"The primary outcome was mRS at discharge. Some have argued that mRS and death may not be the best outcome measures to study the effect of EDLOS, and have proposed looking at other surrogate markers, such as quality adherence and time to antibiotics, as they are less patient specific.22,23 However, the inability of surrogate markers to produce consistent results is well documented, and we felt it more reasonable to use mRS, which is a routinely used functional outcome score for stroke patients.24,25 "
[Show abstract][Hide abstract] ABSTRACT: Introduction: Conflicting data exist regarding the association between the length of stay (LOS) of critically ill patients in the emergency department (ED) and their subsequent outcome. However, such patients are an overall heterogeneous group, and we therefore sought to study the association between EDLOS and outcomes in a specific subgroup of critically ill patients, namely those with acute ischemic stroke/transient ischemic attack (AIS/TIA).
Methods: This was a retrospective review of adult patients with a discharge diagnosis of AIS/TIA presenting to an ED between July 2009 and February 2010. We collected demographics, EDLOS, arrival stroke severity (National Institutes of Health Stroke Scale - NIHSS), intravenous tissue plasminogen activator (IV tPA) use, functional outcome at discharge, discharge destination and hospital-LOS. We analyzed relationship between EDLOS, outcomes and discharge destination after controlling for confounders.
Results: 190 patients were included in the cohort. Median EDLOS was 332 minutes (Inter-Quartile Range -IQR: 250.3–557.8). There was a significant inverse linear association between EDLOS and hospital-LOS (p=0.049). Patients who received IV tPA had a shorter median EDLOS (238 minutes, IQR: 194–299) than patients who did not (median: 387 minutes, IQR: 285–588 minutes; p<0.0001). There was no significant association between EDLOS and poor outcome (p=0.40), discharge destination (p=0.20), or death (p=0.44). This remained true even after controlling for IV tPA use, NIHSS and hospital-LOS; and did not change even when analysis was restricted to AIS patients alone.
Conclusion: There was no significant association between prolonged EDLOS and outcome for AIS/TIA patients at our institution. We therefore suggest that EDLOS alone is an insufficient indicator of stroke care in the ED, and that the ED can provide appropriate acute care for AIS/TIA patients. [West J Emerg Med. 2014;15(3):267–275.]
The western journal of emergency medicine 05/2014; 15(3):267-75. DOI:10.5811/westjem.2013.8.16186
[Show abstract][Hide abstract] ABSTRACT: This paper presents a new method to implement a multiplier using the Quasi Delay Insensitive (QDI) approach. QDI circuits allow unbounded delays on wires and gates, and require the difference among the delays in forks to be less than the delays of their terminating gates. To implement the Booth multiplier following the QDI approach, we considered Martin's method. In this method, an asynchronous circuit is considered as a set of cells that communicate through a handshaking protocol, and is synthesized from a high level definition through different levels of translation. The main problem related to the resulting circuits their considerable overhead due to the implementation of handshaking protocols. In our proposed method, the overhead is reduced 50% by separating the control and data path units. This solution increases the forks, and causes complexity in physical implementation. By applying some of the rules derived from Martin's method, the forks became locally limited to ease up the physical implementation.
[Show abstract][Hide abstract] ABSTRACT: Being critical in terms of time and complexity, emergency medicine is exposed to an emerging imperative for quality improvement strategies. We review current concepts and recent advances in the management of quality in emergency medicine.
There is a strong interdependence between quality of emergency healthcare provision and the education of emergency healthcare providers. Introduction of emergency medical residencies and highly qualified triage liaison physicians helps prevent the overcrowding of emergency departments, accelerate access to emergency medical care and improve patient satisfaction. New advances in detecting and reducing patient management errors include the collection of healthcare provider complaints and the classification of unpreventable and preventable deaths of patients within 1 week of admission via the emergency department. Medical record review and video recording have revealed that frequent patient management problems relate to shortcomings in the diagnostic process, clinical tasks, patient factors, and poor teamwork. Communication skills and patient data/documentation systems may effectively resolve these problems.
According to the available evidence, more performance improvement strategies need to be tested to delineate which process changes would be most effective in improving patient outcome in emergency medicine.
Current Opinion in Anaesthesiology 05/2008; 21(2):233-9. DOI:10.1097/ACO.0b013e3282f5d8eb · 1.98 Impact Factor
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