Introduction: Offload delay is a prolonged interval between ambulance arrival in the emergency department (ED) and transfer of patient care, typically occurring when EDs are crowded. The offload zone (OZ), which manages ambulance patients waiting for an ED bed, has been implemented to mitigate the impact of ED crowding on ambulance availability. Little is known about the safety or efficiency. The study objectives were to process map the OZ and conduct a hazard analysis to identify steps that could compromise patient safety or process efficiency. Methods: A Health Care Failure Mode and Effect Analysis was conducted. Failure modes (FM) were identified. For each FM, a probability to occur and severity of impact on patient safety and process efficiency was determined, and a hazard score (probability X severity) was calculated. For any hazard score considered high risk, root causes were identified, and mitigations were sought. Results: The OZ consists of six major processes: 1) patient transported by ambulance, 2) arrival to the ED, 3) transfer of patient care, 4) patient assessment in OZ, 5) patient care in OZ, and 6) patient transfer out of OZ; 78 FM were identified, of which 28 (35.9%) were deemed high risk and classified as impact on patient safety (n = 7/28, 25.0%), process efficiency (n = 10/28, 35.7%), or both (n = 11/28, 39.3%). Seventeen mitigations were suggested. Conclusion: This process map and hazard analysis is a first step in understanding the safety and efficiency of the OZ. The results from this study will inform current policy and practice, and future work to reduce offload delay.
Introduction: An undefined yet potentially significant risk for Emergency Medical Services (EMS) systems are patients who access 911 with an ambulance response who are not transported to hospital (non-transport). Our objective was to determine the prevalence and associated characteristics of non-transport and potentially clinically adverse non-transports in Nova Scotia. Methods: We conducted a secondary analysis of pooled cross-sectional, population-based administrative data in a provincial EMS system that provides care to 920,000 residents. Electronic patient care record (ePCR) data was retrospectively analyzed for one calendar year (2014). The dependent variables were non-transport status and potentially adverse non-transport status. Potentially adverse non-transports were defined as a repeat call within 48 hours for a related complaint with the outcome of transport or death. Independent variables include patient characteristics, (age, sex, vitals and paramedic clinical impression), operational (crew type and response code) and environmental (time, date, and location). For both objectives we determined the prevalence of the outcome of interest, and associated characteristics. Results: There were 74,471 EMS responses between January to December 2014, 18.9% (n=14, 094/74,471) resulted in a non-transport. The characteristics most associated with non-transport are: age, paramedic clinical impressions, number of co-morbidities, response mode, and incident location type. As age decreased, the likelihood of non-transport increased. Younger non-transported patients (0-15 years old) (OR 2.2, 99.9% CI 1.9-2.5) are more likely to have non-transport. Relative to other paramedic clinical impressions, glycemic issues (OR 4.8; 99.9% CI 3.9-5.7) and wellness checks (OR 6.5; 99.9% CI 5.7-7.3) are more likely to have a non-transport. Non-transports are more likely at a detention facility (OR 4.1; 99.9% CI 3.2-5.1) or a roadway (OR 2.4; 99.9% CI 2.1-2.8). 5.6% (n=798/14094) of non-transport patients were classified as a potentially adverse non-transport. Conclusion: This study demonstrated that a significant portion of patients (18.9%) had a non-transport outcome, but only a small percentage (5.6%) were considered potentially adverse. The results of this study provide timely information to policy makers and healthcare practitioners on the scope of this issue, and suggest potential directions for future study and clinical decision making.
Introduction: Collaborative Emergency Centres (CECs) provide access to care in rural communities. After hours, registered nurses (RNs) and paramedics work together in the ED with telephone support by an emergency medical services (EMS) physician. The safety of such a model is unknown. Relapse visits are often used as a proxy measure for safety in emergency medicine. The primary outcome of this study is to measure unscheduled relapses to emergency care. Methods: The electronic patient care record (ePCR) database was queried for all patients who visited two CECs from April 1, 2012 to April 1, 2013. Abstracted data included demographics, time, acuity score, clinical impression, chief complaint, and disposition. Records were searched for each discharged CEC patient to identify unscheduled relapses to emergency care, defined as presenting back to EMS, CEC, or any other ED within the Health Authority within 48 hours of CEC discharge. Results: There were 894 CEC visits, of which 66 were excluded due to missing data. The dispositions from CEC were: 131/828 (15.8%) transferred to regional ED; 264/828 (31.9%) discharged home; 488/828 (58.9%) discharged with follow up visit booked; and 11/82 (1.2%) left the CEC without being seen. There was 37/828 (4.5%) visits which relapsed back to emergency care, all of whom were discharged from CEC or left without being seen: 3/828 (0.4%) relapsed back to EMS (two taken to regional ED and one to CEC); 16/828 (1.9%) relapsed to regional ED (by walking-in); and 18/828 (2.2%) had a relapse to the CEC (walk-in). 516/828 (62.3%) CEC visits were resolved in a single visit. Conclusion: This study was based on only two of the 7 operating CECs due to accessing paper-based charts for multiple health regions. We also acknowledge the limitations of using relapse as a proxy for safety, and that low volumes and acuity will make detection of adverse events challenging. Albeit a proxy measure, the rate of patients who relapse to emergency care was under 5% in this case series of two CECs. Most patients had their concern resolved in a single visit to a CEC. Further research is underway to determine the effectiveness, optimal utilization and safety of this collaborative model of rural emergency care.
Health professions students need to have increasing exposure to interprofessional and international experience in developing the knowledge and skills needed to work with older adults. As students, the authors explore in this article the significant elements of our learning that took place in a blended Gerontology Across the Professions and the Atlantic course for participants from the United States, Canada, and Norway. These factors focus on the following aspects of this course: (1) weekly online topic discussions and learning experiences, (2) group case studies and presentations, (3) international perspectives, (4) interprofessional perspectives, and (5) the final course seminar in Bergen. The authors end their discussion by sharing sidebar stories of their experiences in this course that brought together the powerful, transformative elements of interprofessional and international insights into the challenges of geriatric care in the future.
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