Emergency department patient flow: the influence of hospital census variables on emergency department length of stay

Merging of two level-1 trauma centers in Amsterdam: premerger demand in integrated acute trauma care

PURPOSE

Availability of adequate and appropriate trauma care is essential. A merger of two Dutch academic level-1 trauma centers is upcoming. However, in the literature, volume effects after a merger are inconclusive. This study aimed to examine the premerger demand for level-1 trauma care on integrated acute trauma care and evaluate the expected demand on the system.

METHODS

A retrospective observational study was conducted between 1-1-2018 and 1-1-2019 in two level-1 trauma centers in the Amsterdam region using data derived from the local trauma registries and electronic patient records. All trauma patients presented at both centers' Emergency Departments (ED) were included. Patient- and injury characteristics and data concerning all prehospital and in-hospital-delivered trauma care were collected and compared. Pragmatically, the demand for trauma care in the post-merger setting was considered a sum of care demand for both centers.

RESULTS

In total, 8277 trauma patients were presented at both EDs, 4996 (60.4%) at location A and 3281 (39.6%) at location B. Overall, 462 patients were considered severely injured patients (Injury Severity Score ≥ 16). In total, 702 emergency surgeries (< 24 h) were performed, and 442 patients were admitted to the ICU. The sum care demand of both centers resulted in a 167.4% increase in trauma patients and a 151.1% increase in severely injured patients. Moreover, on 96 occasions annually, two or more patients within the same hour would require advanced trauma resuscitation by a specialized team or emergency surgery.

CONCLUSION

A merger of two Dutch level-1 trauma centers would, in this scenario, result in a more than 150% increase in the post-merger setting's demand for integrated acute trauma care.

Hospital length of stay prediction tools for all hospital admissions and general medicine populations: systematic review and meta-analysis

Background

Unwarranted extended length of stay (LOS) increases the risk of hospital-acquired complications, morbidity, and all-cause mortality and needs to be recognized and addressed proactively.

Objective

This systematic review aimed to identify validated prediction variables and methods used in tools that predict the risk of prolonged LOS in all hospital admissions and specifically General Medicine (GenMed) admissions.

Method

LOS prediction tools published since 2010 were identified in five major research databases. The main outcomes were model performance metrics, prediction variables, and level of validation. Meta-analysis was completed for validated models. The risk of bias was assessed using the PROBAST checklist.

Results

Overall, 25 all admission studies and 14 GenMed studies were identified. Statistical and machine learning methods were used almost equally in both groups. Calibration metrics were reported infrequently, with only 2 of 39 studies performing external validation. Meta-analysis of all admissions validation studies revealed a 95% prediction interval for theta of 0.596 to 0.798 for the area under the curve. Important predictor categories were co-morbidity diagnoses and illness severity risk scores, demographics, and admission characteristics. Overall study quality was deemed low due to poor data processing and analysis reporting.

Conclusion

To the best of our knowledge, this is the first systematic review assessing the quality of risk prediction models for hospital LOS in GenMed and all admissions groups. Notably, both machine learning and statistical modeling demonstrated good predictive performance, but models were infrequently externally validated and had poor overall study quality. Moving forward, a focus on quality methods by the adoption of existing guidelines and external validation is needed before clinical application.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021272198.

Need for social work interventions in the emergency department

This paper reports findings from a qualitative study conducted on the Need for Social work interventions in the Emergency Department (ED) at a large tertiary care center in India. The emergency department is an important social work intervention point for individuals with various psychiatric, medical, and social needs who have little or no additional interaction with social services. Social workers are specially trained to understand the impact of social factors on health outcomes and provide interventions that address social barriers to improving health and accessing community resources; social workers are well prepared to provide services in the emergency department. However, limited research is available to understand the impact of psychosocial services in the emergency department. We aimed to identify areas which require integrated social work services and coordination to address the psychosocial issues within the ED. Interviews with 10 healthcare workers are analyzed thematically. Recurring themes throughout the interviews confirm the need for providing social work interventions to ensure the medical, psychological, and social care needs in the emergency department.

Impact of the Emergency Procedure Zone on Emergency Care

Background: Emergency department (ED) overcrowding is a public health crisis that affects patient care quality. Space management in the ED can affect patient flow dynamics and clinical practice. We proposed a novel design of the "emergency procedure zone" (EPZ). The purpose of the EPZ was to provide an isolated area for clinical practice and procedure teaching, to ensure a secure area with adequate equipment and monitors, and safeguard patient privacy and safety. This study aimed to analyze the impact of the EPZ on procedural practice and patient flow dynamics. Methods: This study was conducted at the ED of a tertiary teaching hospital in Taiwan. Data were collected from 1 March 2019 to 31 August 2020 (pre-EPZ period) and from 1 November 2020 to 30 April 2022 (post-EPZ period). Statistical analyses were performed using IBM SPSS Statistics software. This study focused on the number of procedures and length of stay in the emergency department (LOS-ED). Variables were analyzed using the chi-square test and Mann-Whitney U test. Statistical significance was defined as p < 0.05. Results: There were 137,141 (pre-EPZ period) and 118,386 (post-EPZ period) ED visits recorded during this period. The post-EPZ period showed a significant increase in central venous catheter insertion, chest tube or pigtail placement, arthrocentesis, lumbar puncture, and incision and drainage procedures (p < 0.001). For patients who were directly discharged from the ED, the post-EPZ period also had a higher percentage of ultrasound studies performed in the ED and a shorter LOS-ED for patients who were directly discharged from the ED (p < 0.001). Conclusions: The establishment of an EPZ in the ED has a positive impact on procedural efficiency. The EPZ improved diagnosis and disposition efficiency, shortened the length of stay, and provided benefits such as improved management, patient privacy, and teaching opportunities.

Current patterns of care at adult emergency department in Ethiopian tertiary university hospital

BACKGROUND

The complexity and demands of emergency healthcare service are continuously increasing, and it is important to regularly track the patterns of care at the emergency department (ED).

METHODOLOGY

A retrospective study was conducted at the ED of the University of Gondar Comprehensive Specialized Hospital (UoGCSH) from April 1 to June 30, 2021. Ethical approval was obtained from the Emergency and Critical Care Directorate of UoGCSH. Data was collected from the emergency registry and descriptive analysis was performed.

RESULTS

A total of 5232 patients have visited and triaged at the ED. All patients who visited the ED have received triage service within 5 min of arrival. The average length of stay at the ED was 3 days. About 79.1% of patients have stayed at the ED beyond 24 h, and the unavailability of beds at admission areas was responsible for 62% of delays. Mortality rate at the ED was 1.4%, and male to female ratio of death was 1.2 to 1. Shock (all types combined), pneumonia with/without COVID-19, and poisoning were the leading causes of death at the ED which were responsible for 32.5%, 15.5%, and 12.7% of deaths respectively.

CONCLUSIONS

Triage has been done within the recommended time after patient arrival. However, many patients were staying at the ED for an unacceptably prolonged time. Unavailability of beds at the admission areas, waiting long for senior clinicians' decisions, delays in investigation results, and lack of medical equipment were the causes of delayed discharge from the ED. Shock, pneumonia, and poisoning were the leading causes of death. Healthcare administrators should address the lack of medical resources, and clinicians should provide timely clinical decision and investigation results.

Improving Hospital Outpatient Clinics Appointment Schedules by Prediction Models

Patient no-shows and suboptimal patient appointment length scheduling reduce clinical efficiency and impair the clinic's quality of service. The main objective of this study is to improve appointment scheduling in hospital outpatient clinics. We developed generic supervised machine learning models to predict patient no-shows and patient's length of appointment (LOA). We performed a retrospective study using more than 100,000 records of patient appointments in a hospital outpatient clinic. Several machine learning algorithms were used for the development of our prediction models. We trained our models on a dataset that contained patients', physicians', and appointments' characteristics. Our feature set combines both unstudied features and features adopted from previous studies. In addition, we identified the influential features for predicting LOA and no-show. Our LOA model's performance was 6.92 in terms of MAE, and our no-show model's performance was 92.1% in terms of F-score. We compared our models' performance to the performance of previous research models by applying their methods to our dataset; our models demonstrated better performance. We show that the major effector of such differences is the use of our novel features. To evaluate the effect of our prediction results on the quality of schedules produced by appointment systems (AS), we developed an interface layer between our prediction models and the AS, where prediction results comprise the AS input. Using our prediction models, there was an 80% improvement in the daily cumulative patient waiting time and a 33% reduction in the daily cumulative physician idle time.

Effects of staff grade, overcrowding and presentations on emergency department performance: A regression model

OBJECTIVE

To examine the effect of staffing levels by experience of medical officers and overcrowding on ED key performance indicators (KPIs).

METHODS

Presentations to Nepean ED from 6 May to 3 November 2019 were examined. Staff were designated either Fellows of the Australasian College for Emergency Medicine (FACEMs), non-FACEM senior decision-makers (SDMs), non-senior decision-makers greater than 2 years postgraduate (non-SDMs) and junior medical officers up to 2 years postgraduate (JMOs). The number of admitted patients boarded in the ED waiting for a ward bed at 8 am was used as a marker for overcrowding. Multivariable regression analysis was performed using staffing levels, number of admissions at 8 am and total presentations as the independent variables and various ED KPIs as the dependent variables.

RESULTS

FACEM and SDM had a significant effect on most ED KPIs, with the effect of FACEM consistently larger than the effect of SDM. There was minimal effect on performance by non-SDM and JMO staffing. There was significant effect of overcrowding as measured by the number of admitted patients in ED at 8 am on most ED KPIs. Almost no variables had an effect on Emergency Treatment Performance (4-h target) for admitted patients, suggesting poor performance was caused by factors outside of the ED.

CONCLUSION

Increasing numbers of FACEM and non-FACEM SDM, but not junior staff, and a reduction in overcrowding as measured by the number of admitted patients boarded in the ED at 8 am, were associated with improvements in the ED performance.

Hospital Occupancy and its Effect on Emergency Department Evaluation

STUDY OBJECTIVE

To examine whether hospital occupancy was associated with increased testing and treatment during emergency department (ED) evaluations, resulting in reduced admissions.

METHODS

We analyzed the electronic health records of an urban academic ED. We linked data from all ED visits from October 1, 2010, to May 29, 2015, with daily hospital occupancy (inpatients/total staffed beds). Outcome measures included the frequency of laboratory testing, advanced imaging, medication administration, and hospitalizations. We modeled each outcome using multivariable negative binomial or logistic regression, as appropriate, and examined their association with daily hospital occupancy quartiles, controlling for patient and visit characteristics. We calculated the adjusted outcome rates and relative changes at each daily hospital occupancy quartile using marginal estimating methods.

RESULTS

We included 270,434 ED visits with a mean patient age of 48.1 (standard deviation 19.8) years; 40.1% were female, 22.8% were non-Hispanic Black, and 51.5% were commercially insured. Hospital occupancy was not associated with differences in laboratory testing, advanced imaging, or medication administration. Compared with the first quartile, the third and fourth quartiles of daily hospital occupancy were associated with decreases of 1.5% (95% confidence interval [CI] -2.9 to -0.2; absolute change -0.6 percentage points [95% CI -1.2 to -0.1]) and 4.6% (95% CI -6.0 to -3.2; absolute change -1.9 percentage points [95% CI -2.5 to -1.3]) in hospitalizations, respectively.

CONCLUSION

The lack of association between hospital occupancy and laboratory testing, advanced imaging, and medication administration suggest that changes in ED testing or treatment did not facilitate the decrease in admissions during periods of high hospital occupancy.

Predicting need for hospital-specific interventional care after surgery using electronic health record data

BACKGROUND

A significant proportion of surgical inpatients is often admitted longer than necessary. Early identification of patients who do not need care that is strictly provided within hospitals would allow timely discharge of patients to a postoperative nursing home for further recovery. We aimed to develop a model to predict whether a patient needs hospital-specific interventional care beyond the second postoperative day.

METHODS

This study included all adult patients discharged from surgical care in the surgical oncology department from June 2017 to February 2020. The primary outcome was to predict whether a patient still needs hospital-specific interventional care beyond the second postoperative day. Hospital-specific care was defined as unplanned reoperations, radiological interventions, and intravenous antibiotics administration. Different analytical methods were compared with respect to the area under the receiver-operating characteristics curve, sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

Each model was trained on 1,174 episodes. In total, 847 (50.5%) patients required an intervention during postoperative admission. A random forest model performed best with an area under the receiver-operating characteristics curve of 0.88 (95% confidence interval 0.83-0.93), sensitivity of 79.1% (95% confidence interval 0.67-0.92), specificity of 80.0% (0.73-0.87), positive predictive value of 57.6% (0.45-0.70) and negative predictive value of 91.7% (0.87-0.97).

CONCLUSION

This proof-of-concept study found that a random forest model could successfully predict whether a patient could be safely discharged to a nursing home and does not need hospital care anymore. Such a model could aid hospitals in addressing capacity challenges and improve patient flow, allowing for timely surgical care.

Worsening of emergency department length of stay during the COVID-19 pandemic

OBJECTIVE

Our study sought to determine whether there was a change in emergency department (ED) length of stay (LOS) during the coronavirus disease 2019 (COVID-19) pandemic compared to prior years.

METHODS

We performed a retrospective analysis using ED performance data 2018-2020 from 56 EDs across the United States. We used a generalized estimating equation (GEE) model to assess differences in ED LOS for admitted (LOS-A) and discharged (LOS-D) patients during the COVID-19 pandemic period compared to prior years.

RESULTS

GEE modeling showed that LOS-A and LOS-D were significantly higher during the COVID-19 period compared to the pre-COVID-19 period. LOS-A during the COVID-19 period was 10.3% higher compared to the pre-COVID-19 time period, which represents a higher geometric mean of 28 minutes. LOS-D during the COVID-19 period was 2.8% higher compared to the pre-COVID-19 time period, which represents a higher geometric mean of 2 minutes.

CONCLUSIONS

ED LOS-A and LOS-D were significantly higher in the COVID-19 period compared to the pre-COVID-19 period despite a lower volume of patients in the COVID-19 period.

Does crowding influence emergency department treatment time and disposition?

OBJECTIVE

The objective of this study was to determine whether crowding influences treatment times and disposition decisions for emergency department (ED) patients.

METHODS

We conducted a retrospective cohort study at 2 hospitals from January 1, 2014, to July 1, 2014. Adult ED visits with dispositions of discharge, admission, or transfer were included. Treatment times were modeled by linear regression with log-transformation; disposition decisions (admission or transfer vs discharge) were modeled by logistic regression. Both models adjusted for chief complaint, Emergency Severity Index (ESI), and 4 crowding metrics in quartiles: waiting count, treatment count, boarding count, and National Emergency Department Overcrowding Scale.

RESULTS

We included 21,382 visits at site A (12.9% excluded) and 29,193 at site B (15.0% excluded). Respective quartiles of treatment count increased treatment times by 7.1%, 10.5%, and 13.3% at site A (P < 0.001) and by 4.0%, 6.5%, and 10.2% at site B (P < 0.001). The fourth quartile of treatment count increased estimates of treatment time for patients with chest pain and ESI level 2 from 2.5 to 2.9 hours at site A (20 minutes) and from 3.0 to 3.3 hours at site B (18 minutes). Treatment times decreased with quartiles of waiting count by 5.6%, 7.2%, and 7.3% at site B (P < 0.001). Odds of admission or transfer increased with quartiles of waiting count by 8.7%, 9.6%, and 20.3% at site A (P = 0.011) and for the third (11.7%) and fourth quartiles (27.3%) at site B (P < 0.001).

CONCLUSIONS

Local crowding influenced ED treatment times and disposition decisions at 2 hospitals after adjusting for chief complaint and ESI.

Economic Evaluation of the Emergency Department After Implementation of an Emergency Psychiatric Assessment, Treatment, and Healing Unit

OBJECTIVES

We sought to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit on emergency department (ED) revenue, psychiatric boarding time, and length of stay (LOS).

METHODS

We conducted a before-and-after economic evaluation of a single academic midwestern ED (60,000 annual visits) for all adult (≥18 years) patients before (December 2017-May 2018) and after (December 2018-May 2019) opening an EmPATH unit. These are outpatient hospital-based programs that provide emergent treatment and stabilization for mental health emergencies from ED patients. The Holt-Winters method was used to forecast pre-EmPATH expected ED levels of patients leaving without being seen, leaving against medical advice, eloping, or being transferred using 3 years of ED visits. ED revenues were calculated by finding the difference of pre-EmPATH expected and post-EmPATH observed values and multiplying by the revenue per visit. ED boarding time and LOS were obtained from the hospital's electronic medical record.

RESULTS

There were 23,231 and 23,336 ED visits evaluated during the pre- and post-EmPATH unit periods. The ED generated an estimated additional $404,954 in the 6 months and $861,065 annually after the implementation of the EmPATH unit. The median (interquartile range [IQR]) psychiatric boarding time decreased from 212 (119-536) minutes to 152 (86-307) minutes (mean difference = 189 minutes, 95% confidence interval [CI] = 150 to 228 minutes) and median (IQR) LOS decreased from 351 (204-631) minutes to 334 (212-517) minutes (mean difference = 114 minutes, 95% CI = 87 to 143 minutes).

CONCLUSION

The EmPATH unit had a positive impact on ED revenue and decreased ED boarding time and LOS for psychiatric patients.

Delayed flow is a risk to patient safety: A mixed method analysis of emergency department patient flow

INTRODUCTION

Increasing emergency department (ED) demand and crowding has heightened focus on the need for better understanding of patient flow.

AIM

This study aimed to identify input, throughput and output factors contributing to ED patient flow bottlenecks and extended ED length of stay (EDLOS).

METHOD

Concurrent nested mixed method study based on retrospective analysis of attendance data, patient flow observational data and a focus group in an Australian regional ED.

RESULTS

Analysis of 89 013 ED presentations identified increased EDLOS, particularly for patients requiring admission. Mapping of 382 patient journeys identified delays in time to triage assessment (0-39 mins) and extended waiting room stays (0-348 mins). High proportions of patients received care outside ED cubicles. Four qualitative themes emerged: coping under pressure, compromising care and safety, makeshift spaces, and makeshift roles.

CONCLUSION

Three key findings emerged: i) hidden waits such as extended triage-queuing occur during the input phase; ii) makeshift spaces are frequently used to assess and treat patients during times of crowding; and iii) access block has an adverse effect on output flow. Data suggests arrival numbers may not be a key predictor of EDLOS. This research contributes to our understanding of ED crowding and patient flow, informing service delivery and planning.

Association Between Emergency Physician Length of Stay Rankings and Patient Characteristics

OBJECTIVE

Emergency physicians are commonly compared by their patients' length of stay (LOS). We test the hypothesis that LOS is associated with patient characteristics and that accounting for these features impacts physician LOS rankings.

METHODS

This was a retrospective observational study of all encounters at an emergency department in 2010 to 2015. We compared the characteristics of patients seen by physicians in different quartiles of LOS. Primary outcome was variation in patient characteristics at time of physician assignment (age, sex, comorbidities, Emergency Severity Index [ESI], and chief complaint) across LOS quartiles. We also quantified the change in LOS rankings after accounting for difference in characteristics of patients seen by different physicians.

RESULTS

A total of 264,776 encounters seen by 62 attending physicians met inclusion criteria. Physicians in the longest LOS quartile saw patients who were older (age = 49.1 vs 48.6 years, difference = +0.5 years, 95% confidence interval [CI] = 0.3 to 0.7) with more comorbidities (Gagne score = 1.3 vs. 0.9, difference = +0.4, 95% CI = 0.4 to 0.4) and higher acuity (ESI = 2.8 vs. 2.9, difference = -0.1, 95% CI = 0.1 to 0.1) than physicians in the shortest LOS quartile. The odds ratio (OR) of physicians in the longest LOS quartile seeing patients over age 50 compared to the shortest LOS quartile was 1.1 (95% CI = 1.0 to 1.1); the OR of physicians in the longest LOS quartile seeing patients with ESI of 1 or 2 was also 1.1 (95% CI = 1.0 to 1.1). Accounting for variation in patient characteristics seen by different physicians resulted in substantial reordering of physician LOS rankings: 62.9% (39/62) of physicians reclassified into a different quartile with mean absolute percentile change of 25.8 (95% CI = 20.3 to 31.3). A total of 62.5% (10/16) of physicians in the shortest LOS quartile and 56.3% (9/16) in the longest LOS quartile moved into a different quartile after accounting for variation in patient characteristics.

CONCLUSIONS

Length of stay was significantly associated with patient characteristics, and accounting for variation in patient characteristics resulted in substantial reordering of relative physician rankings by LOS. Comparisons of emergency physicians by LOS that do not account for patient characteristics should be reconsidered.

Waiting times in emergency departments: exploring the factors associated with longer patient waits for emergency care in England using routinely collected daily data

Background

Long lengths of stay (also called waiting times) in emergency departments (EDs) are associated with higher patient mortality and worse outcomes.

Objective

To add to the literature using high-frequency data from a large number of hospitals to analyse factors associated with long waiting times, including exploring non-linearities for 'tipping points'.

Methods

Multivariate ordinary least squares regressions with fixed effects were used to analyse factors associated with the proportion of patients in EDs in England waiting more than 4 hours to be seen, treated and admitted or discharged. Daily situation reports (Sitrep), hospital episode statistics and electronic staffing records data over 90 days between December 2016 and February 2017 were used for all 138 English NHS healthcare providers with a major ED.

Results

Higher inpatient bed occupancy was correlated with longer ED waiting times, with a non-linear association. In a full hospital, with 100% bed occupancy, the proportion of patients who remained in the ED for more than 4 hours was 9 percentage points higher (95% CI 7.5% to 11.1%) than with an 85% occupancy level. For each percentage point change in the following factors, the proportion of ED stays over 4 hours also increased: more inpatients with hospital length of stay over 21 days (0.07%, 95% CI 0.008% to 0.13%); higher emergency admissions (0.08%, 95% CI 0.06% to 0.10%); and lower discharges relative to admissions on the same day (0.04%, 95% CI 0.02% to 0.06%), the following day (0.05%, 95% CI 0.03% to 0.06%) and at 2 days (0.05%, 95% CI 0.04% to 0.07%).

Conclusions

These results suggest that tackling patient flow and capacity in the wider hospital, particularly very high bed occupancy levels and patient discharge, is important to reduce ED waiting times and improve patient outcomes.

[Emergency overcrowding and hospital organization: Causes and solutions]

Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.

Utility of ultrasound after a negative CT abdomen and pelvis in the emergency department

PURPOSE

The purpose of this study is to assess the utility of an abdominal and/or pelvic ultrasound (US) performed within 24 h after a negative CT of the abdomen and pelvis (CTAP) in the emergency department (ED). The secondary endpoint is to assess whether there is a significant increase in length of stay (LOS) in the ED due to immediate US reimaging.

METHOD

We reviewed the imaging reports of 335 patients over the course of 3 years in our ED who had an US within 24 h after a negative CTAP. We then assessed type of US and whether the US showed any acute findings. We also evaluated LOS in the ED.

RESULTS

Out of 335 patients, there were only three US cases suspicious for acute surgical pathology (3/335 or 0.9%). On 30-day clinical follow-up, only one of the three cases was confirmed as cholecystitis on pathology. The most common non-surgical findings on US not initially reported on CTAP were ovarian cysts (29/83) and gallstones (9/83). Additionally, the LOS for patients who received both a CTAP and US was 119 min longer than patients who only received a CTAP.

CONCLUSION

US abdomen and/or pelvis reimaging within 24 h following a negative CTAP is unlikely to change surgical management in the acute setting. US reimaging can still be useful in diagnosing non-surgical pathology, which could serve to explain the patient's pain. US reimaging after negative CTAP is associated with an average increase in the ED LOS.

The Distributions of Weekday Discharge Times at Acute Care Hospitals in the State of Florida were Static from 2010 to 2018

When hospital capacity is near census, either due to limits on the number of physical or staffed beds, delays in patients' discharge can result in domino effects of congestion for the emergency department, the intensive care units, the postanesthesia care unit, and the operating room. Hospital administrators often promote increasing the percentage of patients discharged before noon as mitigation. However, benchmark data from multiple hospitals are lacking. We studied the time of weekday inpatient discharges from all 202 acute care hospitals in the state of Florida between 2010 and 2018 using publicly available data. Statewide, the average length of stay (4.63 days) did not change, but hospital discharges increased 6.1%. There was no change over years in the percentage of patients discharged before 12 noon (13.0% ± 0.28% standard error [SE]) or before 3 PM (42.2% ± 0.25% SE). For every year, the median hour of patient discharge was 3 PM. Only 9 of the 202 hospitals (4.5%) reliably achieved a morning weekday discharge rate ≥ 20.0%. Only 19 hospitals (9.4%) in the state reliably achieved a ≥ 50.0% weekday discharge rate before 3 PM. Hospital administrators seeking to achieve earlier patient discharges can use our provided data as realistic benchmarks to guide efforts. Alternatively, administrators could plan based on a model that beds will not be reliably available for new patients until late in the afternoon and apply other well-developed operational strategies to address bottlenecks affecting the internal transfer of patients within the hospital.

A Review of Various Methods of Management of Risk in the Field of Emergency Medicine

BACKGROUND:

The main concept of risk management in the emergency department (ED) contains a broader meaning, so that; it’s known as a sudden event or situation which would happen at an uncertain future that has some negative or positive impacts which could be called threat or opportunity respectively. However, the knowledge of risk management could cover the overall procedures involved with administering the planning of risk management, identification, investigation, monitoring and also step by step clinical examination. One of the main tools for preventing adversities is evaluating and management of possible risks.

AIM:

One of the main objectives of the present study is recognising the most frequent types of the risk happening in the EDs. Moreover, the present study is trying to evaluate the possible risks which could happen among various ED sections.

METHODS:

Six databases of EMBASE, HubMed, Cochrane Library, MEDLINE, PubMed, CHBD and Goggle scholar were chosen for discovering much-related articles from the year 2005 to 2019. A total number of 68 were chosen finally to be reviewed more precisely based on the main objective of the present study.

RESULTS:

Precise planning, preparing sufficiently and conducting the process of continuous monitoring are needed for ensuring the fact that any possible risks could be managed through these planned strategies. On the other hand, by modifying the patients’ beliefs, anticipations and the available social culture about the importance of risk management issue, the overall objective of the present study could be achieved at higher rates.

CONCLUSION:

Moreover, because the potential of occurrence of risk in EDs is high and approximately more than half of them are fatal, more precise adequate systematic plans for management of them should result.

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.

Multicentre, prospective observational study of the correlation between the Glasgow Admission Prediction Score and adverse outcomes

OBJECTIVES

To assess whether the Glasgow Admission Prediction Score (GAPS) is correlated with hospital length of stay, 6-month hospital readmission and 6-month all-cause mortality. This study represents a 6-month follow-up of patients who were included in an external validation of the GAPS' ability to predict admission at the point of triage.

SETTING

Sampling was conducted between February and May 2016 at two separate emergency departments (EDs) in Sheffield and Glasgow.

PARTICIPANTS

Data were collected prospectively at triage for consecutive adult patients who presented to the ED within sampling times. Any patients who avoided formal triage were excluded from the study. In total, 1420 patients were recruited.

PRIMARY OUTCOMES

GAPS was calculated following triage and did not influence patient management. Length of hospital stay, hospital readmission and mortality against GAPS were modelled using survival analysis at 6 months.

RESULTS

Of the 1420 patients recruited, 39.6% of these patients were initially admitted to hospital. At 6 months, 30.6% of patients had been readmitted and 5.6% of patients had died. For those admitted at first presentation, the chance of being discharged fell by 4.3% (95% CI 3.2% to 5.3%) per GAPS point increase. Cox regression indicated a 9.2% (95% CI 7.3% to 11.1%) increase in the chance of 6-month hospital readmission per point increase in GAPS. An association between GAPS and 6-month mortality was demonstrated, with a hazard increase of 9.0% (95% CI 6.9% to 11.2%) for every point increase in GAPS.

CONCLUSION

A higher GAPS is associated with increased hospital length of stay, 6-month hospital readmission and 6-month all-cause mortality. While GAPS's primary application may be to predict admission and support clinical decision making, GAPS may provide valuable insight into inpatient resource allocation and bed planning.

Do Financial Incentives Change Length-of-stay Performance in Emergency Departments? A Retrospective Study of the Pay-for-performance Program in Metro Vancouver

BACKGROUND

Pay-for-performance (P4P) programs have been implemented in various forms to reduce emergency department (ED) patient length of stay (LOS). This retrospective study investigated to what extent the timing of patient disposition in Metro Vancouver EDs was influenced by a LOS-based P4P program.

METHODS

We analyzed ED visit records of four major hospitals in Metro Vancouver, Canada. For each ED, we individually tested whether LOS was distributed discontinuously at the LOS target before and after the P4P program was terminated. For the P4P effective period, we examined whether patients discharged just prior to the LOS target had a higher 7-day return-and-admission (RA) rate-the probability that a patient, after being discharged home, returned to any ED within 7 days and was admitted to an inpatient unit-than patients discharged just after the target.

RESULTS

Prior to the termination of the P4P program, in all four EDs, the LOS density of admitted patients was discontinuous and had a significant drop at the P4P 10-hours admission LOS target; a similar phenomenon was observed among discharged patients at the 4-hours discharge LOS target, but only in the two lower-volume EDs. Furthermore, in a lower-volume ED, patients who were discharged right before the 4-hours P4P LOS target had a higher 7-day RA rate than patients discharged right after the LOS target. After the termination of the discharge incentive, the discontinuity at the discharge LOS target became less evident, but patients were still more frequently admitted just before 10 hours in three of the four EDs as the local health authority continued to support the admission incentive scheme after the government terminated the P4P program.

CONCLUSIONS

The LOS-based financial incentive scheme appears to have influenced the timing of ED patient dispositions. The results suggest mixed consequences of the P4P program-it can reduce access block for admitted patients but may also lead to discharges associated with return visits and admissions.

How I Work Smarter: A Qualitative Analysis of Emergency Physicians' Strategies for Clinical and Non-clinical Productivity

Introduction

Emergency physicians’ (EP) clinical and professional non-clinical environments can be stressful and lead to burnout. However, some EPs thrive in these environments. To date, there is limited research investigating the strategies that successful EPs use to be maximally productive.

Methods

A snowball sampling technique was used to identify peer-nominated EPs who were, within their community of practice, subjectively felt to be successful and efficient. Participants answered a standardized set of questions addressing their efficiency patterns that were published as part of the “How I Work Smarter” blog series on the Academic Life in Emergency Medicine website. Two reviewers performed an inductive qualitative thematic analysis to code and summarize their responses and develop a thematic framework that described patterns of EP productivity.

Results

Two themes, communication and efficiency, were applicable in the clinical and non-clinical arenas. Location and environment was a major theme in the non-clinical arena. The themes task management and prioritization, tools for wellness, and motivators spanned both environments. Each theme included several strategies that were felt by the respondents to improve productivity and efficiency.

Conclusion

We described a thematic framework of productivity strategies for EPs that may increase productivity, improve work-life balance, and decrease burnout. EPs interested in increasing their efficiency both within and beyond the clinical area may consider adopting these strategies.

Preventing pressure injuries in the emergency department: Current evidence and practice considerations

The emergency department (ED) is at the front line of hospital pressure injury (PI) prevention, yet ED clinicians must balance many competing clinical priorities in the care of seriously ill patients. This paper presents the current biomechanical and clinical evidence and management considerations to assist EDs to continue to develop and implement evidence-based PI prevention protocols for the high-risk emergency/trauma patient. The prevention of hospital-acquired pressure injuries has received significant focus internationally over many years because of the additional burden that these injuries place on the patient, the additional costs and impact to the efficiency of the hospital, and the potential for litigation. The development of a PI is the result of a complex number of biomechanical, physiological, and environmental interactions. Our understanding of the interaction of these factors has improved significantly over the past 10 years. We have demonstrated that large reductions in PI incidence rates can be achieved in critical care and general hospital wards through the application of advanced evidence-based prevention protocols and believe that further improvement can be achieved through the application of these approaches in the ED.

The Boarding Patient: Effects of ICU and Hospital Occupancy Surges on Patient Flow

Patients admitted to a hospital's intensive care unit (ICU) often endure prolonged boarding within the ICU following receipt of care, unnecessarily occupying a critical care bed, and thereby delaying admission for other incoming patients due to bed shortage. Using patient-level data over two years at two major academic medical centers, we estimate the impact of ICU and ward occupancy levels on ICU length of stay (LOS), and test whether simultaneous "surge occupancy" in both areas impacts overall ICU length of stay. In contrast to prior studies that only measure total LOS, we split LOS into two individual periods based on physician requests for bed transfers. We find that "service time" (when critically ill patients are stabilized and treated) is unaffected by occupancy levels. However, the less essential "boarding time" (when patients wait to exit the ICU) is accelerated during periods of high ICU occupancy and, conversely, prolonged when hospital ward occupancy levels are high. When the ICU and wards simultaneously encounter bed occupancies in the top quartile of historical levels-which occurs 5% of the time-ICU boarding increases by 22% compared to when both areas experience their lowest utilization, suggesting that ward bed availability dominates efforts to accelerate ICU discharges to free up ICU beds. We find no adverse effects of high occupancy levels on ICU bouncebacks, in-hospital deaths, or 30-day hospital readmissions, which supports our finding that the largely discretionary boarding period fluctuates with changing bed occupancy levels.

Non-urgent use of emergency departments: populations most likely to overestimate illness severity

Patients' overestimation of their illness severity appears to contribute to the national epidemic of emergency department (ED) overcrowding. This study aims to elucidate which patient populations are more likely to have a higher estimation of illness severity (EIS). The investigator surveyed demographic factors of all non-urgent patients at an academic ED. The patients and physicians were asked to estimate the patients' illness severity using a 1-10 scale with anchors. The difference of these values was taken and compared across patient demographic subgroups using a 2-sample t-test. One hundred and seventeen patients were surveyed. The mean patient EIS was 5.22 (IQR 4), while the mean physician EIS was less severe at 7.57 (IQR 3), a difference of 2.35 (p < 0.0001). Patient subgroups with the highest EIS compared to the physicians' EIS include those who were self-referred (difference of 2.65, p = 0.042), with income ≤ $25,000 (difference of 2.96, p = 0.004), with less than a college education (difference of 2.83, p = 0.018), and with acute-on-chronic musculoskeletal pain (difference of 4.17, p = 0.001). If we assume the physicians' EIS is closer to the true illness severity, patients with lower socioeconomic status, lower education status, who were self-referred, and who suffered from acute-on-chronic musculoskeletal pain are more likely to overestimate their illness severity and may contribute to non-urgent use of the ED. They may benefit from further education or resources for care to prevent ED misuse. The large difference of acute-on-chronic musculoskeletal pain may reflect a physician's bias to underestimate the severity of a patients' illness in this particular population.

Emergency department crowding: A systematic review of causes, consequences and solutions

BACKGROUND

Emergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions.

AIM

The aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A structured search of four databases (Medline, CINAHL, EMBASE and Web of Science) was undertaken to identify peer-reviewed research publications aimed at investigating the causes or consequences of, or solutions to, emergency department crowding, published between January 2000 and June 2018. Two reviewers used validated critical appraisal tools to independently assess the quality of the studies. The study protocol was registered with the International prospective register of systematic reviews (PROSPERO 2017: CRD42017073439).

RESULTS

From 4,131 identified studies and 162 full text reviews, 102 studies met the inclusion criteria. The majority were retrospective cohort studies, with the greatest proportion (51%) trialling or modelling potential solutions to emergency department crowding. Fourteen studies examined causes and 40 investigated consequences. Two studies looked at both causes and consequences, and two investigated causes and solutions.

CONCLUSIONS

The negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. This review identified a mismatch between causes and solutions. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Solutions aimed at the introduction of whole-of-system initiatives to meet timed patient disposition targets, as well as extended hours of primary care, demonstrated promising outcomes. While the review identified increased presentations by the elderly with complex and chronic conditions as an emerging and widespread driver of crowding, more research is required to isolate the precise local factors leading to ED crowding, with system-wide solutions tailored to address identified causes.

Managing Multiplicity: Conceptualizing Physician Cognition in Multipatient Environments

PURPOSE

Emergency physicians (EPs) regularly manage multiple patients simultaneously, often making time-sensitive decisions around priorities for multiple patients. Few studies have explored physician cognition in multipatient scenarios. The authors sought to develop a conceptual framework to describe how EPs think in busy, multipatient environments.

METHOD

From July 2014 to May 2015, a qualitative study was conducted at McMaster University, using a think-aloud protocol to examine how 10 attending EPs and 10 junior residents made decisions in multipatient environments. Participants engaged in the think-aloud exercise for five different simulated multipatient scenarios. Transcripts from recorded interviews were analyzed inductively, with an iterative process involving two independent coders, and compared between attendings and residents.

RESULTS

The attending EPs and junior residents used similar processes to prioritize patients in these multipatient scenarios. The think-aloud processes demonstrated a similar process used by almost all participants. The cognitive task of patient prioritization consisted of three components: a brief overview of the entire cohort of patients to determine a general strategy; an individual chart review, whereby the participant created a functional patient story from information available in a file (i.e., vitals, brief clinical history); and creation of a relative priority list. Compared with residents, the attendings were better able to construct deeper and more complex patient stories.

CONCLUSIONS

The authors propose a conceptual framework for how EPs prioritize care for multiple patients in complex environments. This study may be useful to teachers who train physicians to function more efficiently in busy clinical environments.

Decreased Nursing Staffing Adversely Affects Emergency Department Throughput Metrics

Introduction

The effect of nurse staffing on emergency department (ED) efficiency remains a significant area of interest to administrators, physicians, and nurses. We believe that decreased nursing staffing adversely affects key ED throughput metrics.

Methods

We conducted a retrospective observational review of our electronic medical record database from 1/1/2015 to 12/31/2015 at a high-volume, urban public hospital. We report nursing hours, door-to-discharge length of stay (LOS) and door-to-admit LOS, and percentage of patients who left without being seen (LWBS). ED nursing hours per day was examined across quartiles with the effect evaluated using analysis of covariance and controlled for total daily ED volume, hospital occupancy and ED admission rate.

Results

From 1/1/15–12/31/15, 105,887 patients presented to the ED with a range of 336 to 580 nursing hours per day with a median of 464.7. Independent of daily ED volume, hospital occupancy and ED admission rate, days in the lowest quartile of nursing hours experienced a 28.2-minute increase per patient in door-to-discharge LOS compared to days in the highest quartile of nursing hours. Door-to-admit LOS showed no significant change across quartiles. There was also an increase of nine patients per day who left without being seen by a provider in the lowest quartile of nursing hours compared to the highest quartile.

Conclusion

Lower nursing hours contribute to a statistically significant increase in door-to-discharge LOS and number of LWBS patients, independent of daily ED volume, hospital occupancy and ED admission rate. Consideration of the impact of nursing staffing is needed to optimize throughput metrics for our urban, safety-net hospital.

Interphysician Differences in Emergency Department Length of Stay

BACKGROUND

Emergency physicians differ in many ways with respect to practice. One area in which interphysician practice differences are not well characterized is emergency department (ED) length of stay (LOS).

OBJECTIVE

To describe how ED LOS differs among physicians.

METHODS

We performed a 3-year, five-ED retrospective study of non-fast-track visits evaluated primarily by physicians. We report each provider's observed LOS, as well as each provider's ratio of observed LOS/expected LOS (LOS_O/E); we determined expected LOS based on site average adjusted for the patient characteristics of age, gender, acuity, and disposition status, as well as the time characteristics of shift, day of week, season, and calendar year.

RESULTS

Three hundred twenty-seven thousand, seven hundred fifty-three visits seen by 92 physicians were eligible for analysis. For the five sites, the average shortest observed LOS was 151 min (range 106-184 min), and the average longest observed LOS was 232 min (range 196-270 min); the average difference was 81 min (range 69-90 min). For LOS_O/E, the average lowest LOS_O/E was 0.801 (range 0.702-0.887), and the average highest LOS_O/E was 1.210 (range 1.186-1.275); the average difference between the lowest LOS_O/E and the highest LOS_O/E was 0.409 (range 0.305-0.493).

CONCLUSION

There are significant differences in ED LOS at the level of the individual physician, even after accounting for multiple confounders. We found that the LOS_O/E for physicians with the lowest LOS_O/E at each site averaged approximately 20% less than predicted, and that the LOS_O/E for physicians with the highest LOS_O/E at each site averaged approximately 20% more than predicted.

The durability of operational improvements with rotational patient assignment

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Failure to flow: An exploration of learning and teaching in busy, multi-patient environments using an interpretive description method

INTRODUCTION

As patient volumes continue to increase, more attention must be paid to skills that foster efficiency without sacrificing patient safety. The emergency department is a fertile ground for examining leadership and management skills, especially those that concern prioritization in multi-patient environments. We sought to understand the needs of emergency physicians (EPs) and emergency medicine junior trainees with regards to teaching and learning about how best to handle busy, multi-patient environments.

METHOD

A cognitive task analysis was undertaken, using a qualitative approach to elicit knowledge of EPs and residents about handling busy emergency department situations. Ten experienced EPs and 10 junior emergency medicine residents were interviewed about their experiences in busy emergency departments. Transcripts of the interviews were analyzed inductively and iteratively by two independent coders using an interpretive description technique.

RESULTS

EP teachers and junior residents differed in their perceptions of what makes an emergency department busy. Moreover, they focused on different aspects of patient care that contributed to their busyness: EP teachers tended to focus on volume of patients, junior residents tended to focus on the complexity of certain cases. The most important barrier to effective teaching and learning of managerial skills was thought to be the lack of faculty development in this skill set.

CONCLUSIONS

This study presents qualitative data that helps us elucidate how patient volumes affect our learning environments, and how clinical teachers and residents operate within these environments.

Uniting emergency and inpatient clinicians across the ED-inpatient interface: The last frontier?

Unwell patients in the ED requiring inpatient admission must negotiate the interface between the ED and inpatient wards. Despite its importance and scale, this ED-inpatient interface (EDii) is poorly characterised. The aim of this paper is to clearly define the EDii and to describe its importance to (i) the patient: delays to admission and errors in communication across the EDii can increase adverse outcomes; (ii) the hospital: poor EDii function reduces hospital efficiency and effectiveness; and (iii) the healthcare system: half of all hospital inpatient admissions occur via the EDii and so EDii affects system-wide performance. The EDii can be defined as the dynamic, transitional phase of patient care in which responsibility for, and delivery of care, is shared between ED and inpatient hospital services. The EDii is characterised by a complex interplay of patient, hospital and system factors. A clear definition of the EDii and an understanding of its importance will assist future research and interventions to improve patient outcomes.

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.

Resource Utilization in Emergency Department Patients with Known or Suspected Poisoning

INTRODUCTION

Previous work has shown poisoning-related emergency department (ED) visits are increasing, and these visits are resource-intensive. Little is known, however, about how resource utilization for patients with known or suspected poisoning differs from that of general ED patients.

METHODS

We reviewed 4 years of operational data at a single ED. We identified visits due to known or suspected poisoning (index cases), and paired them with time-matched controls. In the primary analysis, we compared the groups with respect to a broad array of resource utilization characteristics. In a secondary analysis, we performed the same comparison after excluding patients ultimately transferred to a psychiatric facility.

RESULTS

There were 405 index cases and 802 controls in the primary analysis, and 374 index cases and 741 controls in the secondary analysis. In the primary/secondary analyses, patients with known or suspected poisoning had longer ED lengths of stay in minutes (370 vs. 232/295 vs. 234), higher rates of laboratory results per patient (40.4 vs. 26.8/39.6 vs. 26.8), greater administration of intravenous medications and fluids per patient (2.0 vs. 1.6/2.1 vs. 1.6), higher rates of transfer to a psychiatric facility (7.7 vs. 0.2%/not applicable), and higher rates of both admission (40.2 vs. 32.8/43.6 vs. 33.1%) and admission to an advanced care bed (21.5 vs. 7.6/23.3 vs. 7.8%). Patients with known or suspected poisoning had lower rates of imaging per patient, for both plain radiographs (0.4 vs. 0.5/0.4 vs. 0.5) and advanced imaging studies (0.3 vs. 0.5/0.4 vs. 0.5).

CONCLUSIONS

ED patients with known or suspected poisoning are more resource intensive than general ED patients. These results may have implications for both resource allocation (particularly for departments that might see a high volume of such patients) and ED operations management.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Text mining approach to predict hospital admissions using early medical records from the emergency department

OBJECTIVE

Emergency department (ED) overcrowding is a serious issue for hospitals. Early information on short-term inward bed demand from patients receiving care at the ED may reduce the overcrowding problem, and optimize the use of hospital resources. In this study, we use text mining methods to process data from early ED patient records using the SOAP framework, and predict future hospitalizations and discharges.

DESIGN

We try different approaches for pre-processing of text records and to predict hospitalization. Sets-of-words are obtained via binary representation, term frequency, and term frequency-inverse document frequency. Unigrams, bigrams and trigrams are tested for feature formation. Feature selection is based on χ² and F-score metrics. In the prediction module, eight text mining methods are tested: Decision Tree, Random Forest, Extremely Randomized Tree, AdaBoost, Logistic Regression, Multinomial Naïve Bayes, Support Vector Machine (Kernel linear) and Nu-Support Vector Machine (Kernel linear).

MEASUREMENTS

Prediction performance is evaluated by F1-scores. Precision and Recall values are also informed for all text mining methods tested.

RESULTS

Nu-Support Vector Machine was the text mining method with the best overall performance. Its average F1-score in predicting hospitalization was 77.70%, with a standard deviation (SD) of 0.66%.

CONCLUSIONS

The method could be used to manage daily routines in EDs such as capacity planning and resource allocation. Text mining could provide valuable information and facilitate decision-making by inward bed management teams.

Increased door to admission time is associated with prolonged throughput for ED patients discharged home

BACKGROUND

Emergency Department (ED) service evaluations are typically based on surveys of discharged patients. Physicians/administrators benefit from data that quantifies system-based factors that adversely impact the experience of those who represent the survey cohort.

OBJECTIVE

While investigators have established that admitted patient boarding impacts overall ED throughput times, we sought to specifically quantify the relationship between throughput times for patients admitted (EDLOS) versus discharged home from the ED (DCLOS).

METHODS

We performed a prospective analysis of consecutive patient encounters at an inner-city ED. Variables collected: median daily DCLOS for ED patients, ED daily census, left without being seen (LWBS), median door to doctor, median room to doctor, and daily number admitted. Admitted patients divided into 2 groups based on daily median EDLOS for admits (<6 hours, ≥6 hours). Continuous variables analyzed by t-tests. Multivariate regression utilized to identify independent effects of the co-variants on median daily DCLOS.

RESULTS

We analyzed 24,127 patient visits. ED patient DCLOS was longer for patients seen on days with prolonged EDLOS (193.7 minutes, 95%CI 186.7-200.7 vs. 152.8, 144.9-160.5, P< .0001). Variables that were associated with increased daily median EDLOS for admits included: daily admits (P= 0.01), room to doctor time (P< .01), number of patients that left without being seen (P< .01). When controlling for the covariate daily census, differences in DCLOS remained significant for the ≥6 hours group (189.4 minutes, 95%CI 184.1-194.7 vs. 164.8, 155.7-173.9 (P< .0001).

CONCLUSION

Prolonged ED stays for admitted patients were associated with prolonged throughput times for patients discharged home from the ED.

Impact of a well-developed primary care system on the length of stay in emergency departments in the Netherlands: a multicenter study

Background

The Netherlands has a well-developed primary care system, which increasingly collaborates with hospital emergency departments (EDs). In this setting, insight into crowding in EDs is limited. This study explored links between patients’ ED Length of Stay (LOS) and their care pathways.

Methods

Observational multicenter study of 7000 ED patient records from 1 February 2013. Seven EDs spread over the Netherlands, representing overall Dutch EDs, were included. This included three EDs with and four EDs without an integrated primary-care-physician (PCP) cooperative, forming one Emergency Care Access Point (ECAP). The main outcome was LOS of patients comparing different care pathways (origin and destination of ED attenders).

Results

The median LOS of ED attenders was 130.0 min (IQR 79.0–140.0), which increased with patients’ age. Random coefficient regression analysis showed that LOS for patients referred by medical professionals was 32.9 min longer compared to self-referred patients (95 % CI 27.7–38.2 min). LOS for patients admitted to hospital was 41.2 min longer compared to patients followed-up at the outpatient clinic (95 % CI 35.3–46.6 min), 49.9 min longer compared to patients followed-up at the PCP (95 % CI 41.5–58.3 min) and 44.6 min longer compared to patients who did not receive follow-up (95 % CI 38.3–51.0 min). There was no difference in LOS between hospitals with or without an ECAP.

Conclusions

With 130 min, the median LOS in Dutch EDs is relatively short, comparing to other Western countries, which ranges from 176 to 480 min. Although integration of EDs with out-of-hours primary care was not related to LOS, the strong primary care system probably contributed to the overall short LOS of ED patients in the Netherlands.

Real-time prediction of inpatient length of stay for discharge prioritization

OBJECTIVE

Hospitals are challenged to provide timely patient care while maintaining high resource utilization. This has prompted hospital initiatives to increase patient flow and minimize nonvalue added care time. Real-time demand capacity management (RTDC) is one such initiative whereby clinicians convene each morning to predict patients able to leave the same day and prioritize their remaining tasks for early discharge. Our objective is to automate and improve these discharge predictions by applying supervised machine learning methods to readily available health information.

MATERIALS AND METHODS

The authors use supervised machine learning methods to predict patients' likelihood of discharge by 2 p.m. and by midnight each day for an inpatient medical unit. Using data collected over 8000 patient stays and 20 000 patient days, the predictive performance of the model is compared to clinicians using sensitivity, specificity, Youden's Index (i.e., sensitivity + specificity - 1), and aggregate accuracy measures.

RESULTS

The model compared to clinician predictions demonstrated significantly higher sensitivity (P < .01), lower specificity (P < .01), and a comparable Youden Index (P > .10). Early discharges were less predictable than midnight discharges. The model was more accurate than clinicians in predicting the total number of daily discharges and capable of ranking patients closest to future discharge.

CONCLUSIONS

There is potential to use readily available health information to predict daily patient discharges with accuracies comparable to clinician predictions. This approach may be used to automate and support daily RTDC predictions aimed at improving patient flow.

Assessing the Physical Environment of Emergency Departments

Background:

Emergency Department (ED) is considered to be the heart of a hospital. Based on many studies, a well-organized physical environment can enhance efficacy.

Objectives:

In this study, we aimed to investigate the influence of physical environment in EDs on efficacy.

Materials and Methods:

This analytical cross-sectional study was conducted via the faculty members of the ED and residents of Shahid Beheshti University of Medical Sciences in Tehran, Iran. Data were collected using a predefined questionnaire. Descriptive statistics and ANOVA were used to analyze the data.

Results:

Sixty-two participants, including 21 females and 41 males, completed the questionnaires. The mean age of the participants was 37 years (SD: 8.42). The mean work experience was 8 years (SD: 4.52) and all the studied variables varied within a range of 3.3 - 4.2. Time indices had the highest mean among variables followed by capacity, work space, treatment units, critical care units and, triage indices, respectively.

Conclusions:

In general, time indices including length of patient stay in the ED and space capacity, emphasizing the need to address these shortcomings.

Length of stay in EDs: variation across classifications of clinical condition and patient discharge disposition

STUDY OBJECTIVE

Duration of a stay in an emergency department (ED) is considered a measure of quality, but current measures average lengths of stay across all conditions. Previous research on ED length of stay has been limited to a single condition or a few hospitals. We use a census of one state's data to measure length of ED stays by patients' conditions and dispositions and explore differences between means and medians as quality metrics.

METHODS

The data source was the Healthcare Cost and Utilization Project 2011 State Emergency Department Databases and State Inpatient Databases for Florida. Florida is unique in collecting ED length of stay for both released and admitted patients. Clinical Classifications Software was used to group visits based on first-listed International Classification of Disease, Ninth Edition, Clinical Modification, diagnoses.

RESULTS

For the 10 most common diagnoses, patients with relatively minor injuries typically required the shortest mean stay (3 hours or less); conditions resulting in admission or transfer tended to be more serious, resulting in longer stays. Patients requiring the longest stays, by disposition, had discharge diagnoses of nonspecific chest pain (mean 7.4 hours among discharged patients), urinary tract infections (4.8 hours among admissions), and schizophrenia (9.6 hours among transfers) among the top 10 diagnoses.

CONCLUSION

Emergency department length of stay as a measure of ED quality should take into account the considerable variation by condition and disposition of the patient. Emergency department length of stay measurement could be improved in the United States by standardizing its definition; distinguishing visits involving treatment, observation, and boarding; and incorporating more distributional information.

Predictors of frequent emergency department use among patients with psychiatric illness

OBJECTIVE

To identify the patient characteristics associated with frequent emergency department (ED) use and develop a tool to predict risk for returning in the next month.

METHOD

Prospective cohort study of 863 adults with psychiatric illness presenting to one of four general hospital EDs. ED visits and relevant clinical information in the year before and one month after the index visit were abstracted.

RESULTS

One hundred sixty-seven of the patients (19%) were considered frequent users. Characteristics associated with frequent user status were homelessness, cocaine-positive toxicology screen, Medicare insurance, a personality disorder and hepatobiliary disease (all P<.05). Patients scoring in the highest risk category had nearly five times the odds of returning to the ED in the month subsequent to the index visit.

CONCLUSIONS

Psychiatric patients with frequent ED use are a heterogeneous group, but there are specific target conditions which, if confirmed, may facilitate reduced ED use and be replaced by more appropriate treatment.

Increases in emergency department occupancy are associated with adverse 30-day outcomes

OBJECTIVES

The associations between emergency department (ED) crowding and patient outcomes have not been investigated comprehensively in different types of ED. The study objective was to examine the associations of changes over time in ED occupancy with patient outcomes in a sample of EDs that vary by size and location. A secondary objective was to explore whether the relationship between ED occupancy and patient outcomes differed by ED characteristics (size/type and medical and nursing staffing ratios).

METHODS

Using linked administrative databases, the authors constructed a cohort of 677,475 patients who visited one of 42 hospital EDs with complete data for 2005 on ED bed and waiting room occupancy. Crowding was measured with the relative occupancy ratio separately for ED bed and waiting room patients, defined as the ratio of ED occupancy on the day of the index ED visit to the average annual occupancy at that same ED. Multivariable logistic regression (adjusting for patient and ED characteristics) was used to analyze 30-day outcomes: mortality, return ED visits, and hospital admission at the first return ED visit.

RESULTS

After adjustment for ED and patient characteristics, a 10% increase in ED bed relative occupancy ratio was associated with 3% increases in death and hospital admission at a return visit. A 10% increase in ED waiting room crowding was associated with a small decrease in return visits. There was a stronger association between bed crowding and mortality among larger EDs.

CONCLUSIONS

In Quebec EDs, increases in bed occupancy are associated with an increase in the rates of 30-day adverse outcomes, even after adjustment for patient and ED characteristics. The results raise important concerns about the quality of care during periods of ED crowding.

Hospital factors impact variation in emergency department length of stay more than physician factors

INTRODUCTION

To analyze the correlation between the many different emergency department (ED) treatment metric intervals and determine if the metrics directly impacted by the physician correlate to the "door to room" interval in an ED (interval determined by ED bed availability). Our null hypothesis was that the cause of the variation in delay to receiving a room was multifactorial and does not correlate to any one metric interval.

METHODS

We collected daily interval averages from the ED information system, Meditech©. Patient flow metrics were collected on a 24-hour basis. We analyzed the relationship between the time intervals that make up an ED visit and the "arrival to room" interval using simple correlation (Pearson Correlation coefficients). Summary statistics of industry standard metrics were also done by dividing the intervals into 2 groups, based on the average ED length of stay (LOS) from the National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary.

RESULTS

Simple correlation analysis showed that the doctor-to-discharge time interval had no correlation to the interval of "door to room (waiting room time)", correlation coefficient (CC) (CC=0.000, p=0.96). "Room to doctor" had a low correlation to "door to room" CC=0.143, while "decision to admitted patients departing the ED time" had a moderate correlation of 0.29 (p <0.001). "New arrivals" (daily patient census) had a strong correlation to longer "door to room" times, 0.657, p<0.001. The "door to discharge" times had a very strong correlation CC=0.804 (p<0.001), to the extended "door to room" time.

CONCLUSION

Physician-dependent intervals had minimal correlation to the variation in arrival to room time. The "door to room" interval was a significant component to the variation in "door to discharge" i.e. LOS. The hospital-influenced "admit decision to hospital bed" i.e. hospital inpatient capacity, interval had a correlation to delayed "door to room" time. The other major factor affecting department bed availability was the "total patients per day." The correlation to the increasing "door to room" time also reflects the effect of availability of ED resources (beds) on the patient evaluation time. The time that it took for a patient to receive a room appeared more dependent on the system resources, for example, beds in the ED, as well as in the hospital, than on the physician.

Reduction of admit wait times: the effect of a leadership-based program

OBJECTIVES

Prolonged admit wait times in the emergency department (ED) for patients who require hospitalization lead to increased boarding time in the ED, a significant cause of ED congestion. This is associated with decreased quality of care, higher morbidity and mortality, decreased patient satisfaction, increased costs for care, ambulance diversion, higher numbers of patients who leave without being seen (LWBS), and delayed care with longer lengths of stay (LOS) for other ED patients. The objective was to assess the effect of a leadership-based program to expedite hospital admissions from the ED.

METHODS

This before-and-after observational study was undertaken from 2006 through 2011 at one community hospital ED. A team of ED and hospital leaders implemented a program to reduce admit wait times, using a computerized hospital-wide tracking system to monitor inpatient and ED bed status. The team collaboratively and consistently moved ED patients to their inpatient beds within an established goal of 60 minutes after an admission decision was reached. Top leadership actively intervened in real time by contacting staff whenever delays occurred to expedite immediate solutions to achieve the 60-minute goal. The primary outcome measures were the percentage of ED patients who were admitted to inpatient beds within 60 minutes from the time the beds were requested and ED boarding time. LOS, patient satisfaction, LWBS rate, and ambulance diversion hours were also measured.

RESULTS

After ED census, hospital admission rates, and ED bed capacity were controlled for using a multivariable linear regression analysis, the admit wait time reduction program contributed to an increase in patients being admitted to the hospital within 60 minutes by 16 percentage points (95% confidence intervals [CI] = 10 to 22 points; p < 0.0001) and a decrease in boarding time per admission of 46 minutes (95% CI = 63 to 82 minutes; p < 0.0001). LOS decreased for admitted patients by 79 minutes (95% CI = 55 to 104 minutes; p < 0.0001), for discharged patients by 17 minutes (95% CI = 12 to 23 minutes; p < 0.0001), and for all patients by 34 minutes (95% CI = 25 to 43 minutes; p < 0.0001). Patient satisfaction increased 4.9 percentage points (95% CI = 3.8 to 6.0 points; p < 0.0001). LWBS patients decreased 0.9 percentage points (95% CI = 0.6 to 1.2 points; p < 0.0001) and monthly ambulance diversion decreased 8.2 hours (95% CI = 4.6 to 11.8 hours; p < 0.0001).

CONCLUSIONS

A leadership-based program to reduce admit wait times and boarding times was associated with a significant increase in the percentage of patients admitted to the hospital within 60 minutes and a significant decrease in boarding time. Also associated with the program were decreased ED LOS, LWBS rate, and ambulance diversion, as well as increased patient satisfaction.

Racial Disparity in Duration of Patient Visits to the Emergency Department: Teaching Versus Non-teaching Hospitals

Introduction:

The sources of racial disparity in duration of patients’ visits to emergency departments (EDs) have not been documented well enough for policymakers to distinguish patient-related factors from hospital- or area-related factors. This study explores the racial disparity in duration of routine visits to EDs at teaching and non-teaching hospitals.

Methods:

We performed retrospective data analyses and multivariate regression analyses to investigate the racial disparity in duration of routine ED visits at teaching and non-teaching hospitals. The Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) were used in the analyses. The data include 4.3 million routine ED visits encountered in Arizona, Massachusetts, and Utah during 2008. We computed duration for each visit by taking the difference between admission and discharge times.

Results:

The mean duration for a routine ED visit was 238 minutes at teaching hospitals and 175 minutes at non-teaching hospitals. There were significant variations in duration of routine ED visits across race groups at teaching and non-teaching hospitals. The risk-adjusted results show that the mean duration of routine ED visits for Black/African American and Asian patients when compared to visits for white patients was shorter by 10.0 and 3.4%, respectively, at teaching hospitals; and longer by 3.6 and 13.8%, respectively, at non-teaching hospitals. Hispanic patients, on average, experienced 8.7% longer ED stays when compared to white patients at non-teaching hospitals.

Conclusion:

There is significant racial disparity in the duration of routine ED visits, especially in non-teaching hospitals where non-White patients experience longer ED stays compared to white patients. The variation in duration of routine ED visits at teaching hospitals when compared to non-teaching hospitals was smaller across race groups.