תוצאת חיפוש

Referrals and Self-Referrals to an Emergency Department

Sasson Nakar, Shlomo Vinker, Yaacov Or, Mordechai Schadel, Yosi Niego, Gavriel Plotkin

Central District of General Sick Fund and Family Medicine Dept., Sackler Faculty of Medicine, Tel Aviv University, and Emergency Dept., Kaplan Medical Center, Rehovot (Affiliated with Hebrew University-Hadassah Faculty of Medicine, Jerusalem)

The Israeli health system has been undergoing major changes in recent years. Considerations of cost containment have led sick funds to open new out-of-hours services in the community to reduce visits to hospital emergency departments.

Referred and self-referred visits to our emergency department during a 1-month period were studied. Patients after trauma or whose visits resulted in hospitalization were excluded. Of the 505 encounters 56.3% were of women; the average age was 52.5±19.3 years (range 18-96). 57.4% visits were during working hours of primary care clinics ("working hours"), while the others were "out-of-hours" visits. Only 52.7% had a referral letter, 75% of them from the family physician. The quality of the handwriting in 46% was good, in 44% fair and the remaining 10% were illegible. A specific clinical question was asked in only 16% of the letters. A third of "working-hours" visits were self- referrals, rising to 64% in "out-of-hours" visits (p<0.001).

The most common diagnoses in discharge letters were: chest or abdominal pain, asthma, back pain, headache, nephrolithiasis and upper respiratory tract infection. The rate of self-referrals was relatively high throughout the day. Cost-containment efforts did not seem to eliminate self-referrals with "primary care" problems. The quality of referral letters should be improved both with regard to format and content.

Violence in the Emergency Department

H. Derazon, S. Nissimian, C. Yosefy, R. Peled, E. Hay

Dept. of Emergency Medicine and Epidemiology Unit, Barzilai Medical Center, Ashkelon

There is an international epidemic of violence in the emergency department (ED) which threatens medical staff daily. The problem is underestimated in Israel and there are as yet no regulations of the Ministry of Health and the Bureau of Security and Safety that deal with the problem.

At the beginning of 1997 we conducted a retrospective survey to estimate the extent of this problem and to define its causes and the various options for management. An anony-mous questionnaire was given to all permanent workers of our ED: physicians, nurses and reception clerks, as well as physicians who worked in the ED during evening and night shifts at least twice a week.

74% of (questionnaire) responders experienced violent events, most of them 5 or more times during the previous 2 years. Violence was experienced by 90% of nurses, 70% of physicians and 64% of clerks. The main reason for violence was prolonged waiting in the ED. Other causes were dissatisfaction with treatment, refusal to leave the ED, and language that displeased the patient.

Most violent patients were middle-aged men, of whom alcohol and drug users were only a small proportion. Most victims of physical violence called hospital security personnel, but only a third of the victims of verbal violence pressed charges. Half of the staff who were physically attacked called the police and most pressed charges. Only 2 attackers were convicted; charges were dropped against 3 because of "lack of public concern." We were unable to ascertain the results of the other charges. Most victims of violence didn't press charges because of fear resulting from threats of the patient and/or family.

The violent patient was usually characterized by responders as a middle-aged man, sober, of low socioeconomic level, impatient, with a bad previous hospital experience, dissatisfied with treatment and who insisted on being admitted to hospital.

Suggestions for violence management by questionnaire- responders included 24-hour police protection and a training program in violence management for hospital security and medical staff.