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Biomedical subjects

J Millá

Publications and source records attributed to J Millá.

At least 19 recordsLinked to original sources
PubMed2004

Quality and effectiveness of an emergency department during weekends.

OBJECTIVE: To evaluate whether the quality and effectiveness of an emergency department (ED) are modified during weekends. METHODS: Quality and effectiveness markers were determined during 539 consecutive days, comparing them according to the day of the week. Quality markers were the daily percentage of patients who died in the internal medical unit (deaths, D), leave ED without being seen (flights, F); returned to the ED (revisits, R), and the percentage of registered complaints (C). Effectiveness markers were: the "number of patients waiting to be seen" (WP), the "waiting time to be seen" (WT), and the "length of visit" (LV). RESULTS: Quality and effectiveness of ED do not worsen during weekend days and some markers significantly improved during such days: C experienced a 26% decrease (p = 0.001), WT decreased 65% (p<0.001), WP 59% (p<0.001), and LV 24% (p<0.01). Assessing the relation between daily number of visits to ED and the quality and effectiveness markers, a significant and direct association was found of the number of visits with D, F, R, and WP. CONCLUSION: Some of the quality and effectiveness markers of the ED improved during weekend days compared with workdays.

After-Hours Care↗
PubMed2003

Analysis of patient flow in the emergency department and the effect of an extensive reorganisation.

OBJECTIVES: To evaluate the different internal factors influencing patient flow, effectiveness, and overcrowding in the emergency department (ED), as well as the effects of ED reorganisation on these indicators. METHODS: The study compared measurements at regular intervals of three hours of patient arrivals and patient flow between two comparable periods (from 10 February to 2 March) of 1999 and 2000. In between, a structural and staff reorganisation of ED was undertaken. The main reason for each patient remaining in ED was recorded and allocated to one of four groups: (1) factors related to ED itself; (2) factors related to ED-hospital interrelation; (3) factors related to hospital itself; and (4) factors related to neither ED nor hospital. The study measured the number of patients waiting to be seen and the waiting time to be seen as effectiveness markers, as well as the percentage of time that ED was overcrowded, as judged by numerical and functional criteria. RESULTS: Effectiveness of ED was closely related with some ED related and hospital related factors. After the reorganisation, patients who remained in ED because of hospital related or non-ED-non-hospital related factors decreased. ED reorganisation reduced the number of patients waiting to be seen from 5.8 to 2.5 (p<0.001) and waiting time from 87 to 24 minutes (p<0.001). Before the reorganisation, 31% and 48% of the time was considered to be overcrowded in numerical and functional terms respectively. After the reorganisation, these figures were reduced to 8% and 15% respectively (p<0.001 for both). CONCLUSIONS: ED effectiveness and overcrowding are not only determined by external pressure, but also by internal factors. Measurement of patient flow across ED has proved useful in detecting these factors and in being used to plan an ED reorganisation.

Analysis of Variance↗
PubMed2002

Short-term effectiveness of ceftriaxone single dose in the initial treatment of acute uncomplicated pyelonephritis in women. A randomised controlled trial.

OBJECTIVE: To compare the short-term effectiveness of ceftriaxone single dose followed by cefixime with a standard treatment of acute uncomplicated pyelonephritis in women. METHODS: An open, prospective, and randomised trial of women with acute uncomplicated pyelonephritis was performed. Group A were given a daily intravenous dose of 1 g ceftriaxone; group B: ceftriaxone 1 g intravenous single dose followed by oral cefixime. When urine culture was received, both groups completed a 10 day treatment based in sensitivity studies. Only women with positive initial urine culture were included. After three days of treatment, clinical and bacteriological efficacy was assessed. Clinical response was classified as "cured" if acute symptoms (fever, urinary syndrome and flank pain) were settled. Bacteriological response was classified as: eradication, or no eradication. RESULTS: Of 144 eligible patients, urine culture was positive in 54 of 72 (75%) women in group A and 51 of 72 (71%) in group B. There were no significant differences between groups in resolution of acute symptoms. Clinical cure was observed in 49 of 54 (91%) patients in the group A and in 47 of 51 (92%) patients in the group B (p = 0.68). After three days of treatment urine culture was negative for all patients. No adverse effects were observed in either of the groups. CONCLUSION: These data suggest that a intravenous single dose of ceftriaxone followed by oral cefixime is both effective and safe for the initial treatment of acute uncomplicated pyelonephritis in women. This regimen could be useful in managing selected patients with pyelonephritis as outpatients.

Acute Disease↗
PubMed2001

[Impact in the quality of health care and cost-effectiveness analysis of the reform of an emergency medicine service].

BACKGROUND: To determine the effects that the reform of an emergency department (ED) have on efficacy, health care quality and efficiency. MATERIAL AND METHOD: Reforms consisted of 50% and 34% increases in structural and human resources, respectively. Roles of each ED member were redetermined, new assistance pathways were implemented, and the relationship between ED and the remaining hospital departments was reassessed. As efficacy markers, we determined the number of patients waiting to be attended (Pesp), the waiting time of patients to receive medical assistance (T(esp)),and the total waiting time of patients staying in the ED (T(total)). As health-care quality markers, we determined the percentage of patients leaving ED without having been visited by a physician(IPNV), the percentage of patients who were visited again (IPR),and the percentage of mortality (IPF). We also quantified the number of visits to the ED. All these data were obtained daily over 3 weeks, before (February 1999) and after (February 2000)the reforms. Effectiveness was estimated from the ratio P(total)/T(esp)(E1) and P(total)/P(esp) (E2). Costs were recorded for both periods and a cost-effectiveness analysis was performed to study the efficiency. RESULTS: In 2000, the number of visits increased by +12% (CI 95%: 2% to 22%). Despite this increase, we observed an improvement of most efficacy and health-care quality markers after the ED reforms. E1 increased by 996% (CI 95%: 335% to 1,658%) and E2 increased by 186% (CI 95%: -23%to 395%). Cost-effectiveness analysis showed 70% (CI 95%: 33%to 107%) and 56% (CI 95%: 18% to 94%) increases regarding E1 and E2, respectively, after the reforms. CONCLUSIONS: Providing ED with the necessary resources leads to an objective improvement of its efficacy and health-care quality and, consequently, the service and quality perceived by users improve. Despite the total cost increase after the ED reforms, efficiency also improves.

Cost-Benefit Analysis↗
PubMed2001

[Quality assessment in Emergency Department: behavior respect to attendance demand].

BACKGROUND: We sought to evaluate whether the quality markers used to assess the outcomes of emergency care are modified by emergency department (ED) overcrowding. PATIENTS AND METHOD: The study was performed during 4 consecutive years (208 weeks) at the Internal Medicine Unit (IMU) of ED of a third level urban hospital. To quantify attendance requirement we used the number of weekly visits to the IMU as marker. The markers used to quantify quality of care were the weekly percentage of the following: a) patients who leave ED the department without being seen by a physician (LWBS); b) those who leave ED against medical advice (AMA); c) return visits to the department before 72 hours of previous discharge (revisited, R), and d) those who died in the IMU (dead, D). We quantified also the percentage of registered complaints (C). We considered the use of the IMU to be adequate when less than 700 patients/week, to be excessive if was between 701 and 800, and to have the overcrowded IMU if was more than 800. RESULTS: We registered a mean of 723 (60) weekly visits. LWBS, AMA, R, D and C indexes were 0.90% (CI: 0.76-1.03%), 0.19% (CI: 0.15-0.22%), 1.77% (CI: 1.69-1.86%), 0-87% (CI: 0.80-0.91%) and 0.24% (CI: 0.21-0.27%), respectively. In 38% of weeks the use of the IMU was adequate, in 51% was excessive, and in 11% was overcrowded. When we compared quality markers in relation to the level of occupation, we found a significant increase in LWBS, R and D indexes during the weeks of excessive occupation or overcrowding in relation to the weeks of adequate occupation (p < 0.0001; p < 0.0001, and p < 0.05, respectively). We also found a significant positive correlation between the number of weekly visits to IMU and LWBS, AMA R and D values (p < 0.0001; p = 0.002; p = 0.0001, and p < 0.05, respectively). CONCLUSION: ED overcrowding is associated to a decrease in the majority of quality markers.

Emergency Service, Hospital↗
PubMed2001

Reappraisal of the aetiology and prognostic factors of severe acute respiratory failure in HIV patients.

The introduction of highly active antiretroviral therapy with protease inhibitors in 1996 has changed the morbidity and mortality of acquired immune deficiency syndrome patients. Therefore, the aetiologies and prognostic factors of human immunodeficiency virus (HIV)-infected patients with life-threatening respiratory failure requiring intensive care unit (ICU) admission need to be reassessed. From 1993 to 1998, we prospectively evaluated 57 HIV patients (mean+/-SEM age 36.5+/-1.3 yrs) admitted to the ICU showing pulmonary infiltrates and acute respiratory failure. A total of 21 and 30 patients were diagnosed as having Pneumocystis carinii and bacterial pneumonia, respectively, of whom 13 and eight died during their ICU stay (p=0.01). Both groups of patients had similar age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and severity in respiratory failure. The number of cases with bacterial pneumonia admitted to ICU decreased after 1996 (p=0.05). Logistic regression analysis showed that (APACHE) II score >17, serum albumin level <25 g.(-1), and diagnosis of P. carinii pneumonia were the only factors at entry associated with ICU mortality (p=0.02). Patients with bacterial pneumonia are less frequently admitted to the intensive care unit after the introduction of highly active antiretroviral therapy with protease inhibitors in 1996. Compared to the previous series, it was observed that the few Pneumocystis carinii pneumonia patients that need intensive care still have a bad prognosis.

AIDS-Related Opportunistic Infections↗
PubMed2000

[Relative effects of external and internal factors on emergency department efficiency].

BACKGROUND: To know the relative effect of external and internal factors on emergency department (ED) efficiency. PATIENTS AND METHOD: Along 3 consecutive weeks we compute at 3 hours-interval the number or patient waiting for visit and the mean waiting time for visit (efficiency markers), the number of patients arriving to ED (external pressure marker) and the number of patients remaining in ED after beginning the visit (internal pressure marker), which was divided in ED-related factors, hospital-related factors, ED-hospital interelation-related factors, or not caused by ED nor hospital-related factors. RESULTS: Only the increase of internal pressure was associated with a decline in ED efficiency (p < 0.001). ED-related and hospital-related factors were those significantly associated with such a decline (p < 0.05 and p < 0.01, respectively). CONCLUSION: Internal pressure generated by the own ED exerts a prominent role in its dysfunction; therefore, policies addressed to reduce such internal pressure should be encouraged.

Efficiency, Organizational↗
PubMed2000

[Prospective study of patients who leave the emergency department before being seen by the physician].

BACKGROUND: To define epidemiological characteristics, the main reasons, and outcome of patients who leave the emergency department (ED) without being seen by a physician. PATIENTS AND METHODS: We performed a prospective survey of patients who left the ED before medical visit over a period of 26 consecutive weeks. For every non-visited patient (NV), the next visited patient (V) was included as a control. Clinical and epidemiological data, reasons to leave ED and outcome were obtained from clinical records and personal telephone interview. RESULTS: Out of a total of 21,022 patients who were attended in the ED, 383 (1.8%) were NV. To be under 50-year-old, to come the ED alone, to be previously visited by a community physician, and to previous expect short waiting times for ED visit were associated with higher risk for being NV (p < 0.01, p < 0.01, p < 0.05 and p < 0.0001, respectively). The main reasons noted to leave the ED were: feeling better (35%), feeling too sick to wait longer (30%) and being too angry to wait (25%). Only 46% of the NV looked for medical care in the 72 following hours and 6.5% of them needing to be further to hospital. NV-patients considered as suffering a serious pathology at ED arrival, and those being visited by a community physician previously to go to ED were found to be at increased risk to be subsequently admitted (p = 0.01 and p = 0.001, respectively). CONCLUSIONS: Patients who leave ED department before being seen by a doctor are usually young, literate, have not previously visited their community physician, and consulted for minor complaints. The main reason to leave is their own impression of suffering a minor disease, and less than 50% visit another physician after their leaving, being the rate of hospital admission low. We should be particularly cautious with those patients referred by a community doctor and those identified as to have a seriously affected health status at their arrival at the hospital, since they are at increased risk to be admitted.

Age Factors↗
PubMed2000

[Football, television and emergency services].

BACKGROUND: To know the influence of televised football on the use of emergency department (ED). PATIENTS AND METHODS: We assessed the number, demographic characteristics and acuity of patients attended during the broadcast of football matches played by FC Barcelona during Champions' League (n = 12), and they were compared with days without televised football (n = 12). RESULTS: Televised football was associated with a decrease in visits to ED (-18%; p = 0.002). Such a decrease was observed for all ED units, but only for traumatology unit reached statistical significance (-28%; p = 0.006). Decay of ED visits were mainly due to a decrease of low-acuity consults (-30%; p = 0.04). CONCLUSION: There is a significant decrease on ED use associated with televised football.

Adult↗
PubMed1999

[Study of mortality in a medical unit of emergency department: incidence, causes and consequences].

OBJECTIVES: To define the mortality pattern in a medical unit of emergency department (ED) and to know the satisfaction of relatives with ED provided care. PATIENTS AND METHODS: We computed the number of patients visited and dead from 1989 to 1996. From all patients dying during 1996, we recorded clinical and epidemiological data and we interviewed the patients' family to know their satisfaction with ED provided care. RESULTS: Whole mortality rate was 0.71 (0.15)% X (SD) with an annual increase of 10.4% (r = 0.78, p < 0.05). The clinical profile of patient dying at ED is an individual of advanced age, with a poor quality of life, and in whom the death was expected when arrived to ED. From the family interview, 61% of cases preferred that their relative was dying in the hospital, and 88% were satisfied with ED provided care. CONCLUSIONS: Although the annual mortality rate has progressively increased in ED, family satisfaction with the received care is good.

Age Factors↗
PubMed1999

[Unscheduled revisits in medical emergency units at the hospital: incidence and related factors].

BACKGROUND: To known the revisit rate in an emergency department (ED), to define the clinical and epidemiological profile of revisited patients, and to identify influencing factors for revisits. PATIENTS AND METHODS: During one year period, we included all revisited patients returning to ED before 72 h of a previous discharge from medical unit of ED. As controls we included the next patient seen after every case being discharged. We compiled clinical and epidemiological data from both groups. For revisited patients, we identify the cause of the revisit, changes in diagnosis and/or treatment, diagnosis mistakes and final destination of the patient. RESULTS: We identified 406 revisits (revisit rate: 1.42%). Multivariate analysis disclosed, as positive predictive factors for revisit, and age over 60 years (p = 0.006), male sex (p = 0.02), visit performed at level 2 (severe diseases) (p = 0.02), initial assessment by junior resident (p = 0.01), number of complementary procedures higher than 2 (p = 0.01) and gastrointestinal disease as diagnosis after the first visit (p = 0.03). On the other hand, dermatologic symptoms as initial complaint and unspecific symptoms (p = 0.01) were negative predictors for revisit. In only 16% of cases, the revisit did not imply changes in the diagnosis or treatment. Revisits were due to disease-related factors in 34% of cases, physician-related factors in 33%, patients-related factors in 10%, system-related factors in 3% and there were no relationship with the previous visit in 15% (in 5% of cases the cause was unassessable). The diagnosis error most frequently seen was "nonspecific abdominal syndrome". Seventy six percent of revisited patients were admitted. CONCLUSIONS: The revisit rate in our ED is relatively low. Patients being revisited have well-defined clinical and epidemiological profile. The majority of revisited patients require to be admitted.

Appointments and Schedules↗
PubMed1999

Decreased health care quality associated with emergency department overcrowding.

The objective of this study was to assess the influence of overcrowding on health care quality provided by emergency departments (ED). The study was carried out in an urban, university tertiary care hospital. All patients seen at the internal medicine unit (IMU) of the ED who returned during the following 72 hours, and those who died in the ED rooms were included in the study. During a consecutive period of 2 years (104 weeks), we prospectively quantified the number of weekly visits, revisits and deaths. We calculated revisit and mortality rates (in respect of percentage of all visited patients) for each week. Correlation between the number of weekly visits, and revisit and mortality rates was assessed using a simple linear regression model. We consigned 81,301 visits, 1137 revisits and 648 deaths; mean (+/- SD) number of weekly visits, revisits and deaths were 782 (68), 10.93 (3.97) and 6.23 (3.04) respectively; weekly revisit rate was 1.40% (0.48%) and weekly mortality rate was 0.79% (0.36%). We observed a significant, positive correlation between mortality rates and weekly number of visits (p = 0.01). Although a similar trend was also found for revisit rates, such an increase did not reach statistical significance (p = 0.06). It is concluded that since revisit and mortality rates constitute good health care quality markers, present data demonstrate that ED overcrowding implies a decrease in the health care quality provided by it.

Crowding↗
PubMed1998

[Availability, use and cost of antidotes in Catalonia].

BACKGROUND: To know the availability of antidotes in hospital and extra-hospital emergency services in Catalonia (Spain), their real use, and the cost. PATIENTS AND METHODS: Availability was studied by means of a transversal questionnaire carried out in 24 hospitals and 3 extra-hospital emergency services in Catalonia; the real use of antidotes was investigated using a prospective study carried out for one year in the same 24 hospitals, and the cost was determined using the data obtained over 12 months in one large hospital. RESULTS: Average availability was 35 antidotes in hospital and 13 in extra-hospital emergency services. In no service did the availability coincide exactly with that of another service, nor with the recommendations made by international institutions (World Health Organization and International Programme for Chemical Safety) or the Government of Catalonia. The low incidence of availability of antidotes to cyanide was notable. Antidotes were used in 12.9% of acute intoxications. In 167 cases treated with these drugs, only 9 different antidotes were used. The consumption of these antidotes represents 0.1% of the budget of a pharmacy service in one large hospital. CONCLUSIONS: The availability of antidotes in Catalonia is heterogeneous and some services lack antidotes whose use is considered essential. Antidotes are scarcely used in acute intoxications and their economic cost is low.

Antidotes↗