, we investigated whether meeting the International Society for the Study of Fatty Acids and Lipids recommendation for dietary ALA (0.7% of total energy) at baseline was related to all‐cause and cardiovascular disease mortality. We also examined the effect of meeting the society's recommendation for long‐chain n‐3 polyunsaturated fatty acids (≥500 mg/day).Methods and ResultsWe longitudinally evaluated 7202 participants in the PREvención con DIeta MEDiterránea (PREDIMED) trial. Multivariable‐adjusted Cox regression models were fitted to estimate hazard ratios. ALA intake correlated to walnut consumption (r=0.94). During a 5.9‐y follow‐up, 431 deaths occurred (104 cardiovascular disease, 55 coronary heart disease, 32 sudden cardiac death, 25 stroke). The hazard ratios for meeting ALA recommendation (n=1615, 22.4%) were 0.72 (95% CI 0.56–0.92) for all‐cause mortality and 0.95 (95% CI 0.58–1.57) for fatal cardiovascular disease. The hazard ratios for meeting the recommendation for long‐chain n‐3 polyunsaturated fatty acids (n=5452, 75.7%) were 0.84 (95% CI 0.67–1.05) for all‐cause mortality, 0.61 (95% CI 0.39–0.96) for fatal cardiovascular disease, 0.54 (95% CI 0.29–0.99) for fatal coronary heart disease, and 0.49 (95% CI 0.22–1.01) for sudden cardiac death. The highest reduction in all‐cause mortality occurred in participants meeting both recommendations (hazard ratio 0.63 [95% CI 0.45–0.87]).ConclusionsIn participants without prior cardiovascular disease and high fish consumption, dietary ALA, supplied mainly by walnuts and olive oil, relates inversely to all‐cause mortality, whereas protection from cardiac mortality is limited to fish‐derived long‐chain n‐3 polyunsaturated fatty acids.Clinical Trial Registration URL: http://www.Controlled-trials.com/. Unique identifier: ISRCTN35739639.