The effect of emergency department crowding on clinically oriented outcomes

Causes of Prolonged Emergency Department Stay; a Cross-sectional Action Research

INTRODUCTION

Based on the existing standards, patients presenting to emergency department (ED) should receive a decision in a maximum of 6 hours after admission to ED and leave ED in this time. Unfortunately, most of the time, especially in general and referral hospitals, we witness patients staying in the ED for hours or even days after a decision has been made.

OBJECTIVE

the present study was performed with the aim of evaluating the causes of patients' prolonged length of stay in ED of one of the major hospitals in Tehran, Iran.

METHOD

The present cross-sectional action research was carried out in the ED of Imam Khomeini Hospital, Tehran, Iran, in November and December 2016. The studied population consisted of patients who stayed in ED for more than 12 hours. In a panel consist of specialists, semi-structured and open questions were asked from the participants. All the interviews were recorded and converted to text. Effective factors of staying more than 12 hours in ED mentioned by the interviewees were extracted. A checklist of evaluating the causes of more than 12 hours stay in ED was prepared. In the next stage, by daily visit to the ED of the studied hospital, profile of the patients who had stayed in the ED for more than 12 hours was evaluated and the variables determined in the checklist were assessed.

RESULTS

In the present study, 407 patients with the mean age of 54.07±20.18 years (minimum 1 and maximum 113 years) were studied, 270 (65.7%) of which were male. Respectively, 26 (6.4%) were admitted in triage level 1, 203 (49.9%) in triage level 2, 168 (41.3%) in triage level 3, 9 (2.2%) in triage level 4 and 1 (0.2%) in triage level 5. Based on these findings, "services not wanting to transfer patients with decisions to the service" was the most common factor.

CONCLUSION

In the present study, specialized services not tending to dislocate the patients that have been decided upon to their respective department, a considerable number of complicated patients and patients with advanced underlying illnesses among those presenting to ED, and shortage of beds in specialized departments and ICU, were the most common causes affecting more than 12 hours stay of patients in the studied ED.

A Discrete Event Simulation Model of Patient Flow in a General Hospital Incorporating Infection Control Policy for Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococcus (VRE)

BACKGROUND

Hospitalized patients are assigned to available staffed beds based on patient acuity and services required. In hospitals with double-occupancy rooms, patients must be additionally matched by gender. Patients with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) must be bedded in single-occupancy rooms or cohorted with other patients with similar MRSA/VRE flags.

METHODS

We developed a discrete event simulation (DES) model of patient flow through an acute care hospital. Patients are matched to beds based on acuity, service, gender, and known MRSA/VRE colonization. Outcomes included time to bed arrival, length of stay, patient-bed acuity mismatches, occupancy, idle beds, acuity-related transfers, rooms with discordant MRSA/VRE colonization, and transmission due to discordant colonization.

RESULTS

Observed outcomes were well-approximated by model-generated outcomes for time-to-bed arrival (6.7 v. 6.2 to 6.5 h) and length of stay (3.3 v. 2.9 to 3.0 days), with overlapping 90% coverage intervals. Patient-bed acuity mismatches, where patient acuity exceeded bed acuity and where patient acuity was lower than bed acuity, ranged from 0.6 to 0.9 and 8.6 to 11.1 mismatches per h, respectively. Values for observed occupancy, total idle beds, and acuity-related transfers compared favorably to model-predicted values (91% v. 86% to 87% occupancy, 15.1 v. 14.3 to 15.7 total idle beds, and 27.2 v. 22.6 to 23.7 transfers). Rooms with discordant colonization status and transmission due to discordance were modeled without an observed value for comparison. One-way and multi-way sensitivity analyses were performed for idle beds and rooms with discordant colonization.

CONCLUSIONS

We developed and validated a DES model of patient flow incorporating MRSA/VRE flags. The model allowed for quantification of the substantial impact of MRSA/VRE flags on hospital efficiency and potentially avoidable nosocomial transmission.

The durability of operational improvements with rotational patient assignment

INTRODUCTION

Previous work has suggested that Emergency Department rotational patient assignment (a system in which patients are algorithmically assigned to physicians) is associated with immediate (first-year) improvements in operational metrics. We sought to determine if these improvements persisted over a longer follow-up period.

METHODS

Single-site, retrospective analysis focused on years 2-4 post-implementation (follow-up) of a rotational patient assignment system. We compared operational data for these years with previously published data from the last year of physician self-assignment and the first year of rotational patient assignment. We report data for patient characteristics, departmental characteristics and facility characteristics, as well as outcomes of length of stay (LOS), arrival to provider time (APT), and rate of patients who left before being seen (LBBS).

RESULTS

There were 140,673 patient visits during the five year period; 138,501 (98.7%) were eligible for analysis. LOS, APT, and LBBS during follow-up remained improved vs. physician self-assignment, with improvements similar to those noted in the first year of implementation. Compared with the last year of physician self-assignment, approximate yearly average improvements during follow-up were a decrease in median LOS of 18min (8% improvement), a decrease in median APT of 21min (54% improvement), and a decrease in LBBS of 0.69% (72% improvement).

CONCLUSION

In a single facility study, rotational patient assignment was associated with sustained operational improvements several years after implementation. These findings provide further evidence that rotational patient assignment is a viable strategy in front-end process redesign.

Effect of the 4-h target on ‘time-to-ECG’ in patients presenting with chest pain to an emergency department: a pilot retrospective observational study

Objectives The aim of this study was to assess the relationship between compliance with time-based Emergency Department (ED) targets (known as NEAT) and the time taken to collect an electrocardiogram (TTE) in patients presenting with chest pain. Methods This was a pilot descriptive retrospective cohort study completed in a large inner city tertiary ED. Patients who presented with active or recent chest pain between July 2014 and June 2015 were eligible for inclusion. Pregnant patients, inter-hospital transfers, and traumatic chest pain were excluded. A random selection of 300 patients from the eligible cohort comprised the final sample. The differences of TTE between categories of NEAT compliance were compared using Kruskal-Wallis test. Also, the factors affecting with the acquisition of ECG within ten minutes of arrival were explored using proportional hazards regression. Results There was a significant inverse association between the percentage of admitted patients leaving the ED within four hours (admitted NEAT) and TTE. As admitted NEAT compliance increased TTE decreased (p = 0.004). A number of variables including triage score, arrival time, total NEAT, first location, doctor wait time, and cardiac diagnosis were all significant predictors of TTE. After adjusting for other variables Admitted NEAT remained as an independent predictor of TTE. Conclusion There is likely to be a relationship between NEAT and TTE that is reflective of overall hospital and not just ED functioning; however the exact relationship remains uncertain. Further study in a multisite study is warranted to further explore the relationship between NEAT, TTE and other important clinical metrics of ED performance. What is known about the topic? The 4-h time target or National Emergency Access Target (NEAT) is implemented in Australia to ease crowding and access block. However, little is known of its effect on important clinical endpoints, particularly ‘time-to-ECG’ (TTE). What does this paper add? This paper demonstrates a complex relationship between measures of time-based targets, such as time to ECG. It is likely that increasing compliance with admitted NEAT shortens TTE, demonstrating the effect of hospital functioning on the ability to deliver quality care in the emergency department. What are the implications for practitioners? Emergency department flow has an effect on the ability of the department to deliver key assessment. There is a relationship between NEAT compliance and TTE, but the exact relationship requires further exploration in larger multicentre studies.

Reducing High-Users' Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study

Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use-based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users' mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P < .001). Postintervention, the visit rates of new high-users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users' rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention.

A 2-hour Accelerated Chest Pain Protocol to Assess Patients with Chest Pain Symptoms in an Accident and Emergency Department in Hong Kong

Background

The present study is a follow up analysis of ASPECT study. We aimed to prospectively validate a 2-hour accelerated chest pain protocol (ACPP) to assess patients presenting to emergency department with chest pain symptoms suggestive of acute coronary syndrome.

Methods

This observational study was carried out between June 2009 and July 2010. Patients were included if they were older than 18 years old and presented with at least 5 minutes duration of chest pain. The ACPP included modified Thrombolysis in Myocardial Infarction score, electrocardiograph and point-of-care troponin I at presentation and 2-hour after. Primary endpoint was major adverse cardiac event (MACE) at 45-day of initial hospital attendance.

Results

A total of 384 Chinese patients were recruited and completed 45-day follow up. Forty-five (11.7%) had 45-d MACE. The ACPP identified 124 (32.3%) low risk patients who could be discharged early. No MACE occurred within 45 days among these patients, giving a sensitivity of 100% (95% CI 90-100), a negative predictive value of 100% (96-100), and a specificity of 36.6% (31.5-42).

Conclusions

The ACPP is able to identify very low risk chest pain patients who might be suitable for early discharge without increasing risk of developing MACE. The observation period can be shortened to 2-hour of ED presentation. The variables are objective and easily available. This 2-hour Hong Kong Chest Pain Rule is applicable to Chinese population and has the potential to change the current practice in Emergency Departments in Hong Kong and China.

Analysis of the Internal Bed Regulation Committees from hospitals of a Southern Brazilian city

Objective

To evaluate the composition of the Internal Regulation Committees created in hospitals of a capital city.

Methods

A cross-sectional descriptive study assessing the structure, processes and results of each Committee.

Results

The main reasons for implementing the committees were legal issues and overcrowding in the emergency department. The most monitored indicators were the occupancy rate and the mean length of stay, and the most observed results were reductions in the latter. Institutional protocols were developed in 70% of cases, and the degree of support that the Internal Regulation Committee received from the hospital managers was high, despite being only average the support received from the medical teams. Promoting the efficient use of beds seemed to be the main goal. To achieve it, the Internal Regulation Committee had to control hospital capacity at levels that allowed proper and safe bed turnover for patients. The strategies for this were varied and needed to integrate administrative and care issues.

Conclusion

The Internal Regulation Committees were a management tool with great potential and promising results in the experiences evaluated.

Prognosticating Clinical Prediction Scores Without Clinical Gestalt for Patients With Chest Pain in the Emergency Department

BACKGROUND

Assessment of patients with chest pain is a regular challenge in the emergency department (ED). Recent guidelines recommended quantitative assessment of ischemic risk by means of risk scores.

OBJECTIVE

Our aim was to assess the performance of Thrombosis in Myocardial Infarction (TIMI); Global Registry of Acute Coronary Events (GRACE); history, electrocardiogram, age, risk factors, and troponin (HEART) scores; and the North America Chest Pain Rule (NACPR) without components of clinical gestalt in predicting 30-day major adverse cardiac events (MACE).

METHODS

We performed a prospective cohort study in adult patients who attended the ED with undifferentiated chest pain. Clinical prediction rules were applied and calculated. The clinical prediction rules were modified from the original ones, excluding components requiring judgment by clinical gestalt. The primary outcome was MACE. Performance of the tests were evaluated by receive operating characteristic curves and the area under curves (AUC).

RESULTS

There were 1081 patients included in the study. Thirty-day MACE occurred in 164 (15.2%) patients. The AUC of the GRACE score was 0.756, which was inferior to the TIMI score (AUC 0.809) and the HEART score (AUC 0.845). A TIMI score ≥ 1 had a sensitivity of 97% and a specificity of 45.7%. A GRACE score ≥ 50 had a sensitivity of 99.4% and a specificity of 7.5%. A HEART score ≥ 1 had a sensitivity of 98.8% and a specificity of 11.7%. The NACPR had a sensitivity of 93.3% and a specificity of 51.5%.

CONCLUSIONS

Without clinical gestalt, the modified HEART score had the best discriminative capacity in predicting 30-day MACE.

Understanding ED performance after the implementation of activity-based funding

OBJECTIVE

The aim of this study was to describe emergency department (ED) activities and staffing after the introduction of activity-based funding (ABF) to highlight the challenges of new funding arrangements and their implementation.

METHODS

A retrospective study of public hospital EDs in Queensland, Australia, was undertaken for 2013-2014. The ED and hospital characteristics are described to evaluate the alignment between activity and resourcing levels and their impact on performance.

RESULTS

Twenty EDs participated (74% response rate). Weighted activity units (WAUs) and nursing staff varied based on hospital type and size. Larger hospital EDs had on average 9076 WAUs and 13 full time equivalent (FTE) nursing staff per 1000 WAUs; smaller EDs had on average 4587 WAUs and 10.3 FTE nursing staff per 1000 WAUs. Medical staff was relatively consistent (8.1-8.7 FTE per 1000 WAUs). The proportion of patients admitted, discharged, or transferred within 4 hours ranged from 73% to 79%. The ED medical and nursing staffing numbers did not correlate with the 4-hour performance.

CONCLUSION

Substantial variation exists across Queensland EDs when resourcing service delivery in an activity-based funding environment. Historical inequity persists in the staffing profiles for regional and outer metropolitan departments. The lack of association between resourcing and performance metrics provides opportunity for further investigation of efficient models of care.

Application of time series analysis in modelling and forecasting emergency department visits in a medical centre in Southern Taiwan

OBJECTIVE

Emergency department (ED) overcrowding is acknowledged as an increasingly important issue worldwide. Hospital managers are increasingly paying attention to ED crowding in order to provide higher quality medical services to patients. One of the crucial elements for a good management strategy is demand forecasting. Our study sought to construct an adequate model and to forecast monthly ED visits.

METHODS

We retrospectively gathered monthly ED visits from January 2009 to December 2016 to carry out a time series autoregressive integrated moving average (ARIMA) analysis. Initial development of the model was based on past ED visits from 2009 to 2016. A best-fit model was further employed to forecast the monthly data of ED visits for the next year (2016). Finally, we evaluated the predicted accuracy of the identified model with the mean absolute percentage error (MAPE). The software packages SAS/ETS V.9.4 and Office Excel 2016 were used for all statistical analyses.

RESULTS

A series of statistical tests showed that six models, including ARIMA (0, 0, 1), ARIMA (1, 0, 0), ARIMA (1, 0, 1), ARIMA (2, 0, 1), ARIMA (3, 0, 1) and ARIMA (5, 0, 1), were candidate models. The model that gave the minimum Akaike information criterion and Schwartz Bayesian criterion and followed the assumptions of residual independence was selected as the adequate model. Finally, a suitable ARIMA (0, 0, 1) structure, yielding a MAPE of 8.91%, was identified and obtained as Visit_t=7111.161+(a_t+0.37462 a_t-1).

CONCLUSION

The ARIMA (0, 0, 1) model can be considered adequate for predicting future ED visits, and its forecast results can be used to aid decision-making processes.

Routine blood tests are associated with short term mortality and can improve emergency department triage: a cohort study of >12,000 patients

BACKGROUND

Prioritization of acutely ill patients in the Emergency Department remains a challenge. We aimed to evaluate whether routine blood tests can predict mortality in unselected patients in an emergency department and to compare risk prediction with a formalized triage algorithm.

METHODS

A prospective observational cohort study of 12,661 consecutive admissions to the Emergency Department of Nordsjælland University Hospital during two separate periods in 2010 (primary cohort, n = 6279) and 2013 (validation cohort, n = 6383). Patients were triaged in five categories by a formalized triage algorithm. All patients with a full routine biochemical screening (albumin, creatinine, c-reactive protein, haemoglobin, lactate dehydrogenase, leukocyte count, potassium, and sodium) taken at triage were included. Information about vital status was collected from the Danish Central Office of Civil registration. Multiple logistic regressions were used to predict 30-day mortality. Validation was performed by applying the regression models on the 2013 validation cohort.

RESULTS

Thirty-day mortality was 5.3%. The routine blood tests had a significantly stronger discriminative value on 30-day mortality compared to the formalized triage (AUC 88.1 [85.7;90.5] vs. 63.4 [59.1;67.5], p < 0.01). Risk stratification by routine blood tests was able to identify a larger number of low risk patients (n = 2100, 30-day mortality 0.1% [95% CI 0.0;0.3%]) compared to formalized triage (n = 1591, 2.8% [95% CI 2.0;3.6%]), p < 0.01.

CONCLUSIONS

Routine blood tests were strongly associated with 30-day mortality in acutely ill patients and discriminatory ability was significantly higher than with a formalized triage algorithm. Thus routine blood tests allowed an improved risk stratification of patients presenting in an emergency department.

The effect on the patient flow in local health care services after closing a suburban primary care emergency department: a controlled longitudinal follow-up study

Background

It has not been studied what happens to patient flow to EDs and other parts of local health care system if distances to ED services are manipulated as a part of health policy in urban areas.

Methods

The present work was an observational and quasi-experimental study with a control and it was based on before-after comparisons. The impact of terminating a geographically distant suburban primary care ED on patient flow to doctors in local public primary care EDs, office-hour primary care, secondary care EDs and in private primary care was studied. The effect of this intervention was compared with a primary care system where no similar intervention was performed. The number of monthly visits to doctors in different departments of health care was scored as the main measure of the study in each department studied (e.g. in primary care EDs, secondary care ED, office-hour public primary care and private primary care). Monthly mortality rates were also recorded.

Results

Increasing the distance to ED services by terminating a peripheral ED did not cause an increase in the use of local office-hour services in those areas whose local ED was terminated, although use of ED services decreased by 25% in these areas (P < 0.001). The total use of primary care doctor services rather decreased - if anything - after this intervention while use of doctor services in secondary care ED remained unaffected. Doctor visits to the complementary private primary care increased but this was probably not associated with the intervention because a simultaneous increase in this parameter was observed in the control. There was no increased mortality in any age groups.

Conclusion

Manipulating distances to ED services can be used to direct patient flows to different parts of the health care system. The correlation between distance to ED and the tendency to use ED by inhabitants is negative. If secondary care ED was available there were no life-threatening side-effects at the level of general public health when a minor ED was closed in a primary care ED system.

Introduction of a Horizontal and Vertical Split Flow Model of Emergency Department Patients as a Response to Overcrowding

INTRODUCTION

ED overcrowding is an issue that is affecting every emergency department and every hospital. The inability to maintain patient flow into and out of the emergency department paralyzes the ability to provide effective and timely patient care. Many solutions have been proposed on how to mitigate the effects of ED overcrowding. Solutions involve either hospital-wide initiatives or ED-based solutions. In this article, the authors seek to describe and provide metrics for a patient flow methodology that targets ESI 3 patients in a vertical flow model.

METHODS

In the Stanford Emergency Department, a vertical flow model was created from existing ED space by removing fold-down horizontal stretchers and replacing them with multiple chairs that allowed for assessment and medical management in an upright sitting position. The model was launched and sustained through frequent interdisciplinary huddles, detailed inclusion and exclusion criteria, scripted text on how to promote the flow model to patients, and close analytics of metrics. Metrics for success included patient length of stay (LOS) for those triaged to the vertical flow area compared with ESI 3 patients triaged to the traditional emergency department as a comparison group. The secondary outcome is the total number of patients seen in the vertical flow area. This was a 6-month-September 2014, to February 2015-retrospective pre- and postintervention study that examined LOS as a marker for effective launch and implementation of a vertical patient workflow model.

RESULTS

The patients triaged to the vertical flow area in the study period tended to be younger than in the control period (43 years versus 52 years, P = 0.00). There was a significant decrease in our primary end point: the total LOS for ESI 3 patients triaged to the vertical flow area (270 minutes versus 384 minutes, P = 0.00).

CONCLUSION

Implementation of a vertical patient flow strategy can decrease LOS for the vertical ESI 3 patients based upon the inclusion and exclusion criteria. Furthermore, this is accomplished with minimal financial investment within the physical constraints of an existing emergency department.

Nursing Perceptions of the Emergency Severity Index as a Triage Tool in the United Arab Emirates: A Qualitative Analysis

INTRODUCTION

With emergency department crowding becoming an increasing problem across the globe, nursing triage to prioritize patients receiving care is ever more important. ESI is the most common triage system used in the United States and is increasingly used worldwide. This qualitative study that explores emergency nursing perceptions of the ESI identifies strengths, weaknesses, and barriers to implementation of the ESI internationally.

METHODS

We conducted a cross-sectional qualitative analysis using semistructured interviews of 27 emergency triage nurses. Content analysis was performed by 2 independent coders, using NVivo software to identify and analyze important themes.

RESULTS

Interview coding revealed 7 core themes related to use of the ESI (frequencies indicated in parentheses): ease of use (90), speed and efficiency (135), patient safety (12), accuracy and reliability (30), challenging patient characteristics (123), subjectivity and variability (173), and effect of triage system on team dynamics (100). Intercoder agreement was excellent (Cohen's unweighted kappa = 0.84). Subjectivity and variability in ESI score assignment consistently emerged in all interviews and included variability in number and use of resources, definition of "high risk," nursing experience, and subjectivity in pain assessment.

DISCUSSION

Although emergency nurses perceive the ESI as easy to use, there are concerns about the subjectivity and variability inherent in the ESI that can lead to a functional lack of triage and a burden of undifferentiated ESI level 3 patients. These limitations in separating critically ill patients and in stratifying patients based on anticipated required resources points to the need for improvement in the ESI algorithm or a more objective triage system that can predict patient outcomes.

Advanced Imaging Reduces Cost Compared to Standard of Care in Emergency Department of Triage of Acute Chest Pain

OBJECTIVE

To evaluate medical costs of novel therapies in complex medical settings using registry data.

DATA SOURCE/STUDY SETTING

Primary data, from 2008 to 2010. We used patient registry data to evaluate cost and quality performance of coronary computed tomography angiography (CCTA) in triaging chest pain patients in our tertiary care emergency department and to model financial performance under Medicare's two midnight rule.

STUDY DESIGN

Using generalized linear modeling, we retrospectively compared estimated expenditures for evaluation of low-to-intermediate-risk chest pain for demographic and medically risk matched samples of 894 patients each, triaged with CCTA or local standard of care (SOC) using Medicare reimbursement as a proxy.

DATA COLLECTION/EXTRACTION METHODS

Predefined data elements were downloaded from the hospital mainframe into the CCTA registry, where they were validated and maintained electronically.

PRINCIPLE FINDINGS

We found that predicted standard of care costs were 2.5 times higher on the initial visit and 1.98 times higher over 30 days (p < .001) than those using CCTA. Predicted cost was 1.6 times higher when we applied our two midnight rule model (p < .001).

CONCLUSION

Rapid assessment of treatment using registry data is a promising means of analyzing cost performance in complex health care environments.

We all make choices: A decision analysis framework for disposition decision in the ED

BACKGROUND

Emergency Department (ED) providers' disposition decision impacts patient care and safety. The objective of this brief report is to gain a better understanding of ED providers' disposition decision and risk tolerance of associated outcomes.

METHODS

We synthesized qualitative and quantitative methods including decision mapping, survey research, statistical analysis, and word clouds. Between July 2017 and August 2017, a 10-item survey was developed and conducted at the study hospital. Descriptive and statistical analyses were used to assess the relationship between the participant characteristics (age, gender, years of experience in the ED, and level of expertise) and risk tolerance of outcomes (72-h return and negative outcome) associated with disposition decision. Word clouds facilitated prioritization of qualitative responses regarding information impacting and supporting the disposition decision.

RESULTS

Total of 46 participants completed the survey. The mean age was 39.5 (standard deviation (SD) 10years), and mean years of experience was 9.6years (SD 8.7years). Decision map highlighted the connections between patient-, provider-, and system-related factors. Survey results showed that negative outcome resulted in less risk tolerance compared to 72-h return. Chi-square tests did not provide sufficient evidence to indicate that the responses are independent of participants characteristics - except age and the risk of 72-h return (p=0.046).

CONCLUSION

Discharge decision making in the ED is complex as it involves interconnected patient, provider, and system factors. Synthesizing qualitative and quantitative methods promise enhanced understanding of how providers arrive to disposition decision, as well as safety and quality of care in the ED.

The Clinical Differences between Urgent Visits and Non-Urgent Visits in Emergency Department During the Neonatal Period

As neonates are brought to the emergency department (ED) for various complaints, it is challenging for emergency physicians to clinically determine the urgency of the visit. We sought to explore clinical characteristics associated with urgent visits to the ED. We conducted a retrospective study by reviewing medical records of neonatal visits to a tertiary pediatric regional emergency center for 5 years. Cases of patients who were discharged after checking only chest or abdominal X-ray or discharged without workup, were classified as non-urgent visits. Cases where more examinations were performed, or when the patient was hospitalized, were classified as urgent visits. Various clinical features and process in the ED were compared between the groups. Of the 1,008 cases enrolled in this study, 856 (84.9%) were urgent and 152 (15.1%) were non-urgent visits. After adjustment by multiple logistic regression analysis, non-urgent visits were associated with self-referrals rather than physician-referrals (odds ratio [OR], 5.96), visits in the evening rather than at night or daytime (OR, 2.51), patient visits from home rather than from medical facilities (OR, 2.19; 95). Fever and jaundice were the most common complaints (25.7% and 24.5%, respectively), and their OR of non-urgent visit was relatively low (adjusted OR 0.03 and 0.03, respectively). However, other common complaints, such as vomiting and cough (7.4% and 7.1%, respectively), were more likely to be non-urgent visits (adjusted OR 2.96 and 9.83, respectively). For suspected non-urgent visits, emergency physicians need to try to reduce unnecessary workup and shorten length of stay in ED.

A Custom-Developed Emergency Department Provider Electronic Documentation System Reduces Operational Efficiency

STUDY OBJECTIVE

Electronic health record implementation can improve care, but may also adversely affect emergency department (ED) efficiency. We examine how a custom, ED provider, electronic documentation system (eDoc), which replaced paper documentation, affects operational performance.

METHODS

We analyzed retrospective operational data for 1-year periods before and after eDoc implementation in a single ED. We computed daily operational statistics, reflecting 60,870 pre- and 59,337 postimplementation patient encounters. The prespecified primary outcome was daily mean length of stay; secondary outcomes were daily mean length of stay for admitted and discharged patients and daily mean arrival time to disposition for admitted patients. We used a prespecified multiple regression model to identify differences in outcomes while controlling for prespecified confounding variables.

RESULTS

The unadjusted change in length of stay was 8.4 minutes; unadjusted changes in secondary outcomes were length of stay for admitted patients 11.4 minutes, length of stay for discharged patients 1.8 minutes, and time to disposition 1.8 minutes. With a prespecified regression analysis to control for variations in operational characteristics, there were significant increases in length of stay (6.3 minutes [95% confidence interval 3.5 to 9.1 minutes]) and length of stay for discharged patients (5.1 minutes [95% confidence interval 1.9 to 8.3 minutes]). There was no statistically significant change in length of stay for admitted patients or time to disposition.

CONCLUSION

In our single-center study, the isolated implementation of eDoc was associated with increases in overall and discharge length of stay. Our findings suggest that a custom-designed electronic provider documentation may negatively affect ED throughput. Strategies to mitigate these effects, such as reducing documentation requirements or adding clinical staff, scribes, or voice recognition, would be a valuable area of future research.

Systematically assessed symptoms as outcome predictors in emergency patients

INTRODUCTION

It is known that symptoms are predictive of mortality in "nonsurgical" emergency patients. It is unknown whether a prospective, systematic, and "unscreened" assessment of all symptoms is of any prognostic value. Therefore, we aimed to examine the association between symptoms and outcomes in an all-comer population.

METHODS

Data were acquired during 6weeks at the ED of the University Hospital Basel, a tertiary hospital. Consecutive patients presenting to the ED were included. Symptoms at presentation were systematically assessed using a comprehensive questionnaire.

RESULTS

A consecutive sample of 3960 emergency patients with a median age of 51years (51.7% male) was studied. The median number of symptoms was two. In the group of patients with the most prevalent symptoms, the median number of symptoms ranged between two and five. Overall, hospitalisation rate was 31.2%, referral to intensive care was 5.5%, in-hospital-mortality was 1.4%, and one-year mortality was 5.8%. In-hospital mortality ranged from 0% to 4.3%, and one-year mortality from 0% to 14.4% depending on the presenting symptoms. Dyspnoea and weakness were significant predictors of one-year mortality (14.4% and 9.2%, respectively).

DISCUSSION

Most emergency patients indicated two or more symptoms. Systematically assessed symptoms at presentation can be used for prediction of outcomes. While dyspnoea is a known predictor, weakness has not been identified as predictor of mortality before. This knowledge could be used to improve risk stratification- thereby reducing the risk of adverse outcomes.

Concepts, antecedents and consequences of ambulance ramping in the emergency department: A scoping review

BACKGROUND

Patients arriving at the Emergency Department (ED) via ambulance can experience a delay in receiving definitive care. In Australia, this phenomenon is referred to as 'Ambulance Ramping', 'Patient Off Stretcher Time Delay' or 'Offload Delay'. As a direct consequence of crowding, and in the context of a worldwide increase in ED and ambulance usage, hospital and ambulance service function is hampered. The aim of this review was to synthesize the literature with respect to the conceptualisation, meaning, antecedents and consequences of Ambulance Ramping.

METHODS

This was a scoping review and synthesis of the literature. Six search terms were employed: emergency medical technician; paramedic; ambulance; hospital emergency services; delay; and ambulance ramping. Journal articles that discussed Ambulance Ramping (or similar terms), and were published in English between 1983 and March 2015 were included. PubMed and CINAHL Plus databases were searched, with secondary searches of reference lists and grey literature also undertaken.

RESULTS

Thirteen papers were selected and inform this review. Several terms are used internationally to describe phenomena similar to Ambulance Ramping, where there is a delay in patient handover from paramedics to ED clinicians. Antecedents of Ambulance Ramping included reduction/limitation of ambulance diversion, patient acuity, the time of day, the day of the week, insufficient ED staff, insufficient ED beds, and high ED workload. Consequences of Ambulance Ramping include: further delays in patients' ability to receive definitive care and workforce stressors such as missed meal breaks, sick leave and staff attrition.

CONCLUSION

While the existing research literature indicates that Ambulance Ramping is problematic, little is known about the patient's experience of Ambulance Ramping; this is required so that an enhanced understanding of its implications, including those for emergency nurses, can be identified.

Comparative quality measures of emergency care: an outcome cockpit proposal to survey clinical processes in real life

Background

Benchmarking of real-life quality of care may improve evaluation and comparability of emergency department (ED) care. We investigated process management variables for important medical diagnoses in a large, well-defined cohort of ED patients and studied predictors for low quality of care.

Methods

We prospectively included consecutive medical patients with main diagnoses of community-acquired pneumonia, urinary tract infection (UTI), myocardial infarction (MI), acute heart failure, deep vein thrombosis, and COPD exacerbation and followed them for 30 days. We studied predictors for alteration in ED care (treatment times, satisfaction with care, readmission rates, and mortality) by using multivariate regression analyses.

Results

Overall, 2986 patients (median age 72 years, 57% males) were included. The median time to start treatment was 72 minutes (95% CI: 23 to 150), with a median length of ED stay (ED LOS) of 256 minutes (95% CI: 166 to 351). We found delayed treatment times and longer ED LOS to be independently associated with main medical admission diagnosis and time of day on admission (shortest times for MI and longest times for UTI). Time to first physician contact (−0.01 hours, 95% CI: −0.03 to −0.02) and ED LOS (−0.01 hours, 95% CI: −0.02 to −0.04) were main predictors for patient satisfaction.

Conclusion

Within this large cohort of consecutive patients seeking ED care, we found time of day on admission to be an important predictor for ED timeliness, which again predicted satisfaction with hospital care. Older patients were waiting longer for specific treatment, whereas polymorbidity predicted an increased ED LOS.

Suitability of current definitions of ambulatory care sensitive conditions for research in emergency department patients: a secondary health data analysis

OBJECTIVE

The aim of this study was to investigate the suitability of existing definitions of ambulatory care sensitive conditions (ACSC) in the setting of an emergency department (ED) by assessing ACSC prevalence in patients admitted to hospital after their ED stay. The secondary aim was to identify ACSC suitable for specific application in the ED setting.

DESIGN

Observational clinical study with secondary health data.

SETTING

Two EDs of the Charité-Universitätsmedizin Berlin.

PARTICIPANTS

All medical ED patients of the 'The Charité Emergency Medicine Study' (CHARITEM) study, who were admitted as inpatients during the 1-year study period (n=13 536).

OUTCOME MEASURES

Prevalence of ACSC.

RESULTS

Prevalence of ACSC in the study population differed significantly depending on the respective ACSC set used. Prevalence ranged between 19.1% (95% CI 18.4% to 19.8%; n=2586) using the definition by Albrecht et al and 36.6% (95% CI 35.8% to 37.5%; n=4960) using the definition of Naumann et al. (p<0.001). Overall ACSC prevalence (ie, when using all diagnoses used in any of the assessed ACSC-definitions) was 48.1% (95% CI 47.2% to 48.9%; n=6505). Some frequently observed diagnoses such as 'convulsion and epilepsy' (prevalence: 3.4%, 95% CI 3.1% to 3.7%; n=455), 'diseases of the urinary system' (prevalence: 1.4%; 95% CI 1.2% to 1.6%; n=191) or 'atrial fibrillation and flutter' (prevalence: 1.0%, 95% CI 0.8% to 1.2%, n=134) are not included in all of the current ACSC definitions.

CONCLUSIONS

The results highlight the need for an optimised, ED-specific ACSC definition. Particular ACSC diagnoses (such as 'convulsion and epilepsy' or 'diseases of the urinary system' and others) seem to be of special relevance in an ED population but are not included in all available ACSC definitions. Further research towards the development of a suitable and specific ACSC definition for research in the ED setting seems warranted.

TRIAL REGISTRATION

German Clinical Trials Register Deutsches Register für Klinische Studien: DRKS-ID: DRKS00000261.

Overcrowding and Its Association With Patient Outcomes in a Median-Low Volume Emergency Department

Background

Crowding occurs commonly in high volume emergency departments (ED) and has been associated with negative patient care outcomes. We aim to assess ED crowding in a median-low volume setting and evaluate associations with patient care outcomes.

Methods

This was a prospective single-center study from November 14, 2016 until December 14, 2016. ED crowding was measured every 2 h by three different estimation tools: National Emergency Department Overcrowding Score (NEDOCS); Community Emergency Department Overcrowding Score (CEDOCS); and Severely-overcrowding Overcrowding and Not-overcrowding Estimation Tool (SONET) categorized under six different levels of crowding (not busy, busy, extremely busy, overcrowded, severely overcrowded, and dangerously overcrowded). Crowding scores were assigned to each patient upon ED arrival. We evaluated the distributions of crowding and patient ED length of stay (ED LOS) across estimation tools. Accelerated failure time models were utilized to estimate time ratios and their corresponding 95% confidence intervals comparing median LOS across levels of crowding within each estimation tool.

Results

This study comprised 2,557 patients whose median ED LOS was 150 min. Approximately 2% of patients arrived during 2 h time intervals deemed overcrowded regardless of the crowding tool used. Median ED LOS increased with the increased level of ED crowding and prolonged median ED LOS (> 150 min) occurred at ED of extremely busy status. Time ratios ranged from 1.09 to 1.48 for NEDOCS, 1.25 - 1.56 for CEDOCS, and 1.26 - 1.72 for SONET.

Conclusion

Overcrowding rarely occurred in study ED with median-low annual volume and might not be a valuable marker for ED crowding report. Though similar patterns of prolonged ED LOS occurred with increased levels of ED crowding, it seems crowding alerts should be initiated during extremely busy status in this ED setting.

The role of patient perception of crowding in the determination of real-time patient satisfaction at Emergency Department

OBJECTIVE

To evaluate the associations between real-time overall patient satisfaction and Emergency Department (ED) crowding as determined by patient percepton and crowding estimation tool score in a high-volume ED.

DESIGN

A prospective observational study.

SETTING

A tertiary acute hospital ED and a Level 1 trauma center.

PARTICIPANTS

ED patients.

INTERVENTION(S)

Crowding status was measured by two crowding tools [National Emergency Department Overcrowding Scale (NEDOCS) and Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool (SONET)] and patient perception of crowding surveys administered at discharge.

MAIN OUTCOME MEASURE(S)

ED crowding and patient real-time satisfaction.

RESULTS

From 29 November 2015 through 11 January 2016, we enrolled 1345 participants. We observed considerable agreement between the NEDOCS and SONET assessment of ED crowding (bias = 0.22; 95% limits of agreement (LOAs): -1.67, 2.12). However, agreement was more variable between patient perceptions of ED crowding with NEDOCS (bias = 0.62; 95% LOA: -5.85, 7.09) and SONET (bias = 0.40; 95% LOA: -5.81, 6.61). Compared to not overcrowded, there were overall inverse associations between ED overcrowding and patient satisfaction (Patient perception OR = 0.49, 95% confidence limit (CL): 0.38, 0.63; NEDOCS OR = 0.78, 95% CL: 0.65, 0.95; SONET OR = 0.82, 95% CL: 0.69, 0.98).

CONCLUSIONS

While heterogeneity exists in the degree of agreement between objective and patient perceived assessments of ED crowding, in our study we observed that higher degrees of ED crowding at admission might be associated with lower real-time patient satisfaction.

Emergency Department Patient Experience: A Systematic Review of the Literature

Introduction:

Patient experience with emergency department (ED) care is an expanding area of focus, and recent literature has demonstrated strong correlation between patient experience and meeting several ED and hospital goals. The objective of this study was to perform a systematic review of existing literature to identify specific factors most commonly identified as influencing ED patient experience.

Methods:

A literature search was performed, and articles were included if published in peer-reviewed journals, primarily focused on ED patient experience, employed observational or interventional methodology, and were available in English. After a structured screening process, 107 publications were included for data extraction.

Result:

Of the 107 included publications, 51 were published before 2011, 57% were conducted by American investigators, and 12% were published in nursing journals. The most commonly identified themes included staff-patient communication, ED wait times, and staff empathy and compassion.

Conclusion:

The most commonly identified drivers of ED patient experience include communication, wait times, and staff empathy; however, existing literature is limited. Additional investigation is necessary to further characterize ED patient experience themes and identify interventions that effectively improve these domains.

The impact of the improvement in internal medicine consultation process on ED length of stay

INTRODUCTION

Although consultations are essential for delivering safe, high-quality care to patients in emergency departments, they contribute to emergency department patient flow problems and overcrowding which is associated with several adverse outcomes, such as increases in patient mortality and poor quality care. This study aimed to investigate how time flow metrics including emergency department length of stay is influenced by changes to the internal medicine consultation policy.

METHOD

This study is a pre- and post-controlled interventional study. We attempted to improve the internal medicine consultation process to be more concise. After the intervention, only attending emergency physicians consult internal medicine chief residents, clinical fellows, or junior staff of each internal medicine subspecialty who were on duty when patients required special care or an admission to internal medicine.

RESULTS

Emergency department length of stay of patients admitted to the department of internal medicine prior to and after the intervention decreased from 996.94min to 706.62min. The times from consultation order to admission order and admission order to emergency department departure prior to and after the intervention were decreased from 359.59min to 180.38min and from 481.89min to 362.37min, respectively. The inpatient mortality rates and Inpatient bed occupancy rates prior to and after the intervention were similar.

CONCLUSION

The improvements in the internal medicine consultation process affected the flow time metrics. Therefore, more comprehensive and cooperative strategies need to be developed to reduce the time cycle metrics and overcrowding of all patients in the emergency department.

Psychometric Evaluation of the Hospital Culture of Transitions Survey

BACKGROUND

Ineffective or inefficient transitions threaten patient safety, hinder communication, and worsen patient outcomes. The Hospital Culture of Transitions (H-CulT) survey was designed to assess a hospital's organizational culture related to within-hospital transitions in care involving patient movement. In this article, psychometric properties of the H-CulT survey were examined to assess and refine the hospital culture of transitions.

METHODS

A cross-sectional, multicenter, multidisciplinary correlational design and survey methods were used to examine the psychometric properties of the H-CulT survey. Exploratory factor analysis was used to quantify the accuracy of the previously identified structure. Specifically, the analysis involved the principal axis factor method with an oblique rotation, based on a polychoric correlation matrix.

RESULTS

A sample of 492 respondents from 13 diverse hospitals participated. Cronbach's alpha for the instrument was 0.88, indicating strong internal consistency. Seven subscales emerged and were labeled: Hospital Leadership, Unit Leadership, My Unit's Culture, Other Units' Culture, Busy Workload, Priority of Patient Care, and Use of Data. Correlations between subscales ranged from 0.07 to 0.52, providing evidence that the subscales did not measure the same construct. Subscale correlations with the total score were near or above 0.50 (p <0.001). Use of a factor-loading cutoff of 0.40 resulted in the elimination of 12 items because of weak associations with the topic.

CONCLUSION

The H-CulT is a psychometrically sound and practical survey for assessing hospital culture related to patient flow during transitions in care. Survey results may prompt quality improvement interventions that enhance in-hospital transitions and improve staff satisfaction and patient satisfaction with care.

Towards a best measure of emergency department crowding: Lessons from current Australasian practice

OBJECTIVE

Despite extensive literature, how crowding in EDs should be measured is still debated. The present study aimed to describe crowding metrics used in Australasia, what they were used for, the perceived extent and frequency of crowding and the challenges faced when trying to measure crowding.

METHODS

A survey of ED clinical directors was undertaken between December 2014 and July 2015. Free-text responses were categorised and thematically coded. Quantitative data were analysed descriptively and with logistic regression.

RESULTS

There were 113 of 145 responses (78%). Crowding was considered a major problem by 84 of 113 (74%) and not rare by 88 of 111 participants (79%). These constructs were correlated; G = -0.851, P < 0.001. Levels 1-3 EDs were less likely to report crowding as a major problem than Level 4 EDs; odds ratio 0.15 (0.03-0.69), P = 0.02. Sixteen current metrics were identified and categorised into 'time', 'occupancy' and 'workload' metrics. These categories of metric were used differently, and multiple metrics had more uses than single metrics. Previously described complex crowding metrics were infrequently recognised (<20%). Common challenges to measuring crowding were lack of an agreed metric (40%) and lack of buy-in by inpatient teams or hospital management (35%).

CONCLUSION

ED crowding remains a common and important problem in Australasia. Crowding is multifaceted, so a single metric might not capture all important elements of crowding or be relevant to all stakeholders. However, a metric like Access Block, which encompasses elements of time, occupancy and workload and is relevant to stakeholders outside the ED, might hold the most promise.

Psychiatric Boarding in the Pediatric Inpatient Medical Setting: A Retrospective Analysis

BACKGROUND AND OBJECTIVES

Psychiatric concerns are a common presenting problem for pediatric providers across many settings, particularly on inpatient medical services. The volume of youth requiring intensive psychiatric treatment outnumbers the availability of psychiatric placements, and as a result many youth must board on pediatric medical units while awaiting placement. As the phenomenon of boarding in the inpatient pediatric setting increases, it is important to understand trends in boarding volume and characteristics of pediatric psychiatric boarders (PBs) and understand the supports they receive while boarding.

METHODS

A retrospective chart review of patients admitted as PBs to a medical inpatient unit at a large northeastern US pediatric hospital during 2013.

RESULTS

Four hundred thirty-seven PBs were admitted to the medical service from January to December 2013, representing a more than 50% increase from PB admissions in 2011 and 2012. Most PBs were admitted for suicidal attempt and/or ideation. Average length of boarding was 3.11 ± 3.34 days. PBs received a wide range of mental health supports throughout their admissions. PBs demonstrated modest but statistically significant clinical improvements over the course of their stay, with only a small proportion demonstrating clinical deterioration.

CONCLUSIONS

Psychiatric boarding presents many challenges for families, providers, and the health care system, and PBs have complex psychiatric histories and needs. However, boarding may offer a valuable opportunity for psychiatric intervention and stabilization among psychiatrically vulnerable youth.

Quality improvement primer part 1: Preparing for a quality improvement project in the emergency department

Emergency medicine (EM) providers work in a fast-paced and often hectic environment that has a high risk for patient safety incidents and gaps in the quality of care. These challenges have resulted in opportunities for frontline EM providers to play a role in quality improvement (QI) projects. QI has developed into a mature field with methodologies that can dramatically improve the odds of having a successful project with a sustainable impact. However, this expertise is not yet commonly taught during professional training. In this first of three articles meant as a QI primer for EM clinicians, we will introduce QI methodology and strategic planning using a fictional case study as an example. We will review how to identify a QI problem, define components of an effective problem statement, and identify stakeholders and core change team members. We will also describe three techniques used to perform root cause analyses-Ishikawa diagrams, Pareto charts and process mapping-and how they relate to preparing for a QI project. The next two papers in this series will focus on the execution of the QI project itself using rapid-cycle testing and on the evaluation and sustainability of QI projects.

Comparing patient and healthcare worker experiences during a dengue outbreak in Singapore: understanding the patient journey and the introduction of a point-of-care test (POCT) toward better care delivery

BACKGROUND

In the aftermath of an upsurge in the number of dengue cases in 2013 and 2014, the SD BIOLINE Dengue Duo rapid diagnostic Point-of-Care Test (POCT) kit was introduced in Tan Tock Seng Hospital, Singapore in June 2013. It is known that the success of POCT usage is contingent on its implementation within the health system. We evaluated health services delivery and the Dengue Duo rapid diagnostic test kit application in Singapore from healthcare workers' perspectives and patient experiences of dengue at surge times.

METHODS

Focus group discussions were conducted with dengue patients, from before and after the POCT implementation period. In-depth interviews with semi-structured components with healthcare workers were carried out. A patient centred process mapping technique was used for evaluation, which mapped the patient's journey and was mirrored from the healthcare worker's perspective.

RESULTS

Patients and healthcare workers confirmed a wide range of symptoms in adults, making it challenging to determine diagnosis. There were multiple routes to help seeking, and no 'typical patient journey', with patients either presenting directly to the hospital emergency department, or being referred there by a primary care provider. Patients groups diagnosed before and after POCT implementation expressed some differences between speed of diagnoses and attitudes of doctors, yet shared negative feelings about waiting times and a lack of communication and poor information delivery. However, the POCT did not in its current implementation do much to help waiting times. Healthcare workers expressed that public perceptions of dengue in recent years was a major factor in changing patient management, and that the POCT kit was helpful in improving the speed and accuracy of diagnoses.

CONCLUSIONS

Health service delivery for dengue patients in Singapore was overall perceived to be of an acceptable clinical standard, which was enhanced by the introduction of the POCT. However, improvements can be focused on Adapting to outbreaks by reducing and rendering Waiting experiences more comfortable; Advancing education about symptom recognition, while also Recognising better communication strategies; and Expanding follow-up care options. This is presented as the Dengue AWARE model of care delivery.

Time to cranial computerised tomography for acute traumatic brain injury in paediatric patients: Effect of the shorter stays in emergency departments target in New Zealand

AIM

Timely access to computerised tomography (CT) for acute traumatic brain injuries (TBIs) facilitates rapid diagnosis and surgical intervention. In 2009, New Zealand introduced a mandatory target for emergency department (ED) stay such that 95% of patients should leave ED within 6 h of arrival. This study investigated whether this target influenced the timeliness of cranial CT scanning in children who presented to ED with acute TBI.

METHODS

We retrospectively reviewed a random sample of charts of children <15 years with acute TBI from 2006 to 2012. Cases were identified using International Classification of Disease 10 codes consistent with TBI. General linear models investigated changes in time to CT and other indicators before and after the shorter stays in ED target was introduced in 2009.

RESULTS

Among the 190 cases eligible for study (n = 91 pre-target and n = 99 post-target), no significant difference was found in time to CT scan pre- and post-target: least squares mean (LSM) with 95% confidence interval = 68 (56-81) versus 65 (53-78) min, respectively, P = 0.66. Time to neurosurgery (LSM 8.7 (5-15) vs. 5.1 (2.6-9.9) h, P = 0.19, or hospital length of stay (LSM: 4.9 (3.9-6.3) vs. 5.2 (4.1-6.7) days, P = 0.69) did not change significantly. However, ED length of stay decreased by 45 min in the post-target period (LSM = 211 (187-238) vs. 166 (98-160) min, P = 0.006).

CONCLUSION

Implementation of the shorter stays in ED target was not associated with a change in the time to CT for children presenting with acute TBI, but an overall reduction in the time spent in ED was apparent.

Two emergency departments, 6000km apart: Differences in patient flow and staff perceptions about crowding

INTRODUCTION

Emergency department (ED) crowding is a worldwide public health issue. In this study, patient flow and staff perceptions of crowding were assessed in Pakistan (Aga Khan University Hospital (AKUH)) and in the Netherlands (Haaglanden Medical Centre Westeinde (HMCW)). Bottlenecks affecting ED patient flow were identified.

METHODS

First, a one-year review of patient visits was performed. Second, staff perceptions about ED crowding were collected using face-to-face interviews. Non-participant observation and document review were used to interpret the findings.

RESULTS

At AKUH 58,839 (160visits/day) and at HMCW 50,802 visits (140visits/day) were registered. Length of stay (LOS) at AKUH was significantly longer than at HMCW (279min (IQR 357) vs. 100min (IQR 152)). There were major differences in patient acuities, admission and mortality rates, indicating a sicker population at AKUH. Respondents from both departments experienced hampered patient flow on a daily basis, and perceived similar causes for crowding: increased patients' complexity, long treatment times, and poor availability of inpatient beds.

CONCLUSION

Despite differences in environment, demographics, and ED patient flow, respondents perceived similar bottlenecks in patient flow. Interventions should be tailored to specific ED and hospital needs. For both EDs, improving the outflow of boarded patients is essential.

Risk factors for admission at three urban emergency departments in England: a cross-sectional analysis of attendances over 1 month

OBJECTIVE

To investigate factors associated with unscheduled admission following presentation to emergency departments (EDs) at three hospitals in England.

DESIGN AND SETTING

Cross-sectional analysis of attendance data for patients from three urban EDs in England: a large teaching hospital and major trauma centre (site 1) and two district general hospitals (sites 2 and 3). Variables included patient age, gender, ethnicity, deprivation score, arrival date and time, arrival by ambulance or otherwise, a variety of ED workload measures, inpatient bed occupancy rates and admission outcome. Coding inconsistencies in routine ED data used for this study meant that diagnosis could not be included.

OUTCOME MEASURE

The primary outcome for the study was unscheduled admission.

PARTICIPANTS

All adults aged 16 and older attending the three inner London EDs in December 2013. Data on 19 734 unique patient attendances were gathered.

RESULTS

Outcome data were available for 19 721 attendances (>99%), of whom 6263 (32%) were admitted to hospital. Site 1 was set as the baseline site for analysis of admission risk. Risk of admission was significantly greater at sites 2 and 3 (adjusted OR (AOR) relative to site 1 for site 2 was 1.89, 95% CI 1.74 to 2.05, p<0.001) and for patients of black or black British ethnicity (AOR 1.29, 1.16 to 1.44, p<0.001). Deprivation was strongly associated with admission. Analysis of departmental and hospital-wide workload pressures gave conflicting results, but proximity to the "4-hour target" (a rule that limits patient stays in EDs to 4 hours in the National Health Service in England) emerged as a strong driver for admission in this analysis (AOR 3.61, 95% CI 3.30 to 3.95, p<0.001).

CONCLUSION

This study found statistically significant variations in odds of admission between hospital sites when adjusting for various patient demographic and presentation factors, suggesting important variations in ED-level and clinician-level behaviour relating to admission decisions. The 4-hour target is a strong driver for emergency admission.

Implementation and evaluation of a 'Navigator' role to improve emergency department throughput

BACKGROUND

Emergency department overcrowding impacts patients, staff, and quality of care, and there is government pressure to optimize throughput and reduce waiting times. One solution for improving patient flow is the emerging 'navigator' role: a nurse that supports staff in care delivery; facilitating efficient and timely patient movement through the emergency department.

METHODS

A 20-week project was implemented to evaluate an emergency department nurse navigator role. A controlled trial was used. The navigator worked on a week-on-week-off basis, eight hours per day, seven days per week. Time-based and cost-associated outcomes were compared.

RESULTS

Data from nearly 20,000 presentations during the trial period were analysed. All outcomes were improved during the ten weeks the Navigator was working. A slight improvement in National Emergency Access Target compliance was shown, with an average of 4.5min per presentation saved. The labour cost associated with the time saved was estimated to be $170,000.

CONCLUSIONS

The results from this study indicate that for a relatively small investment, complementary nursing roles such as the navigator can impact emergency department patient flow. However, further studies are required to determine optimisation of the role.

RELEVANCE TO PRACTICE

This study provides rigorous evidence of the effects of a nurse navigator role on emergency department throughput. Whilst positive outcomes were demonstrated, suggesting a whole-of-system benefit, the magnitude of effect on a per-presentation basis was relatively small. Further studies are required to demonstrate the clinical relevance of such roles.

The effect on the patient flow in a local health care after implementing reverse triage in a primary care emergency department: a longitudinal follow-up study

OBJECTIVE

Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor's list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors' services in collaborative parts of the health care system.

DESIGN

An observational study.

SETTING

Register-based retrospective quasi-experimental longitudinal follow-up study based on a before-after setting in a Finnish city.

SUBJECTS

Patients who consulted different doctors in a local health care unit.

MAIN OUTCOME MEASURES

Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage.

RESULTS

The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased.

CONCLUSIONS

The data suggested that the reverse triage causes redistribution of the use of doctors' services rather than a true decrease in the use of these services.

The Association Between Hospital Capacity Strain and Inpatient Outcomes in Highly Developed Countries: A Systematic Review

BACKGROUND

Increases in patient needs can strain hospital resources, which may worsen care quality and outcomes. This systematic literature review sought to understand whether hospital capacity strain is associated with worse health outcomes for hospitalized patients and to evaluate benefits and harms of health system interventions to improve care quality during times of hospital capacity strain.

METHODS

Parallel searches were conducted in MEDLINE, CINAHL, the Cochrane Library, and reference lists from 1999-2015. Two reviewers assessed study eligibility. We included English-language studies describing the association between capacity strain (high census, acuity, turnover, or an indirect measure of strain such as delayed admission) and health outcomes or intermediate outcomes for children and adults hospitalized in highly developed countries. We also included studies of health system interventions to improve care during times of capacity strain. Two reviewers extracted data and assessed risk of bias using the Newcastle-Ottawa Score for observational studies and the Cochrane Collaboration Risk of Bias Assessment Tool for experimental studies.

RESULTS

Of 5,702 potentially relevant studies, we included 44 observational and 8 experimental studies. There was marked heterogeneity in the metrics used to define capacity strain, hospital settings, and overall study quality. Mortality increased during times of capacity strain in 18 of 30 studies and in 9 of 12 studies in intensive care unit settings. No experimental studies were randomized, and none demonstrated an improvement in health outcomes after implementing the intervention. The pediatric literature is very limited; only six observational studies included children. There was insufficient study homogeneity to perform meta-analyses.

DISCUSSION

In highly developed countries, hospital capacity strain is associated with increased mortality and worsened health outcomes. Evidence-based solutions to improve outcomes during times of capacity strain are needed.

Factors associated with failure of emergency wait-time targets for high acuity discharges and intensive care unit admissions

Objective

Ontario established emergency department length-of-stay (EDLOS) targets but has difficulty achieving them. We sought to determine predictors of target time failure for discharged high acuity patients and intensive care unit (ICU) admissions.

Methods

This was a retrospective, observational study of 2012 Sunnybrook Hospital emergency department data. The main outcome measure was failing to meet government EDLOS targets for high acuity discharges and ICU emergency admissions. The secondary outcome measures examined factors for low acuity discharges and all admissions, as well as a run chart for 2015 – 2016 ICU admissions. Multiple logistic regression models were created for admissions, ICU admissions, and low and high acuity discharges. Predictor variables were at the patient level from emergency department registries.

Results

For discharged high acuity patients, factors predicting EDLOS target failure were having physician initial assessment duration (PIAD)>2 hours (OR 5.63 [5.22-6.06]), consultation request (OR 10.23 [9.38-11.14]), magnetic resonance imaging (MRI) (OR 19.33 [12.94-28.87]), computed tomography (CT) (OR 4.24 [3.92-4.59]), and ultrasound (US) (OR 3.47 [3.13-3.83]). For ICU admissions, factors predicting EDLOS target failure were bed request duration (BRD)>6 hours (OR 364.27 [43.20-3071.30]) and access block (AB)>1 hour (OR 217.27 [30.62-1541.63]). For discharged low acuity patients, factors predicting failure for the 4-hour target were PIAD>2 hours (OR 15.80 [13.35-18.71]), consultation (OR 20.98 [14.10-31.22]), MRI (OR 31.68 [6.03-166.54]), CT (OR 16.48 [10.07-26.98]), and troponin I (OR 13.37 [6.30-28.37]).

Conclusion

Sunnybrook factors predicting failure of targets for high acuity discharges and ICU admissions were hospital-controlled. Hospitals should individualize their approach to shortening EDLOS by analysing its patient population and resource demands.

Developing quality indicators for the care of patients with musculoskeletal injuries in the Emergency Department: study protocol

BACKGROUND

Musculoskeletal injuries are a common presentation to the Emergency Department (ED). The quality of care provided is important to the patients, clinicians, organisations and purchasers of care. In the context of the increasing burden of musculoskeletal disease, quality of care needs to occur despite financial impacts, variations in care, and pressure to reach time-based performance measures. This study aims to develop a suite of evidence-based quality indicators (QI) which will provide a measure of the quality of care for patients with musculoskeletal injuries in the ED.

METHODS

This study will utilise a multi-phase mixed methods protocol, commencing with a systematic review of the literature to identify and critically appraise existing QIs for musculoskeletal injuries in the ED. The study will then build on the gaps identified in the review to develop a suite of preliminary QIs, in accordance with established research methodology under the governance of an expert panel. The developed QI set will then be field-tested for feasibility and validity in selected EDs. After field-testing, the suite will be refined in consultation with the expert panel and finalised using a formal voting process.

DISCUSSION

The assessment of performance against QIs provides a quantitative measure for the quality of care provided to patients, to identify and target quality improvement activities. The QIs developed through this study will be evidence-based and balanced across the areas of structures, processes and outcomes. The rigorous methodology used to develop and test the QIs will result in QIs that are meaningful, valid, feasible to collect and efficiently measurable, amenable to improvement, and selected by experts in the emergency medicine field. The final QI suite will have applications across EDs that affords comparison, benchmarking and optimisation of emergency care for patients.

The Economics of an Admissions Holding Unit

Introduction

With increasing attention to the actual cost of delivering care, return-on-investment calculations take on new significance. Boarded patients in the emergency department (ED) are harmful to clinical care and have significant financial opportunity costs. We hypothesize that investment in an admissions holding unit for admitted ED patients not only captures opportunity cost but also significantly lowers direct cost of care.

Methods

This was a three-phase study at a busy urban teaching center with significant walkout rate. We first determined the true cost of maintaining a staffed ED bed for one patient-hour and compared it to alternative settings. The opportunity cost for patients leaving without being seen was then conservatively estimated. Lastly, a convenience sample of admitted patients boarding in the ED was observed continuously from one hour after decision-to-admit until physical departure from the ED to capture a record of every interaction with a nurse or physician.

Results

Personnel costs per patient bed-hour were $58.20 for the ED, $24.80 for an inpatient floor, $19.20 for the inpatient observation unit, and $10.40 for an admissions holding area. An eight-bed holding unit operating at practical capacity would free 57.4 hours of bed space in the ED and allow treatment of 20 additional patients. This could yield increased revenues of $27,796 per day and capture opportunity cost of $6.09 million over 219 days, in return for extra staffing costs of $218,650. Analysis of resources used for boarded patients was determined by continuous observation of a convenience sample of ED-boarded patients, which found near-zero interactions with both nursing and physicians during the boarding interval.

Conclusion

Resource expense per ED bed-hour is more than twice that in non-critical care inpatient units. Despite the high cost of available resources, boarded non-critical patients receive virtually no nursing or physician attention. An admissions holding unit is remarkably effective in avoiding the mismatch of the low-needs patients in high-cost care venues. Return on investment is enormous, but this assumes existing clinical space for this unit.