Association between ED crowding and delay in resuscitation effort

Emergency Department Crowding as Contributing Factor Related to Patient-Initiated Violence Against Nurses-A Literature Review

AIM

To synthesise how ED crowding contributes to patient-initiated violence against emergency nurses.

DESIGN

Framework synthesis.

DATA SOURCES

A systematic literature search was conducted in the PubMed, PsycINFO, CINAHL and Scopus databases, covering articles up to 21 March 2024.

REVIEW METHODS

A total of 25 articles were reviewed, evaluating study quality using the Crowe Critical Appraisal Tool and employing a framework synthesis approach to chart and synthesise data.

RESULTS

The review identifies key factors linking emergency department crowding to patient-initiated violence, focusing on crowding conditions, vulnerable populations and adverse outcomes. It emphasises the importance of multidimensional assessments, including input, throughput, output stages and staffing characteristics. Special attention is needed for patients with severe symptoms who are triaged into lower priority categories, as their perceptions of injustice and dissatisfaction may increase the risk of aggressive behaviour. However, limited information is available regarding the perspectives of patients' family members.

CONCLUSION

Accurate assessments of emergency department crowding and a thorough understanding of cognitive and emotional changes in high-risk patients are essential to develop strategies to manage patient-initiated violence effectively.

IMPACT

This review improves emergency nurses' understanding of the dynamics of patient-initiated violence in crowded emergency departments, equipping them with knowledge to better anticipate and respond to such incidents. It also offers insights that are crucial for enhancing nursing practices and ensuring workplace safety, thereby supporting the development of future emergency safety strategies.

NO PATIENT OR PUBLIC CONTRIBUTION

As this is a systematic review and framework synthesis, there was no direct patient or public involvement.

The Need for a New Approach to MCI Readiness in the Era of Emergency Department and Hospital Crowding

Emergency department (ED) visit volumes have increased since 2007, with crowding in the United States reaching its highest levels in 2022. During this same period, mass casualty incidents (MCIs) have increased dramatically, both in frequency and severity, across the United States. Resuscitation of trauma patients is a time-sensitive process that requires immediate patient assessment by coordinated clinical teams in order to successfully diagnose and manage life-threatening injuries. To make resuscitation spaces immediately available for incoming patients, typical MCI plans call for rapidly relocating ED patients from their rooms into hallways or transferring them to open inpatient areas. With current levels of crowding, however, such alternate care spaces are often already in use and traditional MCI plans are increasingly unrealistic. With ED crowding worsening and the frequency of MCIs rising, there is a worrisome risk that EDs could fail in their efforts to save patients due to insufficient resources and spaces to meet the demands of critically injured patients. Hospitals must use innovative, novel response strategies to ensure sufficient patient care spaces in a short timeframe to save the most lives possible. In this commentary, we describe the use of buffer zones to help EDs mobilize an effective response to MCIs in the current context of severe hospital crowding.

Determinants of decision-making for the initiation of resuscitation: a mixed-methods systematic review of barriers and facilitators

AIM

This study aimed to comprehensively examine the factors influencing healthcare providers' decision-making for initiation of resuscitation (IOR).

BACKGROUND

In-hospital resuscitation survival hinges on timely and effective interventions. Despite guidelines, decision-making during resuscitation remains challenging, impacted by both clinical and non-clinical factors.

METHODS

A mixed-methods systematic review (MMSR) was conducted, searching PubMed, Web of Science, Scopus, and Embase in May 2024. Twenty peer-reviewed studies of adult in-hospital resuscitation decision-making (≥ 18 years) were included. Data were extracted and synthesized using the Joanna Briggs Institute (JBI) convergent integrated approach.

RESULTS

A database search yielded 4398 studies, of which 1216 were duplicates. After screening 3182 unique studies, 20 articles (five qualitative, 12 quantitative, three mixed methods) were included. Data synthesis identified three overarching themes: patient, provider, and system factors. These themes encompassed barriers and facilitators to IOR.

CONCLUSION

This review underscores the importance of understanding patient-related, provider-related, and system-related factors influencing IOR. By addressing these factors, healthcare organizations can improve resuscitation practices and outcomes. Future research should focus on enhancing collaboration, communication, and resource availability while considering non-medical factors in decision-making for IOR.

RELEVANCE TO CLINICAL PRACTICE

Understanding the multifaceted barriers and facilitators identified in this study can enhance the effectiveness of resuscitation protocols and ultimately improve patient outcomes during critical care situations.

Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures

BACKGROUND

There is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications.

METHODS

We identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879).

RESULTS

The search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis.

CONCLUSION

We found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.

Development of a machine-learning algorithm to predict in-hospital cardiac arrest for emergency department patients using a nationwide database

In this retrospective observational study, we aimed to develop a machine-learning model using data obtained at the prehospital stage to predict in-hospital cardiac arrest in the emergency department (ED) of patients transferred via emergency medical services. The dataset was constructed by attaching the prehospital information from the National Fire Agency and hospital factors to data from the National Emergency Department Information System. Machine-learning models were developed using patient variables, with and without hospital factors. We validated model performance and used the SHapley Additive exPlanation model interpretation. In-hospital cardiac arrest occurred in 5431 of the 1,350,693 patients (0.4%). The extreme gradient boosting model showed the best performance with area under receiver operating curve of 0.9267 when incorporating the hospital factor. Oxygen supply, age, oxygen saturation, systolic blood pressure, the number of ED beds, ED occupancy, and pulse rate were the most influential variables, in that order. ED occupancy and in-hospital cardiac arrest occurrence were positively correlated, and the impact of ED occupancy appeared greater in small hospitals. The machine-learning predictive model using the integrated information acquired in the prehospital stage effectively predicted in-hospital cardiac arrest in the ED and can contribute to the efficient operation of emergency medical systems.

Critical Care Unit Organizational and Personnel Factors Impact Cardiac Arrest Prevention and Rescue in the Pediatric Cardiac Population

OBJECTIVES

Patient-level factors related to cardiac arrest in the pediatric cardiac population are well understood but may be unmodifiable. The impact of cardiac ICU organizational and personnel factors on cardiac arrest rates and outcomes remains unknown. We sought to better understand the association between these potentially modifiable organizational and personnel factors on cardiac arrest prevention and rescue.

DESIGN

Retrospective analysis of the Pediatric Cardiac Critical Care Consortium registry.

SETTING

Pediatric cardiac ICUs.

PATIENTS

All cardiac ICU admissions were evaluated for cardiac arrest and survival outcomes.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Successful prevention was defined as the proportion of admissions with no cardiac arrest (inverse of cardiac arrest incidence). Rescue was the proportion of patients surviving to cardiac ICU discharge after cardiac arrest. Cardiac ICU organizational and personnel factors were captured via site questionnaires. The associations between organizational and personnel factors and prevention/rescue were analyzed using Fine-Gray and multinomial regression, respectively, accounting for clustering within hospitals. We analyzed 54,521 cardiac ICU admissions (29 hospitals) with 1,398 cardiac arrest events (2.5%) between August 1, 2014, and March 5, 2019. For both surgical and medical admissions, lower average daily cardiac ICU occupancy was associated with better cardiac arrest prevention. Better rescue for medical admissions was observed for higher registered nursing hours per patient day and lower proportions of "part time" cardiac ICU physician staff (< 6 service weeks/yr). Increased registered nurse experience was associated with better rescue for surgical admissions. Increased proportion of critical care certified nurses, full-time intensivists with critical care fellowship training, dedicated respiratory therapists, quality/safety resources, and annual cardiac ICU admission volume were not associated with improved prevention or rescue.

CONCLUSIONS

Our multi-institutional analysis identified cardiac ICU bed occupancy, registered nurse experience, and physician staffing as potentially important factors associated with cardiac arrest prevention and rescue. Recognizing the limitations of measuring these variables cross-sectionally, additional studies are needed to further investigate these organizational and personnel factors, their interrelationships, and how hospitals can modify structure to improve cardiac arrest outcomes.

Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions

It is certain and established that overcrowding represents one of the main problems that has been affecting global health and the functioning of the healthcare system in the last decades, and this is especially true for the emergency department (ED). Since 1980, overcrowding has been identified as one of the main factors limiting correct, timely, and efficient hospital care. The more recent COVID-19 pandemic contributed to the accentuation of this phenomenon, which was already well known and of international interest. Considering what would appear to be a trivial definition of overcrowding, it may seem simple for the reader to hypothesize solutions for what seems to be one of the most avoidable problems affecting the hospital system. However, proposing solutions to overcrowding, as well as their implementation, cannot be separated from a correct and precise definition of the issue, which must consider the main causes and aggravating factors. In light of the need of finding solutions that can put an end to hospital overcrowding, this review aims, through a review of the literature, to summarize the triggering factors, as well as the possible solutions that can be proposed.

Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List

Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.

Intervention in the timeliness of two ECG types for emergency department patients with chest pain: randomized controlled trial (Preprint)

Background

In the emergency department (ED), the result obtained using the 12-lead electrocardiography (ECG) is the basis for diagnosing and treating patients with chest pain. It was found that performing ECG at the appropriate time could improve treatment outcomes. Hence, a wearable ECG device with a timer can ensure that the findings are continuously recorded.

Objective

We aimed to compare the time accuracy of a single-patch 12-lead ECG (SP-ECG) with that of conventional ECG (C-ECG). We hypothesized that SP-ECG would result in better time accuracy.

Methods

Adult patients who visited the emergency room with chest pain but were not in shock were randomly assigned to one of the following 2 groups: the SP-ECG group or the C-ECG group. The final analysis included 33 (92%) of the 36 patients recruited. The primary outcome was the comparison of the time taken by the 2 groups to record the ECG. The average ages of the participants in the SP-ECG and C-ECG groups were 63.7 (SD 18.4) and 58.1 (SD 12.4) years, respectively.

Results

With a power of 0.95 and effect sizes of 0.05 and 1.36, the minimum number of samples was calculated. The minimum sample size for each SP-ECG and C-ECG group is 15.36 participants, assuming a 20% dropout rate. As a result, 36 patients with chest pain participated, and 33 of them were analyzed. The timeliness of SP-ECG and C-ECG for the first follow-up ECG was 87.5% and 47.0%, respectively (P=.74). It was 75.0% and 35.2% at the second follow-up, respectively (P=.71).

Conclusions

Continuous ECG monitoring with minimal interference from other examinations is feasible and essential in complex ED situations. However, the precision of SP-ECG has not yet been proved. Nevertheless, the application of SP-ECG is expected to improve overcrowding and human resource shortages in EDs, though more research is needed.

Trial Registration

ClinicalTrials.gov NCT04114760; https://clinicaltrials.gov/ct2/show/NCT04114760

Developing a time-adaptive prediction model for out-of-hospital cardiac arrest: Results from a nationwide cohort study in Korea (Preprint)

Background

Out-of-hospital cardiac arrest (OHCA) is a serious public health issue, and predicting the prognosis of OHCA patients can assist clinicians in making decisions about the treatment of patients, use of hospital resources, or termination of resuscitation.

Objective

This study aimed to develop a time-adaptive conditional prediction model (TACOM) to predict clinical outcomes every minute.

Methods

We performed a retrospective observational study using data from the Korea OHCA Registry in South Korea. In this study, we excluded patients with trauma, those who experienced return of spontaneous circulation before arriving in the emergency department (ED), and those who did not receive cardiopulmonary resuscitation (CPR) in the ED. We selected patients who received CPR in the ED. To develop the time-adaptive prediction model, we organized the training data set as ongoing CPR patients by the minute. A total of 49,669 patients were divided into 39,602 subjects for training and 10,067 subjects for validation. We compared random forest, LightGBM, and artificial neural networks as the prediction model methods. Model performance was quantified using the prediction probability of the model, area under the receiver operating characteristic curve (AUROC), and area under the precision recall curve.

Results

Among the three algorithms, LightGBM showed the best performance. From 0 to 30 min, the AUROC of the TACOM for predicting good neurological outcomes ranged from 0.910 (95% CI 0.910-0.911) to 0.869 (95% CI 0.865-0.871), whereas that for survival to hospital discharge ranged from 0.800 (95% CI 0.797-0.800) to 0.734 (95% CI 0.736-0.740). The prediction probability of the TACOM showed similar flow with cohort data based on a comparison with the conventional model’s prediction probability.

Conclusions

The TACOM predicted the clinical outcome of OHCA patients per minute. This model for predicting patient outcomes by the minute can assist clinicians in making rational decisions for OHCA patients.

Comparing the Ability and Accuracy of mSOFA, qSOFA, and qSOFA-65 in Predicting the Status of Nontraumatic Patients Referred to a Hospital Emergency Department: A Prospective Study

Introduction

This study was proposed to compare the ability and accuracy of modified sequential organ failure assessment (mSOFA), quick SOFA (qSOFA), and qSOFA-65 in predicting the status of nontraumatic patients referred to hospital emergency departments (EDs).

Materials and methods

This study was a prospective design that performed on the 746 nontraumatic patients referred to the ED. Each patient data was collected using a demographic questionnaire, mSOFA, qSOFA, and qSOFA-65 scales. Related variables of each scale were recorded based on patients’ medical records. Then, the outcome of each patient in the ED was followed up and recorded. The severity and specificity of each scale were estimated by the area under receiver operating characteristic (AUROC) curve at 99% confidence interval (CI).

Results

The mean and standard deviation of scores were as follows: mSOFA = 4.40 ± 2.58, qSOFA = 0.50 ± 0.70, and qSOFA-65 = 0.92 ± 0.96. Patients requiring admission to the intensive care unit (ICU) were identified with AUROC curve as follows: mSOFA = 0.882 (99% CI = 0.778–0.865); qSOFA = 0.717 (99% CI = 0.662–0.773); and qSOFA-65 = 0.771 (99% CI = 0.721–0.820), which showed that mSOFA has higher sensitivity and specificity than the other two scales in identifying patients requiring admission to the ICU.

Conclusion

All three scales were found to be reliable for identifying nontraumatic patients at risk of death and patients requiring admission to the ICU. However, since the time and data required to complete qSOFA and qSOFA-65 are much less than those of mSOFA, it is recommended that qSOFA and especially qSOFA-65 be used in ED to identify critically ill nontraumatic patients.

How to cite this article

Ebrahimian A, Shahcheragh SMT, Fakhr-Movahedi A. Comparing the Ability and Accuracy of mSOFA, qSOFA, and qSOFA-65 in Predicting the Status of Nontraumatic Patients Referred to a Hospital Emergency Department: A Prospective Study. Indian J Crit Care Med 2020;24(11):1045–1050.

The effects of unexpected changes in demand on the performance of emergency departments

Crowding in emergency departments (EDs) is increasing in many health systems. Previous studies of the relationship between crowding and care quality are limited by the use of data from single hospitals, a focus on particular patient groups, a focus on a narrow set of quality measures, and use of crowding measures which induce bias from unobserved hospital and patient characteristics. Using data from 139 hospitals covering all major EDss in England, we measure crowding using quasi-exogenous variation in the volume of EDs attendances and examine its impacts on indicators of performance across the entire EDs care pathway. We exploit variations from expected volume estimated using high-dimensional fixed effects capturing hospital-specific variation in attendances by combinations of month and hour-of-the-week. Unexpected increases in attendance volume result in substantially longer waiting times, lower quantity and complexity of care, more patients choosing to leave without treatment, changes in referral and discharge decisions, but only small increases in reattendances and no increase in mortality. Causal bounds under potential omitted variable bias are narrow and exclude zero for the majority of outcomes. Results suggest that physician and patient responses may largely mitigate the impacts of demand increases on patient outcomes in the short-run.

Impact of trauma centre capacity and volume on the mortality risk of incoming new admissions

INTRODUCTION

Trauma centre capacity and surge volume may affect decisions on where to transport a critically injured patient and whether to bypass the closest facility. Our hypothesis was that overcrowding and high patient acuity would contribute to increase the mortality risk for incoming admissions.

METHODS

For a 6-year period, we merged and cross-correlated our institutional trauma registry with a database on Trauma Resuscitation Unit (TRU) patient admissions, movement and discharges, with average capacity of 12 trauma bays. The outcomes of overall hospital and 24 hours mortality for new trauma admissions (NEW) were assessed by multivariate logistic regression.

RESULTS

There were 42 003 (mean=7000/year) admissions having complete data sets, with 36 354 (87%) patients who were primary trauma admissions, age ≥18 and survival ≥15 min. In the logistic regression model for the entire cohort, NEW admission hospital mortality was only associated with NEW admission age and prehospital Glasgow Coma Scale (GCS) and Shock Index (SI) (all p<0.05). When TRU occupancy reached ≥16 patients, the factors associated with increased NEW admission hospital mortality were existing patients (TRU >1 hour) with SI ≥0.9, recent admissions (TRU ≤1 hour) with age ≥65, NEW admission age and prehospital GCS and SI (all p<0.05).

CONCLUSION

The mortality of incoming patients is not impacted by routine trauma centre overcapacity. In conditions of severe overcrowding, the number of admitted patients with shock physiology and a recent surge of elderly/debilitated patients may influence the mortality risk of a new trauma admission.

Is the fast-track process efficient and safe for older adults admitted to the emergency department?

BACKGROUND

The efficiency of the fast-track (FT) process in the management of patients in Emergency Departments is well demonstrated, but there is a lack of research focused on older adults. The aim of our study was to verify whether the FT process is efficient and safe for older adults admitted to ED.

METHODS

Observational case-control single-centre study.

RESULTS

Five hundred four cases and 504 controls were analysed. The mean age was 75 years, and there was a predominance of women. In total 96% of subjects were classified with a "less-urgent" tag. The length of stay was significantly lower in the fast-track group than in the control group (median 178 min, interquartile range 184 min, and 115 min, interquartile range 69 min, respectively, p < 0.001), as well as the time spent between the ED physician's visit and patient discharge (median 78 min, interquartile range 120 min, and median 3 min, interquartile range 6 min, respectively, p < 0.001). There weren't any increases in the number of unplanned readmissions within 48 h, 7 days and 30 days.

CONCLUSIONS

The fast-track appears to be an efficient and safe strategy to improve the management of older adults admitted to the ED with minor complaints.

Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study

Background

Emergency Department (ED) overcrowding adversely affects patients’ health, accessibility, and quality of healthcare systems for communities. Several studies have addressed this issue. This study aimed to conduct a systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals.

Methods

Original research articles on crowding of emergencies at hospitals published from 1st January 2007, and 1st August 2018 were utilized. Relevant studies from the PubMed and EMBASE databases were assessed using suitable keywords. Two reviewers independently screened the titles, abstracts and the methodological validity of the records using data extraction format before their inclusion in the final review. Discussions with the senior faculty member were used to resolve any disagreements among the reviewers during the assessment phase.

Results

Out of the total 117 articles in the final record, we excluded 11 of them because of poor quality. Thus, this systematic review synthesized the reports of 106 original articles. Overall 14, 55 and 29 of the reviewed refer to causes, effects, and solutions of ED crowding, respectively. The review also included four articles on both causes and effects and another four on causes and solutions. Multiple individual patients and healthcare system related challenges, experiences and responses to crowding and its consequences are comprehensively synthesized.

Conclusion

ED overcrowding is a multi-facet issue which affects by patient-related factors and emergency service delivery. Crowding of the EDs adversely affected individual patients, healthcare delivery systems and communities. The identified issues concern organizational managers, leadership, and operational level actions to reduce crowding and improve emergency healthcare outcomes efficiently.

Association of sudden in-hospital cardiac arrest with emergency department crowding

BACKGROUND

In Taiwan, emergency department (ED) crowding is inevitable; many studies have investigated the various negative effects of ER crowding on patients. In general, ED crowding reduces patient satisfaction, delays treatment, and increases mortality. However, most studies have focused on the relationship between ED crowding and delay mortality rather than sudden mortality. This study investigates the association of ED crowding with sudden unexpected in-hospital cardiac arrest (IHCA).

METHODS

The retrospective observational study recruited patients with sudden IHCA in an ED from February 2016 to September 2017. Exclusion criteria included (1) out-of-hospital cardiac arrest, (2) patient with signed do-not-resuscitate consent, (3) pediatric patient, and (4) trauma patient. ED crowding parameters, including ED bed occupancy rates (EDBORs), number of boarding patients, and patients with boarding time to general ward or intensive care unit of >24 and >48 h, all were recorded every 2 h.

RESULTS

Significant increments were noted in IHCA incidence when EDBOR was >260%, with a rate ratio of 1.50 (95% confidence interval [CI], 1.03-2.17). However, the number of boarding patients was not associated with IHCA incidence (P > 0.05). Prolonged boarding time to general ward and ICU of >24 and >48 h both increased the IHCA incidence.

CONCLUSION

This first study investigating the relationship between ED crowding and sudden IHCA found EDBORs and prolonged boarding to general wards or ICUs were associated with increased sudden IHCA incidence.

Evaluating the impact of emergency department crowding on disposition patterns and outcomes of discharged patients

BACKGROUND

Crowding is a major challenge faced by EDs and is associated with poor outcomes.

OBJECTIVES

Determine the effect of high ED occupancy on disposition decisions, return ED visits, and hospitalizations.

METHODS

We conducted a retrospective analysis of electronic health records of patients evaluated at an adult, urban, and academic ED over 20 months between the years 2012 and 2014. Using a logistic regression model predicting admission, we obtained estimates of the effect of high occupancy on admission disposition, adjusted for key covariates. We then stratified the analysis based on the presence or absence of high boarder patient counts.

RESULTS

Disposition decisions during a high occupancy hour decreased the odds of admission (OR = 0.93, 95% CI: [0.89, 0.98]). Among those who were not admitted, high occupancy was not associated with increased odds of return in the combined (OR = 0.94, 95% CI: [0.87, 1.02]), with-boarders (OR = 0.96, 95% CI: [0.86, 1.09]), and no-boarders samples (OR = 0.93, 95% CI: [0.83, 1.04]). Among those who were not admitted and who did return within 14 days, disposition during a high occupancy hour on the initial ED visit was not associated with a significant increased odds of hospitalization in the combined (OR = 1.04, 95% CI: [0.87, 1.24]), the with-boarders (OR = 1.12, 95% CI: [0.87, 1.44]), and the no-boarders samples (OR = 0.98, 95% CI: [0.77, 1.24]).

CONCLUSION

ED crowding was associated with reduced likelihood of hospitalization without increased likelihood of 2-week return ED visit or hospitalization. Furthermore, high occupancy disposition hours with high boarder patient counts were associated with decreased likelihood of hospitalization.

The influence of crowding on clinical practice in the emergency department

BACKGROUND

This study aimed to clarify the association between the crowding and clinical practice in the emergency department (ED).

METHODS

This 1-year retrospective cohort study conducted in two EDs in Taiwan included 70,222 adult non-trauma visits during the day shift between July 1, 2011, and June 30, 2012. The ED occupancy status, determined by the number of patients staying during their time of visit, was used to measure crowding, grouped into four quartiles, and analyzed in reference to the clinical practice. The clinical practices included decision-making time, patient length of stay, patient disposition, and use of laboratory examinations and computed tomography (CT).

RESULT

The four quartiles of occupancy statuses determined by the number of patients staying during their time of visit were <24, 24-39, 39-62, and >62. Comparing >62 and <24 ED occupancy statuses, the physicians' decision-making time and patients' length of stay increased by 0.3h and 1.1h, respectively. The percentage of patients discharged from the ED decreased by 15.5% as the ED observation, general ward, and intensive care unit admissions increased by 10.9%, 4%, and 0.7%, respectively. CT and laboratory examination slightly increased in the fourth quartile of ED occupancy.

CONCLUSION

Overcrowding in the ED might increase physicians' decision-making time and patients' length of stay, and more patients could be admitted to observation units or an inpatient department. The use of CT and laboratory examinations would also increase. All of these could lead more patients to stay in the ED.

The impact of ED crowding on early interventions and mortality in patients with severe sepsis

OBJECTIVE

Critically ill patients require significant time and care coordination in the emergency department (ED). We hypothesized that ED crowding would delay time to intravenous fluids and antibiotics, decrease utilization of protocolized care, and increase mortality for patients with severe sepsis or septic shock.

METHODS

This was a retrospective cohort study of severe sepsis patients admitted to the hospital from the ED between January 2005 and February 2010. Associations between four validated measures of ED crowding (occupancy, waiting patients, admitted patients, and patient-hours) assigned at triage, and time of day, time to antibiotics and fluids, and mortality were tested by analyzing trends across crowding quartiles.

RESULTS

During the study period, 2913 severe sepsis patients were admitted to the hospital and 1127 (38.7%) qualified for protocolized care. In-hospital mortality was 14.3% overall and 26% for patients qualifying for protocolized care. Time to IV fluids was delayed as ED occupancy rate increased and as patient hours increased. Time to antibiotics increased as occupancy rates, patient hours, and the number of boarding inpatients increased. Implementation rates of protocolized care decreased from 71.3% to 50.5% (p<0.0001, OR 0.39) as the number of ED inpatient boarders increased; initiation of protocolized care was significantly higher as occupancy increased (OR 1.52). Mortality was unaffected by crowding parameters in all analyses.

CONCLUSIONS

With increased ED crowding, time to critical severe sepsis therapies significantly increased and protocolized care initiation decreased. As crowding increases, EDs must implement systems that optimize delivery of time-sensitive therapies to critically ill patients.

Emergency department waiting room nurse role: A key informant perspective

BACKGROUND

Emergency departments have become overcrowded with increased waiting times. Strategies to decrease waiting times include time-based key performance indicators and introduction of a waiting room nurse role. The aim of the waiting room nurse role is to expedite care by assessing and managing patients in the waiting room. There is limited literature examining this role.

METHODS

This paper presents results of semi-structured interviews with five key informants to explore why and how the waiting room nurse role was implemented in Australian emergency departments. Data were thematically analysed.

RESULTS

Five key informants from five emergency departments across two Australian jurisdictions (Victoria and New South Wales) reported that the role was introduced to reduce waiting times and improve quality and safety of care in the ED waiting room. Critical to introducing the role was defining and supporting the scope of practice, experience and preparation of the nurses. Role implementation required champions to overcome identified challenges, including funding. There has been limited evaluation of the role.

CONCLUSIONS

The waiting room nurse role was introduced to decrease waiting times and contributed to risk mitigation. Common to all roles was standing orders, while preparation and experience varied. Further research into the role is required.

Correlation between classification in risk categories and clinical aspects and outcomes

Objective

to correlate classification in risk categories with the clinical profiles, outcomes and origins of patients.

Method

analytical cross-sectional study conducted with 697 medical forms of adult patients. The variables included: age, sex, origin, signs and symptoms, exams, personal antecedents, classification in risk categories, medical specialties, and outcome. The Chi-square and likelihood ratio tests were used to associate classifications in risk categories with origin, signs and symptoms, exams, personal antecedents, medical specialty, and outcome.

Results

most patients were women with an average age of 44.5 years. Pain and dyspnea were the symptoms most frequently reported while hypertension and diabetes mellitus were the most common comorbidities. Classifications in the green and yellow categories were the most frequent and hospital discharge the most common outcome. Patients classified in the red category presented the highest percentage of ambulance origin due to surgical reasons. Those classified in the orange and red categories also presented the highest percentage of hospitalization and death.

Conclusion

correlation between clinical aspects and outcomes indicate there is a relationship between the complexity of components in the categories with greater severity, evidenced by the highest percentage of hospitalization and death.

Implementing Triage Standing Orders in the Emergency Department Leads to Reduced Physician-to-Disposition Times

Emergency departments (EDs) throughout USA have improvised various processes to curb the “national epidemic” termed ED “crowding.” Standing orders (SOs), one such process, are medical orders approved by the medical director and entered by nurses when patients cannot be seen expeditiously, expediting medical decision-making and decreasing length of stay (LOS) and time to disposition. This retrospective cohort study evaluates the impact of SOs on ED LOS and disposition time at a large university ED. Results indicate that SOs significantly improve ED throughput by reducing disposition time by up to 16.9% (p=0.04), which is especially significant in busy ED settings. SOs by themselves are not sufficient for a complete diagnostic assessment. Strategies such as having a provider in the waiting area may help make key decisions earlier.

Who is less likely to die in association with improved National Emergency Access Target (NEAT) compliance for emergency admissions in a tertiary referral hospital?

Objective The aim of the present study was to identify patient and non-patient factors associated with reduced mortality among patients admitted from the emergency department (ED) to in-patient wards in a major tertiary hospital that had previously reported a near halving in mortality in association with a doubling in National Emergency Access Target (NEAT) compliance over a 2-year period from 2012 to 2014. Methods We retrospectively analysed routinely collected data from the Emergency Department Information System (EDIS) and hospital discharge abstracts on all emergency admissions during calendar years 2011 (pre-NEAT interventions) and 2013 (post-NEAT interventions). Patients admitted to short-stay wards and then discharged home, as well as patients dying in the ED, were excluded. Patients included in the study were categorised according to age, time and day of arrival to the ED, mode of transport to the ED, emergency triage category, type of clinical presentation and major diagnostic codes. Results The in-patient mortality rate for emergency admissions decreased from 1.9% (320/17 022) in 2011 to 1.2% (202/17 162) in 2013 (P < 0.001). There was no change from 2011 to 2013 in the percentage of deaths in the ED (0.19% vs 0.17%) or those coded as in-patient palliative care (17.9% vs 22.2%). Although deaths were not associated with age by itself, the mortality rate of older patients admitted to medical wards decreased significantly from 3.5% to 1.7% (P = 0.011). A higher mortality rate was seen among patients presenting to ED triage between midnight and 12 noon than at other times in 2011 (2.5% vs 1.5%; P < 0.001), but this difference disappeared by 2013 (1.3% vs 1.1%; P = 0.150). A similar pattern was seen among patients presenting on weekends versus weekdays: 2.2% versus 1.7% (P = 0.038) in 2011 and 1.3% versus 1.1% (P = 0.150) in 2013. Fewer deaths were noted among patients with acute cardiovascular or respiratory disease in 2013 than in 2011 (1.7% vs 3.6% and 1.5% vs 3.4%, respectively; P < 0.001 for both comparisons). Mode of transport to the ED or triage category was not associated with changes in mortality. These analyses took account of any possible confounding resulting from differences over time in emergency admission rates. Conclusions Improved NEAT compliance as a result of clinical redesign is associated with improved in-patient mortality among particular subgroups of emergency admissions, namely older patients with complex medical conditions, those presenting after hours and on weekends and those presenting with time-sensitive acute cardiorespiratory conditions. What is known about the topic? Clinical redesign aimed at improving compliance with NEAT and reducing time spent within the ED of acutely admitted patients has been associated with reduced mortality. To date, no study has attempted to identify subgroups of patients who potentially derive the greatest benefit from improved NEAT compliance in terms of reduced risk of in-patient death. It also remains unclear as to what extent non-patient factors (e.g. admission practices and differences in coding of palliative care patients) affect or confound this reduced risk. What does this paper add? The present study is the first to reveal that enhanced NEAT compliance is associated with lower mortality among particular subgroups of emergency patients admitted to in-patient wards. These include older patients with complex medical conditions, those presenting after hours or on weekends or those with time-sensitive acute cardiorespiratory conditions. These results took account of any possible confounding resulting from differences over time in emergency admission rates, deaths in the ED, numbers of short-stay ward admissions and coding of palliative care deaths. What are the implications for practitioners? Efforts aimed at improving NEAT compliance and efficiencies at the ED–in-patient interface appear to be worthwhile in reducing in-patient mortality among particular subgroups of emergency admissions at high risk. More research is urgently needed in identifying patient- and system-level factors that predispose to higher mortality rates in such populations, but are potentially amenable to focused interventions aimed at optimising transitions of care at the ED–in-patient interface and increasing NEAT compliance for patients admitted to in-patient wards from the ED.

ED crowding is associated with inpatient mortality among critically ill patients admitted via the ED: post hoc analysis from a retrospective study

BACKGROUND

Adverse effects of emergency department (ED) crowding among critically ill patients are not well known.

OBJECTIVES

We evaluated the association between ED crowding and inpatient mortality among critically ill patients admitted via the ED, and analyzed subsets of patients according to admission diagnosis.

METHODS

We performed a post hoc analysis using data from a previous retrospective study. We enrolled admitted patients via the ED with an initial systolic blood pressure of 90 mm Hg or lower when presenting to the ED. The ED occupancy ratio was used as a measure of crowding. The primary outcome was inpatient mortality. Multivariable logistic regression models adjusted for potential confounding variables were constructed for the entire cohort and for subsets according to admission diagnosis (infection, cardiac and vascular disease, trauma, gastrointestinal bleeding, and other factors).

RESULTS

A total of 1801 patients were enrolled, with a mortality rate of 14.6% (262 patients). The mortality rate by ED occupancy ratio quartile was 9.7% for the first quartile, 15.9% for the second quartile, 18.2% for the third quartile, and 14.4% for the fourth quartile. This resulted in adjusted odds ratios of 1.95, 2.51, and 1.93 and corresponding 95% confidence intervals of 1.23-3.12, 1.58-3.99, and 1.21-3.09 for the second, third, and fourth quartiles, respectively, compared with the first quartile. The effect of ED crowding was highest in the trauma subset, followed by the infection subset, whereas ED crowding did not appear to have any effect on the cardiac and vascular disease subsets.

CONCLUSION

Emergency department crowding was associated with increased inpatient mortality among critically ill patients admitted via the ED.

Providing Care in Emergency Department Hallways: Demands, Dangers, and Deaths

Emergency departments (ED) worldwide have experienced dramatic increases in crowding over the past 20 years that now have reached critical levels. One consequence of ED crowding has been the routine use of ED hallways for patient care. This includes ED patients who are awaiting care but are considered unstable to remain in the waiting room, patients who are undergoing active medical and trauma treatment, and patients who have been stabilized but await transfer to an inpatient bed (boarding) or another institution. Compared with licensed hospital or standard ED beds, care in ED hallways results in increased patient morbidity and mortality, as well as patient and staff dissatisfaction. Complications experienced by hallway patients include unrecognized sudden respiratory arrest or unstable cardiac arrhythmias, delay in time-sensitive procedures and laboratory testing, delay in receiving important medications, excessive or unrelieved pain, overall increased length of stay, increased disability, and exposure to traumatic psychological events. While much has been published on the general problems of ED crowding, only recently have studies focused exclusively on the issues of providing care in ED hallways. This review summarizes the current issues, challenges, and solutions for hallway care.

Caring for inpatient boarders in the emergency department: improving safety and patient and staff satisfaction

Hospital capacity constraints lead to large numbers of inpatients being held for extended periods in the emergency department. This creates concerns with safety, quality of care, and dissatisfaction of patients and staff. The aim of this quality-improvement project was to improve satisfaction and processes in which nurses provided care to inpatient boarders held in the emergency department. A quality-improvement project framework that included the use of a questionnaire was used to ascertain employee and patient dissatisfaction and identify opportunities for improvement. A task force was created to develop action plans related to holding and caring for inpatients in the emergency department. A questionnaire was sent to nursing staff in spring 2012, and responses from the questionnaire identified improvements that could be implemented to improve care for inpatient boarders. Situation-background-assessment-recommendation (SBAR) communications and direct observations were also used to identify specific improvements. Post-questionnaire results indicated improved satisfaction for both staff and patients. It was recognized early that the ED inpatient area would benefit from the supervision of an inpatient director, managers, and staff. Outcomes showed that creating an inpatient unit within the emergency department had a positive effect on staff and patient satisfaction.

Boarding is associated with higher rates of medication delays and adverse events but fewer laboratory-related delays

BACKGROUND

Hospital crowding and emergency department (ED) boarding are large and growing problems. To date, there has been a paucity of information regarding the quality of care received by patients boarding in the ED compared with the care received by patients on an inpatient unit. We compared the rate of delays and adverse events at the event level that occur while boarding in the ED vs while on an inpatient unit.

METHODS

This study was a secondary analysis of data from medical record review and administrative databases at 2 urban academic teaching hospitals from August 1, 2004, through January 31, 2005. We measured delayed repeat cardiac enzymes, delayed partial thromboplastin time level checks, delayed antibiotic administration, delayed administration of home medications, and adverse events. We compared the incidence of events during ED boarding vs while on an inpatient unit.

RESULTS

Among 1431 patient medical records, we identified 1016 events. Emergency department boarding was associated with an increased risk of home medication delays (risk ratio [RR], 1.54; 95% confidence interval [CI], 1.26-1.88), delayed antibiotic administration (RR, 2.49; 95% CI, 1.72-3.52), and adverse events (RR, 2.36; 95% CI, 1.15-4.72). On the contrary, ED boarding was associated with fewer delays in repeat cardiac enzymes (RR, 0.17; 95% CI, 0.09-0.27) and delayed partial thromboplastin time checks (RR, 0.54; 95% CI, 0.27-0.96).

CONCLUSION

Compared with inpatient units, ED boarding was associated with more medication-related delays and adverse events but fewer laboratory-related delays. Until we can eliminate ED boarding, it is critical to identify areas for improvement.

Evaluating the effect of emergency department crowding on triage destination

Background

Emergency Department (ED) crowding has been studied for the last 20 years, yet many questions remain about its impact on patient care. In this study, we aimed to determine if ED crowding influenced patient triage destination and intensity of investigation, as well as rates of unscheduled returns to the ED. We focused on patients presenting with chest pain or shortness of breath, triaged as high acuity, and who were subsequently discharged home.

Methods

This pilot study was a health records review of 500 patients presenting to two urban tertiary care EDs with chest pain or shortness of breath, triaged as high acuity and subsequently discharged home. Data extracted included triage time, date, treatment area, time to physician initial assessment, investigations ordered, disposition, and return ED visits within 14 days. We defined ED crowding as ED occupancy greater than 1.5. Data were analyzed using descriptive statistics and the χ² and Fisher exact tests.

Results

Over half of the patients, 260/500 (52.0%) presented during conditions of ED crowding. More patients were triaged to the non-monitored area of the ED during ED crowding (65/260 (25.0%) vs. 39/240 (16.3%) when not crowded, P = 0.02). During ED crowding, mean time to physician initial assessment was 132.0 minutes in the non-monitored area vs. 99.1 minutes in the monitored area, P <0.0001. When the ED was not crowded, mean time to physician initial assessment was 122.3 minutes in the non-monitored area vs. 67 minutes in the monitored area, P = 0.0003. Patients did not return to the ED more often when triaged during ED crowding: 24/260 (9.3%) vs. 29/240 (12.1%) when ED was not crowded (P = 0.31). Overall, when triaged to the non-monitored area of the ED, 44/396 (11.1%) patients returned, whereas in the monitored area 9/104 (8.7%) patients returned, P = 0.46.

Conclusions

ED crowding conditions appeared to influence triage destination in our ED leading to longer wait times for high acuity patients. This did not appear to lead to higher rates of return ED visits amongst discharged patients in this cohort. Further research is needed to determine whether these delays lead to adverse patient outcomes.

The probability of patients being admitted from the emergency department is negatively correlated to in-hospital bed occupancy - a registry study

Background

The association between emergency department (ED) overcrowding and poor patient outcomes is well described, with recent work suggesting that the phenomenon causes delays in time-sensitive interventions, such as resuscitation. Even though most researchers agree on the fact that admitted patients boarding in the ED is a major contributing factor to ED overcrowding, little work explicitly addresses whether in-hospital occupancy is associated to the probability of patients being admitted from the ED. The objective of the present study is to investigate whether such an association exists.

Methods

Retrospective analysis of data on all ED visits to Helsingborg General Hospital in southern Sweden between January 1, 2011, and December 31, 2012, was undertaken. The fraction of admitted patients was calculated separately for strata of in-hospital occupancy <95%, 95–100%, 100–105%, and >105%. Multivariate models were constructed in an attempt to take confounding factors, e.g., presenting complaints, age, referral status, triage priority, and sex into account. Subgroup analysis was performed for each specialty unit within the ED.

Results

Overall, 118,668 visits were included. The total admitted fraction was 30.9%. For levels of in-hospital occupancy <95%, 95–100%, 100–105%, and >105% the admitted fractions were 31.5%, 30.9%, 29.9%, and 28.7%, respectively. After taking confounding factors into account, the odds ratio for admission were 0.88 (CI 0.84–0.93, P >0.001) for occupancy level 95–100%, 0.82 (CI 0.78–0.87, P >0.001) for occupancy level 100–105%, and 0.74 (CI 0.67–0.81, P >0.001) for occupancy level >105%, relative to the odds ratio for admission at occupancy level <95%. A similar pattern was observed upon subgroup analysis.

Conclusions

In-hospital occupancy was significantly associated with a decreased odds ratio for admission in the study population. One interpretation is that patients who would benefit from inpatient care instead received suboptimal care in outpatient settings at times of high in-hospital occupancy. A second interpretation is that physicians admit patients who could be managed safely in the outpatient setting, in times of good in-hospital bed availability. Physicians thereby expose patients to healthcare-associated infections and other hazards, in addition to consuming resources better needed by others.

Patients overwhelmingly prefer inpatient boarding to emergency department boarding

BACKGROUND

Boarding of admitted patients in the emergency department (ED) is a major cause of crowding. One alternative to boarding in the ED, a full-capacity protocol where boarded patients are redeployed to inpatient units, can reduce crowding and improve overall flow.

OBJECTIVE

Our aim was to compare patient satisfaction with boarding in the ED vs. inpatient hallways.

METHODS

We performed a structured telephone survey regarding patient experiences and preferences for boarding among admitted ED patients who experienced boarding in the ED hallway and then were subsequently transferred to inpatient hallways. Demographic and clinical characteristics, as well as patient preferences, including items related to patient comfort and safety using a 5-point scale, were recorded and descriptive statistics were used to summarize the data.

RESULTS

Of 110 patients contacted, 105 consented to participate. Mean age was 57 ± 16 years and 52% were female. All patients were initially boarded in the ED in a hallway before their transfer to an inpatient hallway bed. The overall preferred location after admission was the inpatient hallway in 85% (95% confidence interval 75-90) of respondents. In comparing ED vs. inpatient hallway boarding, the following percentages of respondents preferred inpatient boarding with regard to the following 8 items: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED.

CONCLUSIONS

Patients overwhelmingly preferred the inpatient hallway rather than the ED hallway when admitted to the hospital.