The effect of emergency department crowding on clinically oriented outcomes

Effectiveness of multifunction paediatric short-stay units: a French multicentre study

AIM

To describe the characteristics of the activities of multifunction paediatric 'short-stay units' (SSU) including observation unit (OU), medical assessment and planning unit (MAPU) and holding unit (HU), to evaluate their effectiveness and to explore predictors of inappropriate admissions for OU patients.

METHODS

Admissions to nine French paediatric SSUs were analysed. The main outcome measures were SSU length of stay with associated outcome for all patients and appropriate admission rate for OU patients.

RESULTS

Of 1084 patients included in the study, 66% were OU patients (n = 718), 21% MAPU patients (n = 225) and 13% HU patients (n = 141). The OU patients constituted the majority of the SSU admissions. The appropriate OU admission rates ranged from 52% to 86%. Head trauma and seizure were the conditions with the highest appropriate OU admission rates (82%). Age <1 year, and need for IV fluids or medications, CT-Scan or MRI and cardiorespiratory monitoring were associated with an increased risk of inappropriate OU admission. Eighteen per cent of the MAPU patients and 5% of the HU patients were discharged home within 24 h.

CONCLUSION

By providing extended and easily available facilities for diagnostics and early treatment for a wide range of sick children, the French paediatric SSU is an effective model for 'observation medicine' in emergency department-managed units. The experience and principles may be applicable to similar units in other health care systems.

Improving patient flow in acute coronary syndromes in the face of hospital crowding

BACKGROUND

The current paradigm for the evaluation of patients with suspected acute coronary syndromes (ACS) in the emergency department (ED) is focused on the identification of patients with active underlying coronary disease. The majority of patients evaluated in the ED setting do not have active underlying cardiac disease.

OBJECTIVE

To measure the effect of bedside point-of-care (POC) cardiac biomarker testing on telemetry unit admissions from the ED. Furthermore, to evaluate the effect telemetry admissions have on ED length of stay (LOS) and overall hospital LOS.

METHODS

Primary data were collected over two 6-month periods in an urban teaching hospital ED. This was an observational cohort study conducted pre- and post-availability of a POC testing platform for cardiac biomarkers. Major measures included number of overall telemetry admissions, ED LOS, hospital LOS, and disposition. Patients were followed at 30 days for significant cardiac events, repeat ED visit or admission, and death.

RESULTS

In the post-implementation period there was a 30% (95% confidence interval [CI] 36-44%) reduction in admissions to telemetry with a 33% (95% CI 26-39%) reduction in ED LOS and a 20% (95% CI 7-34%) reduction in hospital LOS. There was a 62% reduction in overall mortality between the pre-implementation period and the post-implementation period (p=0.001).

CONCLUSION

The focused use of a rapid cardiac disposition protocol can dramatically impact resource utilization, expedite patient flow, and improve short-term outcomes for patients with suspected ACS.

Emergency department triage: an ethical analysis

Background

Emergency departments across the globe follow a triage system in order to cope with overcrowding. The intention behind triage is to improve the emergency care and to prioritize cases in terms of clinical urgency.

Discussion

In emergency department triage, medical care might lead to adverse consequences like delay in providing care, compromise in privacy and confidentiality, poor physician-patient communication, failing to provide the necessary care altogether, or even having to decide whose life to save when not everyone can be saved. These consequences challenge the ethical quality of emergency care. This article provides an ethical analysis of "routine" emergency department triage. The four principles of biomedical ethics - viz. respect for autonomy, beneficence, nonmaleficence and justice provide the starting point and help us to identify the ethical challenges of emergency department triage. However, they do not offer a comprehensive ethical view. To address the ethical issues of emergency department triage from a more comprehensive ethical view, the care ethics perspective offers additional insights.

Summary

We integrate the results from the analysis using four principles of biomedical ethics into care ethics perspective on triage and propose an integrated clinically and ethically based framework of emergency department triage planning, as seen from a comprehensive ethics perspective that incorporates both the principles-based and care-oriented approach.

A randomized trial of computer kiosk-expedited management of cystitis in the emergency department

OBJECTIVES

The objective was to assess the efficiency and safety of an interactive computer kiosk module for the management of uncomplicated urinary tract infections (UTI) in emergency departments (EDs).

METHODS

This was a prospective unblinded randomized trial. Women age 18 to 64 years seeking care for suspected UTI in three urban EDs were referred to a computer kiosk after triage. The kiosk evaluated women for uncomplicated UTI (based on patient report of at least one irritable voiding symptom within 7 days and absence of complicating features), and eligible patients were randomized to expedited management or usual ED care. Expedited management consisted of a brief clinician encounter to confirm computer kiosk responses and selection of one of four standard antibiotic regimens. Study outcomes included urine culture results, duration of ED visit, time to illness resolution, return visits, and satisfaction with care.

RESULTS

Seventeen percent (n = 103) of 624 participants with suspected UTI fulfilled uncomplicated criteria and were randomized. Sixty-nine percent of these women had a positive urine culture. Compared with the control group, the computer-expedited management group had lower median visit duration (89 minutes, interquartile range [IQR] = 65 to 150 minutes vs. 146 minutes, IQR = 105 to 216 minutes) for a decrease of 57 minutes (95% confidence interval [CI] = 27 to 87, p = 0.004). They had similar time to illness resolution, number of return visits, and satisfaction with care.

CONCLUSIONS

An interactive computer kiosk accurately, efficiently, and safely expedited the management of women with uncomplicated UTI in a busy, urban ED. Expanding the use of this technology to other conditions could help to improve ED patient flow.

Emergency department crowding and analgesic delay in pediatric sickle cell pain crises

OBJECTIVES

The objectives of the study were to test the impact of emergency department (ED) crowding and to identify factors associated with delay in analgesic administration in pediatric sickle cell pain crises.

METHODS

This was a cross-sectional study at a children's hospital ED. Data included demographics, clinical features, triage acuity, 10-level triage pain score, and arrival-to-analgesic-administration time. Emergency department census was the crowding measure assigned to each patient at arrival. Severe pain was a triage pain score of more than 7. Delays of more than 60 minutes from arrival to analgesic administration represented poor care. Logistic regression tested the effect of ED census on time to analgesic administration after adjusting for patient demographic and clinical characteristics.

RESULTS

From 243 encounters (161 patients), we excluded 11 visits (missing charts [n = 7], no pain at triage [n = 3], analgesic refusal [n = 1]). Final analysis involved 232 encounters (150 patients). Most were black with hemoglobin SS. Median age was 12 years. Mean ED census was 57. Median time from arrival to analgesic administration was 90 minutes. Analgesics were administered in less than 60 minutes in 70 encounters (30%). Most delays occurred after triage. Univariate analysis revealed that analgesic administration within 60 minutes of arrival was associated with severe pain at triage. After controlling for other factors, analgesic administration was significantly delayed during higher ED census and significantly earlier for young children and those with severe pain at triage. The time to analgesic administration from arrival significantly increased per increasing quartile of ED census (P = 0.0009).

CONCLUSION

Emergency department crowding is associated with delay in analgesic administration in pediatric patients with sickle cell pain crisis.

Emergency department crowding is associated with decreased quality of care for children

OBJECTIVE

We sought to determine which of several simple indicators of emergency department crowding are most predictive of quality of care in 2 pediatric disease models: acute asthma and pain associated with long-bone fractures.

METHODS

We performed a retrospective, cross-sectional study of patients 2 to 21 years old seen for acute asthma and patients 0 to 21 years old seen for acute, isolated long-bone fractures from November 1, 2007, to October 31, 2008, at a single, academic children's hospital emergency department. The main outcome measures were quality measures based on 3 asthma care-related processes-asthma score, β-agonist, and corticosteroid-and 2 fracture-related processes-analgesic and opioid analgesic. Good quality care was defined as receipt of an indicated process within 1 hour of arrival. Poor quality care was defined as nonreceipt or delayed receipt of an indicated process. Nine crowding measures were assigned based on conditions at each patient's arrival. We calculated the adjusted risk of receiving good quality care for each quality measure at 5 percentiles of crowding for each crowding measure.

RESULTS

The asthma population included 927 patients, and the fracture population included 1229 patients. Among the 5 quality measures, we found rates of good quality care ranging from 23% to 64%. In adjusted models, we found an inverse association between crowding and quality. The 2 crowding measures with a consistently inverse association with the 5 quality measures across both populations were total patient-care hours and number arriving in prior 6 hours. Across the 10 models combining 1 of 2 key crowding variables with 1 of 5 quality measures, patients in the 2 populations were 0.40 (95% confidence interval, 0.27-0.55) to 0.78 (confidence interval, 0.71-0.85) times as likely to receive the indicated care process within 1 hour when each crowding measure was at the 75th than at the 25th percentile.

CONCLUSIONS

Two measures of ED crowding are consistently associated with lower-quality asthma- and fracture-specific care in the ED for pediatric patients.

Trapped between doing and being: first providers' experience of "front line" work

A common focus in research studies within the Emergency Department (ED) is physician patient relations, experiences of the triage model and nurses' experiences of caring. Little has, however, been written about different first providers' experiences of working on the "front line" at the ED. The aim of this study was to describe and understand experiences of being the first provider on the "front line" at the ED, as expressed by nurse assistants, registered nurses and physicians. A reflective lifeworld research approach was used in four different caring situations. The data consisted of eight open-ended interviews with first providers. The analysis showed that being the first provider on the "front line" at the ED entails a continuous movement between providing and responding through performing "life-saving" actions and at the same time create a good relationship with the patient and the next of kin. Five constituents further described the variations of the phenomenon. The readiness to save lives creates a perceived stress of time pressure and the first providers adopt different strategies to cope with the work. Instead of leaving the first providers to find their own way to cope with the complex situation, there are needs for a redesigning of the internal work process within ED organizations.

Association between ambulance diversion and survival among patients with acute myocardial infarction

CONTEXT

Ambulance diversion, a practice in which emergency departments (EDs) are temporarily closed to ambulance traffic, might be problematic for patients experiencing time-sensitive conditions, such as acute myocardial infarction (AMI). However, there is little empirical evidence to show whether diversion is associated with worse patient outcomes.

OBJECTIVE

To analyze whether temporary ED closure on the day a patient experiences AMI, as measured by ambulance diversion hours of the nearest ED, is associated with increased mortality rates among patients with AMI. DESIGN, STUDY, AND PARTICIPANTS: A case-crossover design of 13,860 Medicare patients with AMI from 508 zip codes within 4 California counties (Los Angeles, San Francisco, San Mateo, and Santa Clara) whose admission date was between 2000 and 2005. Data included 100% Medicare claims data that covered admissions between 2000 and 2005, linked with date of death until 2006, and daily ambulance diversion logs from the same 4 counties. Among the hospital universe, 149 EDs were identified as the nearest ED to these patients.

MAIN OUTCOME MEASURES

The percentage of patients with AMI who died within 7 days, 30 days, 90 days, 9 months, and 1 year from admission (when their nearest ED was not on diversion and when that same ED was exposed to <6, 6 to <12, and ≥12 hours of diversion out of 24 hours on the day of admission).

RESULTS

Between 2000 and 2006, the mean (SD) daily diversion duration was 7.9 (6.1) hours. Based on analysis of 11,625 patients admitted to the ED between 2000 and 2005, and whose nearest ED had at least 3 diversion exposure levels (3541, 3357, 2667, and 2060 patients for no exposure, exposure to <6, 6 to <12, and ≥12 hours of diversion, respectively), there were no statistically significant differences in mortality rates between no diversion and exposure to less than 12 hours of diversion. Exposure to 12 or more hours of diversion was associated with higher 30-day mortality vs no diversion status (unadjusted mortality rate, 392 patients [19%] vs 545 patients [15%]; regression adjusted difference, 3.24 percentage points; 95% confidence interval [CI], 0.60-5.88); higher 90-day mortality (537 patients [26%] vs 762 patients [22%]; 2.89 percentage points; 95% CI, 0.13-5.64); higher 9-month mortality (680 patients [33%] vs 980 patients [28%]; 2.93 percentage points; 95% CI, 0.15-5.71); and higher 1-year mortality (731 patients [35%] vs 1034 patients [29%]; 3.04 percentage points; 95% CI, 0.33-5.75).

CONCLUSION

Among Medicare patients with AMI in 4 populous California counties, exposure to at least 12 hours of diversion by the nearest ED was associated with increased 30-day, 90-day, 9-month, and 1-year mortality.

Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada

OBJECTIVE

To determine whether patients who are not admitted to hospital after attending an emergency department during shifts with long waiting times are at risk for adverse events.

DESIGN

Population based retrospective cohort study using health administrative databases. Setting High volume emergency departments in Ontario, Canada, fiscal years 2003-7.

PARTICIPANTS

All emergency department patients who were not admitted (seen and discharged; left without being seen).

OUTCOME MEASURES

Risk of adverse events (admission to hospital or death within seven days) adjusted for important characteristics of patients, shift, and hospital.

RESULTS

13,934,542 patients were seen and discharged and 617,011 left without being seen. The risk of adverse events increased with the mean length of stay of similar patients in the same shift in the emergency department. For mean length of stay ≥ 6 v <1 hour the adjusted odds ratio (95% confidence interval) was 1.79 (1.24 to 2.59) for death and 1.95 (1.79 to 2.13) for admission in high acuity patients and 1.71 (1.25 to 2.35) for death and 1.66 (1.56 to 1.76) for admission in low acuity patients). Leaving without being seen was not associated with an increase in adverse events at the level of the patient or by annual rates of the hospital.

CONCLUSIONS

Presenting to an emergency department during shifts with longer waiting times, reflected in longer mean length of stay, is associated with a greater risk in the short term of death and admission to hospital in patients who are well enough to leave the department. Patients who leave without being seen are not at higher risk of short term adverse events.

Using information technology to improve the quality and safety of emergency care

With the 2010 federal health care reform passage, a renewed focus has emerged for the integration of electronic health records (EHRs) into the U.S. health care system. A consensus conference in October 2009 met to discuss the future research agenda with regard to using information technology (IT) to improve the future quality and safety of emergency department (ED) care. The literature is mixed as to how the use of computerized provider order entry (CPOE), clinical decision support (CDS), EHRs, and patient tracking systems has improved or degraded the safety and quality of ED care. Such mixed findings must be considered in the national push for rapid implementation of health IT. We present a research agenda addressing the major questions that are posed by the introduction of IT into ED care; these questions relate to interoperability, patient flow and integration into clinical work, real-time decision support, handoffs, safety-critical computing, and the interaction between IT systems and clinical workflows.

Predictors of psychiatric boarding in the pediatric emergency department: implications for emergency care

OBJECTIVES

Patients who present to the emergency department (ED) and require psychiatric hospitalization may wait in the ED or be admitted to a medical service because there are no available inpatient psychiatric beds. These patients are psychiatric "boarders." This study describes the extent of the boarder problem in a large, urban pediatric ED, compares characteristics of psychiatrically hospitalized patients with boarders, and compares predictors of boarding in 2 ED patient cohorts.

METHODS

A retrospective cohort study was conducted in 2007-2008. The main outcome measure was placement into a psychiatric facility or boarding. Predictors of boarding in the present analysis were compared with predictors from a similar study conducted in the same ED in 1999-2000.

RESULTS

Of 461 ED patient encounters requiring psychiatric admission, 157 (34.1%) boarded. Mean and median boarding duration for the sample were 22.7(SD, 8.08) and 21.18 hours, respectively. Univariate generalized estimating equations demonstrated increased boarding odds for patients carrying Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnoses of autism, mental retardation, and/or developmental delay (P = 0.01), presenting during the weekend (P = 0.03) or presenting during months without school vacation (P = 0.02). Suicidal ideation (SI) significantly predicted boarding status, with increased likelihood of boarding for severe SI (P = 0.02). Age, race, insurance status, and homicidal ideation did not significantly predict boarding in the 2007-2008 patient cohort, although they did in the earlier study. Systemic factors and SI predicted boarding status in both cohorts.

CONCLUSIONS

Suicidal patients continue to board. Limits within the system, including timing of ED presentation and a dearth of specialized services, still exist, elevating the risk of boarding for some populations. Implications for pediatric ED psychiatric care delivery are discussed.

Exploring strategies to improve emergency department intake

BACKGROUND

The emergency department (ED) is the point of entry for nearly two-thirds of patients admitted to the average United States (US) hospital. Due to unacceptable waits, 3% of patients will leave the ED without being seen by a physician.

OBJECTIVES

To study intake processes and identify new strategies for improving patient intake.

METHODS

A year-long learning collaborative was created to study innovations involving the intake of ED patients. The collaborative focused on the collection of successful innovations for ED intake for an "improvement competition." Using a qualitative scoring system, finalists were selected and their innovations were presented to the members of the collaborative at an Association for Health Research Quality-funded conference.

RESULTS

Thirty-five departments/organizations submitted abstracts for consideration involving intake innovations, and 15 were selected for presentation at the conference. The innovations were presented to ED leaders, researchers, and policymakers. Innovations were organized into three groups: physical plant changes, technological innovations, and process/flow changes.

CONCLUSION

The results of the work of a learning collaborative focused on ED intake are summarized here as a qualitative review of new intake strategies. Early iterations of these new and unpublished innovations, occurring mostly in non-academic settings, are presented.

Linking ambulance, emergency department and hospital admissions data: understanding the emergency journey

OBJECTIVE

To assess the accuracy of data linkage across the spectrum of emergency care in the absence of a unique patient identifier, and to use the linked data to examine service delivery outcomes in an emergency department (ED) setting.

DESIGN

Automated data linkage and manual data linkage were compared to determine their relative accuracy. Data were extracted from three separate health information systems: ambulance, ED and hospital inpatients, then linked to provide information about the emergency journey of each patient. The linking was done manually through physical review of records and automatically using a data linking tool (Health Data Integration) developed by the CSIRO (Commonwealth Scientific and Industrial Research Organisation). Match rate and quality of the linking were compared.

SETTING

10,835 patient presentations to a large, regional teaching hospital ED over a 2-month period (August - September 2007).

RESULTS

Comparison of the manual and automated linkage outcomes for each pair of linked datasets demonstrated a sensitivity of between 95% and 99%; a specificity of between 75% and 99%; and a positive predictive value of between 88% and 95%.

CONCLUSIONS

Our results indicate that automated linking provides a sound basis for health service analysis, even in the absence of a unique patient identifier. The use of an automated linking tool yields accurate data suitable for planning and service delivery purposes and enables the data to be linked regularly to examine service delivery outcomes.

Factors associated with closures of emergency departments in the United States

CONTEXT

Between 1998 and 2008, the number of hospital-based emergency departments (EDs) in the United States declined, while the number of ED visits increased, particularly visits by patients who were publicly insured and uninsured. Little is known about the hospital, community, and market factors associated with ED closures. Federal law requiring EDs to treat all in need regardless of a patient's ability to pay may make EDs more vulnerable to the market forces that govern US health care.

OBJECTIVE

To determine hospital, community, and market factors associated with ED closures.

DESIGN

Emergency department and hospital organizational information from 1990 through 2009 was acquired from the American Hospital Association (AHA) Annual Surveys (annual response rates ranging from 84%-92%) and merged with hospital financial and payer mix information available through 2007 from Medicare hospital cost reports. We evaluated 3 sets of risk factors: hospital characteristics (safety net [as defined by hospitals caring for more than double their Medicaid share of discharges compared with other hospitals within a 15-mile radius], ownership, teaching status, system membership, ED size, case mix), county population demographics (race, poverty, uninsurance, elderly), and market factors (ownership mix, profit margin, location in a competitive market, presence of other EDs).

SETTING

All general, acute, nonrural, short-stay hospitals in the United States with an operating ED anytime from 1990-2009.

MAIN OUTCOME MEASURE

Closure of an ED during the study period.

RESULTS

From 1990 to 2009, the number of hospitals with EDs in nonrural areas declined from 2446 to 1779, with 1041 EDs closing and 374 hospitals opening EDs. Based on analysis of 2814 urban acute-care hospitals, constituting 36,335 hospital-year observations over an 18-year study interval (1990-2007), for-profit hospitals and those with low profit margins were more likely to close than their counterparts (cumulative hazard rate based on bivariate model, 26% vs 16%; hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.5-2.1, and 36% vs 18%; HR, 1.9; 95% CI, 1.6-2.3, respectively). Hospitals in more competitive markets had a significantly higher risk of closing their EDs (34% vs 17%; HR, 1.3; 95% CI, 1.1-1.6), as did safety-net hospitals (10% vs 6%; HR, 1.4; 95% CI, 1.1-1.7) and those serving a higher share of populations in poverty (37% vs 31%; HR, 1.4; 95% CI, 1.1-1.7).

CONCLUSION

From 1990 to 2009, the number of hospital EDs in nonrural areas declined by 27%, with for-profit ownership, location in a competitive market, safety-net status, and low profit margin associated with increased risk of ED closure.

The impact of emergency department overcrowding on resident education

BACKGROUND

Few studies have evaluated the effect of Emergency Department (ED) overcrowding on resident education.

OBJECTIVES

To determine the impact of ED overcrowding on Emergency Medicine (EM) resident education.

MATERIALS AND METHODS

A prospective cross-sectional study was performed from March to May 2009. Second- and third-year EM residents, blinded to the research objective, completed a questionnaire at the end of each shift. Residents were asked to evaluate the educational quality of each shift using a 10-point Likert scale. Number of patients seen and procedures completed were recorded. Responses were divided into ED overcrowding (group O) and non-ED overcrowding (group N) groups. ED overcrowding was defined as >2 h of ambulance diversion per shift. Questionnaire responses were compared using Mann-Whitney U tests. Number of patients and procedures were compared using unpaired T-tests.

RESULTS

During the study period, 125 questionnaires were completed; 54 in group O and 71 in group N. For group O, the median educational value score was 8 (interquartile range [IQR] 7-10), compared to 8 (IQR 8-10) for group N (p = 0.24). Mean number of patients seen in group O was 12.3 (95% confidence interval [CI] 11.4-13.2), compared to 13.9 (95% CI 12.7-15) in group N (p = 0.034). In group O, mean number of procedures was 0.9 (95% CI 0.6-1.2), compared to 1.3 (95% CI 1-1.6) in group N (p = 0.047).

CONCLUSIONS

During overcrowding, EM residents saw fewer patients and performed fewer procedures. However, there was no significant difference in resident perception of educational value during times of overcrowding vs. non-overcrowding.

Measures of crowding in the emergency department: a systematic review

OBJECTIVES

Despite consensus regarding the conceptual foundation of crowding, and increasing research on factors and outcomes associated with crowding, there is no criterion standard measure of crowding. The objective was to conduct a systematic review of crowding measures and compare them in conceptual foundation and validity.

METHODS

This was a systematic, comprehensive review of four medical and health care citation databases to identify studies related to crowding in the emergency department (ED). Publications that "describe the theory, development, implementation, evaluation, or any other aspect of a 'crowding measurement/definition' instrument (qualitative or quantitative)" were included. A "measurement/definition" instrument is anything that assigns a value to the phenomenon of crowding in the ED. Data collected from papers meeting inclusion criteria were: study design, objective, crowding measure, and evidence of validity. All measures were categorized into five measure types (clinician opinion, input factors, throughput factors, output factors, and multidimensional scales). All measures were then indexed to six validation criteria (clinician opinion, ambulance diversion, left without being seen (LWBS), times to care, forecasting or predictions of future crowding, and other).

RESULTS

There were 2,660 papers identified by databases; 46 of these papers met inclusion criteria, were original research studies, and were abstracted by reviewers. A total of 71 unique crowding measures were identified. The least commonly used type of crowding measure was clinician opinion, and the most commonly used were numerical counts (number or percentage) of patients and process times associated with patient care. Many measures had moderate to good correlation with validation criteria.

CONCLUSIONS

Time intervals and patient counts are emerging as the most promising tools for measuring flow and nonflow (i.e., crowding), respectively. Standardized definitions of time intervals (flow) and numerical counts (nonflow) will assist with validation of these metrics across multiple sites and clarify which options emerge as the metrics of choice in this "crowded" field of measures.

Emergency department crowding is associated with decreased quality of care for children with acute asthma

STUDY OBJECTIVE

We seek to determine which dimensions of quality of care are most influenced by emergency department (ED) crowding for patients with acute asthma exacerbations.

METHODS

This cross-sectional study with retrospective data collection included patients aged 2 to 21 years treated for acute asthma during November 2007 to October 2008 at a children's hospital ED. We studied 3 processes of care-asthma score, β-agonist, and corticosteroid administration-and 9 quality measures representing 3 quality dimensions: timeliness (1-hour receipt of each process), effectiveness (receipt/nonreceipt of each process), and equity (language, identified primary care provider, and insurance). Primary independent variables were 2 crowding measures: ED occupancy and number waiting to see an attending-level physician. Models were adjusted for age, language, insurance, primary care access, triage level, ambulance arrival, oximetry, smoke exposure, and time of day. For timeliness and effectiveness quality measures, we calculated the adjusted risk of each quality measure at 5 percentiles of crowding for each crowding measure and assessed the significance of the adjusted relative interquartile risk ratios. For equity measures, we tested their role as moderators of the crowding-quality models.

RESULTS

The asthma population included 927 patients. Timeliness and effectiveness quality measures showed an inverse, dose-related association with crowding, an effect not moderated by equity measures. Patients were 52% to 74% less likely to receive timely care and were 9% to 14% less likely to receive effective care when each crowding measure was at the 75th rather than at the 25th percentile (P<.05).

CONCLUSION

ED crowding is associated with decreased timeliness and effectiveness-but not equity-of care for children with acute asthma.

A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study

BACKGROUND

Patients with chest pain contribute substantially to emergency department attendances, lengthy hospital stay, and inpatient admissions. A reliable, reproducible, and fast process to identify patients presenting with chest pain who have a low short-term risk of a major adverse cardiac event is needed to facilitate early discharge. We aimed to prospectively validate the safety of a predefined 2-h accelerated diagnostic protocol (ADP) to assess patients presenting to the emergency department with chest pain symptoms suggestive of acute coronary syndrome.

METHODS

This observational study was undertaken in 14 emergency departments in nine countries in the Asia-Pacific region, in patients aged 18 years and older with at least 5 min of chest pain. The ADP included use of a structured pre-test probability scoring method (Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiograph, and point-of-care biomarker panel of troponin, creatine kinase MB, and myoglobin. The primary endpoint was major adverse cardiac events within 30 days after initial presentation (including initial hospital attendance). This trial is registered with the Australia-New Zealand Clinical Trials Registry, number ACTRN12609000283279.

FINDINGS

3582 consecutive patients were recruited and completed 30-day follow-up. 421 (11.8%) patients had a major adverse cardiac event. The ADP classified 352 (9.8%) patients as low risk and potentially suitable for early discharge. A major adverse cardiac event occurred in three (0.9%) of these patients, giving the ADP a sensitivity of 99.3% (95% CI 97.9-99.8), a negative predictive value of 99.1% (97.3-99.8), and a specificity of 11.0% (10.0-12.2).

INTERPRETATION

This novel ADP identifies patients at very low risk of a short-term major adverse cardiac event who might be suitable for early discharge. Such an approach could be used to decrease the overall observation periods and admissions for chest pain. The components needed for the implementation of this strategy are widely available. The ADP has the potential to affect health-service delivery worldwide.

FUNDING

Alere Medical (all countries), Queensland Emergency Medicine Research Foundation and National Health and Medical Research Council (Australia), Christchurch Cardio-Endocrine Research Group (New Zealand), Medquest Jaya Global (Indonesia), Science International (Hong Kong), Bio Laboratories Pte (Singapore), National Heart Foundation of New Zealand, and Progressive Group (Taiwan).

Operational and financial impact of physician screening in the ED

BACKGROUND

Physician screening is one of many front-end interventions being implemented to improve emergency department (ED) efficiency.

STUDY OBJECTIVE

We aimed to quantify the operational and financial impact of this intervention at an urban tertiary academic center.

METHODS

We conducted a 2-year before-after analysis of a physician screening system at an urban tertiary academic center with 90 000 annual visits. Financial impact consisted of the ED and inpatient revenue generated from the incremental capacity and the reduction in left without being seen (LWBS) rates. The ED and inpatient margin contribution as well as capital expenditure were based on available published data. We summarized the financial impact using net present value of future cash flows performing sensitivity analysis on the assumptions. Operational outcome measures were ED length of stay and percentage of LWBS.

RESULTS

During the first year, we estimate the contribution margin of the screening system to be $2.71 million and the incremental operational cost to be $1.86 million. Estimated capital expenditure for the system was $1 200 000. The NPV of this investment was $2.82 million, and time to break even from the initial investment was 13 months. Operationally, despite a 16.7% increase in patient volume and no decrease in boarding hours, there was a 7.4% decrease in ED length of stay and a reduction in LWBS from 3.3% to 1.8%.

CONCLUSIONS

In addition to improving operational measures, the implementation of a physician screening program in the ED allowed for an incremental increase in patient care capacity leading to an overall positive financial impact.

Improving door-to-physician times in 2 community hospital emergency departments

Door-to-physician time in the emergency department (ED) correlates with patient satisfaction and clinical quality and outcomes. Delays in seeing a provider result in a 3% nationwide rate of patients leaving without being seen (LWBS) after presenting for ED care. Two community hospitals had door-to-physician times of 51 and 47 minutes. The LWBS rates were 3% and 2%. A quality improvement project was initiated with a change package, including prompts, training, and feedback. Door-to-physician times decreased to 31 and 27 minutes. The change occurred in less than a month and was sustained for 6 months after the study. In addition, the LWBS rates at each facility fell by one third. Basic process improvement strategies borrowed from service industries were used in 2 EDs to improve the door-to-physician process.

Matching capacity to demand: a regional dashboard reduces ambulance avoidance and improves accessibility of receiving hospitals

OBJECTIVES

ambulance diversion is a dangerous repercussion of emergency department (ED) crowding and can reflect fragmentation and a lack of coordination in designating optimal patient offload sites for prehospital providers. The objective of this study was to evaluate whether proactive destination selection through the Regional Emergency Patient Access and Coordination (REPAC) program would enhance capacity and ED flow management.

METHODS

the REPAC system provides a dashboard that synthesizes real-time capacity and acuity data for all three adult EDs in the city of Calgary, assigning a color code to reflect receiving status. It assigns destination for the next patient transported by emergency medical services (EMS) by categorizing ED sites as having either a favorable (green/yellow) status or unfavorable (orange/red) status. Three time windows were analyzed: a 6-month window prior to REPAC implementation (pre), the first 6-month window immediately following (post1), and the second 6-month period following (post2). Primary outcomes of interest were the proportion of time spent in favorable versus unfavorable status and EMS avoidances for all adult ED sites in the region (percentage of total time with any center on EMS bypass). Information on total number of ED visits, percentage of patients arriving by EMS transports, admission rates, patient acuity (Canadian Triage and Acuity Score), age, and length of stay (LOS) for admitted and discharged patients was collected. The Kruskal-Wallis test was employed for primary outcome analysis.

RESULTS

implementation of the REPAC system resulted in an increase in the proportion of total time region hospitals reported favorable status (57.5% vs. 64.1%) pre versus post1, an effect that was accentuated at 1 year (post2, 78.7%; p < 0.001 for both comparisons). There was a concomitant decrease in EMS avoidances as a result of the REPAC system, 4.4% to 1.8% (pre vs. post1), also further improved at 1 year to 0.6% (p < 0.001 for both comparisons).

CONCLUSIONS

proactive EMS destination selection through a real-time integrated electronic surveillance system enhances regional capacity and flow management while significantly reducing ambulance diversions.

Out of hours care: a profile analysis of patients attending the emergency department and the general practitioner on call

Background

Overuse of emergency departments (ED) is of concern in Western society and it is often referred to as 'inappropriate' use. This phenomenon may compromise efficient use of health care personnel, infrastructure and financial resources of the ED. To redirect patients, an extensive knowledge of the experiences and attitudes of patients and their choice behaviour is necessary. The aim of this study is to quantify the patients and socio-economical determinants for choosing the general practitioner (GP) on call or the ED.

Methods

Data collection was conducted simultaneously in 4 large cities in Belgium. All patients who visited EDs or used the services of the GP on call during two weekends in January 2005 were enrolled in the study in a prospective manner. We used semi-structured questionnaires to interview patients from both services.

Results

1611 patient contacts were suitable for further analysis. 640 patients visited the GP and 971 went to the ED. Determinants that associated with the choice of the ED are: being male, having visited the ED during the past 12 months at least once, speaking another language than Dutch or French, being of African (sub-Saharan as well as North African) nationality and no medical insurance. We also found that young men are more likely to seek help at the ED for minor trauma, compared to women.

Conclusions

Patients tend to seek help at the service they are acquainted with. Two populations that distinctively seek help at the ED for minor medical problems are people of foreign origin and men suffering minor trauma. Aiming at a redirection of patients, special attention should go to these patients. Informing them about the health services' specific tasks and the needlessness of technical examinations for minor trauma, might be a useful intervention.

Identifying key metrics for reducing premature departure from the pediatric emergency department

OBJECTIVES

Approximately 2% to 5% of children presenting to pediatric emergency departments (PEDs) leave prior to a complete evaluation. This study assessed risk factors for premature departure (PD) from a PED to identify key metrics and cutoffs for reducing the PD rate.

METHODS

A 3-year cohort (June 2004-May 2007) of children presenting to a PED was evaluated. Children were excluded if they presented for psychiatric issues, were held awaiting hospital admission in the PED due to a lack of inpatient beds, were more than 21 years old, or died before disposition. Univariate analyses, multivariable logistic regression, and recursive partitioning were used to identify factors associated with PD. A fourth year of data (June 2007-May 2008) was used for validation and sensitivity analysis.

RESULTS

There were 132,324 patient visits in the 3-year derivation data set with a 3.8% PD rate, and 45,001 visits in the fourth-year validation data set with a 4.3% PD rate. PDs were minimized when average wait time was below 110 minutes, concurrent PDs were fewer than two, and average length of stay (LOS) was less than 224 minutes in the derivation set, with similar results in the validation set. When these metrics were exceeded, PD rates were over 10% among low-acuity patients. These findings were robust across a broad range of assumptions during sensitivity analysis.

CONCLUSIONS

The authors identified five key metrics associated with PD in the PED: average wait time, average LOS, acuity, concurrent PDs, and arrival rate. Operational cutoffs for these metrics, determined by recursive partitioning, may be useful to physicians and administrators when selecting specific interventions to address PDs from the PED.

The relationship between inpatient discharge timing and emergency department boarding

BACKGROUND

Patient crowding and boarding in Emergency Departments (EDs) impair the quality of care as well as patient safety and satisfaction. Improved timing of inpatient discharges could positively affect ED boarding, and this hypothesis can be tested with computer modeling.

STUDY OBJECTIVE

Modeling enables analysis of the impact of inpatient discharge timing on ED boarding. Three policies were tested: a sensitivity analysis on shifting the timing of current discharge practices earlier; discharging 75% of inpatients by 12:00 noon; and discharging all inpatients between 8:00 a.m. and 4:00 p.m.

METHODS

A cross-sectional computer modeling analysis was conducted of inpatient admissions and discharges on weekdays in September 2007. A model of patient flow streams into and out of inpatient beds with an output of ED admitted patient boarding hours was created to analyze the three policies.

RESULTS

A mean of 38.8 ED patients, 22.7 surgical patients, and 19.5 intensive care unit transfers were admitted to inpatient beds, and 81.1 inpatients were discharged daily on September 2007 weekdays: 70.5%, 85.6%, 82.8%, and 88.0%, respectively, occurred between noon and midnight. In the model base case, total daily admitted patient boarding hours were 77.0 per day; the sensitivity analysis showed that shifting the peak inpatient discharge time 4h earlier eliminated ED boarding, and discharging 75% of inpatients by noon and discharging all inpatients between 8:00 a.m. and 4:00 p.m. both decreased boarding hours to 3.0.

CONCLUSION

Timing of inpatient discharges had an impact on the need to board admitted patients. This model demonstrates the potential to reduce or eliminate ED boarding by improving inpatient discharge timing in anticipation of the daily surge in ED demand for inpatient beds.

Emergency department throughput, crowding, and financial outcomes for hospitals

Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals. This is because ED crowding allows hospitals to maximize occupancy with well-insured, elective patients while patients wait in the ED. In this article, the authors propose a more holistic model of hospital flow and revenue that contradicts this notion and offer suggestions for improvements in ED and hospital management that may not only reduce crowding and improve quality, but also increase hospital revenues. Also proposed is that increased efficiency and quality in U.S. hospitals will require changes in systematic microeconomic and macroeconomic incentives that drive the delivery of health services in the United States. Finally, the authors address several questions to propose mutually beneficial solutions to ED crowding that include the realignment of hospital incentives, changing culture to promote flow, and several ED-based strategies to improve ED efficiency.

The impact on patient flow after the integration of nurse practitioners and physician assistants in 6 Ontario emergency departments

OBJECTIVE

We sought to assess the impact of the integration of the new roles of primary health care nurse practitioners (NPs) and physician assistants (PAs) on patient flow, wait times and proportions of patients who left without being seen in 6 Ontario emergency departments (EDs).

METHODS

We performed a retrospective review of health records data on patient arrival time, time of initial assessment by a physician, time of discharge from the ED and discharge status.

RESULTS

Whether a PA or NP was directly involved in the care of patients or indirectly involved by being on duty, the wait times, lengths of stay and proportion of patients who left without being seen were significantly reduced. When a PA or NP were directly involved in patients' care, patients were 1.6 (95% confidence interval [CI] 1.3-2.1, p < 0.05) and 2.1 (95% CI 1.6-2.8, p < 0.05) times more likely to be seen within the wait time benchmarks, respectively. Lengths of stay were 30.3% (95% CI 21.6%-39.0%, p < 0.01) and 48.8% (95% CI 35.0%-62.7%, p < 0.01) lower when PAs and NPs, respectively, were involved. When PAs and NPs were not on duty, the proportion of patients who left without being seen were 44% (95% CI 31%-63%, p < 0.01) and 71% (95% CI 53%-96%, p < 0.05), respectively.

CONCLUSION

The addition of PAs or NPs to the ED team can improve patient flow in medium-sized community hospital EDs. Given the ongoing shortage of physicians, use of alternative health care providers should be considered. These results require validation, as their generalizability to other locations or types of EDs is not known.

Electronic Medical Records and the Efficiency of Hospital Emergency Departments

This study examined the relationship between electronic medical records (EMR) sophistication and the efficiency of U.S. hospital emergency departments (EDs). Using data from the 2006 National Hospital Ambulatory Medical Care Survey, survey-weighted ordinary least squares regressions were used to estimate the association of EMR sophistication with ED throughput and probability a patient left without treatment. Instrumental variables were used to test for the presence of endogeneity and reverse causality. Greater EMR sophistication had a mixed association with ED efficiency. Relative to EDs with minimal or no EMR, fully functional EMR was associated with 22.4% lower ED length of stay and 13.1% lower diagnosis/treatment time. However, the relationships varied by patient acuity level and diagnostic services provided. Surprisingly, EDs with basic EMR were not more efficient on average, and basic EMR had a nonlinear relationship with efficiency that varied with the number of EMR functions used.

At-risk populations and the critically ill rely disproportionately on ambulance transport to emergency departments

STUDY OBJECTIVE

Emergency department (ED) crowding increases ambulance diversion. Ambulance diversion disproportionately affects individuals who rely on ambulance transport. The purpose of this study is to determine which populations rely most on ambulance transport.

METHODS

We queried the National Hospital Ambulatory Medical Care Survey database for 1997 to 2000 and 2003 to 2005 for patients who arrived by ambulance or personal transport. We performed bivariate analysis to assess the extent to which all patients and a subset of critically ill patients use ambulance transport relative to self-transport.

RESULTS

In our sample, 30,455 (15%; 95% confidence interval [CI] 15% to 16%) patients arrived by ambulance and 162,091 (85%; 95% CI 84% to 85%) arrived by walk-in/self-transport. Overall, patients with Medicare insurance were more likely to rely on ambulance transport, at 34% (95% CI 33% to 35%), than the privately insured, at 11% (95% CI 10% to 11%). Among the critically ill, privately insured patients were less likely to rely on ambulance transport, at 47% (95% CI 42% to 52%), than those with Medicare insurance (61%; 95% CI 58% to 65%), the publicly insured (60%; 95% CI 52% to 67%), or the uninsured (57%; 95% CI 49% to 64%). Among the critically ill, patients aged 15 to 24 years and those older than 74 years were most likely to rely on ambulance transport, at 63% (95% CI 53% to 72%) and 67% (95% CI 62% to 71%), respectively. Fifty-seven percent (95% CI 54% to 59%) of the critically ill used ambulance versus 15% (95% CI 14% to 15%) of noncritical patients.

CONCLUSION

Patients with Medicare insurance or public insurance, the uninsured, the elderly, and the critically ill disproportionately rely on ambulance transport to the ED. Ambulance diversion may disproportionately affect these populations.

Supplemented Triage and Rapid Treatment (START) improves performance measures in the emergency department

BACKGROUND

Emergency Department (ED) crowding is well recognized, and multiple studies have demonstrated its negative effect on patient care.

STUDY OBJECTIVES

This study aimed to assess the effect of an intervention, Supplemented Triage and Rapid Treatment (START), on standard ED performance measures. The START program complemented standard ED triage with a team of clinicians who initiated the diagnostic work-up and selectively accelerated disposition in a subset of patients.

METHODS

This retrospective before-after study compared performance measures over two 3-month periods (September-November 2007 and 2008) in an urban, academic tertiary care ED. Data from an electronic patient tracking system were queried over 12,936 patients pre-intervention, and 14,220 patients post-intervention. Primary outcomes included: 1) overall length of stay (LOS), 2) LOS for discharged and admitted patients, and 3) the percentage of patients who left without complete assessment (LWCA).

RESULTS

In the post-intervention period, patient volume increased 9% and boarder hours decreased by 1.3%. Median overall ED LOS decreased by 29 min (8%, 361 min pre-intervention, 332 min post-intervention; p < 0.001). Median LOS for discharged patients decreased by 23 min (7%, 318 min pre-intervention, 295 min post-intervention; p < 0.001), and by 31 min (7%, 431 min pre-intervention, 400 min post-intervention) for admitted patients. LWCA was decreased by 1.7% (4.1% pre-intervention, 2.4% post-intervention; p < 0.001).

CONCLUSIONS

In this study, a comprehensive screening and clinical care program was associated with a significant decrease in overall ED LOS, LOS for discharged and admitted patients, and rate of LWCA, despite an increase in ED patient volume.

Premature departure from the pediatric emergency department: a cohort analysis of process- and patient-related factors

OBJECTIVE

Previous literature suggests that process-related factors (eg, time of day, patient volume) and patient-related factors (eg, acuity, socioeconomic status) are associated with premature departure from emergency departments. We sought to evaluate the relationship of these and other factors with premature departure in a large, unselected cohort of pediatric emergency department patients.

METHODS

This study was a retrospective cohort analysis of visits to a single tertiary site during a 1-year period. Patients' zip codes determined assignment of census-based socioeconomic metrics. Multivariate regression identified factors associated with premature departure. Sensitivity and subset analyses were performed. Return visits within 48 hours after premature departure were also reviewed.

RESULTS

There were 46,417 visits, of which 2164 were premature departures. In multivariate analysis, independent predictors of premature departures were arrival time, arrival month, arrival day of week, patient acuity, concurrent premature departures, arrival rate, arrival period average length of stay, and poverty rate. Aside from patient acuity and poverty rate, no patient-related factors were significant in multivariate analysis. These results were robust in sensitivity analysis across different multivariate models. Among premature departures, there were 120 return visits (5.5%), of which 15 were admitted (0.7%). There were no deaths. Acuity was similar between initial and subsequent visits.

CONCLUSIONS

Process-related factors and individual patient acuity have the strongest influence on premature departure from the pediatric emergency department. Health care organizations concerned with premature departure should focus efforts on improving pediatric emergency process flow.