Background: Emergency departments (EDs) are operating at or above capacity, which has negative consequences on patients in terms of quality of care and morbi-mortality. Redirection strategies for low-acuity ED patients to primary care practices are usually based on subjective eligibility criteria that sometimes necessitate formal medical assessment. Literature investigating the effect of those interventions is equivocal. The aim of the present study was to assess the safety of a redirection process using an electronic clinical support system used by the triage nurse without physician assessment.Methods: A single cohort observational study was performed in the ED of a level 1 academic trauma center. All low-acuity patients redirected to nearby clinics through a clinical decision support system (February–August 2017) were included. This system uses different sets of medical prerequisites to identify patients eligible to redirection. Data on safety and patient experience were collected through phone questionnaires on day 2 and 10 after ED visit. The primary endpoint was the rate of redirected patients returning to any ED for an unexpected visit within 48 h. Secondary endpoints were the incidence of 7-day return visit and satisfaction rates.Results: A total of 980 redirected low-acuity patients were included over the period: 18 patients (2.8%) returned unexpectedly to an ED within 48 h and 31 patients (4.8%) within 7 days. No hospital admission or death were reported within 7 days following the first ED visit. Among redirected patients, 81% were satisfied with care provided by the clinic staff.Conclusion: The implementation of a specific electronic-guided decision support redirection protocol appeared to provide safe deferral to nearby clinics for redirected low-acuity patients. EDs are pivotal elements of the healthcare system pathway and redirection process could represent an interesting tool to improve the care to low-acuity patients.

Obese patients are raising specific questions in emergency care such as equipment issues or urgent procedures. Even though obesity prevalence and subsequent health expenditure are increasing worldwide, there is scarce literature about their specific resource utilization of Emergency Departments (ED). These few studies do not take into account both socio-economic situation and comorbidities which are well-known factors influencing healthcare use. Our objective was to assess the emergency care resource utilization of obese individuals (Body Mass Index (BMI) ≥ 30kg.m^-2) compared to normal-weight individuals taking into account comorbidities and social-economic situations. The French CONSTANCES epidemiologic cohort is a randomly selected sample of French adults. Participants data are linked to the National Health Insurance Database collecting all medical acts. The rate of ED visits of obese (and each obesity class) and normal-weight participants were compared considering confounding factors (comorbidities, various socio-economic data). The primary endpoint was to have visited the ED between 2010 and 2013. Sex-separated analysis and multivariate logistic regression models were performed and adjusted odds-ratios [OR] (95% Confidence Intervals [CI]) were calculated. We included 21,035 normal-weight and 5,003 obese participants. Obese participants visited the ED more often than normal-weight participants (men: 30.5% vs. 26.7%; women: 30.3% vs. 24.4%, P<0.001). Obese participants presented more comorbidities and a lower socio-economic situation than normal-weight participants. After adjustment, obese participants had a higher risk of visiting ED (men: OR = 1.18; 95% CI: 1.04–1.33; and women: OR = 1.36; 95% CI: 1.22–1.52), with a higher risk for class III participants (BMI ≥ 40 kg.m^-2) (men: OR = 2.18; CI 95%: 1.32–3.63; and women: OR = 1.85; 95% CI: 1.38–2.49). Obese individuals have a higher level of emergency care resource utilization than normal-weight individuals and it increases with severe obesity. Further studies are needed to better understand their healthcare pathways leading to EDs.

Background: We aimed to describe red blood cell (RBC) transfusions in the emergency department (ED) with a particular focus on the hemoglobin (Hb) level thresholds that are used in this setting. Methods: This was a cross-sectional study of 12 EDs including all adult patients that received RBC transfusion in January and February 2018. Descriptive statistics were reported. Logistic regression was performed to assess variables that were independently associated with a pre-transfusion Hb level ≥ 8 g/dL. Results: During the study period, 529 patients received RBC transfusion. The median age was 74 (59–85) years. The patients had a history of cancer or hematological disease in 185 (35.2%) cases. Acute bleeding was observed in the ED for 242 (44.7%) patients, among which 145 (59.9%) were gastrointestinal. Anemia was chronic in 191 (40.2%) cases, mostly due to vitamin or iron deficiency or to malignancy with transfusion support. Pre-transfusion Hb level was 6.9 (6.0–7.8) g/dL. The transfusion motive was not notified in the medical chart in 206 (38.9%) cases. In the multivariable logistic regression, variables that were associated with a higher pre-transfusion Hb level (≥8 g/dL) were a history of coronary artery disease (OR: 2.09; 95% CI: 1.29–3.41), the presence of acute bleeding (OR: 2.44; 95% CI: 1.53–3.94), and older age (OR: 1.02/year; 95% CI: 1.01–1.04). Conclusion: RBC transfusion in the ED was an everyday concern and involved patients with heterogeneous medical situations and severity. Pre-transfusion Hb level was rather restrictive. Almost half of transfusions were provided because of acute bleeding which was associated with a higher Hb threshold.

Overcrowded emergency departments (EDs) are associated with higher morbidity and mortality and suboptimal quality-of-care. Most ED flow management strategies focus on early identification and redirection of low-acuity patients to primary care settings. To assess the impact of redirecting low-acuity ED patients to medical clinics using an electronic clinical decision support system on four ED performance indicators. We performed a retrospective observational study in the ED of a Canadian tertiary trauma center where a redirection process for low-acuity patients was implemented. The process was based on a clinical decision support system relying on an algorithm based on chief complaint, performed by nurses at triage and not involving physician assessment. All patients visiting the ED from 2013 to 2017 were included. We compared ED performance indicators before and after implementation of the redirection process (June 2015): length-of-triage, time-to-initial-physician-assessment, length-of-stay and rate of patients leaving without being seen. We performed an interrupted time series analysis adjusted for age, gender, time of visit, triage category and overcrowding. Of 242,972 ED attendees over the study period, 9546 (8% of 121,116 post-intervention patients) were redirected to a nearby primary medical clinic. After the redirection process was implemented, length-of-triage increased by 1 min [1;2], time-to-initial assessment decreased by 13 min [-16;-11], length-of-stay for non-redirected patients increased by 29 min [13;44] (p < 0.001), minus 20 min [-42;1] (p = 0.066) for patients assigned to triage 5 category. The rate of patients leaving without being seen decreased by 2% [-3;-2] (p < 0.001). Implementing a redirection process for low-acuity ED patients based on a clinical support system was associated with improvements in two of four ED performance indicators.