A Panel of International Experts was convened by the Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) to update the 1999 Uncomplicated Urinary Tract Infection Guidelines by the IDSA. Co-sponsoring organizations include the American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine. The focus of this work is treatment of women with acute uncomplicated cystitis and pyelonephritis, diagnoses limited in these guidelines to premenopausal, non-pregnant women with no known urological abnormalities or co-morbidities. The issues of in vitro resistance prevalence and the ecological adverse effects of antimicrobial therapy (collateral damage) were considered as important factors in making optimal treatment choices and thus are reflected in the rankings of recommendations.

/pdf/international-clinical-practice-guidelines-for-the-treatment-3c2xkupm2f.pdf

International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases

Systematic Review of Emergency Department Crowding: Causes, Effects, and Solutions

Background: An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated.

Objectives:  The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs).

Methods:  We reviewed the English-language literature for the years 1989–2007 for case series, cohort studies, and clinical trials addressing crowding’s effects on COOs. Keywords searched included “ED crowding,”“ED overcrowding,”“mortality,”“time to treatment,”“patient satisfaction,”“quality of care,” and others.

Results:  A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding’s effects on patient satisfaction and other quality endpoints.

Conclusions:  A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2008.00295.x

The effect of emergency department crowding on clinically oriented outcomes

Objective: To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission. Design: Retrospective analysis of 62495 probabilistically linked emergency hospital admissions and death records. Setting: Three tertiary metropolitan hospitals between July 2000 and June 2003. Participants: All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period. Main outcome measures: Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital. Results: There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r= 0.98; 95% Cl, 0.79-1.00). An Overcrowding Hazard Scale > 2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% Cl, 1.1-1.6), 1.3 (95% Cl, 1.2-1.5) and 1.2 (95% Cl, 1.1-1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale > 2 compared with one of < 3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% Cl, 1.1-1.1; P< 0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% Cl, 1.1-1.3; P = 0.01). Conclusions: Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.

/pdf/the-association-between-hospital-overcrowding-and-mortality-25f8gvxxc1.pdf

The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments

Clinical presentation helps differentiate between upper and lower urinary tract infections (UTIs). UTIs are classified as either complicated or uncomplicated. A complicated UTI is associated with an underlying condition that increases the risk of failing therapy. Primary laboratory tests for UTIs consist of urinalysis and urine culture. The most common pathogen for uncomplicated cystitis and pyelonephritis is Escherichia coli. Nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are first-line therapies for acute uncomplicated cystitis. Decisions regarding antibiotic agents should be individualized based on patients' allergies, tolerability, community resistance rates, cost, and availability.

https://www.primarycare.theclinics.com/article/S0095-4543(13)00067-5/pdf

Urinary tract infections.

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.

Decreased health care quality associated with emergency department overcrowding

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.

https://emj.bmj.com/content/emermed/20/2/143.full.pdf

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

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.

https://emj.bmj.com/content/emermed/19/1/19.full.pdf

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

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.

https://emj.bmj.com/content/emermed/21/5/573.full.pdf

J Millá

Papers

Decreased health care quality associated with emergency department overcrowding

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

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

Quality and effectiveness of an emergency department during weekends