Background: Nearly all Dutch citizens have a general practitioner (GP), acting as a gatekeeper to secondary care. Some patients bypass the GP and present to the emergency department (ED). To make best use of existing emergency care, Dutch health policy makers and insurance companies have proposed the integration of EDs and GP cooperatives (GPCs) into one facility. In this study, we examined ED use and assessed the characteristics of self-referrals and non-self-referrals, their need for hospital emergency care and self-referrals' motives for presenting at the ED. Methods: A descriptive cohort study was conducted in a Dutch level 1 trauma centre. Differences in patient characteristics, time of presentation and need for hospital emergency care were analysed using χ2 tests and t tests. A patient was considered to need hospital emergency care when he/she was admitted to the hospital, had an extremity fracture and/or when diagnostic tests were performed. Main determinants of self-referral were identified via logistic regression. Results: Of the 5,003 consecutive ED patients registering within the 5-week study period, 3,028 (60.5%) were self-referrals. Thirty-nine percent of the self-referrals had urgent acuity levels, as opposed to 65% of the non-self-referrals. Self-referrals more often suffered from injuries (49 vs. 20%). One third of the self-referrals presented during office hours. Of all self-referrals, 51% needed hospital emergency care. Younger age; non-urgent acuity level; chest pain, ear, nose or throat problems; and injuries were independent predictors for self-referral. Most cited motives for self-referring were ‘accessibility and convenience’ and perceived ‘medical necessity’. Conclusions: A substantial part of the self-referrals needed hospital emergency care. The 49% self-referrals who were eligible for GP care presented during out-of-hours as well as during office hours. This calls for an integrative approach to this health care problem.@en

OBJECTIVES: The aim of this study was to assess the walkout rate and to identify influencing patient and visit characteristics on walkout. Furthermore, we assessed the reasons for leaving and medical care needs after leaving. METHODS: In a 4-month population-based cohort study, the characteristics and influencing factors of walkout from two emergency departments in the Netherlands were studied. Afterwards, a follow-up telephone interview was conducted to assess the reasons for leaving and medical care needed. RESULTS: A total of 169 out of 23 780 (0.7%) registered patients left without treatment, of whom 62% left after triage. Of the triaged walkouts, 26% had urgent or highly urgent medical complaints and target times to treatment had elapsed for 54% of the triaged walkouts. Independent predictors of leaving without treatment included being self-referred, arriving during the evening or night or during crowded conditions, and relatively lower urgency triage allocation. Ninety (53%) walkouts were contacted afterwards by phone. Long waiting time (61%) was the most-cited prime reason for leaving. Medical problems had resolved spontaneously in 19 of the 90 (21%) walkouts, and 47 (52%) walkouts reported having sought medical care elsewhere. For 24 of the 90 (27%) walkouts with persisting complaints, medical care was advised during the follow-up telephone call. CONCLUSION: The average observed daily walkout rate was 1.4 patients over the 4-month period. In general, walkouts are self-referrals with lower urgent complaints, arriving during the evening or night shift or during crowded conditions. Most walkouts leave because of perceived long waiting times.@en

When acute stroke care is organised using a “drip-and-ship” model, patients receive immediate treatment at the nearest primary stroke centre followed by transfer to a comprehensive stroke centre (CSC). When stroke care is further centralised into the “direct-to-mothership” model, patients with stroke symptoms are immediately brought to a CSC to further reduce treatment times and enhance stroke outcomes. We investigated the effects of the ongoing centralization in a Dutch urban setting on treatment times of patients with confirmed ischemic stroke in a 4-year period. Next, in a non-randomized controlled trial, we assessed treatment times of patients with suspected ischemic stroke, and treatment times of patients with neurologic disorders other than suspected ischemic stroke, before and after the intervention in the CSC and the decentralized hospitals, the intervention being the change from “drip and ship” into “direct-to-mothership”. Our findings provide support for the ongoing centralization of acute stroke care in urban areas. Treatment times for patients with ischemic stroke decreased significantly, potentially improving functional outcomes. Improvements in treatment times for patients with suspected ischemic stroke were achieved without negative side effects for self-referrals with stroke symptoms and patients with other neurological disorders.@en

Objective: The aim of this study was to describe the impact of additional medical specialists, non-emergency physicians (non-EPs), performing direct supervision or a combination of direct and indirect supervision at an EP-led emergency department (ED), on patient flow and satisfaction. Patients and methods: An observational, cross-sectional, three-part study was carried out including staff surveys (n=379), a before and after 16-week data collection using data of visits during the peak hours (n=5270), and patient questionnaires during 1 week before the pilot and during week 5 of the pilot. Content analysis and descriptive statistics were used for analyses. Results: The value of being present at the ED was acknowledged by medical specialists in 49% of their surveys and 35% of the EPs' and ED nurses' surveys, especially during busy shifts. Radiologists were most often (67.3%) convinced of their value of being on-site, which was agreed upon by the ED professionals. Perceived improved quality of care, shortening of length of stay, and enhanced peer consultation were mentioned most often. During the pilot period, length of stay of boarded patients decreased from 197 min (interquartile range: 121 min) to 181 min (interquartile range: 113 min, P=0.006), and patient recommendation scores increased from -15 to +20. Conclusion: Although limited by the mix of direct and indirect supervision, our results suggest a positive impact of additional medical specialists during busy shifts. Throughput of admitted patients and patient satisfaction improved during the pilot period. Whether these findings differ between direct supervision and combination of direct and indirect supervision by the medical specialists requires further investigation.@en

Background The impact of delays in emergency department (ED) care has not been described in European countries where ED crowding is not universally recognized. The aim of this study was to determine the relationship of ED crowding with delays in triage and treatment, and 24-h mortality in patients admitted to the ED. Methods Five years of data from adults admitted to the hospital were analysed retrospectively from an inner-city ED in the Netherlands. Variables included the following: crowded versus noncrowded time, time to triage, triage category, time to treatment, age, 24-h mortality and 10-day mortality. Results A total of 39 110 patients met the inclusion criteria. ED crowding occurred 30.8% of the time. There were no differences in mortality between patients arriving during crowding versus those arriving during noncrowding. Delays in triage during ED crowding occurred 29.7% of the time versus 14.6% during noncrowding. Delays in treatment occurred 11.7 and 7.3% of the time during crowding and noncrowding, respectively. Conclusion In this hospital, ED crowding results in increased times to triage and to treatment, not in increased 24-h or 10-day mortality.@en

Background: Emergency departments (EDs) worldwide face crowding, which hampers patient flow. In this study, the impact of a dedicated neurologist present at the ED on patient flow during out-of-office hours was assessed. Methods: A cross-sectional, mixed methods study was undertaken at a Dutch ED, including a pre-post analysis of data of patients who had a primary neurological disease (n = 458) and staff surveys (n = 152). Descriptive statistics and content analysis were used for analyses. Results: Despite a 36% increase in the number of neurological patients (control period: n = 194, intervention period n = 264), a 30 min per patient decrease in ED median length of stay (LOS) was reached during the intervention period. Furthermore, the admission percentage decreased significantly (57.7% in the control period vs. 47.7% in the intervention period, p = 0.03). During half of the shifts neurologists stated that their presence had been valuable. Perceived reasons for this added value mentioned were improved quality of care, enhanced throughput of patients, and quicker consultations with other medical specialists. Conclusions: In our hypothesis-generating study, a dedicated neurologist present at the ED during out-of-office hours was associated with decreased patients’ LOS and a decreased admission percentage, indicating increased decisiveness when the neurologist is present at the ED.@en

Background: Patients with high emergency department (ED) utilization account for a disproportionate number of ED visits. The existing research on high ED utilization has raised doubts about the homogeneity of the frequent ED user. Attention to differences among the subgroups of frequent visitors (FV) and highly frequent visitors (HFV) is necessary in order to plan more effective interventions. In the Netherlands, the incidence of high ED utilization is unknown. The purpose of this study was to investigate if the well-documented international high ED utilization also exists in the Netherlands and if so, to characterize these patients. Therefore, we assessed the proportion of FV and HFV; compared age, sex, and visit outcomes between patients with high ED utilization and patients with single ED visits; and explored the factors associated with high ED utilization. Methods: A 1-year retrospective descriptive correlational study was performed in two Dutch EDs, using thresholds of 7 to 17 visits for frequent ED use, and greater than or equal to 18 visits for highly frequent ED use. Results: FV and HFV (together accounting for 0.5% of total ED patients) attended the ED 2,338 times (3.3% of the total number of ED visits). FV and HFV were equally likely to be male or female, were less likely to be self-referred, and they suffered from urgent complaints more often compared to patients with single visits. FV were significantly older than patients with single visits and more often admitted than patients with single visits. Several chief complaints were indicative for frequent and highly frequent ED use, such as shortness of breath and a psychiatric disorder. Conclusions: Based on this study, high ED utilization in the Netherlands seems to be less a problem than outlined in international literature. No major differences were found between FV and HFV, they presented with the same, often serious, problems. Our study supports the notion that most patients with high ED utilization visit the ED for significant medical problems.@en

Background: The objective of the current study was to assess the effect of an unusual 10-day snow and ice period on the prevalence of fractures in an emergency department (ED) in the Netherlands. Furthermore, patients with fractures during the snow and ice period were compared to those in the control period with respect to gender, age, location of accident, length of stay, disposition, and anatomical site of the injury. Methods: Fracture prevalence during a 10-day study period with snow and ice (January 14, 2013 until January 23, 2013) was compared to a similar 10-day control period without snow or ice (January 16, 2012 until January 25, 2012). The records of all patients with a fracture were manually selected. Besides this, basic demographics, type of fracture, and location of the accident (inside or outside) were compared. Results: A total of 1,785 patients visited the ED during the study period and 1,974 during the control period. A fracture was found in 224 patients during the study period and in 109 patients during the control period (P <0.01). More fractures sustained outside account for this difference. No differences were found in gender, mean age, and length of ED stay. However, during the snow and ice period the percentage of fractures in the middle-aged (31-60 yrs) was significantly higher than in the control period (P <0.01). Conclusions: The number of fractures sustained more than doubled during a period with snow and ice as compared to the control period. In contrast to other studies outside the Netherlands, not the elderly, but the middle-aged were most affected by the slippery conditions.@en