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Canellas MM, Jewell M, Edwards JL, Olivier D, Jun-O'Connell AH, Reznek MA. Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing. Ann Emerg Med 2024:S0196-0644(24)00221-X. [PMID: 38795079 DOI: 10.1016/j.annemergmed.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/20/2024] [Accepted: 04/09/2024] [Indexed: 05/27/2024]
Abstract
STUDY OBJECTIVE Boarding admitted patients in emergency departments (EDs) is a national crisis that is worsening despite potential financial disadvantages. The objective of this study was to assess costs associated with boarding. METHODS We conducted a prospective, observational investigation of patients admitted through an ED for management of acute stroke at a large, urban, academic, comprehensive stroke center hospital. We employed time-driven activity-based costing methodology to estimate cost for patient care activities during admission and aggregated results to estimate the total cost of boarding versus inpatient care. Primary outcomes were total daily costs per patient for medical-surgical (med/surg) boarding, med/surg inpatient care, ICU boarding, and ICU inpatient care. RESULTS The total daily cost per patient with acute stroke was US$1856, for med/surg boarding versus US$993 for med/surg inpatient care and US$2267, for ICU boarding versus US$2165, for ICU inpatient care. These differences were even greater when accounting for costs associated with traveler nurses. ED nurses spent 293 min/d (mean) caring for each med/surg boarder; inpatient nurses spent 313 min/d for each med/surg inpatient. ED nurses spent 419 min/d caring for each ICU boarder; inpatient nurses spent 787 min/d for each ICU inpatient. Neurology attendings and residents spent 25 and 52 min/d caring for each med/surg boarder versus 62 minutes and 90 minutes for each med/surg inpatient, respectively. CONCLUSION Using advanced cost-accounting methods, our investigation provides novel evidence that boarding of admitted patients is financially costly, adding greater urgency for elimination of this practice.
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Affiliation(s)
- Maureen M Canellas
- Department of Emergency Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA; Department of Emergency Medicine, UMass Memorial Health, Worcester, MA.
| | - Marcella Jewell
- University of Massachusetts T.H. Chan School of Medicine, Worcester, MA
| | - Jennifer L Edwards
- Department of Emergency Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA; Department of Emergency Medicine, UMass Memorial Health, Worcester, MA
| | - Danielle Olivier
- Department of Emergency Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA; Department of Emergency Medicine, UMass Memorial Health, Worcester, MA
| | - Adalia H Jun-O'Connell
- Department of Neurology, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA; Department of Neurology, UMass Memorial Health, Worcester, MA
| | - Martin A Reznek
- Department of Emergency Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA; Department of Emergency Medicine, UMass Memorial Health, Worcester, MA
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MacIsaac M, Peter E. Emergency department crowding: An examination of older adults and vulnerability. Nurs Ethics 2024:9697330241238333. [PMID: 38476026 DOI: 10.1177/09697330241238333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Emergency departments in many nations worldwide have been struggling for many years with crowding and the subsequent provision of care in hallways and other unconventional spaces. While this issue has been investigated and analyzed from multiple perspectives, the ethical dimensions of the place of emergency department care have been underexamined. Specifically, the impacts of the place of care on patients and their caregivers have not been robustly explored in the literature. In this article, a feminist ethics and human geography framing is utilized to argue that care provision in open and unconventional spaces in the emergency department can be unethical, as vulnerability can be amplified by the place of care for patients and their caregivers. The situational and pathogenic vulnerability of patients can be heightened by the place of the emergency department and by the constraints to healthcare providers' capacity to promote patient comfort, privacy, communication, and autonomy in this setting. The arrangements of care in the emergency department are of particular concern for older adults given the potential increased risks for vulnerability in this population. As such, hallway healthcare can reflect the normalized inequities of structural ageism. Recommendations are provided to address this complicated ethical issue, including making visible the moral experiences of patients and their caregivers, as well as those of healthcare providers in the emergency department, advocating for a systems-level accounting for the needs of older adults in the emergency department and more broadly in healthcare, as well as highlighting the need for further research to examine how to foster autonomy and care in the emergency department to reduce the risk for vulnerabilities.
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3
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Loke DE, Green KA, Wessling EG, Stulpin ET, Fant AL. Clinicians' Insights on Emergency Department Boarding: An Explanatory Mixed Methods Study Evaluating Patient Care and Clinician Well-Being. Jt Comm J Qual Patient Saf 2023; 49:663-670. [PMID: 37479591 DOI: 10.1016/j.jcjq.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND The aim of this study was to describe clinicians' insights into the quality and safety of patient care delivered to emergency department (ED) boarding patients, as well as clinician safety and satisfaction related to ED boarding. METHODS This was a single-site, mixed methods sequential explanatory study. Quantitative data were obtained from a cross-sectional survey sent to ED attending physicians, resident physicians, advanced practice providers, and nurses. Semistructured focus group interviews with a subsample of participants sought to add depth to the interpretation of survey data and identify areas of improvement in boarding care. Chi-square and Wilcoxon rank sum tests were used to evaluate for response differences between groups. Qualitative data were thematically coded and analyzed. RESULTS A total of 94 questionnaires were obtained for a response rate of 34.1%. Clinicians reported that boarding highly contributed to the perception of burnout. All groups reported high rates of perceived verbal and/or physical abuse from boarding patients (86.8% of nurses, 41.1% of providers, p = 0.0002). A total of 39 clinicians participated in focus groups regarding boarding care, and six themes were identified, including patient safety concerns, lack of knowledge/resources/training, and poor communication. Key themes identified as possible solutions to improve care included standardization of care, proactive planning, and culture change. CONCLUSION Clinicians identified many concerns regarding patient safety and the quality of care delivered to boarding patients and identified several areas for improvement. Clinicians also felt that boarding negatively affected their satisfaction and safety.
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Anesi GL, Xiong RA, Delgado MK. Frequency and Trends of Pre-Pandemic Surge Periods in U.S. Emergency Departments, 2006-2019. Crit Care Explor 2023; 5:e0954. [PMID: 37614798 PMCID: PMC10443743 DOI: 10.1097/cce.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVES To quantify the frequency, outside of the pandemic setting, with which individual healthcare facilities faced surge periods due to severe increases in demand for emergency department (ED) care. DESIGN Retrospective cohort study. SETTING U.S. EDs. PATIENTS All ED encounters in the all-payer, nationally representative Nationwide Emergency Department Sample from the Healthcare Cost and Utilization Project, 2006-2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Frequency of surge periods defined as ED months in which an individual facility ED saw a greater than 50% increase in ED visits per month above facility-/calendar month-specific medians. During 2006-2019, 3,317 U.S. EDs reported 354,534,229 ED visits across 142,035 ED months. Fifty-seven thousand four hundred ninety-five ED months (40.5%) during the study period had a 0% to 50% increase in ED visits that month above facility-specific medians and 1,952 ED months (1.4%) qualified as surge periods and had a greater than 50% increase in ED visits that month above facility-specific medians. These surge months were experienced by 397 unique facility EDs (12.0%). Compared with 2006, the most proximal pre-pandemic period of 2016-2019 had a notably elevated likelihood of ED-month surge periods (odds ratios [ORs], 2.36-2.84; all p < 0.0005). Compared with the calendar month of January, the winter ED months in December through March have similar likelihood of an ED-month qualifying as a surge period (ORs, 0.84-1.03; all p > 0.05), while the nonwinter ED months in April through November have a lower likelihood of an ED-month qualifying as a surge period (ORs, 0.65-0.81; all p < 0.05). CONCLUSIONS Understanding the frequency of surges in demand for ED care-which appear to have increased in frequency even before the COVID-19 pandemic and are concentrated in winter months-is necessary to better understand the burden of potential and realized acute surge events and to inform cost-effectiveness preparedness strategies.
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Affiliation(s)
- George L Anesi
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ruiying Aria Xiong
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - M Kit Delgado
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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5
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Canellas M, Michael S, Kotkowski K, Reznek M. Operations Factors Associated with Emergency Department Length of Stay: Analysis of a National Operations Database. West J Emerg Med 2023; 24:178-184. [PMID: 36976590 PMCID: PMC10047726 DOI: 10.5811/westjem.2022.10.56609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 10/08/2022] [Indexed: 03/20/2023] Open
Abstract
Introduction: Prolonged emergency department (ED) length of stay (LOS) has been shown to adversely affect patient care. We sought to determine factors associated with ED LOS via analysis of a large, national, ED operations database.
Methods: We performed retrospective, multivariable, linear regression modeling using the 2019 Emergency Department Benchmarking Alliance survey results to identify associated factors of ED LOS for admitted and discharged patients.
Results: A total of 1,052 general and adult-only EDs responded to the survey. Median annual volume was 40,946. The median admit and discharge LOS were 289 minutes and 147 minutes, respectively. R-squared values for the admit and discharge models were 0.63 and 0.56 with out-of-sample R-squared values of 0.54 and 0.59, respectively. Both admit and discharge LOS were associated with academic designation, trauma level designation, annual volume, proportion of ED arrivals occurring via emergency medical services, median boarding, and use of a fast track. Additionally, admit LOS was associated with transfer-out percentage, and discharge LOS was associated with percentage of high Current Procedural Terminology, percentage of patients <18 years old, use of radiographs and computed tomography, and use of an intake physician.
Conclusion: Models derived from a large, nationally representative cohort identified diverse associated factors of ED length of stay, several of which were not previously reported. Dominant within the LOS modeling were patient population characteristics and other factors extrinsic to ED operations, including boarding of admitted patients, which was associated with both admitted and discharged LOS. The results of the modeling have significant implications for ED process improvement and appropriate benchmarking.
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Affiliation(s)
- Maureen Canellas
- University of Massachusetts Medical School, Department of Emergency Medicine, Worcester, Massachusetts
| | - Sean Michael
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Kevin Kotkowski
- University of Massachusetts Medical School, Department of Emergency Medicine, Worcester, Massachusetts
| | - Martin Reznek
- University of Massachusetts Medical School, Department of Emergency Medicine, Worcester, Massachusetts
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Affiliation(s)
| | - Stevan Bruijns
- Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
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7
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Anesi GL, Liu VX, Chowdhury M, Small DS, Wang W, Delgado MK, Bayes B, Dress E, Escobar GJ, Halpern SD. Association of ICU Admission and Outcomes in Sepsis and Acute Respiratory Failure. Am J Respir Crit Care Med 2022; 205:520-528. [PMID: 34818130 PMCID: PMC8906481 DOI: 10.1164/rccm.202106-1350oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Many decisions to admit patients to the ICU are not grounded in evidence regarding who benefits from such triage, straining ICU capacity and limiting its cost-effectiveness. Objectives: To measure the benefits of ICU admission for patients with sepsis or acute respiratory failure. Methods: At 27 United States hospitals across two health systems from 2013 to 2018, we performed a retrospective cohort study using two-stage instrumental variable quantile regression with a strong instrument (hospital capacity strain) governing ICU versus ward admission among high-acuity patients (i.e., laboratory-based acute physiology score v2 ⩾ 100) with sepsis and/or acute respiratory failure who did not require mechanical ventilation or vasopressors in the emergency department. Measurements and Main Results: Among patients with sepsis (n = 90,150), admission to the ICU was associated with a 1.32-day longer hospital length of stay (95% confidence interval [CI], 1.01-1.63; P < 0.001) (when treating deaths as equivalent to long lengths of stay) and higher in-hospital mortality (odds ratio, 1.48; 95% CI, 1.13-1.88; P = 0.004). Among patients with respiratory failure (n = 45,339), admission to the ICU was associated with a 0.82-day shorter hospital length of stay (95% CI, -1.17 to -0.46; P < 0.001) and reduced in-hospital mortality (odds ratio, 0.75; 95% CI, 0.57-0.96; P = 0.04). In sensitivity analyses of length of stay, excluding, ignoring, or censoring death, results were similar in sepsis but not in respiratory failure. In subgroup analyses, harms of ICU admission for patients with sepsis were concentrated among older patients and those with fewer comorbidities, and the benefits of ICU admission for patients with respiratory failure were concentrated among older patients, highest-acuity patients, and those with more comorbidities. Conclusions: Among high-acuity patients with sepsis who did not require life support in the emergency department, initial admission to the ward, compared with the ICU, was associated with shorter length of stay and improved survival, whereas among patients with acute respiratory failure, triage to the ICU compared with the ward was associated with improved survival.
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Affiliation(s)
- George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care,,Palliative and Advanced Illness Research (PAIR) Center, and,Leonard Davis Institute of Health Economics
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | | | - Dylan S. Small
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Wei Wang
- Palliative and Advanced Illness Research (PAIR) Center, and
| | - M. Kit Delgado
- Palliative and Advanced Illness Research (PAIR) Center, and,Center for Emergency Care Policy and Research, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania;,Leonard Davis Institute of Health Economics
| | - Brian Bayes
- Palliative and Advanced Illness Research (PAIR) Center, and
| | - Erich Dress
- Palliative and Advanced Illness Research (PAIR) Center, and
| | | | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care,,Palliative and Advanced Illness Research (PAIR) Center, and,Leonard Davis Institute of Health Economics
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8
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Choe B, Basile J, Cambria B, Youssef E, Podlog M, Mathews K, Berwald N, Hahn B. The Effect of a Nursing Hold Team on Patient Satisfaction for Admitted Patients Discharged Directly From the Emergency Department. Cureus 2021; 13:e17100. [PMID: 34527486 PMCID: PMC8432432 DOI: 10.7759/cureus.17100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 11/11/2022] Open
Abstract
Objectives: Emergency departments (ED) across the United States face challenges related to patient volume, available capacity, and patient throughput. Patient satisfaction is adversely affected by crowding and lengthy boarding times. This study aimed to determine whether the implementation of a dedicated nursing hold team (NHT) would improve patient satisfaction scores for admitted patients discharged directly from the ED. Methods: This was a retrospective, observational study with a pre-/post-test design. All admitted adult patients who returned a Press Ganey (PG) survey were included in the study. There were two twelve-month study periods before and after implementing an ED NHT. The primary outcome was the percentage of patients who gave top box scores for all questions in the Nursing Communication Domain. Results: During the pre-implementation period, 108 patients (59%) gave an overall top box rating for the Nursing Communication Domain versus the post-implementation period, where 99 patients (66%) provided a top box rating (OR 1.375, p = 0.16). There was a trend toward increased satisfaction for individual categories. However, these differences were not statistically significant. Conclusions: Implementing a dedicated NHT showed an increase in the overall top box PG Nursing Communication Domain score and several of the individual domain questions. Future studies should examine other potential benefits from a dedicated NHT, such as the rate of adverse events and medication delays.
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Affiliation(s)
- Brittany Choe
- Emergency Medicine, Staten Island University Hospital (SIUH), Staten Island, USA
| | - Joseph Basile
- Emergency Medicine, Staten Island University Hospital (SIUH), Staten Island, USA
| | - Bartholomew Cambria
- Emergency Medicine, Staten Island University Hospital (SIUH), Staten Island, USA
| | - Elias Youssef
- Emergency Medicine, Staten Island University Hospital (SIUH), Staten Island, USA
| | - Mikhail Podlog
- Emergency Medicine, Staten Island University Hospital (SIUH), Staten Island, USA
| | - Kurien Mathews
- Emergency Medicine, Staten Island University Hospital (SIUH), Staten Island, USA
| | - Nicole Berwald
- Emergency Medicine, Staten Island University Hospital (SIUH), Staten Island, USA
| | - Barry Hahn
- Emergency Medicine, Staten Island University Hospital (SIUH), Staten Island, USA
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9
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Canellas MM, Kotkowski KA, Michael SS, Reznek MA. Financial Implications of Boarding: A Call for Research. West J Emerg Med 2021; 22:736-738. [PMID: 34125054 PMCID: PMC8203028 DOI: 10.5811/westjem.2021.1.49527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 01/23/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Maureen M Canellas
- University of Massachusetts Medical School, Department of Emergency Medicine, Worcester, Massachusetts
| | - Kevin A Kotkowski
- University of Massachusetts Medical School, Department of Emergency Medicine, Worcester, Massachusetts
| | - Sean S Michael
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Martin A Reznek
- University of Massachusetts Medical School, Department of Emergency Medicine, Worcester, Massachusetts
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10
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Rantala A, Nordh S, Dvorani M, Forsberg A. The Meaning of Boarding in a Swedish Accident & Emergency Department: A Qualitative Study on Patients' Experiences of Awaiting Admission. Healthcare (Basel) 2021; 9:healthcare9010066. [PMID: 33445751 PMCID: PMC7828189 DOI: 10.3390/healthcare9010066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/04/2021] [Accepted: 01/10/2021] [Indexed: 01/10/2023] Open
Abstract
The number of in-hospital beds in Sweden has decreased during recent decades, resulting in the smallest number (2.2 available beds/1000 inhabitants) within the European Union. At the same time, the number of patients attending Accident and Emergency (A&E) departments has increased, resulting in overcrowding and boarding. The aim of this study was to explore the meaning of being subjected to boarding at an A&E department, as experienced by patients. A phenomenological-hermeneutic approach was chosen to interpret and understand the meaning of boarding at A&E. The study was carried out at a hospital in the south of Sweden. Seventeen participants with a mean age of 64 years (range: 35-86 years) were interviewed. The thematic structural analysis covers seven themes: Being in a state of uncertainty, Feeling abandoned, Fearing death, Enduring, Adjusting to the circumstances, Being a visitor in an unsafe place, and Acknowledging the staff, all illustrating that the participants were in a state of constant uncertainty and felt abandoned with no guidance or support from the clinicians. The conclusion is that the situation where patients are forced to wait in A&E, i.e., boarding, violates all conditions for professional ethics, presumably causing profound ethical stress in the healthcare professionals involved. Thus, boarding should be avoided.
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Affiliation(s)
- Andreas Rantala
- Department of Health Sciences, Lund University, SE-221 00 Lund, Sweden;
- Emergency Department, Helsingborg General Hospital, SE-251 87 Helsingborg, Sweden;
- Centre of Interprofessional Cooperation within Emergency Care (CICE), Linnaeus University, SE-251 95 Växjö, Sweden
- Correspondence:
| | - Sören Nordh
- Emergency Department, Helsingborg General Hospital, SE-251 87 Helsingborg, Sweden;
| | - Mergime Dvorani
- Premedic AB, Ambulance Service Hässleholm, SE-281 25 Hässleholm, Sweden;
| | - Anna Forsberg
- Department of Health Sciences, Lund University, SE-221 00 Lund, Sweden;
- Department of Cardiothoracic Surgery, Skåne University Hospital, SE-224 42 Lund, Sweden
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11
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Valipoor S, Hatami M, Hakimjavadi H, Akçalı E, Swan WA, De Portu G. Data-Driven Design Strategies to Address Crowding and Boarding in an Emergency Department: A Discrete-Event Simulation Study. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2020; 14:161-177. [PMID: 33176477 DOI: 10.1177/1937586720969933] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To address prolonged lengths of stay (LOS) in a Level 1 trauma center, we examined the impact of implementing two data-driven strategies with a focus on the physical environment. BACKGROUND Crowding in emergency departments (EDs) is a widely reported problem leading to increased service times and patients leaving without being seen. METHODS Using ED historical data and expert estimates, we created a discrete-event simulation model. We analyzed the likely impact of initiating care and boarding patients in the hallway (hallway care) instead of the exam rooms and adding a dedicated triage space for patients who arrive by emergency medical services (EMS triage) to decrease hallway congestion. The scenarios were compared in terms of LOS, time spent in exam rooms and hallway spaces, service time, blocked time, and utilization rate. RESULTS The hallway care scenario resulted in significantly lower LOS and exam room time only for EMS patients but when implemented along with the EMS triage scenario, a significantly lower LOS and exam room time was observed for all patients (EMS and walk-in). The combination of two simulated scenarios resulted in significant improvements in other flow metrics as well. CONCLUSIONS Our findings discourage boarding of admitted patients in ED exam rooms. If space limitations require that admitted patients be placed in ED hallways, designers and planners should consider enabling hallway spaces with features recommended in this article. Alternative locations for boarding should be prioritized in or out of the ED. Our findings also encourage establishing a triage area dedicated to EMS patients in the ED.
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Affiliation(s)
- Shabboo Valipoor
- Department of Interior Design, College of Design, Construction & Planning, 3463University of Florida, Gainesville, FL, USA
| | - Mohsen Hatami
- M. E. Rinker, Sr. School of Construction Management, College of Design, Construction & Planning, 3463University of Florida, Gainesville, FL, USA
| | - Hesamedin Hakimjavadi
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, 3463University of Florida, Gainesville, FL, USA
| | - Elif Akçalı
- Department of Industrial & Systems Engineering, Herbert Wertheim College of Engineering, 3463University of Florida, Gainesville, FL, USA
| | | | - Giuliano De Portu
- Department of Emergency Medicine, College of Medicine, 3463University of Florida, Gainesville, FL, USA
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12
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Smalley CM, Simon EL, Meldon SW, Muir MR, Briskin I, Crane S, Delgado F, Borden BL, Fertel BS. The impact of hospital boarding on the emergency department waiting room. J Am Coll Emerg Physicians Open 2020; 1:1052-1059. [PMID: 33145557 PMCID: PMC7593429 DOI: 10.1002/emp2.12100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Patient boarding in the emergency department (ED) is a significant issue leading to increased morbidity/mortality, longer lengths of stay, and higher hospital costs. We examined the impact of boarding patients on the ED waiting room. Additionally, we determined whether facility type, patient acuity, time of day, or hospital occupancy impacted waiting rooms in 18 EDs across a large healthcare system. METHODS This was a retrospective multicenter study that included all ED encounters between January 1, 2018, and September 30, 2019. Encounters with missing Emergency Severity Index (ESI) level were excluded. ESI levels were defined as high (ESI 1,2), middle (ESI 3), and low (ESI 4,5). Spearman correlation coefficients measured the relationship between boarded patients and number of patients in ED waiting room. A multivariable mixed effects model identified drivers of this relationship. RESULTS A total of 1,134,178 encounters were included. Spearman correlation coefficient was significant between number of patients in the ED waiting room and patient boarding (0.54). For every additional patient boarded/hour, the number of patients waiting/hour in the waiting room increased by 8% (95% confidence interval [CI] = 1.08-1.09). The number of patients waiting for a room/hour was 2.28 times higher for middle than for high acuity. The number of patients in waiting room slightly decreased as hospital occupancy increased (95% CI = 0.997-0.997). CONCLUSION Number of patients in ED waiting room are directly related to boarding times and hospital occupancy. ED waiting room times should be considered as not just an ED operational issue, but an aspect of hospital throughput.
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Affiliation(s)
- Courtney M. Smalley
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve UniversityClevelandOhioUSA
| | - Erin L. Simon
- Department of Emergency MedicineAkron General Medical CenterAkronOhioUSA
- Northeast Ohio Medical University (NEOMED)RootstownOhioUSA
| | - Stephen W. Meldon
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve UniversityClevelandOhioUSA
| | - McKinsey R. Muir
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
| | - Isaac Briskin
- Department of Quantitative Health SciencesCleveland Clinic Health SystemClevelandOhioUSA
| | - Steven Crane
- Department of Emergency MedicineAkron General Medical CenterAkronOhioUSA
| | - Fernando Delgado
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
| | - Bradford L. Borden
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve UniversityClevelandOhioUSA
| | - Baruch S. Fertel
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve UniversityClevelandOhioUSA
- Enterprise Quality and Patient SafetyCleveland Clinic Health SystemClevelandOhioUSA
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13
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Kreindler SA, Star N, Hastings S, Winters S, Johnson K, Mallinson S, Brierley M, Goertzen LN, Anwar MR, Aboud Z. "Working Against Gravity": The Uphill Task of Overcapacity Management. Health Serv Insights 2020; 13:1178632920929986. [PMID: 32587459 PMCID: PMC7294368 DOI: 10.1177/1178632920929986] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/04/2020] [Indexed: 11/17/2022] Open
Abstract
While most health systems have implemented interventions to manage situations in which patient demand exceeds capacity, little is known about the long-term sustainability or effectiveness of such interventions. A large multi-jurisdictional study on patient flow in Western Canada provided the opportunity to explore experiences with overcapacity management strategies across 10 diverse health regions. Four categories of interventions were employed by all or most regions: overcapacity protocols, alternative locations for emergency patients, locations for discharge-ready inpatients, and meetings to guide redistribution of patients. Two mechanisms undergirded successful interventions: providing a capacity buffer and promoting action by inpatient units by increasing staff accountability and/or solidarity. Participants reported that interventions demanded significant time and resources and the ongoing active involvement of middle and senior management. Furthermore, although most participants characterized overcapacity management practices as effective, this effectiveness was almost universally experienced as temporary. Many regions described a context of chronic overcapacity, which persisted despite continued intervention. Processes designed to manage short-term surges in demand cannot rectify a long-term mismatch between capacity and demand; solutions at the level of system redesign are needed.
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Affiliation(s)
- Sara A Kreindler
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg Regional Health Authority/University of Manitoba, Winnipeg, MB, Canada
| | - Noah Star
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Stephanie Hastings
- Health Systems Evaluation & Evidence, Alberta Health Services, Calgary, AB, Canada
| | - Shannon Winters
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg Regional Health Authority/University of Manitoba, Winnipeg, MB, Canada
| | - Keir Johnson
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg Regional Health Authority/University of Manitoba, Winnipeg, MB, Canada
| | - Sara Mallinson
- Health Systems Evaluation & Evidence, Alberta Health Services, Calgary, AB, Canada
| | - Meaghan Brierley
- Health Systems Evaluation & Evidence, Alberta Health Services, Calgary, AB, Canada
| | | | | | - Zaid Aboud
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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Napoli AM, Ali S, Lawrence A, Baird J. Boarding is Associated with Reduced Emergency Department Efficiency that is not Mitigated by a Provider in Triage. West J Emerg Med 2020; 21:647-652. [PMID: 32421514 PMCID: PMC7234689 DOI: 10.5811/westjem.2020.2.45728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/03/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Boarding of patients in the emergency department (ED) is associated with decreased ED efficiency. The provider-in-triage (PIT) model has been shown to improve ED throughput, but it is unclear how these improvements are affected by boarding. We sought to assess the effects of boarding on ED throughput and whether implementation of a PIT model mitigated those effects. METHODS We performed a multi-site retrospective review of 955 days of ED operations data at a tertiary care academic ED (AED) and a high-volume community ED (CED) before and after implementation of PIT. Key outcome variables were door to provider time (D2P), total length of stay of discharged patients (LOSD), and boarding time (admit request to ED departure [A2D]). RESULTS Implementation of PIT was associated with a decrease in median D2P by 22 minutes or 43% at the AED (p < 0.01), and 18 minutes (31%) at the CED (p < 0.01). LOSD also decreased by 19 minutes (5.9%) at the AED and 8 minutes (3.3%) at the CED (p<0.01). After adjusting for variations in daily census, the effect of boarding (A2D) on D2P and LOSD was unchanged, despite the implementation of PIT. At the AED, 7.7 minutes of boarding increased median D2P by one additional minute (p < 0.01), and every four minutes of boarding increased median LOSD by one minute (p < 0.01). At the CED, 7.1 minutes of boarding added one additional minute to D2P (p < 0.01), and 4.8 minutes of boarding added one minute to median LOSD (p < 0.01). CONCLUSION In this retrospective, observational multicenter study, ED operational efficiency was improved with the implementation of a PIT model but worsened with boarding. The PIT model was unable to mitigate any of the effects of boarding. This suggests that PIT is associated with increased efficiency of ED intake and throughput, but boarding continues to have the same effect on ED efficiency regardless of upstream efficiency measures that may be designed to minimize its impact.
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Affiliation(s)
- Anthony M Napoli
- Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | - Shihab Ali
- Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | - Alexis Lawrence
- Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | - Janette Baird
- Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island
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Ok M, Choi A, Kim MJ, Roh YH, Park I, Chung SP, Kim JH. Emergency short-stay wards and boarding time in emergency departments: A propensity-score matching study. Am J Emerg Med 2019; 38:2495-2499. [PMID: 31859191 DOI: 10.1016/j.ajem.2019.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/05/2019] [Accepted: 12/06/2019] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES This study aimed to validate the effectiveness of an emergency short-stay ward (ESSW) and its impact on clinical outcomes. METHODS This retrospective observational study was performed at an urban tertiary hospital. An ESSW has been operating in this hospital since September 2017 to reduce emergency department (ED) boarding time and only targets patients indicated for admission to the general ward from the ED. Propensity-score matching was performed for comparison with the control group. The primary outcome was ED boarding time, and the secondary outcomes were subsequent intensive care unit (ICU) admission and 30-day in-hospital mortality. RESULTS A total of 7461 patients were enrolled in the study; of them, 1523 patients (20.4%) were admitted to the ESSW. After propensity-score matching, there was no significant difference in the ED boarding time between the ESSW group and the control group (P = 0.237). Subsequent ICU admission was significantly less common in the ESSW group than in the control group (P < 0.001). However, the 30-day in-hospital mortality rate did not differ significantly between the two groups (P = 0.292). When the overall hospital bed occupancy ranged from 90% to 95%, the proportion of hospitalization was the highest in the ESSW group (29%). An interaction effect test using a general linear model confirmed that the ESSW served as an effect modifier with respect to bed occupancy and boarding time (P < 0.001). CONCLUSION An ESSW can alleviate prolonged boarding time observed with hospital bed saturation. Moreover, the ESSW is associated with a low rate of subsequent ICU admission.
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Affiliation(s)
- Min Ok
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Arom Choi
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Min Joung Kim
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Yun Ho Roh
- Department of Biostatistics Collaboration Unit, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Incheol Park
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea.
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Beltran-Aroca CM, Labella F, Font-Ugalde P, Girela-Lopez E. Assessment of Doctors' Knowledge and Attitudes Towards Confidentiality in Hospital Care. SCIENCE AND ENGINEERING ETHICS 2019; 25:1531-1548. [PMID: 30604354 DOI: 10.1007/s11948-018-0078-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 11/30/2018] [Indexed: 06/09/2023]
Abstract
The physician's duty of confidentiality is based on the observance of the patient's privacy and intimacy and on the importance of respecting both of these rights, thus creating a relationship of confidence and collaboration between doctor and patient. The main objective of this work consists of analyzing the aspects that are related to the confidentiality of patients' data with respect to the training, conduct and opinions of doctors from different Clinical Management Units of a third-level hospital via a questionnaire. The present study aimed to define the problem and determine whether the opinions of these professionals correspond to those observed in a previous work conducted at the same center. Of the 200 questionnaires that were collected, 62.5% were from consultants and the rest were from residents (37.5%) with an average of 14.4 ± 12.5 years in professional practice. The respondents noted habitual situations in which confidentiality was breached in the reference hospital (74%). The section on their attitudes and behaviors towards situations related to confidentiality showed a slightly lower average score than that of their medical knowledge; significant differences in these scores were observed between the consultants and residents as well as between the extreme age groups (≤ 30 vs. ≥ 51 years) and years of professional practice, thus more inadequate attitudes were consistently noted in younger doctors who had fewer years of experience. Finally, the respondents answered that the training of doctors in the aspects of healthcare law and ethics was the most important measure that the hospital could adopt regarding confidentiality practices.
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Affiliation(s)
- Cristina M Beltran-Aroca
- Sección de Medicina Legal y Forense, Facultad de Medicina y Enfermería, Universidad de Córdoba, Avda Menéndez Pidal s/n, 14004, Córdoba, Spain.
| | - Fernando Labella
- Sección de Oftalmología, Departamento de Especialidades Médico-Quirúrgicas, Facultad de Medicina y Enfermería, Universidad de Córdoba, 14004, Córdoba, Spain
| | - Pilar Font-Ugalde
- Sección de Bioestadística, Departamento de Medicina, Facultad de Medicina y Enfermería, Universidad de Córdoba, 14004, Córdoba, Spain
| | - Eloy Girela-Lopez
- Sección de Medicina Legal y Forense, Facultad de Medicina y Enfermería, Universidad de Córdoba, Avda Menéndez Pidal s/n, 14004, Córdoba, Spain
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Alishahi Tabriz A, Birken SA, Shea CM, Fried BJ, Viccellio P. What is full capacity protocol, and how is it implemented successfully? Implement Sci 2019; 14:73. [PMID: 31319857 PMCID: PMC6637572 DOI: 10.1186/s13012-019-0925-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 07/09/2019] [Indexed: 11/18/2022] Open
Abstract
Background Full capacity protocol (FCP) is an internationally recognized intervention designed to address emergency department (ED) crowding. Despite FCP international recognition and positive effects on hospital performance measures, many hospitals, even the most crowded ones, have not implemented FCP. We conducted this study to identify the core components of FCP, explore the key barriers and facilitators associated with the FCP implementation, and provide practical recommendations on how to overcome those barriers. Methods To identify the core components of FCP, we used a non-experimental approach. We conducted semi-structured interviews with key informants (e.g., division chiefs, medical directors) involved in the implementation of FCP. We used the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis. We used a template analysis approach to determine the relevance of the CFIR constructs to implementing the FCP. We analyzed the responses to the interview questions about FCP definition and FCP key principles, compared different hospitals’ FCP official documents, and consulted with the original FCP developer. We then used an adaptation framework to categorize the core components of FCP into three main groups. Finally, we summarized practical recommendations for each barrier based on information provided by the interviewees. Results A total of 32 interviews were conducted. We observed that FCP has evolved from the idea of transferring boarded patients from ED hallways to inpatient hallways to a practical hospital-wide intervention with several components and multiple levels. The key determinant of successful FCP implementation was collaboration with inpatient nursing staff, as they were often reluctant to have patients boarded in inpatient hallways. Other determinants of successful FCP implementation were reaching consensus about the criteria for activation of each FCP level and actions in each FCP level, modifying the electronic health records system, restructuring the inpatient units to have adequate staffing and resources, complying with external regulations and policies such as fire marshal guidelines, and gaining hospital leaders’ support. Conclusions The key determinant in implementing FCP is creating a supportive and cooperative hospital culture and encouraging key stakeholders, including inpatient nursing staff, to acknowledge that crowding is a hospital-wide problem that requires a hospital-wide response. Electronic supplementary material The online version of this article (10.1186/s13012-019-0925-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amir Alishahi Tabriz
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 016 Beard Hall, 301 Pharmacy Lane, Chapel Hill, NC, 27599-7355, USA.
| | - Sarah A Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1103E McGavran-Greenberg, CB #7411, Chapel Hill, NC, 27599-7411, USA
| | - Christopher M Shea
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1103E McGavran-Greenberg, CB #7411, Chapel Hill, NC, 27599-7411, USA
| | - Bruce J Fried
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1103E McGavran-Greenberg, CB #7411, Chapel Hill, NC, 27599-7411, USA
| | - Peter Viccellio
- Department of Emergency Medicine, Stony Brook University, Health Sciences Center, Level 4 - Room 080, SUNY at Stony Brook, Stony Brook, NY, 11794-8350, USA
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McKenna P, Heslin SM, Viccellio P, Mallon WK, Hernandez C, Morley EJ. Emergency department and hospital crowding: causes, consequences, and cures. Clin Exp Emerg Med 2019; 6:189-195. [PMID: 31295991 PMCID: PMC6774012 DOI: 10.15441/ceem.18.022] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 07/04/2018] [Indexed: 11/25/2022] Open
Abstract
Overcrowding with associated delays in patient care is a problem faced by emergency departments (EDs) worldwide. ED overcrowding can be the result of poor ED department design and prolonged throughput due to staffing, ancillary service performance, and flow processes. As such, the problem may be addressed by process improvements within the ED. A broad body of literature demonstrates that ED overcrowding can be a function of hospital capacity rather than an ED specific issue. Lack of institutional capacity leads to boarding in the ED with resultant ED crowding. This is a problem not solvable by the ED and must be addressed as an institution-wide problem. This paper discusses the causes of ED overcrowding, provides a brief overview of the drastic consequences, and discusses possible cures that have been successfully implemented.
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Affiliation(s)
- Peter McKenna
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Samita M Heslin
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Peter Viccellio
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - William K Mallon
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Cristina Hernandez
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Eric J Morley
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
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Lee MO, Arthofer R, Callagy P, Kohn MA, Niknam K, Camargo CA, Shen S. Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds. Am J Emerg Med 2019; 38:272-277. [PMID: 31085010 DOI: 10.1016/j.ajem.2019.04.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/12/2019] [Accepted: 04/30/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Inpatient hallway beds are one solution to mitigate emergency department (ED) crowding due to boarding of admitted patients. Alternative Care Areas (AltCA) beds are located in inpatient hallways, cardiac catheterization lab, and endoscopy. We examined whether AltCA beds were associated with increased risk of patient safety and quality outcomes: transfer to Intensive Care Unit (ICU), mortality, hospital-acquired infections (HAI), falls, and 72-hour hospital readmission. METHODS Retrospective cohort study of patients age >18 years admitted from the ED to non-ICU beds at an urban, academic hospital. AltCA bed exclusion criteria: dementia, frequent respiratory interventions, contact or airborne isolation, psychiatric admission, and inability to ambulate. The study periods were: pre-intervention 9/1/2014-3/31/2015, transition 9/1/2015-3/31/2016, and post-intervention 9/1/2016-3/31/2017. Data analysis used unadjusted and multivariable analyses which controlled for age, sex, race, ethnicity, insurance, ED triage Emergency Service Index (ESI) level, and telemetry order. RESULTS The study included 16,801 patients, with 622 (3.7%) patients in AltCA beds. AltCA beds had younger patients than standard inpatient beds, 57.7 years and 61.7 years; fewer telemetry order, 48.4% and 59.3%; and fewer ESI level 2, 16.1% and 26.2%. AltCA beds had shorter hospital LOS than standard inpatient beds, 2.7 days and 3.4 days. AltCA beds had decreased risk of transfer to ICU -10.6 (95%CI: -18.3, -2.8) and HAI -13.4 (95%CI: -20.3, -6.5) compared to standard inpatient beds. CONCLUSION Patients in AltCA beds did not have increased risk of patient safety and quality outcomes but rather decreased risk of transfer to ICU and HAI than standard inpatient beds.
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Affiliation(s)
- Moon O Lee
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, MC 5119, Suite 350, Stanford, CA 94304, United States of America.
| | - Rudolph Arthofer
- Stanford Hospital and Clinics, 300 Pasteur Drive, Stanford, CA 94305, United States of America.
| | - Patrice Callagy
- Stanford Hospital and Clinics, 300 Pasteur Drive, Stanford, CA 94305, United States of America.
| | - Michael A Kohn
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, MC 5119, Suite 350, Stanford, CA 94304, United States of America.
| | - Kian Niknam
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, MC 5119, Suite 350, Stanford, CA 94304, United States of America.
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston, MA 02114, United States of America..
| | - Sam Shen
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, MC 5119, Suite 350, Stanford, CA 94304, United States of America.
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Rixe JA, Liu JH, Breaud HA, Nelson KP, Mitchell PM, Feldman JA. Is hallway care dangerous? An observational study. Am J Emerg Med 2018; 36:1451-1454. [DOI: 10.1016/j.ajem.2018.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/02/2018] [Indexed: 11/28/2022] Open
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Emergency department boarding: a descriptive analysis and measurement of impact on outcomes. CAN J EMERG MED 2018; 20:929-937. [PMID: 29619913 DOI: 10.1017/cem.2018.18] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Delays in transfer of admitted patients boarded in the emergency department (ED) to an inpatient bed is a major driver of ED overcrowding. We sought to identify explanatory factors behind ED boarding as well as the impact of boarding on total inpatient length of stay (IP LOS) and inpatient mortality. METHODS We conducted a retrospective single-centre observational study during the period between January 1 and December 31, 2015 at a very high volume community hospital. All patients admitted from the ED to Medicine, Pediatrics, Surgery, and Critical Care were identified. The mean ED LOS and boarding time as well as patient-specific and institutional factors that were independently associated with prolonged ED LOS (≥24 hours) and prolonged boarding time (≥12 hours) were identified. Mean inpatient length of stay (IP LOS) and the odds of inpatient mortality were calculated for those patients with prolonged ED wait times. RESULTS There were 13,872 unique admissions during the study period. Patients admitted to the Medicine service exhibited significantly higher ED wait times than other services. Within Medicine patients, there was a statistically significant greater odds of prolonged ED wait times for patients who were older, had a greater comorbidity burden, and required more specialized inpatient care. Medicine patients with prolonged boarding times also experienced a mean of 0.9 days longer IP LOS even after adjusting for confounders. CONCLUSION Within our cohort, older, sicker patients and those patients requiring more resource-intensive inpatient care had the longest ED wait times. These prolonged wait times are associated with significantly increased IP LOS.
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DESCRIPCIÓN Y ANÁLISIS DEL SISTEMA DE RED DE URGENCIA (RDU) EN CHILE. RECOMENDACIONES DESDE UNA MIRADA SISTÉMICA. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Warner LSH, Pines JM, Chambers JG, Schuur JD. The Most Crowded US Hospital Emergency Departments Did Not Adopt Effective Interventions To Improve Flow, 2007-10. Health Aff (Millwood) 2017; 34:2151-9. [PMID: 26643637 DOI: 10.1377/hlthaff.2015.0603] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Emergency department (ED) crowding adversely affects patient care and outcomes. Despite national recommendations to address crowding, it persists in most US EDs today. Using nationally representative data, we evaluated the use of interventions to address crowding in US hospitals in the period 2007-10. We examined the relationship between crowding within an ED itself, measured as longer ED lengths-of-stay, and the number of interventions adopted. In our study period the average number of interventions adopted increased from 5.2 to 6.6, and seven of the seventeen studied interventions saw a significant increase in adoption. In general, more crowded EDs adopted greater numbers of interventions than less crowded EDs. However, in the most crowded quartile of EDs, a large proportion had not adopted effective interventions: 19 percent did not use bedside registration, and 94 percent did not use surgical schedule smoothing. Thus, while adoption of strategies to reduce ED crowding is increasing, many of the nation's most crowded EDs have not adopted proven interventions.
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Affiliation(s)
- Leah S Honigman Warner
- Leah S. Honigman Warner is an attending physician in the Department of Emergency Medicine at Long Island Jewish Medical Center, in New Hyde Park, New York. At the time this research was completed, she was an attending physician in the Department of Emergency Medicine at the George Washington University, in Washington, D.C
| | - Jesse M Pines
- Jesse M. Pines is director of the Office for Clinical Practice Innovation, School of Medicine and Health Sciences, and a professor of emergency medicine and health policy, both at the George Washington University
| | - Jennifer Gibson Chambers
- Jennifer Gibson Chambers is a resident in emergency medicine at Albany Medical College, in New York
| | - Jeremiah D Schuur
- Jeremiah D. Schuur is an attending physician; chief of the Division of Health Policy Translation; and director of quality, patient safety, and performance improvement, all in the Department of Emergency Medicine, Brigham and Women's Hospital, in Boston, Massachusetts. He is also an assistant professor of emergency medicine at Harvard Medical School
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Sullivan C, Staib A, Eley R, Scanlon A, Flores J, Scott I. National Emergency Access Targets metrics of the emergency department-inpatient interface: measures of patient flow and mortality for emergency admissions to hospital. AUST HEALTH REV 2016; 39:533-538. [PMID: 25981330 DOI: 10.1071/ah14162] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 03/22/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Movement of emergency patients across the emergency department (ED)-inpatient ward interface influences compliance with National Emergency Access Targets (NEAT). Uncertainty exists as to how best measure patient flow, NEAT compliance and patient mortality across this interface. OBJECTIVE To compare the association of NEAT with new and traditional markers of patient flow across the ED-inpatient interface and to investigate new markers of mortality and NEAT compliance across this interface. METHODS Retrospective study of consecutive emergency admissions to a tertiary hospital (January 2012 to June 2014) using routinely collected hospital data. The practical access number for emergency (PANE) and inpatient cubicles in emergency (ICE) are new measures reflecting boarding of inpatients in ED; traditional markers were hospital bed occupancy and ED attendance numbers. The Hospital Standardised Mortality Ratio (HSMR) for patients admitted via ED (eHSMR) was correlated with inpatientNEAT compliance rates. Linear regression analyses assessed for statistically significant associations (expressed as Pearson R coefficient) between all measures and inpatient NEAT compliance rates. RESULTS PANE and ICE were inversely related to inpatient NEAT compliance rates (r = 0.698 and 0.734 respectively, P < 0.003 for both); no significant relation was seen with traditional patient flow markers. Inpatient NEAT compliance rates were inversely related to both eHSMR (r = 0.914, P = 0.0006) and all-patient HSMR (r = 0.943, P = 0.0001). CONCLUSIONS Traditional markers of patient flow do not correlate with inpatient NEAT compliance in contrast to two new markers of inpatient boarding in ED (PANE and ICE). Standardised mortality rates for both emergency and all patients show a strong inverse relation with inpatient NEAT compliance.
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Affiliation(s)
- Clair Sullivan
- Princess Alexandra Hospital, Metro South Health, 199 Ipswich Road, Woolloongabba, Qld 4102, Australia. ; ;
| | - Andrew Staib
- Princess Alexandra Hospital, Metro South Health, 199 Ipswich Road, Woolloongabba, Qld 4102, Australia. ; ;
| | - Rob Eley
- Princess Alexandra Hospital, Metro South Health, 199 Ipswich Road, Woolloongabba, Qld 4102, Australia. ; ;
| | - Alan Scanlon
- Princess Alexandra Hospital, Metro South Health, 199 Ipswich Road, Woolloongabba, Qld 4102, Australia. ; ;
| | - Judy Flores
- Princess Alexandra Hospital, Metro South Health, 199 Ipswich Road, Woolloongabba, Qld 4102, Australia. ; ;
| | - Ian Scott
- Princess Alexandra Hospital, Metro South Health, 199 Ipswich Road, Woolloongabba, Qld 4102, Australia. ; ;
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Kelen G, Peterson S, Pronovost P. In the Name of Patient Safety, Let's Burden the Emergency Department More. Ann Emerg Med 2015; 67:737-740. [PMID: 26707360 DOI: 10.1016/j.annemergmed.2015.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Gabor Kelen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter Pronovost
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Blom MC, Landin-Olsson M, Lindsten M, Jonsson F, Ivarsson K. Patients presenting at the emergency department with acute abdominal pain are less likely to be admitted to inpatient wards at times of access block: a registry study. Scand J Trauma Resusc Emerg Med 2015; 23:78. [PMID: 26446825 PMCID: PMC4596503 DOI: 10.1186/s13049-015-0158-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 09/23/2015] [Indexed: 11/10/2022] Open
Abstract
Background Also known as access block, shortage of inpatient beds is a common cause of emergency department (ED) boarding and overcrowding, which are both associated with impaired quality of care. Recent studies have suggested that access block not simply causes boarding in EDs, but may also result in that patients are less likely to be admitted to the hospital from the ED. The present study’s aim was to investigate whether this effect remained for patients with acute abdominal pain, for which different management strategies have emerged. Access block was defined in terms of hospital occupancy and the appropriateness of ED discharges addressed as 72 h revisits to the ED. Methods As a registry study of ED administrative data, the study examined a population of patients who presented with acute abdominal pain at the ED of a 420-bed hospital in southern Sweden during 2011–2013. Associations between exposure and outcomes were addressed in contingency tables and by logistic regression models. Results Crude analysis revealed a negative association between access block and the probability of inpatient admission (38.6 % admitted at 0–95 % occupancy, 37.8 % at 95–100 % occupancy, and 35.0 % at ≥100 % occupancy) (p < .001). No significant associations between exposure and 72 h revisits emerged. Multivariable models indicated an odds ratio of inpatient admission of 0.992 (95 % CI: 0.986–0.997) per percentage increase in hospital occupancy. Conclusions Study findings indicate that patients with acute abdominal pain are less likely to be admitted to the hospital from the ED at times of access block and that other management strategies are employed instead. No association with 72 h revisits was seen, but future studies need to address more granular outcomes in order to clarify the safety aspects of the effect. Electronic supplementary material The online version of this article (doi:10.1186/s13049-015-0158-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M C Blom
- Department of Clinical Sciences Lund, Lund University, HS 32, EA-blocket, 2nd floor, SE-22185, Lund, Sweden.
| | - M Landin-Olsson
- Department of Clinical Sciences Lund, Lund University, HS 32, EA-blocket, 2nd floor, SE-22185, Lund, Sweden.
| | - M Lindsten
- Department of Surgery, Ystad General Hospital, Kristianstadsvägen 3A, SE-27182, Ystad, Sweden.
| | - F Jonsson
- Department of Pre- and Intrahospital Emergency Medicine, Helsingborg General Hospital, S Vallgatan 5, SE-25187, Helsingborg, Sweden.
| | - K Ivarsson
- Department of Clinical Sciences Lund, Lund University, HS 32, EA-blocket, 2nd floor, SE-22185, Lund, Sweden.
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Abstract
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.
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McClelland M, Asplin B, Epstein SK, Kocher KE, Pilgrim R, Pines J, Rabin EJ, Rathlev NK. The Affordable Care Act and emergency care. Am J Public Health 2014; 104:e8-10. [PMID: 25121814 DOI: 10.2105/ajph.2014.302052] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The Affordable Care Act (ACA) will have far-reaching effects on the way health care is designed and delivered. Several elements of the ACA will directly affect both demand for ED care and expectations for its role in providing coordinated care. Hospitals will need to employ strategies to reduce ED crowding as the ACA expands insurance coverage. Discussions between EDs and primary care physicians about their respective roles providing acute unscheduled care would promote the goals of the ACA.
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Affiliation(s)
- Mark McClelland
- Mark McClelland is with the Office of Nursing Research and Innovation, Cleveland Clinic Health System, Cleveland, OH. Brent Asplin is with Catholic Health Partners, Cincinnati, OH. Stephen K. Epstein is with the Harvard Medical School Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. Keith Eric Kocher is with the University of Michigan Department Of Emergency Medicine, Ann Arbor. Randy Pilgrim is with the Schumacher Group, Lafayette, LA. Jesse Pines is with the Departments of Emergency Medicine and Health Policy, George Washington University, Washington, DC. Elaine Rabin is with the Department of Emergency, Medicine Icahn School of Medicine at Mount Sinai, New York, NY. Niels Kumar Rathlev is with Tufts University School of Medicine, Baystate Medical Center, Boston
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