Overcrowding in emergency rooms is a persistent problem caused by myths rather than reality. While it is often claimed that inappropriate or minor patients are the cause, evidence shows this is false. The true cause is a lack of overall hospital capacity. When capacity is increased, overcrowding decreases. Attempts to solve overcrowding through minor initiatives like phone lines or clinics do not work because they do not address the underlying lack of beds. Overcrowding has serious consequences for patient care and outcomes. Access block is avoidable when capacity is appropriately increased across the entire hospital system.
Hardwiring Hospital-Wide Flow To Drive Competitive PerformanceEmCare
Thom Mayer, MD, FACEP, FAAP and Kirk Jensen, MD, MBA, FACEP, authors of “Hardwiring Flow” and “The Patient Flow Advantage, " share their secrets for streamlining processes, changing behaviors, and achieving sustainable advances in hardwiring flow throughout your hospital system.
This presentation is an abridged version of the webinar that Drs. Jensen and Mayer delivered July 9, 2015, in partnership with Becker's Hospital Review.
Simulation modeling of pre/post bed needs for an Interventional PlatformSIMUL8 Corporation
Architect Frank Zilm discusses how simulation software was used to explore the implementation of an interventional platform concept, integrating surgery, cardiac procedures, interventional radiology and endoscopy services, at Saint Louis University Hospital.
Dr David Maltz: The challenge of length of stayNuffield Trust
In this slideshow, Dr David Maltz, of The Oak Group, explores the challenge of length of stay and opportunities for improvement.
Dr Maltz spoke at the Nuffield Trust ‘Reducing the length of stay’ event in September 2014.
Prof David Oliver: older people and acute care. Nuffield Trust
In this slideshow, Prof David Oliver, Consultant Geriatrician, Royal Berkshire NHS Foundation Trust, presents on how we can shorten and improve hospital care for older people with complex needs.
Dr Thompson spoke at the Nuffield Trust ‘Reducing the length of stay’ event in September2014.
Hardwiring Hospital-Wide Flow To Drive Competitive PerformanceEmCare
Thom Mayer, MD, FACEP, FAAP and Kirk Jensen, MD, MBA, FACEP, authors of “Hardwiring Flow” and “The Patient Flow Advantage, " share their secrets for streamlining processes, changing behaviors, and achieving sustainable advances in hardwiring flow throughout your hospital system.
This presentation is an abridged version of the webinar that Drs. Jensen and Mayer delivered July 9, 2015, in partnership with Becker's Hospital Review.
Simulation modeling of pre/post bed needs for an Interventional PlatformSIMUL8 Corporation
Architect Frank Zilm discusses how simulation software was used to explore the implementation of an interventional platform concept, integrating surgery, cardiac procedures, interventional radiology and endoscopy services, at Saint Louis University Hospital.
Dr David Maltz: The challenge of length of stayNuffield Trust
In this slideshow, Dr David Maltz, of The Oak Group, explores the challenge of length of stay and opportunities for improvement.
Dr Maltz spoke at the Nuffield Trust ‘Reducing the length of stay’ event in September 2014.
Prof David Oliver: older people and acute care. Nuffield Trust
In this slideshow, Prof David Oliver, Consultant Geriatrician, Royal Berkshire NHS Foundation Trust, presents on how we can shorten and improve hospital care for older people with complex needs.
Dr Thompson spoke at the Nuffield Trust ‘Reducing the length of stay’ event in September2014.
A presentation by Dr Imran Waheed, Consultant Psychiatrist, on strategies to reduce the length of stay of psychiatric inpatients. Delivered in Birmingham, UK in July 2010.
A presentation by Sven Erik Gisvold at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
How health analytics are changing the way we understand and manage healthcare. Presented by Professor Enrico Coiera, Faculty of Medicine at the University of NSW, Australia, at HINZ 2014, 11 November 2014, 10am, Plenary Room
The Deteriorating Patient and National Early Warning Score (NEWS) programme, marks the two year anniversary of the launch of the West of England Patient Safety Collaborative. These slides focus on celebrating our impact and demonstrable results across the region.
To address family history collection, interpretation, and application in busy primary care practices, NCHPEG has collaborated collaborating with the March of Dimes, Genetic Alliance, Harvard Partners, and the Health Resources and Services Administration to develop and evaluate a novel family history tool that focuses on prenatal and neonatal health. The tool helps to improve health outcomes for the female patient, fetus, and family by providing clinical decision support and educational resources for risk assessment based on family history. A set of screenshots and an overview of the module can be reviewed via this downloadable ppt.
Palliative Care and Acute Oncology IntegrationRecoveryPackage
Dr Catherine O'Doherty, Consultant in Palliative Medicine, Trust Acute Oncology Lead and Lead Cancer Clinician, Basildon and Thurrock University Hospitals NHS Foundation Trust
Karen Andrews, Head of Nursing for Macmillan/Acute Oncology and EOL services, Basildon and Thurrock University Hospitals NHS Foundation Trust
A new report suggests that risks of misdiagnoses or treatment delays are higher when hospital ER overcrowding leads to patients being cared for in hallways.
A presentation by Dr Imran Waheed, Consultant Psychiatrist, on strategies to reduce the length of stay of psychiatric inpatients. Delivered in Birmingham, UK in July 2010.
A presentation by Sven Erik Gisvold at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
How health analytics are changing the way we understand and manage healthcare. Presented by Professor Enrico Coiera, Faculty of Medicine at the University of NSW, Australia, at HINZ 2014, 11 November 2014, 10am, Plenary Room
The Deteriorating Patient and National Early Warning Score (NEWS) programme, marks the two year anniversary of the launch of the West of England Patient Safety Collaborative. These slides focus on celebrating our impact and demonstrable results across the region.
To address family history collection, interpretation, and application in busy primary care practices, NCHPEG has collaborated collaborating with the March of Dimes, Genetic Alliance, Harvard Partners, and the Health Resources and Services Administration to develop and evaluate a novel family history tool that focuses on prenatal and neonatal health. The tool helps to improve health outcomes for the female patient, fetus, and family by providing clinical decision support and educational resources for risk assessment based on family history. A set of screenshots and an overview of the module can be reviewed via this downloadable ppt.
Palliative Care and Acute Oncology IntegrationRecoveryPackage
Dr Catherine O'Doherty, Consultant in Palliative Medicine, Trust Acute Oncology Lead and Lead Cancer Clinician, Basildon and Thurrock University Hospitals NHS Foundation Trust
Karen Andrews, Head of Nursing for Macmillan/Acute Oncology and EOL services, Basildon and Thurrock University Hospitals NHS Foundation Trust
A new report suggests that risks of misdiagnoses or treatment delays are higher when hospital ER overcrowding leads to patients being cared for in hallways.
• A study of 20 million patients
• Examining mortality in relation to NEAT
• Tracking quality indicators
Speakers: Clair Sullivan Deputy Chair Medicine Princess Alexandra Hospital, QLD & Andrew Staib Deputy Director Emergency Princess Alexandra Hospital, QLD
Associate Professor Ian Scott - Princess Alexandra Hospital; University of Qu...Informa Australia
Associate Professor Ian Scott
Director
Internal Medicine & Clinical Epidemiology; Associate Professor of Medicine
Princess Alexandra Hospital; University of Queensland
• Implementing ACE in 100 aged care facilities
• Building relationships with aged care staff for improved patient outcomes
• Examining savings and delivering results
Speaker: Jacqueline Hewitt Clinical Nurse Consultant John Hunter Hospital, NSW
Can we solve the adult primary care shortage without more physicians? CHC Connecticut
Tom Bodenheimer,of the Center for Excellence in Primary Care at UCSF Dep’t of Family and Community Medicine talks about addressing the primary care shortage at the 2014 Weitzman Symposium
ANZICS S&Q 2014 - RRT: Robert Herkes on why ward staff should manage their ow...ANZICS
Robert Herkes makes the argument that ward staff should manage their own deteriorating patients. Presented at the ANZICS S&Q Conference 2014 on Rapid Response Teams.
Family members are a vital part of the healthcare team and are often best positioned to recognize the sometimes subtle, yet very important changes in their loved one's condition that may indicate deterioration. You may not know WHAT is wrong, but you know something just isn't right. Empower yourself and your loved ones with information and resources to help you recognize the signs of deteriorating patient condition and effectively discuss your concerns with the healthcare provider.
Review of the perils and pitfalls of social medicine. How to deal with the explosion in social media and maintain your composure; retain your identity and refrain from ethical and confidentiality breaches as a medical student
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
2. Myth-quotes
• What a man believes upon grossly insufficient evidence is an index into
his desires - desires of which he himself is often unconscious. If a man is
offered a fact which goes against his instincts, he will scrutinize it closely,
and unless the evidence is overwhelming, he will refuse to believe it. If, on
the other hand, he is offered something which affords a reason for
acting in accordance to his instincts, he will accept it even on the
slightest evidence. The origin of myths is explained in this way.
• Bertrand Russell
• The great enemy of the truth is very often not the lie ; deliberate,
contrived and dishonest ,but the myth - persistent, persuasive and
unrealistic.
• JFK
3. • Creation myths :
– An ED problem due to GP type patients and inefficient EDs
• Outcomes / management myth :
– Poor patient outcomes are rare
– Poor outcomes have minimal consequences
therefore
– EDs are good places to store excess admitted patients
• Solution myths:
– Access block is inevitable and insoluble
AND / OR
– Can be sorted out by GP clinics, telephone lines or bigger/ better EDs
Major Myth-conceptions of ED overcrowding
4. Causation myths for Access block:
Caused by inappropriate / GP patients and poor ED practices
In response to the state of our public hospitals
AIHW report showing a 30% worsening in ED
patients time to be seen in WA
• “the pressure on emergency departments is
caused by patients seeking help who did not
need to be treated at hospital and should
have seen a GP instead.”
Acting Director-General Health WA 1/7/2008
5. GP patients – the evidence
• Tertiary EDs <15% GP “inappropriate”
• Use 3% or < of resources
• Easy - quick to treat
• 95% of stay in WR
• Admissions < 1% (v 5% triage category 5)
• Commonest attendance reason = GP referral
• Think (know) they should be there!
» Emerg Med Australas. 2005 Feb ;17 (1):11-5 15675899 Ambulance
diversion is not associated with low acuity patients attending Perth
metropolitan emergency departments. Peter Sprivulis
» Australian Health Rev 2004;28(3):285:291 After-hours general practice
clinics are unlikely to reduce low acuity patient attendances to metropolitan
Perth emergency departments. Nagree Y, Ercleve TN and Sprivulis P.C
9. The Effect of Hospital Occupancy / Admissions in ED on:
ED LOS, Overcrowding and Pt Disposition/ Diversion
Research conclusions:
Hospital occupancy (admitted pts.) strongly associated w ED LOS
– Alan J. Forster MD, MSc , I Stiell et al; Academic Emerg Med Vol
10;2, p127 - 133 June-08
Admitted patients in ED are important determinant of ambulance diversion.
Reducing volumes of walk-in patients is unlikely to < the use of diversion.
– Michael J. Schull MD Ann Emerg Med. 2003;41:467-476.
ED overcrowding (r = 0.96; 95% confidence interval (CI) 0.91 to 0.98),
Ambulance diversion (r = 0.75; 95% CI 0.49 to 0.88), and
ED waiting times for care (r = 0.83; 95% CI 0.65 to 0.93) were
Strongly correlated with high ED occupancy by access blocked pts
• Fatovich D et al Emerg Med J 2005; 22:351-354
Capacity loss isn’t the cause of overcrowding?
The Evidence
11. The data:
BEDS v Access BLOCK 1999 to 2006 WA
WA’s public beds have reduced 18% % of admitted patients Access Blocked
Australian public beds have reduced 10%
3.1
2.9
2.5
2.6
2
2.2
2.4
2.6
2.8
3
3.2
WA Australia
1999
2005
Beds per 1000 population
The state of our public hospitals, June 2006 report
0
10
20
30
40
50
60
FH RPH SCGH
2000
2001
2002
2003
2004
2005
2006
2007
DoH WA data
12. Access block in a department experiencing
major improvements in efficiency
15. The Truth
• GP / “inappropriate” patients don’t
• Cause Access Block
• Use ED resource OR hospital capacity
• EDs don’t “stay and play” with patients
• Lack of Hospital and System capacity causes ED Overcrowding
17. Myth: Overcrowding has minimal effect on patient care.
A deliberate mythology?
Standard DoH/ Health ministry responses minimising clinical
compromise from overcrowded EDs/ hospitals
“Western Australia now has some of the safest emergency departments in
the country, contrary to the findings of a 2003 report published in the
Medical Journal of Australia today. He said the report into overcrowding
in EDs was based on three-year-old information and many of the issues
raised were already being addressed”. 3/3/06
• Director Health Policy and Clinical Reform DoH WA in response to release of
Sprivulis et al mJA 2006 study showing OR of death of 1.3 in overcrowded WA
hospitals
“All public hospitals have procedures in place to ensure that patients who
present at emergency departments are promptly triaged and monitored,
and patients requiring urgent medical treatment are seen immediately,”
he said. 6/08
• A/DGH WA in response to concerns that an extra 2-300 patients a year were
probably dying due to chronic overcrowding in ED and hospitals
Access block from
2000-06
(worse again 2007)
18. Published adverse events from ED overcrowding
Deaths: 60-100 extra per 1 M population p.a.
Patients with time critical illness
e.g. Heart attack, trauma, stroke, pneumonia etc
• Delays to hospital ↑
• Delayed diagnosis and tx
• Complications, recurrence, deaths ↑
Pain relief ↓ amount ,↑ time
Starvation / dehydration
Errors ↑
LOS and Costs ↑
Complications ↑
(e.g. pressure sores/ DVT/ poor healing,,wrong tx)
Did not Waits ↑
Staff stress , burnout, turnover
Complaints/ legal issues/ press↑
19. The true effects of overcrowding
Delayed discharge
costing operations-
Qld Courier Mail
RIP
1200-3000pa
Nurses resign, 8 beds closed- WA News
'Demoralised' doctors
leaving NSW hospitals-
ABC
22. Q- who needs most expert, specialised care?
Acutely unwell, possibly deteriorating and undiagnosed
– OR
Patients who are stable, diagnosed and close to discharge
The 2000 year old
triage system
Myth- managing Access Block
23. Managing hospital overcrowding- myths
Best place for patients without a bed is ED
Differences in: ED Wards
(across hospital)
Beds/ space (% of hosp) 1-6% 50-90%
Space per patient 2 -4m2
3-8 m2
Additional spaces Minimal Spare rooms/ wait areas
Patient acuity Generally unwell –critical Stable- occas unstable
Standard bed Trolley- hard (bed sores >) Bed -soft (< bed sore)
Environment Noisy, light, no privacy, poor
access, frightening, irregular
food
Darkened, quiet, good access,
less frightening, regular meals
20 extra patients:
Effects on function
Functional capacity ↓40-80%
120-200% occupancy
Double/ triple rooms-corridor
functional capacity ↓ 2-5%
Run at 100-105% occupancy
Extra space 1 room- occas
corridor
Work practice alters? Yes- dramatic, change
function and nursing ratios ++
Minimal- moderate (worse if
patients on wrong units)
Staff morale Severe +++ Mild-moderate
24. The Truth
• Canadian Association of Emergency Physicians
Position Statement :
– “Emergency departments are loud, brightly lit environments
where patients lie on hard stretchers with limited privacy or
dignity, poor access to bathroom facilities, and little or no
opportunity for sleep. These are not reasonable, safe or
humane conditions for sick people. Patients requiring
hospital admission should not be held in emergency
departments, hallways or waiting rooms for more than 6
hours.”
28. The truth- avoidable / fixable
Key features of interventions that can
work are:
Capacity ↑
Activity ↓
and
System buy in
Overcrowding is a feature of
overzealous application of the
“efficiency” mantra that rations using
bed/ capacity cuts.
29. The Evidence
Examples:
Before 1999 Access Block was minimal in WA/ Qld/ ACT
UK A+E turned around with 4 hr targets- >90% achievement
When capacity ↑ activity ↓ e.g. holiday periods / strikes then
Access Block ↓ :
» Reduced access block causes shorter emergency department waiting times: An
historical control observational study – Dunn et al
» Effect of a holiday service reduction period on a hospital's emergency department
access block. Thomas J
Moving patients at 6 hrs to wards (overcensus):
ED function ↑ +++ / hospital LOS reduced by 1 day!
» Innes G et al Acad Emerg Med 2007 14(5) S1-8 Abs 206
30. SCGH :doubled ED capacity-
attendances from 40000 to 50000/ admit rate 45-47%
31. Solution myths- data
Clinics, Call Centres and Colossal EDs
Call centres
7 studies 5 RCT
No ↓ : 1 ↑ ED attendances
– Bunn F et aL Br J Gen Pract. 2005
December 1; 55(521): 956–961.
GP Clinics/Casualty
Little evidence for need
No ↓ local EDs attendances
Not Cost Effective
– Family Practice Vol. 20, No. 3,
311-317
– http://www.medeserv.com.au/acem
/open/documents/after_hoursgp.pd
f
Bigger-better ED*
Tennessee / WA
100% increase ED size
– Han JH Acad Emerg Med. 2007
Apr;14(4):338-43.
Outcomes
LOS in ED↑
Access block↑
Time to be seen↑
32. The Truth
ED overcrowding is not reduced by:
Co-located / alternative GP emergency services
Call centres- phone triage
Bigger / more efficient EDs
The reason is obvious:
They treat myths OR symptoms but not the Disease
33. Conclusions:
Myths are very bad for patients, staff and systems health
Access block causation:
Not “inappropriate” GP patients or ED practices
BUT a Systemic lack of capacity
Access block and overloaded EDs are associated with:
Severe avoidable adverse events and Deaths (> 1200 a year)
EDs are grossly inappropriate environments to “store” patients
34. Conclusions 2
ED Access Block is neither Inevitable nor Insoluble
It is a self induced disease of “efficiency” driven systems
GP clinics, call centers or bigger, better EDs can’t stop ED
overcrowding because they have little effect on the true cause
Things that we know do work (for a while):
Increased capacity – obs wards, strikes, stop surgery
Moving the patients to wards (share the problem)
Reduced in flows of sick patients ( ? Holland )