Emergency department lengths of stay: characteristics favouring a delay to the admission decision as distinct from a delay while awaiting an inpatient bed

Length of Stay in Emergency Department by ICD-10 Specific and Non-Specific Diagnoses: A Single-Centre Retrospective Study

The definition of non-specific presentation at a hospital emergency department (ED) has not yet been formally established. The purpose of this study was to assess the relationships between primary ED diagnoses identified by ICD-10 codes and ED length of stay (LOS). Over the course of three years, we examined 134,675 visits at a tertiary hospital. LOS was examined in groups with specific (internal, surgical, neurological, and traumatic diseases) and non-specific diagnoses. Our secondary objective was to measure LOS by age, day of the week, time of day, and season. The median LOS was 182 min (interquartile range: 99-264 min). LOS was 99 min in the traumatic group, while it was 132 min in the surgical group, 141 min in the non-specific group, 228 min in the internal medicine group, and 237 min in the neurological group. Other determinants of LOS were age, revisits, day of the week, and time of arrival-but not a season of the year. In the non-specific group (21% of all diagnoses), the percentage of hospitalizations was higher than in the specific groups. Our results suggest that in clinical practice, the non-specific group should be redefined to also encompass diagnoses from ICD-10 Chapter XXI (block Z00-Z99).

Coronary CTA for Acute Chest Pain in the Emergency Department: Comparison of 64-Detector Row Single-Source and Third-Generation Dual-Source Scanners

Background: When performing coronary CTA in the emergency department (ED), a contemporary scanner with improved temporal resolution may eliminate the need to administer beta blockers for heart rate (HR) control, thereby expediting workup. Objective: To compare ED length-of-stay (LOS), image quality, frequency of nondiagnostic examinations, and other clinical outcomes between patients undergoing coronary CTA in the ED by a single-source CT (SSCT) scanner with HR control versus a dual-source CT (DSCT) scanner without HR control. Methods: This retrospective study included 509 patients (mean age, 52.1±15.1 years; 283 men, 226 women) at low-to-intermediate risk for acute coronary syndrome who underwent coronary CTA for acute chest pain during off hours in a single ED from March 1, 2020 to April 25, 2022. A total of 205 patients initially underwent CTA using a 64-detector SSCT with HR control (oral beta-blocker administration if HR was >65 beats per minute); following scanner replacement on April 26, 2021, 304 patients underwent CTA using a third-generation DSCT without HR control. Groups were compared in terms of ED LOS and CT completion time (time from ordering of CTA to completion of acquisition) using propensity score matching, and additional endpoints including image quality and nondiagnostic examinations based on radiology reports. Results: DSCT group, compared with SSCT group, showed no significant difference in median ED LOS (505 vs 457 minutes; P=.37), but shorter median CT completion time (95 vs 117 minutes; P<.001); based on mediation analysis, 89% of reduction in CT completion time for DSCT was attributed to absence of HR control. DSCT group, compared with SSCT group, showed higher frequency of examinations with good or excellent image quality (87.8% vs 60.0%, P<.001) and lower frequency of nondiagnostic examinations (1.6% vs 6.3%, P=.01), but no significant difference in frequencies of emergent cardiology consultation, invasive angiography, ED disposition, or coronary revascularization (all P>.05). No patient in either group experienced 30-day all-cause mortality or major adverse cardiovascular event. Conclusion: Use of a DSCT scanner for coronary CTA can eliminate need for beta-blocker administration for HR control while decreasing nondiagnostic examinations. Clinical Impact: A DSCT scanner can expedite clinical processes in the ED.

Effects of Emergency Transfer Coordination Center on Length of Stay of Critically Ill Patients in the Emergency Department

Introduction: Critically ill patients are frequently transferred from other hospitals to the emergency departments (ED) of tertiary hospitals. Due to the unforeseen transfer, the ED length of stay (LOS) of the patient is likely to be prolonged in addition to other potentially adverse effects. In this study we sought to confirm whether the establishment of an organized unit — the Emergency Transfer Coordination Center (ETCC) — to systematically coordinate emergency transfers would be effective in reducing the ED LOS of transferred, critically ill patients. Methods: The present study is a retrospective observational study focusing on patients who were transferred from other hospitals and admitted to the intensive care unit (ICU) of the ED in a tertiary hospital located in northwestern Seoul, the capital city of South Korea, from January 2019 – December 2020. The exposure variable of the study was ETCC approval before transfer, and ED LOS was the primary outcome. We used propensity score matching for comparison between the group with ETCC approval and the control group. Results: Included in the study were 1,097 patients admitted to the ICU after being transferred from other hospitals, of whom 306 (27.9%) were transferred with ETCC approval. The median ED LOS in the ETCC-approved group was significantly reduced to 277 minutes compared to 385 minutes in the group without ETCC approval. The ETCC had a greater effect on reducing evaluation time than boarding time, which was the same for populations with different clinical features. Conclusion: An ETCC can be effective in systematically reducing the ED LOS of critically ill patients who are transferred from other hospitals to tertiary hospitals that are experiencing severe crowding.

Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality

PURPOSE

Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition.

METHODS

We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients' ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition.

RESULTS

Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload.

CONCLUSIONS

Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.

Emergency short-stay wards and boarding time in emergency departments: A propensity-score matching study

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.

Improving patient flow through applying lean concepts to emergency department

Purpose This paper aims to propose lean-based interventions that address the main causes of emergency department overcrowding. Emergency department overcrowding (EDOC) and increased length of stay (LOS) have been key global issues for more than 20 years, as they have serious repercussions. No measurements have been done to assess the situation nationally. Expanding emergency departments (EDs) and adding more beds have never succeeded in eliminating wastes and targeting the root causes of the problem. Design/methodology/approach This paper is a quantitative analytical applied research. The paper used direct observation for seven days to collect patient flow data on ED patients at a secondary care hospital in Kuwait. It calculated wait times and services to identify the major causes of EDOC and increased LOS. Findings Around one-third of the ED design capacity was used by 12 per cent of the patients who stayed >6 h each. The wasted waiting time represents 56.2 per cent of the aggregated LOS, which puts lean management (LM) on the top of the process reengineering approaches suitable for improving overcrowding by reducing waste. Guided by the LM concepts, the paper proposes solutions that fall into three themes. The selected solutions address the vital few causes of the EDOC and prolonged EDLOS. Originality/value This paper is the first study of its kind in Kuwait, and one of the most outstanding studies in the Gulf region, in terms of the number of the daily ED visits and the comprehensive multi-level proposed interventions.

Deconstructing the 4-h rule for access to emergency care and putting patients first

Evidence suggests improved outcomes for patients requiring emergency admission to hospital are associated with improved emergency department (ED) efficiency and lower transit times. Factors preventing timely transfers of emergency patients to in-patient beds across the ED-in-patient interface are major causes for ED crowding, for which several remedial strategies are possible, including parallel processing of probable admissions, direct-to-ward admissions and single-point medical registrars for receiving and processing all referrals directed at specific speciality units. Dynamic measures of ED overcrowding that focus on boarding time are more indicative of EDs with exit block involving the ED-in-patient interface than static proxy measures such as hospital bed occupancy and numbers of ED presentations. The ideal 4-h compliance rate for all ED presentations is around 80%, based on a large retrospective study of more than 18million presentations to EDs of 59 Australian hospitals over 4 years, which demonstrated a highly significant linear reduction in risk-adjusted in-patient mortality for admitted patients as the compliance rate for all patients rose to 83%, but was not confirmed beyond this rate. Closely monitoring patient outcomes for emergency admissions in addition to compliance with time-based access targets is strongly recommended in ensuring reforms aimed at decongesting EDs do not compromise the quality and safety of patient care.

The relationship between in-hospital location and outcomes of care in patients diagnosed with dementia and/or delirium diagnoses: analysis of patient journey

Background

The discrepancy between the number of admissions and the allocation of hospital beds means that many patients admitted to hospital can be placed in units or wards other than that which specialise in the patient’s primary health issue (home-ward). These patients are called ‘outlier’ patients. Risk factors and health system outcomes of hospital care for ‘outlier’ patients diagnosed with dementia and/or delirium are unknown. Therefore, the aim of this research was to examine patient journeys of people with dementia and/or delirium diagnoses, to identify risk factors for ‘inlier’ or ‘outlier’ status and patient or health system outcomes (consequences) of this status.

Methods

A retrospective, descriptive study compared patients who had dementia and/or delirium according to the proportion of time spent on the home ward i.e. ‘inliers’ or ‘outliers’. Data from the patient journey database at Flinders Medical Centre (FMC), a public hospital in South Australia from 2007 and 2014 were extracted and analysed. The analysis was carried out on the patient journeys of people with a dementia and/or delirium diagnosis.

Results

When 6367 inpatient journeys with dementia and/or delirium within FMC were examined, the Emergency Department (ED) Length of Stay (LOS) after being admitted as inpatient was prolonged for ‘outlier’ patients compared to ‘inlier’ patients (OR: 1.068, 95% CI: 1.057–1.079, p = 0.000). However, the inpatient LOS for’outlier’ patients was only marginally shorter than that of the ‘inlier’ patients (OR: 0.998, 95% CI: 0.998–0.998, p = 0.000). The chances of dying within 48 h of admission increased for ‘outlier’ patients (OR: 1.973, 95% CI: 1.158–3.359, p = 0.012) and their Charlson co-morbidity Index was higher (OR: 1.059, 95% CI: 1.021–1.10, p = 0.002). Completion of discharge summaries within 2 days post-discharge for ‘outlier’ patients was compromised (OR: 1.754, 95% CI: 1.492–2.061, p = 0.000).Additionally, ‘outlier’ patients were more likely to be discharged to another hospital for other care types not offered at FMC (OR: 1.931, 95% CI: 1.559–2.391, p = 0.000).

Conclusion

An examination of the patient journeys at FMC has determined that the health system outcomes for patients with dementia and/or delirium who are admitted outside of their home-ward are affected by in-hospital location despite the homogenous nature of the study population.

Characteristics favouring a delayed disposition decision in the emergency department

BACKGROUND

The working hours of a hospital affects efficiency of care within the emergency department (ED). Understanding the influences on ED time intervals is crucial for process redesign to improve ED patient flow.

AIM

To assess characteristics that affect patients' transit through an ED.

METHODS

Retrospective cohort study from 2004 to 2010 of 268 296 adult patients who presented to the ED of an urban tertiary-referral Australian teaching hospital.

RESULTS

After adjustment for Australasian Triage Scale (ATS) category, every decade increase in age meant patients spent an additional 2 min in the ED waiting to be seen (P < 0.001) and an extra 29-min receiving treatment (P < 0.001). For every additional 10 patients in the ED, the 'waiting time' (WT) phase duration increased by 20 min (P < 0.001) and the 'Assessment and Treatment Time' (ATT) phase duration increased by 26 min (P < 0.001). When patients arrived outside working hours, the WT phase duration increased by 20 min (P < 0.001). When seen outside working hours, the ATT phase duration increased by 34.5 min (P < 0.001).

CONCLUSION

Extrinsic to the patients themselves and in addition to ED overcrowding, the working hours of the hospital affected efficiency of care within the ED. Not only should the whole of the hospital be involved in improving efficient and safe transit of patients through an ED, but the whole of the day and every day of the week deserve attention.

The use of model-based iterative reconstruction to decrease ED radiation exposure

INTRODUCTION

The radiation risk posed by diagnostic computed tomography (CT) is a growing concern. The use of model-based iterative reconstruction (MBIR) technology reduces radiation exposure but requires additional processing time. The goal of this study was to compare MBIR and a standard CT reconstructive protocols in terms of emergency department (ED) visit duration and reduction in radiation exposure.

METHODS

A retrospective, matched, case-control design was used to compare patients who received MBIR and standard protocol abdomen and pelvis CTs. ED length of stay (LOS) and radiation exposure were the 2 primary outcome variables.

RESULTS

During the study period, 121 patients met inclusion criteria and were matched to controls for a total of 242 subjects. Although the low-dose group LOS was slightly longer, there was no significant difference in LOS. Mean differences were 18 minutes overall (520 vs 502 minutes; P = .497), 11 minutes for admitted patients (587 vs 576 minutes; P = .839), and 22 minutes for discharged patients (490 vs 468 minutes; P = .482). The mean volume CT dose index for the standard-dose CT was 11.6 ± 8.3 and 7.7 ± 4.6 mGy for the reduced-dose CT, a 34% decrease (P < .001).

CONCLUSION

Use of MBIR in the ED may provide decreased radiation exposure while minimally impacting ED LOS.