Measures of crowding in the emergency department: a systematic review

Pediatric head trauma algorithm for head CT decision-making in the emergency department

BACKGROUND

Traumatic brain injury is a common cause of admission in Emergency Department (ED) for pediatric patients. The aim of this study was to evaluate the application of the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) algorithm in ED for head CT decision-making in pediatric patients. The secondary objective was to evaluate the impact of adherence to this protocol on ED crowding, length of stay, and boarding time.

METHODS

We conducted a retrospective study including children aged ≤ 15 years who were admitted in a level 2 trauma center ED for mild TBI from 1 January 2016 to 31 December 2019. Collected data included amnesia, symptoms, demographics, outcomes, length of ED stay, the patient's outcomes, including intracranial injuries (ICI) and injuries requiring neurosurgery.

RESULTS

A total of 1372 children with mild TBI were included. More than half of the patients were male (59.8%) and ≥ 2 years of age (63.2%). Most of the trauma events (58%) were caused by home injury. Neurosurgical consultation (59.4%) was the most common intervention in the ED. Only 4.3% of patients required neuroimaging and 7 children had intracranial hemorrhage, with only 1 requiring immediate neurosurgical intervention. There were no re-admissions for bleeding. The adoption of this protocol had no negative impact on crowding, and a reduction of ED length of stay.

CONCLUSIONS

The adoption of the PECARNE algorithm led to fewer brain computed tomography scans with good clinical outcomes without increasing crowding.

Understanding Strategies to Reduce the Impact of Non-urgent Visits to the Pediatric Emergency Department: A Scoping Review

CONTEXT

The pediatric emergency department (PED) is increasingly being used for non-urgent reasons. This impacts PED input and throughput, and contributes to overcrowding. To identify solutions, it is essential to identify and describe the approaches that have been trialed.

OBJECTIVE

We completed a scoping review to identify and then describe the design and outcomes of all initiatives undertaken to reduce the impact of non-urgent visits on the PED.

DATA SOURCES

We searched 4 databases (MEDLINE, EMBASE, EBM, and CINAHL) to identify research published from the database inception until March 31, 2024.

STUDY SELECTION

Studies met our inclusion criteria if they focused on the pediatric ED, defined non-urgent visits, described an intervention (hypothesizing it would reduce the impact of non-urgent visits on the PED), and reported on the interventions impact.

DATA EXTRACTION

The title and abstract of each study were independently screened for inclusion by 2 reviewers (E.Q., K.N.), and disagreements were resolved by deliberation until consensus was achieved. This process was then repeated for the full text of all articles.

RESULTS

In total, we screened 11,600 articles and 20 were included. Nine interventions focused on PED input, 10 on PED throughput, and 1 on both PED input and throughput. Definitions of non-urgent visits and outcomes measures used to assess the effectiveness of an intervention differed between studies. Three types of strategies employed to reduce the impact of non-urgent visits on the PED were identified, these include (1) engaging nonpediatric emergency medicine clinicians by including them into the PED or connecting non-urgent patients to community locations for care, (2) reorganizing PED operations in anticipation of non-urgent visits, and (3) providing education to prevent future non-urgent visits.

CONCLUSIONS

Consistent definitions of non-urgent visits and standardized outcome measures may allow for more precise comparisons between studies. We identify 3 commonly employed strategies that may help reduce the impact of non-urgent visits on the PED.

Identifying the Main Bottlenecks in the Workflow of Saudi Arabian Emergency Departments (EDs)

Background: Crowded emergency departments (EDs) adversely affect patient care and healthcare efficiency, leading to prolonged wait times, delayed treatments, and increased medical errors. This issue also diminishes patient satisfaction and disrupts hospital operations. In Saudi Arabia, ED overcrowding impacts response times and staff morale, highlighting the need for efficient patient flow processes to ensure timely and effective care. Objectives: The aim of this study is to identify the main bottlenecks in the workflow of Saudi Arabian EDs from patient arrival to disposition. Design: A retrospective quantitative study analyzed data from 753 patients across multiple hospitals in Saudi Arabia's EDs to identify workflow bottlenecks. Using SPSS and AMOS for data analysis, various statistical methods, including ANOVA and structural equation modeling (SEM), were employed to evaluate key performance metrics and their influence on the total length of stay (LOS). Results: The Doctor to Decision Time is the most significant bottleneck, followed by the Triage to Doctor Time. CTAS3 and CTAS4 categories experience the most significant delays across multiple stages. In addition, the default model in AMOS 29 shows an excellent fit, indicating that reducing delays in Decision to Disposition Time (estimate = 0.840) and Doctor to Decision Time (estimate = 0.442) is crucial for improving the total LOS in the ED. Conclusion: This study identifies significant inefficiencies in the ED workflow in Saudi Arabia, particularly in the Doctor to Decision Time and Triage to Doctor Time stages, and recommends streamlining consultation protocols, enhancing medication delivery, expediting lab and radiology services, and increasing staffing to improve operational efficiency and patient outcomes. Faster bed turnover reduces Decision to Disposition Time and frees up ED beds. Adequate staffing improves triage, evaluation times, and care quality. Well-trained nurses enhance patient interactions and reduce delays. Standardized guidelines ensure timely treatment. Effective communication and teamwork improve patient flow and reduce bottlenecks.

Development and validation of a multivariable predictive model for Emergency Department Overcrowding based on the National Emergency Department Overcrowding Study (NEDOCS) score

Background Predicting potential overcrowding is a significant tool in efficient emergency department (ED) management. Our aim was to develop and validate overcrowding predictive models using accessible and high quality information. Methods Retrospective cohort study of consecutive days in the Hospital Italiano de Buenos Aires ED from june 2016 to may 2018. We estimated hourly NEDOCS score for the entire period, and defined the outcome as Sustained Critical ED Overcrowding (EDOC) equal to occurrence of 8 or more hours with a NEDOCS score ≥ 180. We generated 3 logistic regression predictive models with different related outcomes: beginning, ending or occurrence of Sustained Critical EDOC. We estimated calibration and discrimination as internal (random validation group and bootstrapping) and external validation (different period and different ED). Results The main model included both the beginning and occurrence of NEDOCS, including weather variables, variables related to NEDOCS itself and patient flow variables. The second model considered only the beginning of Sustained Critical EDOC and included variables related to NEDOCS. The last model considered the end of Sustained Critical EDOC and it included variables related to NEDOCS, weather, bed occupancy and management. Discrimination for the main model had an area under the receiveroperator curve of 0.997 (95% CI 0.994 - 1) in the validation group. Calibration for the model was very high on internal validation and acceptable on external validation. Conclusion The Sustained Critical EDOC predictive model includes variables that are easily obtained and can be used for effective resource management in situations of overcrowding.

Measuring Overcrowding in a Large Academic Tertiary Care Pediatric Emergency Department

OBJECTIVE

Overcrowding scores have been studied extensively in adult emergency departments (EDs), but few studies have determined utility in the pediatric setting. The objective of this study was to determine the association between a modified National Emergency Department Overcrowding Score (mNEDOCS) and established ED metrics in a large academic tertiary care pediatric ED.

METHODS

NEDOCS was modified to increase applicability in the pediatric setting by including the number of patients in resuscitation rooms instead of a number of patients on ventilators. Patient characteristics, ED disposition, ED length of stay (LOS), rate of left without being seen (LWBS), hospital LOS (HLOS), ED returns within 72 hours, and mNEDOCS were acquired retrospectively for every ED encounter in 2016-2019 using the electronic health record. Descriptive statistics, Spearman correlation, and multivariate analyses were calculated to evaluate the association between specific ED metrics and mNEDOCS.

RESULTS

Modified NEDOCS positively correlated with ED LOS, LWBS, and rate of 72-hour return visits. A negative correlation was found between mNEDOCS and HLOS. When controlling for select covariates, the odds of LWBS doubled with each increase in mNEDOCS category (odds ratio, 2.03; 95% confidence interval [CI], 2.00-2.06), ED LOS was associated with an increase of 27 minutes as mNEDOCS category increased ( β = 26.80; 95% CI, 26.44-27.16), and the odds of 72-hour return visits increased by 6% when mNEDOCS increased by one category (odds ratio, 1.06; 95% CI, 1.05-1.07). Hospital LOS was associated with a 100-minute decrease per increase in mNEDOCS category ( β = -99.85; 95% CI, -180.68 to -18.48) when controlling for covariates.

CONCLUSION

Modified NEDOCS is positively associated with ED LOS, LWBS, and 72-hour return visits, consistent with adult data. Further investigation is needed to elucidate the association between mNEDOCS and HLOS. This study illustrates the utility of mNEDOCS as a measure of overcrowding in a pediatric ED.

Retrospective Cohort Analysis of the Relationship Between Emergency Department Length of Stay and Timing of First Laboratory Orders

Background The efficiency of patient management in the Emergency Department (ED) is critical for optimizing healthcare delivery. Provider in triage (PIT) and similar ED flow models attempt to expedite throughput by decreasing the amount of time between patient arrival and initial order placement. The exact relationship between ED length of stay (LOS) and the timing of the first laboratory order, however, is unclear. The varying speed at which clinicians of different ages place laboratory orders and move patients through an ED also is understudied.  Methods A retrospective analysis was conducted using SQL from the Clarity data archive to pull all patient encounters in 2023. Linear regression models using Analysis ToolPak in Microsoft Excel were used to create and examine the relationship between LOS and the timing of the first laboratory order. Secondary outcomes using the same models were created to analyze the impact of clinician age on LOS and the relationship between clinician age and the timing of first laboratory orders.  Results Two hundred sixty-nine thousand eight hundred and eight ED visits were reviewed across three academic and 17 community emergency departments. We report a weak but statistically significant positive relationship between the timing of the first laboratory order and LOS (R² = 0.0378, p < 0.001). Secondary outcomes indicated a very weak negative correlation between clinician age and LOS (R² ≈ 0, p < 0.001) and no significant relationship between clinician age and the timing of the first laboratory order (R² ≈ 0, p > 0.05). Conclusion The timing of the first laboratory order is a significant, albeit weak, predictor of LOS in the ED. Clinician age has minimal impact on LOS and does not significantly influence the timing of the first laboratory order.

Emergency department overcrowding and its associated factors at HARME medical emergency center in Eastern Ethiopia

Introduction

Emergency department (ED) overcrowding has become a significant concern as it can lead to compromised patient care in emergency settings. Various tools have been used to evaluate overcrowding in ED. However, there is a lack of data regarding this issue in resource-limited countries, including Ethiopia. This study aimed to validate NEDOCS, assess level of ED overcrowding and identify associated factors at HARME Medical Emergency Center, located in Hiwot Fana Comprehensive Specialized Hospital, Harar, Ethiopia.

Methods

A cross-sectional study was conducted at the HARME Medical Emergency Center, Hiwot Fana Comprehensive Specialized Hospital, involving a total of 899 patients during 120 sampling intervals. The area under the receiver operating characteristic curves (AUC) was calculated to evaluate the agreement between objective and subjective assessments of ED overcrowding. A multivariable logistic regression analysis was employed to identify factors associated with ED overcrowding and statistically significant association was declared using 95 % confidence level and a p-value < 0.05.

Results

The interrater agreement showed a strong correlation with a Cohen's kappa (κ) of 0.80. The National Emergency Department Overcrowding Study Score demonstrated a strong association with subjective assessments from residents and case team nurses, with an AUC of 0.81 and 0.79, respectively. According to residents' perceptions, ED were considered overcrowded 65.8 % of the time. Factors significantly associated with ED overcrowding included waiting time for triage (AOR: 2.24; 95 % CI: 1.54-3.27), working time (AOR: 2.23; 95 % CI: 1.52-3.26), length of stay (AOR: 2.40; 95 % CI: 1.27-4.54), saturation level (AOR: 2.35; 95 % CI: 1.31-4.20), chronic illness (AOR: 2.19; 95 % CI: 1.37-3.53), and abnormal pulse rate (AOR: 1.52; 95 % CI: 1.06-2.16).

Conclusion

The study revealed that ED were overcrowded approximately two-thirds of the time.

Emergency department crowding increases 10-day mortality for non-critical patients: a retrospective observational study

The current evidence suggests that higher levels of crowding in the Emergency Department (ED) have a negative impact on patient outcomes, including mortality. However, only limited data are available about the association between crowding and mortality, especially for patients discharged from the ED. The primary objective of this study was to establish the association between ED crowding and overall 10-day mortality for non-critical patients. The secondary objective was to perform a subgroup analysis of mortality risk separately for both admitted and discharged patients. An observational single-centre retrospective study was conducted in the Tampere University Hospital ED from January 2018 to February 2020. The ED Occupancy Ratio (EDOR) was used to describe the level of crowding and it was calculated both at patient's arrival and at the maximum point during the stay in the ED. Age, gender, Emergency Medical Service transport, triage acuity, and shift were considered as confounding factors in the analyses. A total of 103,196 ED visits were included. The overall 10-day mortality rate was 1.0% (n = 1022). After controlling for confounding factors, the highest quartile of crowding was identified as an independent risk factor for 10-day mortality. The results were essentially similar whether using the EDOR at arrival (OR 1.31, 95% CI 1.07-1.61, p = 0.009) or the maximum EDOR (OR 1.27, 95% CI 1.04-1.56, p = 0.020). A more precise, mortality-associated threshold of crowding was identified at EDOR 0.9. The subgroup analysis did not yield any statistically significant findings. The risk for 10-day mortality increased among non-critical ED patients treated during the highest EDOR quartile.

Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic

STUDY OBJECTIVE

We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022.

METHODS

We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states.

RESULTS

Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day.

CONCLUSION

ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

Determining the Association Between Emergency Department Crowding and Debriefing After Pediatric Trauma Resuscitations

BACKGROUND

Debriefing in the pediatric emergency department (PED) is an invaluable tool to improve team well-being, communication, and performance. Despite evidence, surveys have reported heavy workload as a barrier to debriefing leading to missed opportunities for improvement in an already busy ED. The study aims to determine the association between the incidence of debriefing after pediatric trauma resuscitations and PED crowding.

METHODS

A total of 491 Trauma One activations in Riley Children's Hospital Pediatric Emergency Department that presented between April 2018 to December 2019 were included in the study. Debriefing documentations, patient demographics, time and date of presentation, mechanism of injury, injury severity score, disposition from PED, and length of stay (LOS) were collected and analyzed. The National Emergency Department Overcrowding Scale score at arrival, Average LOS, total PED census, total PED waiting room census, and rates of left without being seen were compared between groups.

RESULTS

Of 491 Trauma One activations presented to our PED, 50 (10%) trauma evaluations had documented debriefing. The National Emergency Department Overcrowding Scale score at presentation was significantly lower in those with debriefing versus without debriefing. In addition, the PED hourly census, waiting room census, average LOS, and left without being seen were also significantly lower in the group with debriefing. In addition, trauma cases with debriefing had a higher proportion of patients with profound injuries and discharges to the morgue.

CONCLUSIONS

Pediatric emergency department crowding is a significant barrier to debriefing after trauma resuscitations. However, profound injuries and traumatic pediatric deaths remain the strongest predictors in conducting debriefing regardless of PED crowding status.

Clinician consensus on "Inappropriate" presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland

BACKGROUND

Utilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the "appropriateness" of attendances to the ED in Ireland.

METHODS

The Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels.

RESULTS

The National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered "inappropriate" (k = 0.341; p < 0.001). For attendances deemed "appropriate" the admission rate was 47% compared to 0% for "inappropriate" attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites.

CONCLUSIONS

Multidisciplinary clinicians agree that "inappropriate" use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.

A Data-Driven Analysis of Ward Capacity Strain Metrics That Predict Clinical Outcomes Among Survivors of Acute Respiratory Failure

Supply-demand mismatch of ward resources ("ward capacity strain") alters care and outcomes. Narrow strain definitions and heterogeneous populations limit strain literature. Evaluate the predictive utility of a large set of candidate strain variables for in-hospital mortality and discharge destination among acute respiratory failure (ARF) survivors. In a retrospective cohort of ARF survivors transferred from intensive care units (ICUs) to wards in five hospitals from 4/2017-12/2019, we applied 11 machine learning (ML) models to identify ward strain measures during the first 24 hours after transfer most predictive of outcomes. Measures spanned patient volume (census, admissions, discharges), staff workload (medications administered, off-ward transports, transfusions, isolation precautions, patients per respiratory therapist and nurse), and average patient acuity (Laboratory Acute Physiology Score version 2, ICU transfers) domains. The cohort included 5,052 visits in 43 wards. Median age was 65 years (IQR 56-73); 2,865 (57%) were male; and 2,865 (57%) were white. 770 (15%) patients died in the hospital or had hospice discharges, and 2,628 (61%) were discharged home and 964 (23%) to skilled nursing facilities (SNFs). Ward admissions, isolation precautions, and hospital admissions most consistently predicted in-hospital mortality across ML models. Patients per nurse most consistently predicted discharge to home and SNF, and medications administered predicted SNF discharge. In this hypothesis-generating analysis of candidate ward strain variables' prediction of outcomes among ARF survivors, several variables emerged as consistently predictive of key outcomes across ML models. These findings suggest targets for future inferential studies to elucidate mechanisms of ward strain's adverse effects.

Emergency department crowding: an overview of reviews describing measures causes, and harms

Crowding in Emergency Departments (EDs) has emerged as a global public health crisis. Current literature has identified causes and the potential harms of crowding in recent years. The way crowding is measured has also been the source of emerging literature and debate. We aimed to synthesize the current literature of the causes, harms, and measures of crowding in emergency departments around the world. The review is guided by the current PRIOR statement, and involved Pubmed, Medline, and Embase searches for eligible systematic reviews. A risk of bias and quality assessment were performed for each review, and the results were synthesized into a narrative overview. A total of 13 systematic reviews were identified, each targeting the measures, causes, and harms of crowding in global emergency departments. Key among the results is that the measures of crowding were heterogeneous, even in geographically proximate areas, and that temporal measures are being utilized more frequently. It was identified that many measures are associated with crowding, and the literature would benefit from standardization of these metrics to promote improvement efforts and the generalization of research conclusions. The major causes of crowding were grouped into patient, staff, and system-level factors; with the most important factor identified as outpatient boarding. The harms of crowding, impacting patients, healthcare staff, and healthcare spending, highlight the importance of addressing crowding. This overview was intended to synthesize the current literature on crowding for relevant stakeholders, to assist with advocacy and solution-based decision making.

Emergency department crowding negatively influences outcomes for adults presenting for chronic obstructive pulmonary disease

OBJECTIVES

Emergency department (ED) crowding leads to poor outcomes. Patients with respiratory conditions like chronic obstructive pulmonary disease (COPD) are especially vulnerable to crowding-related delays in care. We aimed to assess the associations of ED crowding metrics with outcomes for patients presenting with COPD.

METHODS

We conducted a population-based cohort study of adult patients presenting with a diagnosis of COPD to 18 high-volume EDs between 2014 and 2019 in Alberta, Canada. Administrative databases provided date and time data on key stages of the presentation including physician initial assessment and disposition decision. Crowding metrics were calculated using facility-specific median physician initial assessment and length of stay. Patient presentations were grouped by acuity and mixed-effects regression models were fit to adjust for the clustering at the facility level.

RESULTS

There were 49,085 presentations for COPD made by 25,734 patients (median age = 73 years). A 1-h increase in the physician initial assessment metric was associated with an increase in physician initial assessment for COPD patients by 23, 53, and 59 min for the high, moderate, and low acuity groups, respectively, adjusted for other predictors. For the low acuity group, this metric was associated with an increased length of stay of 73 min for admitted individuals. Similarly, an increase in the length of stay metric was also associated with an increased likelihood of being admitted for all acuity groups.

CONCLUSIONS

For patients with COPD, ED crowding results in delays in assessment increased length of stay, and increased proportion of patients admitted. These results suggest that ED crowding mitigation efforts to provide timely care for patients with COPD are urgently needed.

TRIAL REGISTRATION

N/A.

Five Level Triage vs. Four Level Triage in a Quaternary Emergency Department: National Analysis on Waiting Time, Validity, and Crowding-The CREONTE (Crowding and RE-Organization National TriagE) Study Group

Background and Objectives: Triage systems help provide the right care at the right time for patients presenting to emergency departments (EDs). Triage systems are generally used to subdivide patients into three to five categories according to the system used, and their performance must be carefully monitored to ensure the best care for patients. Materials and Methods: We examined ED accesses in the context of 4-level (4LT) and 5-level triage systems (5LT), implemented from 1 January 2014 to 31 December 2020. This study assessed the effects of a 5LT on wait times and under-triage (UT) and over-triage (OT). We also examined how 5LT and 4LT systems reflected actual patient acuity by correlating triage codes with severity codes at discharge. Other outcomes included the impact of crowding indices and 5LT system function during the COVID-19 pandemic in the study populations. Results: We evaluated 423,257 ED presentations. Visits to the ED by more fragile and seriously ill individuals increased, with a progressive increase in crowding. The length of stay (LOS), exit block, boarding, and processing times increased, reflecting a net raise in throughput and output factors, with a consequent lengthening of wait times. The decreased UT trend was observed after implementing the 5LT system. Conversely, a slight rise in OT was reported, although this did not affect the medium-high-intensity care area. Conclusions: Introducing a 5LT improved ED performance and patient care.

Modeling Patient Flow in an Emergency Department under COVID-19 Pandemic Conditions: A Hybrid Modeling Approach

Emergency departments (EDs) had to considerably change their patient flow policies in the wake of the COVID-19 pandemic. Such changes affect patient crowding, waiting time, and other qualities related to patient care and experience. Field experiments, surveys, and simulation models can generally offer insights into patient flow under pandemic conditions. This paper provides a thorough and transparent account of the development of a multi-method simulation model that emulates actual patient flow in the emergency department under COVID-19 pandemic conditions. Additionally, a number of performance measures useful to practitioners are introduced. A conceptual model was extracted from the main stakeholders at the case hospital through incremental elaboration and turned into a computational model. Two agent types were mainly modeled: patient and rooms. The simulated behavior of patient flow was validated with real-world data (Smart Crowding) and was able to replicate actual behavior in terms of patient occupancy. In order to further the validity, the study recommends several phenomena to be studied and included in future simulation models such as more agents (medical doctors, nurses, beds), delays due to interactions with other departments in the hospital and treatment time changes at higher occupancies.

Time-series cohort study to forecast emergency department visits in the city of Milan and predict high demand: a 2-day warning system

OBJECTIVES

The emergency department (ED) is one of the most critical areas in any hospital. Recently, many countries have seen a rise in the number of ED visits, with an increase in length of stay and a detrimental effect on quality of care. Being able to forecast future demands would be a valuable support for hospitals to prevent high demand, particularly in a system with limited resources where use of ED services for non-urgent visits is an important issue.

DESIGN

Time-series cohort study.

SETTING

We collected all ED visits between January 2014 and December 2019 in the five larger hospitals in Milan. To predict daily volumes, we used a regression model with autoregressive integrated moving average errors. Predictors included were day of the week and year-round seasonality, meteorological and environmental variables, information on influenza epidemics and festivities. Accuracy of prediction was evaluated with the mean absolute percentage error (MAPE).

PRIMARY OUTCOME MEASURES

Daily all-cause EDs visits.

RESULTS

In the study period, we observed 2 223 479 visits. ED visits were most likely to occur on weekends for children and on Mondays for adults and seniors. Results confirmed the role of meteorological and environmental variables and the presence of day of the week and year-round seasonality effects. We found high correlation between observed and predicted values with a MAPE globally smaller than 8.1%.

CONCLUSIONS

Results were used to establish an ED warning system based on past observations and indicators of high demand. This is important in any health system that regularly faces scarcity of resources, and it is crucial in a system where use of ED services for non-urgent visits is still high.

The “better data, better planning” census: a cross-sectional, multi-centre study investigating the factors influencing patient attendance at the emergency department in Ireland

Background

Internationally Emergency Department (ED) crowding is a significant health services delivery issue posing a major risk to population health. ED crowding affects both the quality and access of health services and is associated with poorer patient outcomes and increased mortality rates. In Ireland the practising of “Corridor Medicine” and “Trolley Crises” have become prevalent. The objectives of this study are to describe the demographic and clinical profile of patients attending regional EDs and to investigate the factors influencing ED utilisation in Ireland.

Methods

This was a multi-centre, cross-sectional study and recruitment occurred at a selection of urban and rural EDs (n = 5) in Ireland throughout 2020. At each site all adults presenting over a 24 h census period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED.

Results

Demographics differed significantly between ED sites in terms of age (p ≤ 0.05), socioeconomic status (p ≤ 0.001), and proximity of health services (p ≤ 0.001). Prior to ED attendance 64% of participants accessed community health services. Most participants (70%) believed the ED was the “best place” for emergency care or attended due to lack of awareness of other services (30%). Musculoskeletal injuries were the most common reason for presentation to the ED in this study (24%) and almost a third of patients (31%) reported presenting to the ED for an x-ray or scan.

Conclusions

This study has identified regional and socioeconomic differences in the drivers of ED presentations and factors influencing ED attendance in Ireland from the patient perspective. Improved awareness of, and provision of alternative care pathways could potentially decrease ED attendances, which would be important in the context of reducing ED crowding during the COVID-19 pandemic. New strategies for integration of acute care in the community must acknowledge and plan for these issues as a universal approach is unlikely to be implemented successfully due to regional factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07841-6.

How the coronavirus disease 2019 pandemic changed the patterns of healthcare utilization by geriatric patients and the crowding: a call to action for effective solutions to the access block

The geriatric population constitutes a large slice of the population of Western countries and a class of fragile patients, with greater deaths due to COVID-19. The patterns of healthcare utilization change during pandemic disease outbreaks. Identifying the patterns of changes of this particular fragile subpopulation is important for future preparedness and response. Overcrowding in the emergency department (ED) can occur because of the volume of patients waiting to be seen, delays in patient assessment or treatment in the ED, or impediments to leaving the ED once the treatment has been completed. Overcrowding has become a serious and growing issue globally, which represents a serious impediment to healthcare utilization. To estimate the rate of ED visits attributable to the outbreak and guide the planning of strategies for managing ED access or after the outbreak of transmittable respiratory diseases. This observational study was based on a retrospective review of the epidemiological and clinical records of patients aged > 75 years who visited the Foundation IRCCS Policlinic San Matteo during the first wave of COVID-19 outbreak (February 21 to May 1, 2020; pandemic group). The analysis methods included estimation of the changes in the epidemiological and clinical data from the annual baseline data after the start of the COVID-19 pandemic. Outcome measures and analysis: Primary objective is the evaluation of ED admission rate change and ED overcrowding. Secondary objectives are the evaluation of modes of ED access by reason and triage code, access types, clinical outcomes (such as admission and mortality rates). During the pandemic, ED crowding increased dramatically, although the overall number of patients decreased, in the face of a percentage increase in those with high-acuity conditions, because of changes in patient management that have prolonged length of stay (LOS) and increased rates of access block. Overcrowding during the COVID-19 pandemic can be attributed to the Access Block. Access Block solutions are hence required to prevent a recurrence of crowding to any new viral wave or new epidemic in the future.

Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions

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

A new approach for emergency department performance positioning: The quality-efficiency matrix

BACKGROUND

The crowding of emergency departments (EDs) is one of the major poor-quality factors for patients. Because of this, measuring ED performance in Healthcare Systems is a difficult but an important task needed to enhance quality and efficiency.

PURPOSE

(i) Development of a tool to observe and evaluate performance measurement, analysing two critical variables (quality and efficiency), verifying the change in performance due to the implementation of a new organizational model; (ii) the implementation of the tool in two EDs with comparable annual volumes of activity in the Italian context.

METHODS

A literature review on ED performance was conducted in order to identify acknowledged performance measurements used in this context that can be used in the development of a tool for the evaluation of EDs' performance. The goal is to have a matrix that is easily understood and that shows a simple relationship between quality and efficiency. This was possible by setting up a method that translates the ED annual performance data (in this case the data related to year 2018) into a graph with benchmarking purposes, also including an actual situation (AS-IS) view as compared to a TO-BE situation (i.e., before and after an organizational change occurred).

RESULTS

Two real EDs were compared and their results depicted; they can be easily related with each other to benchmark healthcare organisations. More precisely, a comparison can be used for two main tasks: - identifying different strategic areas and observing the positioning of a health organization at any given moment in time, seeing where it stands among its competitors in a matrix; - knowing how to best allocate available resources and where to divert investment. Results show that the tool depicts the situation of EDs, with a clear indication of how performance increases or decreases in the case of AS-IS and TO-BE evaluation, and also offers a quick understanding of the benchmarked EDs' situations.

PRACTICE IMPLICATIONS

The results can be shown on a graph that summarises the performance change for the AS-IS versus TO-BE conditions. This can be a useful tool for the ED and for the hospital decision makers, as it allows for an observation of performance by analysing two critical variables: the quality and the efficiency of the service provided. The former represents customer satisfaction, which in this work is the combination of two factors (i.e., appropriateness of assigning the triage code and patient satisfaction), and the latter represents the ED's efficiency in providing emergency care. The tool also helps the organizational changes to be easily evaluated.

Racial and Language Disparities in Pediatric Emergency Department Triage

OBJECTIVE

The aim of this study was to assess the impact race and language have on emergency department (ED) triage scores while accounting for illness severity. We hypothesized that non-White and non-English-speaking patients were assigned lower-acuity triage scores compared with White and English-speaking patients, respectively.

METHODS

We used a chart review-based retrospective cohort study design, examining patients aged 0 to 17 years at our pediatric ED from July 2015 through June 2016. Illness severity was measured using a truncated Modified Pediatric Early Warning Score calculated from patient vital signs. We used univariate and multivariate multinomial logistic regression to assess the association between race and language with Emergency Severity Index scores.

RESULTS

Our final data set consisted of 10,815 visits from 8928 patients. Non-Hispanic (NH) White patients accounted for 34.6% of patients. In the adjusted analyses, non-White patients had significantly reduced odds of receiving a score of 2 (emergency) (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.33-0.49) or 3 (urgent) (OR, 0.5; 95% CI, 0.45-0.56) and significantly higher odds of receiving a score of 5 (minor) (OR, 1.34; 95% CI, 1.07-1.69) versus a score of 4 (nonurgent). We did not find a consistent disparity in Emergency Severity Index scores when comparing English- and non-English-speaking patients.

CONCLUSIONS

We confirm that non-White patients receive lower triage scores than White patients. A more robust tool is required to account for illness severity and will be critical to understanding whether the relationship we describe reflects bias within the triage system or differences in ED utilization by racial groups.

Wilhelms D. Differentiating properties of occupancy rate and workload to estimate crowding: A Swedish national cross-sectional study

BACKGROUND

Emergency department (ED) crowding causes increased patient morbidity and mortality. ED occupancy rate (OR; patients by treatment beds) is a common measure of crowding, but the comparability of ORs between EDs is unknown. The objective of this investigation was to investigate differences in ORs between EDs using staff-perceived workload as reference.

METHODS

This was a national cross-sectional study in Sweden. EDs provided data on census, treatment beds, staffing, and workload (1-6) at 5 time points. A baseline patient turnover was calculated as the average daily census by treatment beds, denoted turnover per treatment bed (TTB), for each ED. A census ratio (CR), current by daily census, was calculated to adjust for differences in the number of treatment beds.

RESULTS

Data were returned from 37 (51%) EDs. TTB varied considerably (mean = 4, standard deviation = 1.6; range, 2.1-9.2), and the OR was higher in EDs with TTB >4 compared with ≤4, 0.86 versus 0.43 (0.43; 95% confidence interval [CI], 0.27-0.59), but not workload, 2.75 versus 2.52 (0.23; 95% CI, -0.19 to 0.64). After adjusting for confounders, both TTB (k = -0.3; 95% CI, -0.49 to -0.14) and OR (k = 3.4; 95% CI, 1.76-5.03) affected workload. Correlation with workload was better for CR than for OR (r = 0.75 vs 0.60, respectively).

CONCLUSION

OR is affected by patient-to-treatment bed ratios that differ significantly between EDs and should be accounted for when measuring crowding. CR is not affected by baseline treatment beds and is a better comparable measure of crowding compared with OR in this national comparator study.

Prevalence of Prolonged Length of Stay in an Emergency Department in Urban Denmark: A Retrospective Health Records Repository Review

INTRODUCTION

Prolonged length of stay in emergency departments is associated with increased hospitalization, hospital-acquired pressure ulcers, medication errors, and mortality. In acute admissions in Denmark in 2018, 67% of patients experienced waiting time from arrival to examination. This study aimed to estimate the prevalence of prolonged length of stay (≥6 hours) and identify risk factors related to input, throughput, and output components.

METHODS

A retrospective health records repository review included 4743 patients admitted to a single urban emergency department in Denmark in January 2019. Data collected from the electronic health record system repository included demographic and organizational characteristics and were analyzed using descriptive statistics and logistic regression.

RESULTS

Among patients admitted in the study period, 31% had a prolonged length of stay of ≥6 hours. Prolonged length of emergency department stay was associated with being female (male odds ratio [OR], 0.86; 95% confidence interval [CI], 0.75-0.98), treatment by medical service (OR, 4.25, 95% CI, 3.63-4.98) vs surgical or injury, triage acuity of 2-Orange (OR, 1.45; 95% CI, 1.18-1.78) or 3-Yellow (OR, 1.47; 95% CI, 1.23-1.75) on a 5-level scale, evening (OR, 1.44; 95% CI, 1.24-1.66) or night (OR, 2.36; 95% CI, 1.91-2.91) arrival, ages 56 to 80 (OR, 1.79; 95% CI, 1.52-2.11) and >81 (OR, 2.40; 95% CI, 1.99-2.88) years, and hospital admission (OR, 1.19; 95% CI, 1.04-1.38) vs discharge from the emergency department to home.

DISCUSSION

Female, elderly, and medical patients were each identified as at-risk characteristics for ≥6-hour length of stay in the emergency department. Acute care patient pathways in the emergency department, particularly for evening and night, with guideline-based care and system level improvements in patient flow are warranted. Further research with larger populations is needed to identify and support interventions to decrease prolonged length of stay.

Assessment of Emergency Department Satisfaction Level in Saudi Arabia General Hospital

Background and objectives:

An overcrowded emergency department (ED) cannot meet the patients’ growing demand. This situation harms employees’ performance and, alternatively, causes anxiety and dissatisfaction among patients since the quality of healthcare outcomes fall below their expectations. This study aimed at improving and validating a scale for assessing patient satisfaction in the ED.

Methods:

In this study, 134 participants from Wadi Al-Dawasir General Hospital were enrolled using a convenient sampling technique. A cross-sectional survey was conducted using 5-point Likert scales.

Results:

All tested hypotheses showed statistical significance (P < 0.05). Our results show that male employees were more satisfied compared with their female counterparts. Furthermore, Saudi employees were more satisfied with the health services than non-Saudi ones.

Conclusion:

The findings of this study brought to the fore that patients and their families were satisfied with the healthcare services and their quality. This means better service delivery played a crucial role in enhancing satisfaction levels. Nevertheless, this study also highlights that overcrowding is a significant problem for healthcare organizations. Wadi al-Dawasir General Hospital's ED should continually improve its quality to meet the growing needs of its clients.

Real-Time Measurement of Crowding in Pediatric Emergency Department: Derivation and Validation Using Consensual Perception of Crowding (SOTU-PED)

ABSTRACT

Our study aimed to develop and validate a real-time crowding composite scale for pediatric emergency department (PED). The study took place in one teaching PED for 2 months. The outcome was the perception of crowding evaluated by triage nurses and pediatricians on a 10-level Likert scale. Triage nurses evaluated crowding at each moment of a child's admission and pediatrician at each moment of a child's discharge. The outcome was the hourly mean of all evaluations of crowding (hourly crowding perception). For analysis, originally, we only selected hours during which more than 2 nurses and more than 2 pediatricians evaluated crowding and, moreover, during which evaluations were the most consensual. As predictors, we used hourly means of 10 objective crowding indicators previously selected as consensual in a published French national Delphi study and collected automatically in our software system. The model (SOTU-PED) was developed over a 1-month data set using a backward multivariable linear regression model. Then, we applied the SOTU-PED model on a 1-month validation data set. During the study period, 7341 children were admitted in the PED. The outcome was available for 1352/1392 hours, among which 639 were included in the analysis as "consensual hours." Five indicators were included in the final model, the SOTU-PED (R2 = 0.718). On the validation data set, the correlation between the outcome (perception of crowding) and the SOTU-PED was 0.824. To predict crowded hours (hourly crowding perception >5), the area under the curve was 0.957 (0.933-0.980). The positive and negative likelihood ratios were 8.16 (3.82-17.43) and 0.153 (0.111-0.223), respectively. Using a simple model, it is possible to estimate in real time how crowded a PED is.

Impact of Viral Seasonal Outbreaks on Crowding and Health Care Quality in Pediatric Emergency Departments

ABSTRACT

In pediatric emergency departments (PEDs), seasonal viral outbreaks are believed to be associated with an increase of workload, but no quantification of this impact has been published. A retrospective cross-sectional study aimed to measure this impact on crowding and health care quality in PED. The study was performed in 1 PED for 3 years. Visits related to bronchiolitis, influenza, and gastroenteritis were defined using discharge diagnoses. The daily epidemic load (DEL) was the proportion of visits related to one of these diagnoses. The daily mean of 8 crowding indicators (selected in a published Delphi study) was used. A total of 93,976 children were admitted (bronchiolitis, 2253; influenza, 1277; gastroenteritis, 7678). The mean DEL was 10.4% (maximum, 33.6%). The correlation between the DEL and each indicator was significant. The correlation was stronger for bronchiolitis (Pearson R from 0.171 for number of hospitalization to 0.358 for length of stay). Between the first and fourth quartiles of the DEL, a significant increase, between 50% (patients left without being seen) and 8% (patient physician ratio), of all the indicators was observed. In conclusion, seasonal viral outbreaks have a strong impact on crowding and quality of care. The evolution of "patients left without being seen" between the first and fourth quartiles of DEL could be used as an indicator reflecting the capacity of adaptation of an emergency department to outbreaks.

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.

Predictors of Emergency Room Access and Not Urgent Emergency Room Access by the Frail Older Adults

Background: Emergency rooms (ERs) overcrowded by older adults have been the focus of public health policies during the recent COVID-19 outbreak too. This phenomenon needed a change in the nursing care of older frail people. Health policies have tried to mitigate the frequent use of ER by implementing community care to meet the care demands of older adults. The present study aimed to investigate the predictors of emergency room access (ERA) and not-urgent emergency room access (NUERA) of community-dwelling frail older adults in order to provide an indication for out-of-hospital care services.

Method: Secondary analysis of an observational longitudinal cohort study was carried out. The cohort consisted of 1,246 community-dwelling frail older adults (over 65 years) in the Latium region in Italy. The ER admission rate was assessed over 3 years from the administration of the functional geriatric evaluation (FGE) questionnaire. The ordinal regression model was used to identify the predictors of ERA and NUERA. Moreover, the ERA and NUERA rate per 100 observations/year was analyzed.

Results: The mean age was 73.6 (SD ± 7.1) years, and 53.4% were women. NUERAs were the 39.2% of the ERAs; robust and pre-frail individuals (79.3% of the sample) generated more than two-third of ERAs (68.17%), even if frails and very frails showed the higher ER rates per observation/year. The ordinal logistic regression model highlighted a predictive role on ERAs of comorbidity (OR = 1.13, p < 0.001) and frailty level (OR = 1.29; p < 0.001). Concerning NUERAs, social network (OR 0.54, P = 0.015) and a medium score of pulmo-cardio-vascular function (OR 1.50, P = 0.006) were the predictors.

Conclusion: Comorbidity, lack of social support, and functional limitations increase both ERA and NUERA rates generated by the older adult population. Overall, bio-psycho-social frailty represents an indicator of the frequency of ERAs. However, to reduce the number of ERAs, intervention should focus mainly on the robust and pre-frail needs for prevention and care.

The Oncological Emergency of Intestinal Obstruction: ED Recognition and Treatment Outcomes

OBJECTIVES

Gastrointestinal complications, like blockage, are among the most common oncological emergencies. We investigated whether individuals with cancer presenting at the emergency department (ED) with intestinal obstruction were triaged accurately, and we further evaluated the triage decisions' effect on their ED treatment outcomes.

DATA SOURCES

A retrospective review was completed on all available records of adult cancer patients who were admitted with intestinal obstruction to a tertiary referral hospital. Over 3 years, 46 cancer patients were admitted from the ED with a provisional diagnosis of intestinal obstruction, confirmed by radiological examination. More than half the patients were undertriaged, which often resulted in these patients experiencing a series of risky time delays in the ED. Patients were significantly delayed in reaching five treatment outcomes: first assessment with a physician, initiation of treatment, decision to admit, length of ED stay, and length of hospital stay.

CONCLUSION

The application of triage in practice was inconsistent, inaccurate, and had a significant negative impact on patient treatment outcomes.

IMPLICATIONS FOR NURSING PRACTICE

The study results indicated the need to critically analyze current triage training and policies to increase their effectiveness. Improvement strategies are identified in the literature, and several are discussed. Involving triage nurses in this work is essential.

The influence of a fast-track service on case flow and client satisfaction in a high-volume veterinary emergency department

OBJECTIVE

To assess the benefit of a fast-track service in the emergency department of a large, high-volume veterinary hospital.

DESIGN

Prospective, observational, clinical study.

SETTING

Emergency department of an urban, tertiary referral veterinary hospital.

ANIMALS

All animals presented to the emergency department between April 1 and April 30 in 2017 and 2018 were eligible for inclusion. Only patients seen on days in 2017 corresponding to those days of 2018 during which the fast-track service was available were studied.

MEASUREMENT AND MAIN RESULTS

Triage case logs were collected and reviewed for April 2017 (prefast-track) and 2018 (fast-track). The fast-track service was launched as a pilot program in April 2018 to provide expedited care to low acuity patients presented to the emergency department. The median number of daily emergency department cases did not differ between 2017 (45, range 26-64) and 2018 (47, range 38-64; P = 0.3). The median time from presentation until first discussion with a doctor for low acuity cases was lower in April 2017 (29 min, range 1-163) than in April 2018 (24 min, range 1-100; P < 0.001). This reduction in wait time was observed despite a 40% increase in low acuity case presentations in 2018. Wait times for high acuity patients did not differ between study periods. The number of cases that left without being seen was higher in April 2017 compared to April 2018 (77 and 45 cases, respectively P < 0.001).

CONCLUSIONS

Implementation of a fast-track service reduced wait time for low acuity cases without adversely impacting wait times for sicker patients and led to a reduction in clients leaving without being seen. By introducing the fast-track service in a large volume veterinary hospital, limited resources can be distributed to improve speed of care, case flow, and client satisfaction in the emergency department.

Impact of Coronavirus Disease 2019 Pandemic on Crowding: A Call to Action for Effective Solutions to “Access Block”

Introduction

Healthcare patterns change during disease outbreaks and pandemics. Identification of modified patterns is important for future preparedness and response. Emergency department (ED) crowding can occur because of the volume of patients waiting to be seen, which results in delays in patient assessment or treatment and impediments to leaving the ED once treatment is complete. Therefore, ED crowding has become a growing problem worldwide and represents a serious barrier to healthcare operations.

Methods

This observational study was based on a retrospective review of the epidemiologic and clinical records of patients who presented to the Foundation IRCCS Policlinic San Matteo in Pavia, Italy, during the coronavirus disease 2019 (COVID-19) outbreak (February 21–May 1, 2020, pandemic group). The methods involved an estimation of the changes in epidemiologic and clinical data from the annual baseline data after the start of the COVID-19 pandemic.

Results

We identified reduced ED visits (180 per day in the control period vs 96 per day in the pandemic period; P < 0.001) during the COVID-19 pandemic, irrespective of age and gender, especially for low-acuity conditions. However, patients who did present to the ED were more likely to be hemodynamically unstable, exhibit abnormal vital signs, and more frequently required high-intensity care and hospitalization. During the pandemic, ED crowding dramatically increased primarily because of an increased number of visits by patients with high-acuity conditions, changes in patient management that prolonged length of stay, and increased rates of boarding, which led to the inability of patients to gain access to appropriate hospital beds within a reasonable amount of time. During the pandemic, all crowding output indices increased, especially the rates of boarding (36% vs 57%; P < 0.001), “access block” (24% vs 47%; P < 0.001), mean boarding time (640 vs 1,150 minutes [min]; P 0.001), mean “access block” time (718 vs 1,223 min; P < 0.001), and “access block” total time (650,379 vs 1,359,172 min; P < 0.001).

Conclusion

Crowding in the ED during the COVID-19 pandemic was due to the inability to access hospital beds. Therefore, solutions to this lack of access are required to prevent a recurrence of crowding due to a new viral wave or epidemic.

Do Automated Reminders for Emergency Department Resident Physicians to Review Their Patient List Improve Efficiency?

OBJECTIVES

Navigating the emergency department (ED) workflow in an efficient manner is an important skill every emergency physician or advanced provider must master. There is a paucity of research into ways to improve how efficiently an ED provider works amid these distractions. This study seeks to determine whether the addition of an hourly automated reminder for resident physicians to review their patient list improves throughput metrics.

METHODS

This a double-blinded randomized controlled trial in which resident physicians at a single community ED were randomly assigned to two groups: the intervention group, which received automated hourly notifications within the electronic medical record (EMR) to review their patient list for those whose workup is completed, and the control group, which received no notifications. We prospectively analyzed records for 25,255 encounters with 19,264 individual patients seen by 64 residents over the study period. Three-level mixed-effects regression models were used to examine whether notifications improved ED length of stay (ED-LOS), turnaround time to discharge (TAT-D), or turnaround time to admission (TAT-A).

RESULTS

There was no statistically significant difference in ED-LOS or TAT-D between groups, but the average TAT-A was 20.00 minutes longer in the intervention group compared to the control group (p < 0.001), after accounting for patient- and resident-specific effects. Secondary analysis demonstrated no statistically significant effect of residency specialty on the effect of notifications on ED-LOS, TAT-D, or TAT-A.

CONCLUSIONS

Automated hourly notifications within the EMR reminding residents in the ED to review their patient list did not reduce the ED-LOS, TAT-D, or TAT-A. However, the TAT-A was 20.00 minutes longer in the intervention group compared to the control group. It is unclear whether this represents an unintended effect of the automated reminders or is simply a spurious correlation.

Operational factors associated with emergency department patient satisfaction: Analysis of the Academy of Administrators of Emergency Medicine/Association of Academic Chairs of Emergency Medicine national survey

BACKGROUND

Patient satisfaction is a focus for emergency department (ED) and hospital administrators. ED patient satisfaction studies have tended to be single site and focused on patient and clinician factors. Inclusion of satisfaction scores in a large, national operations database provided an opportunity to conduct an investigation that included diverse operational factors.

METHODS

We performed a retrospective analysis of the 2019 Academy of Administrators in Academic Emergency Medicine/Association of Academic Chairs of Emergency Medicine (AAAEM/AACEM) benchmarking survey to identify associations between operational factors and patient satisfaction. We identified 59 database variables as potential predictors of Press Ganey likelihood-to-recommend and physician overall scores. Using random forest modeling, we identified the top eight predictors in the models and described their associations.

RESULTS

Forty-three (57.3%) academic departments responding to the AAAEM/AACEM survey reported patient satisfaction scores for 78 EDs. Likelihood to recommend ranged from 30.0 to 93.0 (median = 74.8) and was associated with ED length of stay, boarding, use of hallway spaces, hospital annual admissions, faculty base clinical hours, proportion of patients leaving before treatment complete (LBTC), and provider in triage hours per day. Physician overall score ranged from 53.3 to 93.4 (median = 81.9) and was associated with faculty base clinical hours, x-ray utilization, annual ED arrivals, LBTC, use of hallway spaces, arrivals per attending hour, and CT utilization.

CONCLUSIONS

ED patient satisfaction was associated with intrinsic and extrinsic factors, some being potentially manageable within the ED but others being relatively fixed or outside the control of ED operations. For likelihood to recommend, patient flow was dominant, with erosion of satisfaction observed with increased boarding and longer LOS. Factors associated with physician overall score were more varied. The use of hallway spaces and base clinical hours greater than 1,500 per year were associated with both lower likelihood-to-recommend and lower physician overall scores.

Relationship of the Emergency Department Density Level with Nursing Work Stress

BACKGROUND: The imbalance between the increase in the overall volume of patients at the emergency department (ED) with the capacity of the emergency unit can lead to overcrowded conditions in the ED. Factors that cause ED density include lack of beds for inpatients, increased overall patient volume, increased non-emergency patient visits, lack of nursing staff, and lack of administrative support. Overcrowded at the ED can cause work stress on nurses. Nurses in the ED tend to experience more stress than nurses on the ward due to workload and work fatigue. AIM: This study aimed to investigate the correlation between the ED density with nursing work stress. METHODS: This study was conducted a correlational study in a hospital at Central Java in 2020. Total sampling with the criteria of nurses in the ED was the method employed to the respondents. The data analysis used descriptive statistics and rank Spearman, with a significant level of p < 0.05. RESULTS: The most frequent occurred in the ED was overcrowded, while nursing work stress was moderate stress. The result of the rank Spearman test obtained p = 0.000 with a correlation coefficient of 0.725. CONCLUSION: There was a significant correlation between the ED density levels with nursing work stress.

Crowding is the strongest predictor of left without being seen risk in a pediatric emergency department

BACKGROUND

Emergency Department (ED) patients who leave without being seen (LWBS) are associated with adverse safety and medico-legal consequences. While LWBS risk has been previously tied to demographic and acuity related factors, there is limited research examining crowding-related risk in the pediatric setting. The primary objective of this study was to determine the association between LWBS risk and crowding, using the National Emergency Department Overcrowding Score (NEDOCS) and occupancy rate as crowding metrics.

METHODS

We performed a retrospective observational study on electronic health record (EHR) data from the ED of a quaternary care children's hospital and trauma center during the 14-month study period. NEDOCS and occupancy rate were calculated for 15-min windows and matched to patient arrival time. We leveraged multiple logistic regression analyses to demonstrate the relationship between patientlevel LWBS risk and each crowding metric, controlling for characteristics drawn from the pre-arrival state. We performed a chi-squared test to determine whether a difference existed between the receiver operating characteristic (ROC) curves in the two models. Finally, we executed a dominance analysis using McFadden's pseudo-R 2 to determine the relative importance of each crowding metric in the models.

RESULTS

A total of 54,890 patient encounters were studied, 1.22% of whom LWBS. The odds ratio for LWBS risk was 1.30 (95% CI 1.27-1.33) per 10-point increase in NEDOCS and 1.23 (95% CI 1.21-1.25). per 10% increase in occupancy rate. Area under the curve (AUC) was 86.9% for the NEDOCS model and 86.7% for the occupancy rate model. There was no statistically significant difference between the AUCs of the two models (p-value 0.27). Dominance analysis revealed that in each model, the most important variable studied was its respective crowding metric; NEDOCS accounted for 55.6% and occupancy rate accounted for 53.9% of predicted variance in LWBS.

CONCLUSION

Not only was ED overcrowding positively and significantly associated with individual LWBS risk, but it was the single most important factor that determined a patient's likelihood of LWBS in the pediatric ED. Because occupancy rate and NEDOCS are available in real time, each could serve as a monitor for individual LWBS risk in the pediatric ED.

Review article: Emergency department crowding measures associations with quality of care: A systematic review

ED crowding has been reported to reduce the quality of care. There are many proposed crowding metrics, but the metric most strongly associated with care quality remains unknown. The present study aims to determine the crowding metric with the strongest links with processes and outcomes of care linked to the Institute of Medicine quality domains. Systematic searches in healthcare databases were conducted using terms for 'crowding', 'metrics' and 'performance', supplemented by grey literature and citation searches. The level of evidence for each association was assessed using an explicit tool. The body of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. Evidence was synthesised using harvest plots. Titles and abstracts of 2052 studies were screened, 452 selected for full-text review and 183 included. Inter-observer agreement was moderate κ = 0.54 (95% confidence interval 0.50-0.59). Two thirds were from urban tertiary hospitals in North America (65%), Australasia (13%), Europe (12%) and Asia (8%). One third provided Level 3 or higher evidence. Metrics were based on occupancy (38%), time (31%), workload (19%) or combinations (9%). Data were synthesised from 25 607 375 patients, 2368 staff, 9089 hospitals and 101 177 sampling times. Almost all crowding metrics were patient-centred and reflect timeliness and efficiency. ED length of stay, boarding time and total occupancy had the strongest association with safety and effectiveness of care. ED length of stay was also associated with equity. The certainty of evidence for associations between crowding measures varied across domains of quality, from very low to moderate certainty.

Multi-dimensional Measurements of Crowding for Pediatric Emergency Departments: A Systematic Review

The absence of accepted crowding measurement tools that encompass the unique characteristics of pediatric emergency departments (EDs) creates a deficit in advancing efforts to identify and evaluate solutions for this growing problem. In this systematic review, we examined 4 studies that reported on the development and testing of multidimensional pediatric ED crowding measurements. Two investigations involved models (PEDOCS, SOTU-PED) that measured factors indicative or contributory to crowding. A third investigation developed a model mapping the flow of patients through the pediatric ED. The final study modeled the magnitude of physician’s work load, particularly when this load is high when crowding is likely present, based on patient arrivals, presenting complaints and conditions, and tests ordered. These works from 4 studies on measuring crowding in pediatric EDs show promise, but this field is at an early stage. Future work should concentrate on comparing the utility of crowding measurements across multiple pediatric ED settings.

Validation of the modified Skåne emergency department assessment of patient load (mSEAL) model for emergency department crowding and comparison with international models; an observational study

Background

Emergency Department crowding is associated with increased morbidity and mortality but no measure of crowding has been validated in Sweden. We have previously derived and internally validated the Skåne Emergency Department Assessment of Patient Load (SEAL) score as a measure of crowding in Emergency Departments (ED) in a large regional healthcare system in Sweden. Due to differences in electronic health records (EHRs) between health care systems in Sweden, all variables in the original SEAL-score could not be measured reliably nationally. We aimed to derive and validate a modified SEAL (mSEAL) model and to compare it with established international measures of crowding.

Methods

This was an observational cross sectional study at four EDs in Sweden. All clinical staff assessed their workload (1–6 where 6 is the highest workload) at 5 timepoints each day. We used linear regression with stepwise backward elimination on the original SEAL dataset to derive and internally validate the mSEAL score against staff workload assessments. We externally validated the mSEAL at four hospitals and compared it with the National Emergency Department Overcrowding Score (NEDOCS), the simplified International Crowding Measure in Emergency Department (sICMED), and Occupancy Rate. Area under the receiver operating curve (AuROC) and coefficient of determination was used to compare crowding models. Crowding was defined as an average workload of 4.5 or higher.

Results

The mSEAL score contains the variables Patient Hours and Time to physician and showed strong correlation with crowding in the derivation (r² = 0.47), internal validation (r² = 0.64 and 0.69) and in the external validation (r² = 0.48 to 0.60). AuROC scores for crowding in the external validation were 0.91, 0.90, 0.97 and 0.80 for mSEAL, Occupancy Rate, NEDOCS and sICMED respectively.

Conclusions

The mSEAL model can measure crowding based on workload in Swedish EDs with good discriminatory capacity and has the potential to systematically evaluate crowding and help policymakers and researchers target its causes and effects. In Swedish EDs, Occupancy Rate and NEDOCS are good alternatives to measure crowding based on workload.

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.

Central Venous Catheter Adverse Events Are not Associated with Crowding Indicators

Objective

Crowding in the emergency department (ED) impacts a number of important quality and safety metrics. We studied ED crowding measures associated with adverse events (AE) resulting from central venous catheters (CVC) inserted in the ED, as well as the relationship between crowding and the frequency of CVC insertions in an ED cohort admitted to the intensive care unit (ICU).

Methods

We conducted a retrospective observational study from 2008–2010 in an academic tertiary care center. Participants undergoing CVC in the ED or admitted to an ICU were categorized by quartile based on the following: National Emergency Department Overcrowding Scale (NEDOCS); waiting room patients (WR); ED patients awaiting inpatient beds (boarders); and ED occupancy (EDO). Main outcomes were the occurrence of an AE during CVC insertion in the ED, and deferred procedures assessed by frequency of CVC insertions in ED patients admitted to the ICU.

Results

Of 2,284 ED patients who had a CVC inserted, 293 (13%) suffered an AE. There was no association between AEs from ED CVCs and crowding scales when comparing the highest crowding level or quartile to all other quartiles: NEDOCS (dangerous crowding [13.1%] vs other levels [13.0%], P = 0.98); number of WR patients (14.0% vs 12.7%, P = 0.81); EDO (13.0% vs 12.9%, P = 0.99); and number of boarding patients (12.0% vs 13.3%), P = 0.21). In a cohort of ED patients admitted to the ICU, there was no association between CVC placement rates in the ED and crowding scales comparing the highest vs all other quartiles: NEDOCS (dangerous crowding 16% vs all others 16%, P = 0.97); WR patients (16% vs 16%, P = 0.82), EDO (15% vs. 17%, P = 0.15); and number of boarding patients (17% vs 16%, P = 0.08).

Conclusion

In a large, academic tertiary-care center, frequency of CVC insertion in the ED and related AEs were not associated with measures of crowding. These findings add to the evidence that the negative effects of crowding, which impact all ED patients and measures of ED performance, are less likely to impair the delivery of prioritized time-critical interventions.

Modeling Emergency Department crowding: Restoring the balance between demand for and supply of emergency medicine

Emergency Departments (EDs) worldwide are confronted with rising patient volumes causing significant strains on both Emergency Medicine and entire healthcare systems. Consequently, many EDs are in a situation where the number of patients in the ED is temporarily beyond the capacity for which the ED is designed and resourced to manage-a phenomenon called Emergency Department (ED) crowding. ED crowding can impair the quality of care delivered to patients and lead to longer patient waiting times for ED doctor's consult (time to provider) and admission to the hospital ward. In Singapore, total ED attendance at public hospitals has grown significantly, that is, roughly 5.57% per year between 2005 and 2016 and, therefore, emergency physicians have to cope with patient volumes above the safe workload. The purpose of this study is to create a virtual ED that closely maps the processes of a hospital-based ED in Singapore using system dynamics, that is, a computer simulation method, in order to visualize, simulate, and improve patient flows within the ED. Based on the simulation model (virtual ED), we analyze four policies: (i) co-location of primary care services within the ED, (ii) increase in the capacity of doctors, (iii) a more efficient patient transfer to inpatient hospital wards, and (iv) a combination of policies (i) to (iii). Among the tested policies, the co-location of primary care services has the largest impact on patients' average length of stay (ALOS) in the ED. This implies that decanting non-emergency lower acuity patients from the ED to an adjacent primary care clinic significantly relieves the burden on ED operations. Generally, in Singapore, there is a tendency to strengthen primary care and to educate patients to see their general practitioners first in case of non-life threatening, acute illness.

Emergency department crowding and hospital transformation during COVID-19, a retrospective, descriptive study of a university hospital in Stockholm, Sweden

Objectives

COVID-19 presents challenges to the emergency care system that could lead to emergency department (ED) crowding. The Huddinge site at the Karolinska university hospital (KH) responded through a rapid transformation of inpatient care capacity together with changing working methods in the ED. The aim is to describe the KH response to the COVID-19 crisis, and how ED crowding, and important input, throughput and output factors for ED crowding developed at KH during a 30-day baseline period followed by the first 60 days of the COVID-19 outbreak in Stockholm Region.

Methods

Different phases in the development of the crisis were described and identified retrospectively based on major events that changed the conditions for the ED. Results were presented for each phase separately. The outcome ED length of stay (ED LOS) was calculated with mean and 95% confidence intervals. Input, throughput, output and demographic factors were described using distributions, proportions and means. Pearson correlation between ED LOS and emergency ward occupancy by phase was estimated with 95% confidence interval.

Results

As new working methods were introduced between phase 2 and 3, ED LOS declined from mean (95% CI) 386 (373–399) minutes to 307 (297–317). Imaging proportion was reduced from 29 to 18% and admission rate increased from 34 to 43%. Correlation (95% CI) between emergency ward occupancy and ED LOS by phase was 0.94 (0.55–0.99).

Conclusions

It is possible to avoid ED crowding, even during extreme and quickly changing conditions by leveraging previously known input, throughput and output factors. One key factor was the change in working methods in the ED with higher competence, less diagnostics and increased focus on rapid clinical admission decisions. Another important factor was the reduction in bed occupancy in emergency wards that enabled a timely admission to inpatient care. A key limitation was the retrospective study design.

Likelihood of admission to hospital from the emergency department is not universally associated with hospital bed occupancy at the time of admission

Background

The decision to admit into the hospital from the emergency department (ED) is considered to be important and challenging. The aim was to assess whether previously published results suggesting an association between hospital bed occupancy and likelihood of hospital admission from the ED can be reproduced in a different study population.

Methods

A retrospective cohort study of attendances at two Swedish EDs in 2015 was performed. Admission to hospital was assessed in relation to hospital bed occupancy together with other clinically relevant variables. Hospital bed occupancy was categorized and univariate and multivariate logistic regression were performed.

Results

In total 89,503 patient attendances were included in the final analysis. Of those, 29.1% resulted in admission within 24 h. The mean hospital bed occupancy by the hour of the two hospitals was 87.1% (SD 7.6). In both the univariate and multivariate analysis, odds ratio for admission within 24 h from the ED did not decrease significantly with an increasing hospital bed occupancy.

Conclusions

A negative association between admission to hospital and occupancy level, as reported elsewhere, was not replicated. This suggests that the previously shown association might not be universal but may vary across sites due to setting specific circumstances.

Effects of crowding in the emergency department on the diagnosis and management of suspected acute coronary syndrome using rapid algorithms: an observational study

OBJECTIVES

Fast diagnostic algorithms using high-sensitivity troponin (hsTn) in suspected acute coronary syndrome (ACS) are regarded as beneficial to expedite diagnosis and safe discharge of patients in crowded emergency departments (ED). This study investigates the effects of crowding on process times related to the diagnostic protocol itself or other time delays, and outcomes.

DESIGN

Prospective single-centre observational study.

SETTING

ED (Germany).

PARTICIPANTS

Final study population of 2525 consecutive patients with suspected ACS within 12 months, after exclusion of patients with ST-elevation myocardial infarction, missing blood samples, referral from other hospitals or repeated visits.

INTERVENTIONS

Use of fast algorithms as per 2015 European Society of Cardiology guidelines.

MAIN OUTCOME MEASURES

Crowding was defined as mismatch between patient numbers and monitoring capacities, or mean physician time per case, categorised as normal, high and very high crowding. Outcome measures were length of ED stay, direct discharge from ED, laboratory turn around times (TAT), utilisation of fast algorithms, absolute and relative non-laboratory time, as well as mortality.

RESULTS

Crowding was associated with increased length of ED stay (3.75-4.89 hours, p<0.001). While median TAT of the first hsTnT increased (53-57 min, p<0.001), total TAT of serial hsTnT did not increase significantly with higher crowding (p=0.170). Lower utilisation of fast algorithms (p=0.009) and increase of additional hsTnT measurements after diagnosis (p=0.001) were observed in higher crowding. Most importantly, crowding was significantly associated with prolonged absolute (p<0.001), and particularly relative non-laboratory time (63.3%-71.3%, p<0.001). However, there was no significant effect of crowding on mortality, even after adjustment for relevant clinical variables.

CONCLUSIONS

Process times, and particularly non-laboratory times, are prolonged in a crowded ED diminishing some positive effects of fast diagnostic algorithms in suspected ACS. Higher crowding levels were not significantly associated with higher all-cause mortality rates.

TRIAL REGISTRATION NUMBER

NCT03111862.

Validation of the National Emergency Department Overcrowding Score (NEDOCS) in a UK non-specialist emergency department

INTRODUCTION

Emergency department (ED) crowding has significant adverse consequences, however, there is no widely accepted tool to measure it. This study validated the National Emergency Department Overcrowding score (NEDOCS) (range 0-200 points), which uses routinely collected ED data.

METHODS

This prospective single-centre study sampled data during four periods of 2018. The outcome against which NEDOCS performance was assessed was a composite of clinician opinion of crowding (physician and nurse in charge). Area under the receiver operating characteristic curves (AUROCs) and calibration plots were produced. Six-hour stratified sampling was added to adjust for temporal correlation of clinician opinion. Staff inter-rater agreement and NEDOCS association with opinion of risk, safety and staffing levels were collected.

RESULTS

From 905 sampled hours, 448 paired observations were obtained, with the ED deemed crowded 18.5% of the time. Inter-rater agreement between staff was moderate (weighted kappa 0.57 (95% CI 0.56 to 0.60)). AUROC for NEDOCS was 0.81 (95% CI 0.77 to 0.86). Adjusted for temporal correlation, AUROC was 0.80 (95% CI 0.73 to 0.88). At a cut-off of 100 points sensitivity was 75.9% (95% CI 65.3% to 84.6%), specificity 72.1% (95% CI 67.1% to 76.6%), positive predictive value 38.2% (95% CI 30.7% to 46.1%) and negative predictive value 92.9% (95% CI 89.3% to 95.6%). NEDOCS underpredicted clinical opinion on Calibration assessment, only partially correcting with intercept updating. For perceived risk of harm, safety and insufficient staffing, NEDOCS AUROCs were 0.71 (95% CI 0.61 to 0.82), 0.71 (95% CI 0.63 to 0.80) and 0.70 (95% CI 0.64 to 0.76), respectively.

CONCLUSIONS

NEDOCS demonstrated good discriminatory power for clinical perception of crowding. Prior to implementation, determining individual unit ED cut-off point(s) would be important as published thresholds may not be generalisable. Future studies could explore refinement of existing variables or addition of new variables, including acute physiological data, which may improve performance.

[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.

The impact of emergency department triage on the treatment outcomes of cancer patients with febrile neutropenia: A retrospective review

INTRODUCTION

The emergency department (ED) is an important entry point for patients with cancer requiring acute care due to oncological emergencies. Febrile neutropenia (FN) is one of the most common oncological emergencies and carries a significant risk of morbidity and mortality. There is evidence from previous studies that FN patients wait far longer in the ED than recommended by international guidelines.

PURPOSE

The aim was to examine whether individuals with cancer presenting at the ED with FN were triaged appropriately, and to explore if, and how, triage affected their treatment outcomes.

METHODS

A retrospective cohort design was employed to collect data over five years from all available ED records of adult cancer patients who presented with fever.

RESULTS

Of the 431 eligible patients, 63% (n = 272) were assigned triage scores that were detrimental to their immediate health. Findings from the multiple linear regression analyses showed that inaccurate or under triage was significantly associated with delayed times for the initial physician assessment, administration of antibiotics, and decision on admission. The absence of fever at the time of triage assessment contributed significantly to the prediction of under triage.

CONCLUSION

The allocation of patients with FN to a lower, inaccurate priority was partly responsible for the inability of those patients to meet the standard benchmarks for the initial physician assessment and the administration of antibiotics identified by the triage and febrile neutropenia guidelines. Ongoing strategies are needed to both enhance the application of the triage guidelines and institute organizational and system changes that promote timeliness and effectiveness throughout the entire ED episode of care.

The Effect of Operational Stressors on Emergency Department Clinician Scheduling and Patient Throughput

STUDY OBJECTIVE

We assess the effect of emergency department (ED) operational stressors on clinician scheduling and throughput.

METHODS

We evaluated 2014 to 2018 data from a national ED group. Operational stressors included measures of workload, patient acuity, and complexity. We used multilevel linear regression to estimate the effect of operational stressors, temporal factors, and facility characteristics on ED clinician scheduling; patient throughput, measured as shift-level patient departures per corrected clinician hour; and length of stay.

RESULTS

In greater than 14 million ED visits across 359 facility-years, the mean of patient departures per corrected clinician hour was 2.23 (95% confidence interval [CI] 2.15 to 2.31). Temporal and facility effects had the greatest influence on patient departures per hour (eg, -0.55 [95% CI -0.75 to -0.36] in 7 am to 3 pm shifts versus midnight to 7 am on Mondays, 0.25 [95% CI 0.03 to 0.47]) in teaching versus nonteaching hospitals, and 0.43 (95% CI 0.24 to 0.61) in larger EDs (30,000 to 59,999 ED visits/year) versus smaller EDs. Operational stressors had significant but small effects on patient departures per hour (eg, length of stay [per-minute increase] 0.002 [95% CI 0.0019 to 0.0023] and percentage admitted [per 1% increase] -0.003 [95% CI -0.004 to -0.001]). Weekday nights, particularly Mondays, had the highest proportion of shifts with increasing length of stay compared with previous years in the same ED.

CONCLUSION

ED operational stressors had minimal influence on patient throughput when included in adjusted ED clinician scheduling models, whereas temporal and facility factors were more influential. Therefore, incorporating operational stressors into ED clinician scheduling is less likely to balance workloads than accounting for temporal and facility-level factors alone. Length of stay on some shifts, particularly Monday nights, became increasingly long, suggesting they require additional resources.