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A conceptual model of emergency department crowding

ANNALS OF EMERGENCY MEDICINE 2003年第2期42卷 173-180页

作者： Asplin, BR Magid, DJ Rhodes, KV Solberg, LI Lurie, N Camargo, CA Reg Hosp Dept Emergency Med St Paul MN 55101 USA HealthPartners Res Fdn St Paul MN 55101 USA Univ Minnesota Sch Med Dept Emergency Med Minneapolis MN 55455 USA Univ Colorado Hlth Sci Ctr Div Emergency Med Denver CO USA Univ Colorado Hlth Sci Ctr Dept Prevent Med & Biometr Denver CO 80262 USA Univ Colorado Hlth Sci Ctr Clin Res Unit Colorado Permanente Med Grp Denver CO 80262 USA Univ Chicago Hosp Sect Emergency Med Chicago IL 60637 USA HealthPartners Res Fdn Minneapolis MN USA RAND Corp Arlington VA USA Harvard Univ Sch Med Channing Lab Dept Med Boston MA 02115 USA Massachusetts Gen Hosp Dept Emergency Med Boston MA 02114 USA

Emergency department (ED) crowding has become a major barrier to receiving timely emergency care in the United States. Despite widespread recognition of the problem, the research and policy agendas needed to understand and address ED crowding are just beginning to unfold. We present a conceptual model of ED crowding to help researchers, administrators, and policymakers understand its causes and develop potential solutions. The conceptual model partitions ED crowding into 3 interdependent components: input, throughput, and output. These components exist within an acute care system that is characterized by the delivery of unscheduled care. The goal of the conceptual model is to provide a practical framework on which an organized research, policy, and operations management agenda can be based to alleviate ED crowding.

关键词：急性病/治疗病床利用率/统计学和数值数据拥挤效率组织急诊室医院/组织和管理健康计划/组织和管理卫生政策卫生服务易得程度/组织和管理卫生服务研究住院时间/统计学和数值数据模型组织管理需求估价/组织和管理运筹学结果与过程评价(卫生保健)/组织和管理病人入院/统计学和数值数据病人出院/统计学和数值数据研究设计全面质量管理/组织和管理伤病员分拣/组织和管理美国

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Probabilistic linkage of computerized ambulance and inpatient hospital discharge records: A potential tool for evaluation of emergency medical services

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ANNALS OF EMERGENCY MEDICINE 2001年第6期37卷 616-626页

作者： Dean, JM Vernon, DD Cook, L Nechodom, P Reading, J Suruda, A Univ Utah Sch Med Dept Pediat Intermt Injury Control Res Ctr Salt Lake City UT USA Univ Utah Sch Med Dept Family & Prevent Med Intermt Injury Control Res Ctr Salt Lake City UT USA

Study objectives: Emergency medical services (EMS) is an important part of the health care system. The effect of EMS on morbidity, mortality, and costs of illness is difficult to evaluate because hospital information is not available in out-of-hospital databases. We used probabilistic linkage to create such a database from ambulance and inpatient data and demonstrate the potential for linkage to facilitate evaluation of EMS responses resulting in hospital admission. Methods: Statewide ambulance and inpatient hospital discharge records were available for 1994 through 1946. Ambulance records indicating admission to the emergency department or hospital (165,649 records) were linked to inpatient hospital records indicating emergency admission (146,292 records) by using probabilistic linkage. Out-of-hospital data (dispatch code, treatments rendered, and ages), linkage rates, and inpatient data (discharge status, charges, length of stay, and payer category) were analyzed. Results: We linked 24,299 (14.7%) ambulance events to inpatient hospital discharges. If we had used exact linkage methods, we would have only linked 14,621 record pairs, a loss of nearly 40%. linkage rates were relatively constant between years (approximately 15%) but differed by ambulance dispatch codes. Out-of-hospital dispatch codes with high linkage rates included breathing problems (22.6%), chest pain (21.5%), diabetic problems (16.9%), drowning incidents (14.9%), falls (19.2%), strokes (32.8%), and unconsciousness or fainting episodes (16.1%). Linkage to the hospital record provided access to hospital outcome data. Inpatient mortality was 6.8%. Survivors were discharged home (60.7%), transferred to other acute-care facilities (3.6%) or intermediate-care facilities (23.3%), or discharged with home health care provision (4.9%). The median length of stay was 3 days, and median charges were $6,620;total inpatient charges were $286,737,067. Conclusion: Probabilistic linkage enables ambulance and hospita

关键词：救护车/组织和管理数据库管理系统可行性研究卫生服务研究/方法医院收费/统计学和数值数据医院死亡率信息系统/组织和管理住院病人/统计学和数值数据保险健康/统计学和数值数据住院时间/统计学和数值数据病案连锁/方法病案系统计算机化/组织和管理年患病率结果评价(卫生保健) 病人出院/统计学和数值数据病人转诊/统计学和数值数据概率存活率分析犹他/流行病学青少年成年人老年人老年人 80以上儿童儿童学龄前女(雌)性人类婴儿男(雄)性中年人

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The Uniform Data System for Medical Rehabilitation - Report of first admissions for 1998

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AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION 2000年第1期79卷 87-92页

作者： Fiedler, RC Granger, CV Post, LA SUNY Buffalo Dept Rehabil Med Ctr Funct Assessment Res Uniformed Data Syst Med Rehabil Buffalo NY 14214 USA

Given is the ninth annual report on patients discharged from medical rehabilitation hospital programs in the United States that subscribe to the Uniform Data System for Medical Rehabilitation in the calendar year 1998... 详细信息

关键词：日常生活活动规范脑疾病/康复肌疾病/康复神经系统疾病/康复病人入院/统计学和数值数据病人出院/统计学和数值数据康复/分类康复中心/利用美国人类

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Predictors of costs of caring for elderly patients discharged with heart failure

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AMERICAN HEART JOURNAL 2001年第2期142卷 350-357页

作者： Wexler, DJ Chen, J Smith, GL Radford, MJ Yaari, S Bradford, WD Krumholz, HM Yale Univ Sch Med Dept Med New Haven CT 06510 USA Yale Univ Sch Med Dept Epidemiol & Publ Hlth Sect Cardiovasc Med New Haven CT 06510 USA Yale Univ Sch Med Dept Epidemiol & Publ Hlth Sect Hlth Policy & Adm New Haven CT 06510 USA Yale New Haven Med Ctr Ctr Outcomes Res & Evaluat New Haven CT 06504 USA Qualidigm Middletown CT USA Bar Ilan Univ Ramat Gan Israel Med Univ S Carolina Dept Hlth Policy & Adm Charleston SC 29425 USA

Background investments in programs to improve outcomes and reduce readmissions for patients who survive hospitalization with heart failure will be economically most favorable for those who have the highest risk. Little information is available, however, to stratify the risk of these patients incurring costs after discharge. in this study, we sought to determine correlates of costs in a representative sample of patients with heart failure in the 6 months after discharge. Methods We reviewed medical records of 2181 patients aged greater than or equal to 65 years who were discharged alive from 18 Connecticut hospitals in 1994 and 1995 with a principal discharge diagnosis of heart failure. Outcomes 6 months after discharge, including all-cause readmission and cost, heart failure-related readmission and cost, and death, were obtained from the Medicare administrative database. A 2-stage sample selection model was used to identify the independent correlates of cost. Risk scores were calculated to identify subsets of patients at risk for generating high costs. Results On average, patients discharged with heart failure incurred costs of $2388 resulting from heart failure-related admissions and $7101 resulting from admissions from any cause during the 6 months after discharge. An average admission for heart failure cost $7174, whereas an admission resulting from any cause cost $8589. The multivariate models explained 7% of the variation in cost, although clinical characteristics such as recent heart failure admissions, kidney failure, and hypertension were significant independent correlates of increased cost. Older age and a history of stroke were independently associated with decreased cost. Patients without any of the risk factors associated with increased costs still incurred $1500 to $5000, on average, in the 6 months after discharge. Conclusions Patients with heart failure generate substantial hospital costs in the 6 months after discharge. Given the emerging evidence fo

关键词：康涅狄格老年人保健服务/经济学医院费用住院时间/经济学病案 Medicare/经济学模型经济学结果评价(卫生保健) 病人出院/统计学和数值数据病人再入院/经济学试验预期值回顾性研究危险性评估危险因素老年人老年人 80以上女(雌)性人类男(雄)性

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Spectrum of heart failure in older patients: Results from the National Heart Failure project

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AMERICAN HEART JOURNAL 2002年第3期143卷 412-417页

作者： Havranek, EP Masoudi, FA Westfall, KA Wolfe, P Ordin, DL Krumholz, HM Denver Hlth Med Ctr 0960 Denver CO 80220 USA Colorado Fdn Med Care Aurora CO USA Univ Colorado Hlth Sci Ctr Denver CO USA Hlth Care Financing Adm Boston MA USA Yale Univ Sch Med New Haven CT USA

Background The elderly make up the majority of patients with heart failure (HF), but information on this segment of the HF population is lacking because clinical trials typically enroll younger patients and population-based studies lack clinical detail. We sought to describe a contemporary national sample of elderly patients with HF and to examine the sample for age-related trends in clinical characteristics. Methods We studied the charts of 800 Medicare patients per state who were hospitalized with a principal diagnosis of HF between April 1998 and March 1999. There were 34,587 patients in the sample after exclusion of patients who were <65 years old, repeat discharges, discharges to another acute care facility or against medical advice, or receiving long-term hemodialysis. Results Comorbidity was common. About one third of patients had chronic obstructive pulmonary disease, about 40% had diabetes, more than half had coronary heart disease, and more than half had a history of hypertension, but comorbidity rates declined with age, Left ventricular ejection fraction was <40% in only 50.4% of patients in whom it was assessed. Associated laboratory abnormalities were relatively constant across the age spectrum, but renal insufficiency was more common with advancing age. The likelihood that patients were in long-term care facilities before admission rose quite steeply with age. Conclusions Elderly patients with HF are a heterogeneous group and appear to differ substantially from patients enrolled in clinical trials. Evidence-based guidance for treatment in the context of multiple comorbid conditions, poor renal function, HF with preserved left ventricular systolic function, and residence in long-term care facilities is urgently needed.

关键词：共病现象冠心病/流行病学糖尿病/流行病学住院/统计学和数值数据高血压/流行病学 Medicare 病人出院/统计学和数值数据病人遴选肺疾病慢性阻塞性/流行病学每搏输出量美国/流行病学老年人老年人 80以上女(雌)性人类男(雄)性

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Infant mortality and early postpartum discharge

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OBSTETRICS AND GYNECOLOGY 2000年第2期96卷 183-188页

作者： Malkin, JD Garber, S Broder, MS Keeler, E RAND Corp Santa Monica CA USA Univ Calif Los Angeles Sch Med Dept Obstet & Gynecol Los Angeles CA 90024 USA

Objective: To assess additional risk of newborn death owing to early discharge. Methods: This was a historical cohort study using Washington State linked birth certificates, death certificates, and hospital discharge records that covered 47,879 live births in 1989 and 1990. Logistic regression was used to assess risk of death within the first year of life after early discharge (less than 30 hours after birth) compared with later discharge (30-78 hours after birth). Results: Newborns discharged early were more likely to die within 28 days of birth (odds ratio [OR] 3.65;95% confidence interval [CI] 1.56, 8.54), between 29 days and 1 year (OR 1.61;95% CI 1.10, 2.36), and any time within the first year (OR 1.84;95% CI, 1.31, 2.60) of life than newborns sent home later. Newborns discharged early also were more likely to die of heart-related problems (OR 3.72;CI 1.25, 11.04) and infections (OR 4.72;CI1.13, 19.67) within 1 year of birth than newborns discharged later. Conclusion: Newborns discharged within 30 hours of birth are at increased risk of death within the first year of life. (C) 2000 by The American College of Obstetricians and Gynecologists.

关键词：队列研究置信区间婴儿死亡率住院时间/统计学和数值数据 Logistic模型病案比值比病人出院/统计学和数值数据产后期危险因素敏感性与特异性社会阶级华盛顿/流行病学女(雌)性人类婴儿婴儿新生男(雄)性

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Ultra-fast track hospital discharge using conventional cardiac surgical techniques

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ANNALS OF THORACIC SURGERY 1999年第2期67卷 363-369页

作者： Walji, S Peterson, RJ Neis, P DuBroff, R Gray, WA Benge, W SW Cardiol Associates Albuquerque NM USA

Background. Recent introduction of minimally invasive adult cardiac surgical techniques has emphasized the advantage of early hospital discharge. However, we chose an alternative approach to determine the safety, efficacy, and feasibility of ultra-fast track protocols while retaining both standard surgical exposure (median sternotomy) and conventional cardiac surgical techniques (hypothermia, cardiopulmonary bypass with cardiac arrest, and optimal myocardial protection). Methods. From September 1995 to January 1998, a total of 258 consecutive patients underwent cardiac procedures by a single surgeon. Acceleration of clinical pathways was used to initiate earlier discharges. Stringent postdischarge follow-up was implemented. Prospectively entered data were then analyzed retrospectively. Results. A variety of isolated as well as combined coronary and valve procedures were performed. Of the 258 patients ,perated on during this entire study period, a total of 144 patients (56%) were discharged within postoperative days 1 to 4 (ultra-fast track discharge). Over the past 12 months, this incidence increased to 70% (76 of 108 patients). Approximately 50% of these patients were operated on urgently or emergently. To date, there have been no deaths in this ultra-fast track group. There were eight brief readmissions, of which one was for rewiring of a noninfected sternal dehiscence, and the remaining were for cardiac diagnostic studies or a noncardiac problem altogether. Conclusions. Conventional cardiac operation can allow ultrafast hospital discharges while retaining the advantage of time-tested techniques and providing wider application without requiring new or additional training or equipment. (C) 1999 by The Society of Thoracic Surgeons.

关键词：心脏外科手术/统计学和数值数据冠状动脉分流术/统计学和数值数据心脏瓣膜假体植入/统计学和数值数据住院时间/统计学和数值数据新墨西哥病人出院/统计学和数值数据前瞻性研究回顾性研究治疗结果成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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A multicenter study of the coding accuracy of hospital discharge administrative data for patients admitted to cardiac care units in Ontario

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AMERICAN HEART JOURNAL 2002年第2期144卷 290-296页

作者： Austin, PC Daly, PA Tu, JV Inst Clin Evaluat Sci Toronto ON M4N 3M5 Canada Univ Toronto Dept Publ Hlth Sci Toronto ON Canada Sunnybrook & Womens Coll Site Clin Epidemiol & Hlth Care Res Program Toronto ON Canada Sunnybrook & Womens Coll Ctr Hlth Sci Dept Med Div Gen Internal Med Toronto ON Canada Toronto Gen Hosp Dept Med Div Cardiol Toronto ON M5G 1L7 Canada

Background Cardiac health services researchers frequently use cohorts derived from administrative hospital discharge abstract data to study the outcomes and treatment of coronary artery disease. However, relatively limited data exist on the accuracy of the coding of cardiac diagnoses in discharge abstract data. The goal of this study was to examine the accuracy of the coding of acute myocardial infarction and other cardiac diagnoses in the Canadian Institute of Health Information hospital discharge abstracts. Methods Patients admitted to 58 cardiac care units (CCUs) in Ontario that participated in the Fastrak 11 Acute Coronary Syndromes registry were linked to CIHI hospital discharge abstracts. The most responsible diagnosis at hospital discharge in the administrative data was compared with the CCU discharge diagnosis in the clinical registry. Results A total of 58,816 CCU patients were linked to hospital discharge abstract data. The specificity, sensitivity, and positive predictive value of a most responsible diagnosis of acute myocardial infarction were 92.8%, 88.8%, and 88.5%, respectively. The specificity of CIHI diagnosis codes for arrhythmia, congestive heart failure, unstable angina, and chest pain not yet diagnosed were all at least 93.9%. However, the sensitivity of these CIHI diagnosis codes was no greater than 60.7%. Furthermore, the positive predictive values were no larger than 80.8%. Conclusion Myocardial infarction is generally accurately coded in Ontario hospital discharge abstract data. However, other cardiac diagnoses are less reliably coded in discharge abstract data.

关键词：心绞痛不稳定型/分类心绞痛不稳定型/诊断胸痛/病因学冠心病重症监护病房/组织和管理冠心病重症监护病房/利用冠心病/分类冠心病/诊断诊断相关患者组/分类表格和记录管理/标准病案连锁心肌梗死/分类心肌梗死/诊断安大略病人出院/标准病人出院/统计学和数值数据试验预期值登记/统计学和数值数据敏感性与特异性老年人女(雌)性人类男(雄)性

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Hospital admissions for rotavirus infection in the Netherlands

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CLINICAL INFECTIOUS DISEASES 2000年第3期31卷 698-704页

作者： de Wit, MAS Koopmans, MPG van der Blij, JF van Duynhoven, YTHP Natl Inst Publ Hlth & Environm Dept Infect Dis Epidemiol NL-3720 BA Bilthoven Netherlands Natl Inst Publ Hlth & Environm Res Lab Infect Dis NL-3720 BA Bilthoven Netherlands Med Ctr Alkmaar Netherlands

The development of a vaccine against rotavirus (RV) infection has necessitated the estimation of the number of hospitalizations for RV infection in the Netherlands. During 1998, pediatricians have reported all hospitalizations with RV infection and supplied information on the duration of admission, clinical picture, indication for admission, and treatment. Also, data from the National Disease Registry on hospitalizations for gastroenteritis (International Classification of Disease codes 006.6. 006.8, 009, and 558.9) and laboratory surveillance data for 1996-1998 were combined in a Linear regression model to indirectly estimate the incidence and proportion of hospitalizations attributable to RV infection. The direct estimate of admissions for RV infection in children aged <5 years was 0.9 per 1000, and the indirect estimate was 2.7 per 1000 in 1998 (1996, 3.4;1997, 1,6). The proportion of hospitalizations for gastroenteritis attributable to RV ranged from 32% in 1997 to 58% in 1996.

关键词：儿童住院/统计学和数值数据交叉感染/病毒学胃肠炎/流行病学胃肠炎/病毒学住院/统计学和数值数据发病率实验室医院/统计学和数值数据线性模型荷兰/流行病学病人出院/统计学和数值数据人群监测/方法轮状病毒感染/流行病学轮状病毒感染/病毒学时间因素儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性

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The chain of survival

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ANNALS OF EMERGENCY MEDICINE 2001年第4期37卷 S5-S16页

作者： Jacobs, I Callanan, V Nichol, G Valenzuela, T Mason, P Jaffe, AS Landau, W Vetter, N Univ Western Australia Dept Emergency Med Nedlands WA 6907 Australia Townsville Gen Hosp Townsville Qld Australia Ottawa Civic Hosp Ottawa ON K1Y 4E9 Canada Univ Arizona Tucson AZ USA Natl Heart Fdn New Zealand Christchurch New Zealand SUNY Hlth Sci Ctr Syracuse NY 13210 USA Univ Washington Seattle WA 98195 USA UWCM Cardiff S Glam Wales

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