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Savioli G, Ceresa IF, Bressan MA, Piccini GB, Varesi A, Novelli V, Muzzi A, Cutti S, Ricevuti G, Esposito C, Voza A, Desai A, Longhitano Y, Saviano A, Piccioni A, Piccolella F, Bellou A, Zanza C, Oddone E. 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. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040781. [PMID: 37109739 PMCID: PMC10143416 DOI: 10.3390/medicina59040781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
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.
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Affiliation(s)
- Gabriele Savioli
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Maria Antonietta Bressan
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Angelica Varesi
- Faculty of Medicine, University of Pavia, 27100 Pavia, Italy
| | - Viola Novelli
- Health Department, University of Pavia, 27100 Pavia, Italy
| | - Alba Muzzi
- Health Department, University of Pavia, 27100 Pavia, Italy
| | - Sara Cutti
- Health Department, University of Pavia, 27100 Pavia, Italy
| | | | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy
| | - Antonio Voza
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Desai
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Department of Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Angela Saviano
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Fabio Piccolella
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Abdel Bellou
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Christian Zanza
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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Length-of-Stay in the Emergency Department and In-Hospital Mortality: A Systematic Review and Meta-Analysis. J Clin Med 2022; 12:jcm12010032. [PMID: 36614835 PMCID: PMC9821325 DOI: 10.3390/jcm12010032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
The effect of emergency department (ED) length of stay (EDLOS) on in-hospital mortality (IHM) remains unclear. The aim of this systematic review and meta-analysis was to determine the association between EDLOS and IHM. We searched the PubMed, Medline, Embase, Web of Science, Cochrane Controlled Register of Trials, CINAHL, PsycInfo, and Scopus databases from their inception until 14−15 January 2022. We included studies reporting the association between EDLOS and IHM. A total of 11,337 references were identified, and 52 studies (total of 1,718,518 ED patients) were included in the systematic review and 33 in the meta-analysis. A statistically significant association between EDLOS and IHM was observed for EDLOS over 24 h in patients admitted to an intensive care unit (ICU) (OR = 1.396, 95% confidence interval [CI]: 1.147 to 1.701; p < 0.001, I2 = 0%) and for low EDLOS in non-ICU-admitted patients (OR = 0.583, 95% CI: 0.453 to 0.745; p < 0.001, I2 = 0%). No associations were detected for the other cut-offs. Our findings suggest that there is an association between IHM low EDLOS and EDLOS exceeding 24 h and IHM. Long stays in the ED should not be allowed and special attention should be given to patients admitted after a short stay in the ED.
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Das MK, Arora NK, Dalpath SK, Kumar S, Kumar AP, Khanna A, Bhatnagar A, Bahl R, Nisar YB, Qazi SA, Arora GK, Dhankhad RK, Kumar K, Chander R, Singh B. Improving quality of care for pregnancy, perinatal and newborn care at district and sub-district public health facilities in three districts of Haryana, India: An Implementation study. PLoS One 2021; 16:e0254781. [PMID: 34297746 PMCID: PMC8301676 DOI: 10.1371/journal.pone.0254781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 07/04/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction Improving quality of care (QoC) for childbirth and sick newborns is critical for maternal and neonatal mortality reduction. Information on the process and impact of quality improvement at district and sub-district hospitals in India is limited. This implementation research was prioritized by the Haryana State (India) to improve the QoC for maternal and newborn care at the busy hospitals in districts. Methods This study at nine district and sub-district referral hospitals in three districts (Faridabad, Rewari and Jhajjar) during April 2017-March 2019 adopted pre-post, quasi-experimental study design and plan-do-study-act quality improvement method. During the six quarterly plan-do-study-act cycles, the facility and district quality improvement teams led the gap identification, solution planning and implementation with external facilitation. The external facilitators monitored and collected data on indicators related to maternal and newborn service availability, patient satisfaction, case record quality, provider’s knowledge and skills during the cycles. These indicators were compared between baseline (pre-intervention) and endline (post-intervention) cycles for documenting impact. Results The interventions closed 50% of gaps identified, increased the number of deliveries (1562 to 1631 monthly), improved care of pregnant women in labour with hypertension (1.2% to 3.9%, p<0.01) and essential newborn care services at birth (achieved ≥90% at most facilities). Antenatal identification of high-risk pregnancies increased from 4.1% to 8.8% (p<0.01). Hand hygiene practices improved from 35.7% to 58.7% (p<0.01). The case record completeness improved from 66% to 87% (p<0.01). The time spent in antenatal clinics declined by 19–42 minutes (p<0.01). The pooled patient satisfaction scores improved from 82.5% to 95.5% (p<0.01). Key challenges included manpower shortage, staff transfers, leadership change and limited orientation for QoC. Conclusion This multipronged quality improvement strategy improved the maternal and newborn services, case documentation and patient satisfaction at district and sub-district hospitals. The processes and lessons learned shall be useful for replicating and scaling up.
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Affiliation(s)
| | | | - Suresh Kumar Dalpath
- Department of Health and Family Welfare, Government of Haryana, Panchkula, Haryana, India
| | - Saket Kumar
- Department of Health and Family Welfare, Government of Haryana, Panchkula, Haryana, India
| | - Amneet P. Kumar
- Department of Health and Family Welfare, Government of Haryana, Panchkula, Haryana, India
| | | | | | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Gulshan Kumar Arora
- Department of Health and Family Welfare, Office of Chief Medical Officer and Civil Surgeon (Faridabad), Government of Haryana, Faridabad, Haryana, India
| | - R. K. Dhankhad
- Department of Health and Family Welfare, Office of Chief Medical Officer and Civil Surgeon, (Jhajjar), Government of Haryana, Jhajjar, Haryana, India
| | - Krishan Kumar
- Department of Health and Family Welfare, Office of Chief Medical Officer and Civil Surgeon (Rewari), Government of Haryana, Rewari, Haryana, India
| | - Ramesh Chander
- Department of Health and Family Welfare, Office of Chief Medical Officer and Civil Surgeon (Faridabad), Government of Haryana, Faridabad, Haryana, India
| | - Bhanwar Singh
- Department of Health and Family Welfare, Office of Chief Medical Officer and Civil Surgeon (Rewari), Government of Haryana, Rewari, Haryana, India
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Maculotti D, Melis V, Roveron G, Spena PR, Villa G. Patient flow for the management of ostomy patients. MINERVA CHIR 2020; 75:365-372. [PMID: 33210529 DOI: 10.23736/s0026-4733.20.08472-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Subjects undergoing ostomy are increasing and share a reduced quality of life. The patient flow (PF) is the pathway of a patient from hospital admission to discharge and should provide care appropriateness to the patient himself. In the recent literature no paper exists regarding the PF of the patient undergoing (intestinal or urinary) ostomy, which is the objective of the present article. This paper stems from the work done during the Educational Camp entitled "The Patient Flow in Stoma Care," which took place on three separate days (27<sup>th</sup> May, 18<sup>th</sup> September, and 21<sup>st</sup> November 2019) at B. Braun Milano S.p.A. and regarded 33 stomatherapy nurses from all over Italy supervised by the authors. The participants, divided into heterogeneous groups, developed the PF by means of three specific work methodologies: mental maps, timeline and appreciative inquiry. The elaborated PF was inspired to the International Charter of the Ostomates' Rights. The efficacious and empathic communication and the role of the patient and/or the caregiver as the main characters are transversal to every step and must be always pursued. The PF is developed in eight macro-areas: diagnosis; pre-admission; admission and preoperative phase; surgical operation; awakening; postoperative phase; discharge; follow-up. In agreement with the recent literature, this systematic approach will give benefits to the patients in terms of outcome and perception of taking charge before, during and after the ostomy. At the same time the performances, the therapeutic appropriateness, the optimization of technology and healthcare resources and the staff satisfaction will equally be guaranteed.
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Affiliation(s)
- Danila Maculotti
- Fondazione Poliambulanza Istituto Europeo Multispecialistico, Brescia, Italy
| | | | - Gabriele Roveron
- Associazione Tecnico-Scientifica di Stomaterapia e Riabilitazione del Pavimento Pelvico (AIOSS), Padua, Italy
| | - Pier R Spena
- Federazione Associazioni Incontinenti e Stomizzati (FAIS), Milan, Italy
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Wachtel G, Elalouf A. Addressing overcrowding in an emergency department: an approach for identifying and treating influential factors and a real-life application. Isr J Health Policy Res 2020; 9:37. [PMID: 32873328 PMCID: PMC7550853 DOI: 10.1186/s13584-020-00390-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 05/28/2020] [Indexed: 11/16/2022] Open
Abstract
Background Overcrowding in hospital emergency departments that arises from long length-of-stay is an unfortunate common occurrence. While some factors affecting length-of-stay are well known, there may be additional factors that have not yet been properly addressed. This research offers a method for emergency department managers to use available data from their departments to identify new factors that significantly influence emergency departments crowding and patient length-of-stay. Methods We propose an algorithm that can assist emergency department managers in determining which of these factors to address, given budgetary constraints. We implemented it in a case study which takes into account factors that are known to be influential, e.g., reason for arrival, occupancy in the emergency department, and arrival time, as well as factors that are explored for the first time in this paper, such as patient heart rate, the number of accompanying escorts, and the number of tests assigned to patients (e.g., blood tests and urinalysis). Results All the implemented and new factors are shown to have a significant influence on the length-of-stay and crowding. We also obtained additional support for our results by interviewing emergency departments physicians and nurses from various hospitals. Conclusions It is expected that, by taking all the above factors into consideration, emergency departments efficiency can be improved. The algorithm constructed here allows the choice of the most cost-effective factors to be improved, subject to a given budget. We have been able to derive practical recommendations that emergency departments managers might use to limit crowding and patient length-of-stay.
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Affiliation(s)
- Guy Wachtel
- Department of Management, Bar-Ilan University, 5290002, Ramat Gan, Israel.
| | - Amir Elalouf
- Department of Management, Bar-Ilan University, 5290002, Ramat Gan, Israel
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Barros O, Riffo R, Paredes I. Improving service in an emergency department by designing the health production flow. Health Serv Manage Res 2019; 33:76-85. [PMID: 31274339 DOI: 10.1177/0951484819860325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Most emergency departments have overcapacity with poor service measured by length of stay. We hypothesized that a formal design of the emergency department production flows will improve service. Thus, we propose a methodology that was tested in a large hospital, including new flow implementation. Results We implemented new workflows during June to July 2017. A comparison of the patients’ average length of stay from June to September shows a decrease of 26%. Additionally, a comparison with 2016 shows a decrease of 50%. Direct evaluation of the value generated reveals an emergency department admissions increase of 540 monthly, equivalent of a savings of approximately US$250.000 annually. This savings is a very conservative estimate because the most significant value of this work is fast service that diminishes the patients’ risks. Conclusions Production design is an important problem in health services in terms of potential service improvements, executable with a formal, systemic, replicable method founded on several disciplines. Thus, we are replicating the approach at other hospitals with extensions to other services.
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Affiliation(s)
- Oscar Barros
- Industrial Engineering Department, University of Chile, Santiago, Chile
| | - Rodrigo Riffo
- Emergency Department, Hospital San Juan de Dios, Santiago, Chile
| | - Inti Paredes
- Industrial Engineering Department, University of Chile, Santiago, Chile
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Alshareef SM, Aldayel AY, AlKhathlan MA, Alduaij KO, Alshareef FG, Al-Harthi ME, Aldayel AA, Shadid AM, Dahmash AB. Diabetic patients in Saudi Arabia: The evaluation of glycemic control measures based on emergency department utilization and the percentages of adherence to the recommended follow-ups for microvascular complications. Saudi Med J 2019; 40:271-276. [PMID: 30834423 PMCID: PMC6468210 DOI: 10.15537/smj.2019.3.23968] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: To determine the association between emergency department (ED) visits, glycemic control and the quality of preventive diabetes care among diabetic patients in a Saudi community. Methods: This study was an observational, cross-sectional study that collected data through interview-based surveys between February and April 2017. Data were collected from 530 diabetic patients in the diabetes clinics at King Saud Medical City, the tertiary center of Riyadh, Kingdom of Saudi Arabia. Results: This study found statistically significant relationships (p<0.05) between ED visits and patient age, the glycated hemoglobin (HbA1c) and education level. Emergency department visits increased by 43% for each unit of increase in HbA1c (odds ratio [OR]=1.43, 95% confidence interval (CI)=1.26-1.62). Graduating from high school decreased the odds of visiting the ED by 43% (OR=0.57, 95% CI=0.34-0.94). Most of the participants were not followed for possible microvascular complications; the majority did not visit nephrology (96.2%), ophthalmology (78.3%) and neurology (97.9%) clinics within the 12 months prior to the interviews. Conclusion: Emergency department visits can indicate poor glycemic control in diabetic patients. Additionally, the current practices of preventive diabetes care in Saudi Arabia are not sufficient, according to the diabetic standards of care recommended by the American Diabetes Association.
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Affiliation(s)
- Saad M Alshareef
- Department of Medicine, Al Imam Mohammad Ibn Saud Islamic University,Ministry of Education, Riyadh, Kingdom of Saudi Arabia. E-mail.
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Opiro K, Wallis L, Ogwang M. Assessment of hospital-based adult triage at emergency receiving areas in hospitals in Northern Uganda. Afr Health Sci 2017; 17:481-490. [PMID: 29062344 PMCID: PMC5637034 DOI: 10.4314/ahs.v17i2.23] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Limited health service resources must be used in a manner which does "the most for the most". This is partly achieved through the use of a triage system. Whereas efforts have been made to introduce paediatric triage in Uganda such as Emergency Triage Assessment and Treatment Plus (ETAT+), it is not clear if hospitals have local protocols for adult triage being used in each setting. OBJECTIVES To determine the presence of existing hospital triage systems, the cadre of staff undertaking triage and barriers to development/improvement of formal triage systems. METHODOLOGY This was a descriptive cross-sectional study. Acholi sub-region was randomly selected for the study among the three sub-regions in Northern Uganda. The study was conducted in 6 of the 7 hospitals in the region. It was a written self-administered questionnaire. RESULTS Thirty-three participants from 6 hospitals consented and participated in the study. Only one hospital (16.7%) of the 6 hospitals surveyed had a formal hospital-based adult triage protocol in place. Only 2 (33.3%) hospitals had an allocated emergency department, the rest receive emergency patients/perform triage from OPD and wards. Lack of training, variation of triage protocols from hospital to another, shortage of staff on duty, absence of national guidelines on triage and poor administrative support were the major barriers to improvement/development of formal triage in all these hospitals. CONCLUSION Formal adult hospital-based triage is widely lacking in Northern Uganda and staff do perform subjective "eyeball" judgments to make triage decisions.
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Affiliation(s)
- Keneth Opiro
- Gulu University Faculty of Medicine, P.O.Box, 166 Gulu Uganda
| | - Lee Wallis
- University of Cape Town Faculty of Health Sciences, Surgery, Division of Emergency Medicine
| | - Martin Ogwang
- St. Mary's hospital Lacor, P. O. Box, 180, Gulu Uganda, Surgery
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An Application of Business Process Management to Health Care Facilities. Health Care Manag (Frederick) 2017; 36:147-163. [DOI: 10.1097/hcm.0000000000000149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yiadom MYAB, Scheulen J, McWade CM, Augustine JJ. Implementing Data Definition Consistency for Emergency Department Operations Benchmarking and Research. Acad Emerg Med 2016; 23:796-802. [PMID: 27121149 DOI: 10.1111/acem.12988] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/31/2016] [Accepted: 04/03/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective was to obtain a commitment to adopt a common set of definitions for emergency department (ED) demographic, clinical process, and performance metrics among the ED Benchmarking Alliance (EDBA), ED Operations Study Group (EDOSG), and Academy of Academic Administrators of Emergency Medicine (AAAEM) by 2017. METHODS A retrospective cross-sectional analysis of available data from three ED operations benchmarking organizations supported a negotiation to use a set of common metrics with identical definitions. During a 1.5-day meeting-structured according to social change theories of information exchange, self-interest, and interdependence-common definitions were identified and negotiated using the EDBA's published definitions as a start for discussion. Methods of process analysis theory were used in the 8 weeks following the meeting to achieve official consensus on definitions. These two lists were submitted to the organizations' leadership for implementation approval. RESULTS A total of 374 unique measures were identified, of which 57 (15%) were shared by at least two organizations. Fourteen (4%) were common to all three organizations. In addition to agreement on definitions for the 14 measures used by all three organizations, agreement was reached on universal definitions for 17 of the 57 measures shared by at least two organizations. The negotiation outcome was a list of 31 measures with universal definitions to be adopted by each organization by 2017. CONCLUSION The use of negotiation, social change, and process analysis theories achieved the adoption of universal definitions among the EDBA, EDOSG, and AAAEM. This will impact performance benchmarking for nearly half of US EDs. It initiates a formal commitment to utilize standardized metrics, and it transitions consistency in reporting ED operations metrics from consensus to implementation. This work advances our ability to more accurately characterize variation in ED care delivery models, resource utilization, and performance. In addition, it permits future aggregation of these three data sets, thus facilitating the creation of more robust ED operations research data sets unified by a universal language. Negotiation, social change, and process analysis principles can be used to advance the adoption of additional definitions.
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Affiliation(s)
| | - James Scheulen
- Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
| | - Conor M. McWade
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
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Implementing Triage Standing Orders in the Emergency Department Leads to Reduced Physician-to-Disposition Times. ACTA ACUST UNITED AC 2016. [DOI: 10.1155/2016/7213625] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Emergency departments (EDs) throughout USA have improvised various processes to curb the “national epidemic” termed ED “crowding.” Standing orders (SOs), one such process, are medical orders approved by the medical director and entered by nurses when patients cannot be seen expeditiously, expediting medical decision-making and decreasing length of stay (LOS) and time to disposition. This retrospective cohort study evaluates the impact of SOs on ED LOS and disposition time at a large university ED. Results indicate that SOs significantly improve ED throughput by reducing disposition time by up to 16.9% (p=0.04), which is especially significant in busy ED settings. SOs by themselves are not sufficient for a complete diagnostic assessment. Strategies such as having a provider in the waiting area may help make key decisions earlier.
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Pan CL, Chang CF, Chiu CW, Chi CH, Tian Z, Wen JH, Wen JC. What Can Emergency Medicine Learn From Kinetics: Introducing an Alternative Evaluation and a Universal Criterion Standard for Emergency Department Performance. Medicine (Baltimore) 2016; 95:e2972. [PMID: 26986107 PMCID: PMC4839888 DOI: 10.1097/md.0000000000002972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This research focuses on developing an improved and robust measurement for emergency department (ED) performance and a criterion standard for global use via kinetic analysis. Based on kinetic approach, the input-throughput-output conceptual model of ED crowding is compared to the procedure of enzyme catalysis. All in average, the retented patients in EDs are defined as substrate (S), whereas the patients who depart the EDs as product (P). Therefore, the average ED departure velocity (V) can be presented as (P)divided by a given time (t) of the ED length of stay (LOS). The S-V and S²-P plots are depicted hourly for the kinetic analysis. The long-term stability of the kinetic parameters is ascertained by the method of coefficient of variation (CV). The participants collected for this study are from the EDs of Changhua Christian Medical Center and the five branched hospitals, all located in Taiwan. Based on the S-V plot analysis, the results clearly show 2 curves, an upper and a lower curve. The timeline of the lower curve includes approximately the total ED busy hours, and thus it can be used for the subsequent kinetic analysis. In order to explore the adequate kinetic parameters for ED performance, the try-and-error process was followed in this study. As a result, the S²-V plots adapted from the lower curves show the best linear regression of S² on V with a good coefficient of determination (R). The Pan-Wen constant (PW), which is the slope of the liner regression line, and the ED medical personnel unit turnover number (EDMPU TON) were deduced from the kinetic meanings of (Equation is included in full-text article.)plots. In this research, the 2 kinetic parameters, PW and EDMPU TON were applied for the ED performance evaluations. An innovative relationship between the ED retented patients and the ED departure velocity is verified as PW; whereas, a feasible kinetic parameter, the EDMPU TON explicates the teamwork efficiency of the ED providers. Moreover, the EDMPU TON may not only be a reliable universal criterion standard for the ED performance, but also a valuable reference for both ED providers and payers.
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Affiliation(s)
- Chih-Long Pan
- From the Graduate School of Engineering Science and Technology (C-LP), National Yunlin University of Science & Technology, Douliou, Taiwan, China; Department of Emergency Medicine (C-FC, C-WC), Changhua Christian Medical Center, Changhua, Taiwan, China; Department of Emergency Medicine (C-HC), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, China; Key Laboratory of Hydraulics and Mountain River Engineering (ZT), Sichuan University, Chengdu, China; Department of Electrical Engineering (J-HW), Tunghai University, Taichung, Taiwan, China; and Department and Graduate School of Safety and Environment Engineering (J-CW), Research Center for Soil & Water Resources and Natural Disaster Prevention, National Yunlin University of Science & Technology, Douliou, Taiwan, China
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Kriegel J, Jehle F, Moser H, Tuttle-Weidinger L. Patient logistics management of patient flows in hospitals: A comparison of Bavarian and Austrian hospitals. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2016. [DOI: 10.1080/20479700.2015.1119370] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Triplett P, Harrison SD, Daviss SR, Angelino AF. Creating a Statewide Bed Tracker and Patient Registry to Communicate Bed Need and Supply in Emergency Psychiatry: The Maryland Experience. Jt Comm J Qual Patient Saf 2015; 41:569-74. [PMID: 26567147 DOI: 10.1016/s1553-7250(15)41074-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Patrick Triplett
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, Baltimore, USA
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Saghafian S, Austin G, Traub SJ. Operations research/management contributions to emergency department patient flow optimization: Review and research prospects. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/19488300.2015.1017676] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Dixon CA, Punguyire D, Mahabee-Gittens M, Ho M, Lindsell CJ. Patient flow analysis in resource-limited settings: a practical tutorial and case study. GLOBAL HEALTH: SCIENCE AND PRACTICE 2015; 3:126-34. [PMID: 25745126 PMCID: PMC4356281 DOI: 10.9745/ghsp-d-14-00121] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patient flow analysis (PFA), a simple quality improvement tool to identify patient flow patterns, can be used in resource-limited settings to inform service delivery improvements. A PFA at a Ghanaian hospital found that personnel constraints and a mismatch between staffing and patient arrival surges led to long wait and total attendance times. The median time from arrival to first-provider contact was 4.6 hours.
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Affiliation(s)
- Cinnamon A Dixon
- University of Cincinnati, Cincinnati Children's Hospital Medical Center, Division of Emergency Medicine, Cincinnati, OH, USA University of Cincinnati, Cincinnati Children's Hospital Medical Center, Center for Global Health, Department of Pediatrics, Cincinnati, OH, USA
| | | | - Melinda Mahabee-Gittens
- University of Cincinnati, Cincinnati Children's Hospital Medical Center, Division of Emergency Medicine, Cincinnati, OH, USA
| | - Mona Ho
- University of Cincinnati, Cincinnati Children's Hospital Medical Center, Division of Emergency Medicine, Cincinnati, OH, USA
| | - Christopher J Lindsell
- University of Cincinnati, College of Medicine, Department of Emergency Medicine, Cincinnati, OH, USA
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Ajmi I, Zgaya H, Gammoudi L, Hammadi S, Martinot A, Beuscart R, Renard JM. Mapping patient path in the Pediatric Emergency Department: A workflow model driven approach. J Biomed Inform 2014; 54:315-28. [PMID: 25554685 DOI: 10.1016/j.jbi.2014.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 12/08/2014] [Accepted: 12/09/2014] [Indexed: 10/24/2022]
Abstract
The workflow models of the patient journey in a Pediatric Emergency Department (PED) seems to be an effective approach to develop an accurate and complete representation of the PED processes. This model can drive the collection of comprehensive quantitative and qualitative service delivery and patient treatment data as an evidence base for the PED service planning. Our objective in this study is to identify crowded situation indicators and bottlenecks that contribute to over-crowding. The greatest source of delay in patient flow is the waiting time from the health care request, and especially the bed request to exit from the PED for hospital admission. It represented 70% of the time that these patients occupied in the PED waiting rooms. The use of real data to construct the workflow model of the patient path is effective in identifying sources of delay in patient flow, and aspects of the PED activity that could be improved. The development of this model was based on accurate visits made in the PED of the Regional University Hospital Center (CHRU) of Lille (France). This modeling, which has to represent most faithfully possible the reality of the PED of CHRU of Lille, is necessary. It must be detailed enough to produce an analysis allowing to identify the dysfunctions of the PED and also to propose and to estimate prevention indicators of crowded situations. Our survey is integrated into the French National Research Agency (ANR) project, titled: "Hospital: Optimization, Simulation and avoidance of strain" (HOST).
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Affiliation(s)
- Ines Ajmi
- LAGIS UMR CNRS 8219, Ecole Centrale de Lille, France.
| | | | | | - Slim Hammadi
- LAGIS UMR CNRS 8219, Ecole Centrale de Lille, France.
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Chan H, Lo S, Lee L, Lo W, Yu W, Wu Y, Ho S, Yeung R, Chan J. Lean techniques for the improvement of patients' flow in emergency department. World J Emerg Med 2014; 5:24-8. [PMID: 25215143 DOI: 10.5847/wjem.j.issn.1920-8642.2014.01.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 11/17/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Emergency departments (EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called "lean" management. This study aims to (1) evaluate the current patient flow in ED, (2) to identify and eliminate the non-valued added process, and (3) to modify the existing process. METHODS It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage (PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T (hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared. RESULTS Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed (38.24 minutes; SD 66.35) and blood testing result (mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward (EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program (P<0.05). CONCLUSION The application of lean management can improve the patient flow in ED. Acquiescence to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction.
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Affiliation(s)
- Hy Chan
- Emergency Department, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - Sm Lo
- Emergency Department, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - Lly Lee
- Emergency Department, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - Wyl Lo
- Emergency Department, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - Wc Yu
- Emergency Department, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - Yf Wu
- Emergency Department, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - St Ho
- Emergency Department, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - Rsd Yeung
- Emergency Department, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - Jts Chan
- Emergency Department, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
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Vezyridis P, Timmons S. National targets, process transformation and local consequences in an NHS emergency department (ED): a qualitative study. BMC Emerg Med 2014; 14:12. [PMID: 24927819 PMCID: PMC4065387 DOI: 10.1186/1471-227x-14-12] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 06/05/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the attempt to reduce waiting times in emergency departments, various national health services have used benchmarking and the optimisation of patient flows. The aim of this study was to examine staff attitudes and experience of providing emergency care following the introduction of a 4 hour wait target, focusing on clinical, organisational and spatial issues. METHODS A qualitative research design was used and semi-structured interviews were conducted with 28 clinical, managerial and administrative staff members working in an inner-city emergency department. A thematic analysis method was employed and NVivo 8 qualitative data analysis software was used to code and manage the emerging themes. RESULTS The wait target came to regulate the individual and collective timescales of healthcare work. It has compartmentalised the previous unitary network of emergency department clinicians and their workspace. It has also speeded up clinical performance and patient throughput. It has disturbed professional hierarchies and facilitated the development of new professional roles. A new clinical information system complemented these reconfigurations by supporting advanced patient tracking, better awareness of time, and continuous, real-time management of emergency department staff. The interviewees had concerns that this target-oriented way of working forces them to have a less personal relationship with their patients. CONCLUSIONS The imposition of a wait-target in response to a perceived "crisis" of patients' dissatisfaction led to the development of a new and sophisticated way of working in the emergency department, but with deep and unintended consequences. We show that there is a dynamic interrelation of the social and the technical in the complex environment of the ED. While the 4 hour wait target raised the profile of the emergency department in the hospital, the added pressure on clinicians has caused some concerns over the future of their relationships with their patients and colleagues. To improve the sustainability of such sudden changes in policy direction, it is important to address clinicians' experience and satisfaction.
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Affiliation(s)
| | - Stephen Timmons
- Faculty of Medicine & Health Sciences, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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Mumma BE, McCue JY, Li CS, Holmes JF. Effects of emergency department expansion on emergency department patient flow. Acad Emerg Med 2014; 21:504-9. [PMID: 24842500 PMCID: PMC4046120 DOI: 10.1111/acem.12366] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 11/12/2013] [Accepted: 12/09/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Emergency department (ED) crowding is an increasing problem associated with adverse patient outcomes. ED expansion is one method advocated to reduce ED crowding. The objective of this analysis was to determine the effect of ED expansion on measures of ED crowding. METHODS This was a retrospective study using administrative data from two 11-month periods before and after the expansion of an ED from 33 to 53 adult beds in an academic medical center. ED volume, staffing, and hospital admission and occupancy data were obtained either from the electronic health record (EHR) or from administrative records. The primary outcome was the rate of patients who left without being treated (LWBT), and the secondary outcome was total ED boarding time for admitted patients. A multivariable robust linear regression model was used to determine whether ED expansion was associated with the outcome measures. RESULTS The mean (±SD) daily adult volume was 128 (±14) patients before expansion and 145 (±17) patients after. The percentage of patients who LWBT was unchanged: 9.0% before expansion versus 8.3% after expansion (difference = 0.6%, 95% confidence interval [CI] = -0.16% to 1.4%). Total ED boarding time increased from 160 to 180 hours/day (difference = 20 hours, 95% CI = 8 to 32 hours). After daily ED volume, low-acuity area volume, daily wait time, daily boarding hours, and nurse staffing were adjusted for, the percentage of patients who LWBT was not independently associated with ED expansion (p = 0.053). After ED admissions, ED intensive care unit (ICU) admissions, elective surgical admissions, hospital occupancy rate, ICU occupancy rate, and number of operational ICU beds were adjusted for, the increase in ED boarding hours was independently associated with the ED expansion (p = 0.005). CONCLUSIONS An increase in ED bed capacity was associated with no significant change in the percentage of patients who LWBT, but had an unintended consequence of an increase in ED boarding hours. ED expansion alone does not appear to be an adequate solution to ED crowding.
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Affiliation(s)
- Bryn E Mumma
- The Department of Emergency Medicine, University of California Davis, Sacramento, CA
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Areej J, Rabia J. Eliciting Time Motion Study with Involved Pharmacist Interventions in an Emergency Department of a Tertiary Care Hospital. JOURNAL OF MEDICAL SCIENCES 2013. [DOI: 10.3923/jms.2013.555.562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Li ST, Chiu NC, Kung WC, Chen JC. Factors affecting length of stay in the pediatric emergency department. Pediatr Neonatol 2013; 54:179-87. [PMID: 23597551 DOI: 10.1016/j.pedneo.2012.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 06/05/2012] [Accepted: 11/21/2012] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND A large volume of visits can cause an emergency department (ED) to become overcrowded, resulting in a longer length of stay (LOS). The objective of this study was to analyze factors affecting the LOS in the pediatric ED. METHODS Records of all visits to the pediatric ED of the study hospital, from July 1, 2006 to June 31, 2007, were retrospectively retrieved. Data were collected from the hospital's computerized records system. Eta-squared correlation ratio and Cramer's V test evaluated the associations between variables. Two-thirds of the database was randomized for the classification and regression tree (CART) model-building dataset, and one-third was used for the validation dataset. RESULTS A total of 29,035 patients visited the pediatric ED during the evaluation period. Of the total visits, 61.1% were due to complaints of fever. The mean LOS was 2.6 ± 4.67 hours, and 74.3% of visits had an LOS of shorter than 2 hours. The CART analysis selected five factors (waiting time for hospitalization, laboratory tests, door-to-physician time, gastrointestinal symptoms, and patient outcome) to produce a total of nine subgroups of patients. The mean LOS of the model-building dataset closely correlated with that of the validation dataset (r(2) = 0.999). CONCLUSION Patients who were waiting for hospitalization for less than 8 hours or were not admitted, those without any laboratory tests, those having door-to-physician time less than 60 minutes, and those without any gastrointestinal symptoms had the shortest LOS. Patients who waited for hospitalization for more than 16 hours had the longest LOS.
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Affiliation(s)
- Sung-Tse Li
- Department of Pediatrics, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan.
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The emergency department "carousel": an ethnographically-derived model of the dynamics of patient flow. Int Emerg Nurs 2013; 22:3-9. [PMID: 23669027 DOI: 10.1016/j.ienj.2013.01.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 01/04/2013] [Accepted: 01/10/2013] [Indexed: 11/23/2022]
Abstract
Emergency department (ED) overcrowding reduces efficiency and increases the risk of medical error leading to adverse events. Technical solutions and models have done little to redress this. A full year's worth of ethnographic observations of patient flow were undertaken, which involved making hand-written field-notes of the communication and activities of emergency clinicians (doctors and nurses), in two EDs in Sydney, Australia. Observations were complemented by semi-structured interviews. We applied thematic analysis to account for the verbal communication and activity of emergency clinicians in moving patients through the ED. The theoretical model that emerged from the data analysis is the ED "carousel". Emergency clinicians co-construct a moving carousel which we conceptualise visually, and which accounts for the collective agency of ED staff, identified in the findings. The carousel model uniquely integrates diagnosis, treatment and transfer of individual patients with the intellectual labour of leading and coordinating the department. The latter involves managing staff skill mix and the allocation of patients to particular ED sub-departments. The model extends traditional patient flow representations and underlines the importance of valuing ethnographic methods in health services research, in order to foster organisational learning, and generate creative practical and policy alternatives that may, for example, reduce or ameliorate access block and ED overcrowding.
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Burström L, Starrin B, Engström ML, Thulesius H. Waiting management at the emergency department - a grounded theory study. BMC Health Serv Res 2013; 13:95. [PMID: 23496853 PMCID: PMC3626711 DOI: 10.1186/1472-6963-13-95] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 03/04/2013] [Indexed: 12/30/2022] Open
Abstract
Background An emergency department (ED) should offer timely care for acutely ill or injured persons that require the attention of specialized nurses and physicians. This study was aimed at exploring what is actually going on at an ED. Methods Qualitative data was collected 2009 to 2011 at one Swedish ED (ED1) with 53.000 yearly visits serving a population of 251.000. Constant comparative analysis according to classic grounded theory was applied to both focus group interviews with ED1 staff, participant observation data, and literature data. Quantitative data from ED1 and two other Swedish EDs were later analyzed and compared with the qualitative data. Results The main driver of the ED staff in this study was to reduce non-acceptable waiting. Signs of non-acceptable waiting are physical densification, contact seeking, and the emergence of critical situations. The staff reacts with frustration, shame, and eventually resignation when they cannot reduce non-acceptable waiting. Waiting management resolves the problems and is done either by reducing actual waiting time by increasing throughput of patient flow through structure pushing and shuffling around patients, or by changing the experience of waiting by calming patients and feinting maneuvers to cover up. Conclusion To manage non-acceptable waiting is a driving force behind much of the staff behavior at an ED. Waiting management is done either by increasing throughput of patient flow or by changing the waiting experience.
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Affiliation(s)
- Lena Burström
- Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
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Khankeh HR, Khorasani-Zavareh D, Azizi-Naghdloo F, Hoseini MA, Rahgozar M. Triage effect on wait time of receiving treatment services and patients satisfaction in the emergency department: Example from Iran. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2013; 18:79-83. [PMID: 23983733 PMCID: PMC3748560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Long wait time interval in emergency department (ED) of hospitals, from the patients' point of view in ED is a major problem causing patients' dissatisfaction and may result increasing in patient morbidity and indirectly nurses dissatisfaction. Evaluation of wait time intervals in ED and giving nursing feedback may improve the quality of services, as well as patient satisfaction. The present study was designed to investigate the effect of nursing triage on receiving treatment of wait time interval and satisfaction of the patients referring to ED in Shahid Rajaee hospital. MATERIALS AND METHODS This study was conducted on patients those referring to Shahid Rajaee hospital in Karaj, Iran employing quasi experimental design d ividing in two experiment and control groups during 2009. This is a quasi-experimental study of which the data were collected by standard questionnaire covering patient satisfaction and measuring wait time. T-test, Mann-Whitney and frequency analysis were used to evaluate the effect of triage on wait time from receiving treatment services and patients' satisfaction. RESULTS The findings showed that there was a significant difference between experiment and control groups regarding wait time from receiving treatment services and patients' satisfaction. CONCLUSIONS Triage could significantly reduce the wait time interval between patients' entrance to ED to receive treatment services and enhance patients' satisfaction. It may help nursing in emergency ward to have better performance and indirectly their satisfaction.
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Affiliation(s)
- Hamid-Reza Khankeh
- Disaster Rehabilitation Research Center, School of Nursing, University of Social Welfare and Rehabilitation Science, Tehran, Iran,Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Davoud Khorasani-Zavareh
- Social Determinants of Health Research Center, Department of Public Health, Urmia University of Medical Sciencess, Urmia, Iran,Department of Public Health, Division of Social Medicine, Karolinska Institutet, Stockholm, Sweden,Address for correspondence: Prof. Davoud Khorasani-Zavareh, Social Determinants of Health Research Center, Urmia University of Medical Sciences, Resalat Avenue, Urmia, Iran. E-mail:
| | | | - Mohammad-Ali Hoseini
- Disaster Rehabilitation Research Center, School of Nursing, University of Social Welfare and Rehabilitation Science, Tehran, Iran
| | - Mahdi Rahgozar
- Disaster Rehabilitation Research Center, School of Nursing, University of Social Welfare and Rehabilitation Science, Tehran, Iran
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Chong CP, Haywood C, Barker A, Lim WK. Is Emergency Department length of stay associated with inpatient mortality? Australas J Ageing 2012; 32:122-4. [DOI: 10.1111/j.1741-6612.2012.00651.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Casalino E, Choquet C, Bernard J, Debit A, Doumenc B, Berthoumieu A, Wargon M. Predictive variables of an emergency department quality and performance indicator: a 1-year prospective, observational, cohort study evaluating hospital and emergency census variables and emergency department time interval measurements. Emerg Med J 2012; 30:638-45. [PMID: 22906702 DOI: 10.1136/emermed-2012-201404] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Emergency department (ED) crowding impacts negatively on quality of care. The aim was to determine the association between ED quality and input, throughput and output-associated variables. METHODS This 1-year, prospective, observational, cohort study determined the daily percentage of patients leaving the ED in <4 h (ED quality and performance indicator; EDQPI). According to the median EDQPI two groups were defined: best-days and bad-days. Hospital and ED variables and time interval metrics were evaluated as predictors. RESULTS Data were obtained for 67 307 patients over 364 days. Differences were observed between the two groups in unadjusted analysis: number of daily visits, number of patients as a function of final disposition, number boarding in the ED, and time interval metrics including wait time to triage nurse and ED provider, time from ED admission to decision, time from decision to departure and length of stay (LOS) as a function of final disposition. Five variables remained significant predictors for bad-days in multivariate analysis: wait time to triage nurse (OR 2.36; 95% CI 1.36 to 4.11; p=0.002), wait time to ED provider (OR 1.93; 95% CI 1.05 to 3.54; p=0.03), number of patients admitted to hospital (OR 1.86; 95% CI 1.09 to 3.19; p=0.02), LOS of non-admitted patients (OR 9.5; 95% CI 5.17 to 17.48; p<0.000001) and LOS of patients admitted to hospital (OR 2.46; 95% CI 1.44 to 4.2; p=0.0009). CONCLUSIONS Throughput is the major determinant of EDQPI, notably time interval reflecting the work dynamics of medical and nursing teams and the efficacy of fast-track routes for low-complexity patients. Output also significantly impacted on EDQPI, particularly the capacity to reduce the LOS of admitted patients.
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Affiliation(s)
- Enrique Casalino
- Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Bichat-Claude Bernard, Emergency Department, Paris, France.
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Paul JA, Lin L. Models for improving patient throughput and waiting at hospital emergency departments. J Emerg Med 2012; 43:1119-26. [PMID: 22902245 DOI: 10.1016/j.jemermed.2012.01.063] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Revised: 07/11/2011] [Accepted: 01/19/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Overcrowding diminishes Emergency Department (ED) care delivery capabilities. OBJECTIVES We developed a generic methodology to investigate the causes of overcrowding and to identify strategies to resolve them, and applied it in the ED of a hospital participating in the study. METHODS We utilized Discrete Event Simulation (DES) to capture the complex ED operations. Using DES results, we developed parametric models for checking the effectiveness and quantifying the potential gains from various improvement alternatives. We performed a follow-up study to compare the outcomes before and after the model recommendations were put into effect at the hospital participating in the study. RESULTS Insufficient physicians during peak hours, the slow process of admitting patients to inpatient floors, and laboratory and radiology test turnaround times were identified as the causes of reduced ED throughput. Addition of a physician resulted in an almost 18% reduction in the ED Main discharged patient length of stay. CONCLUSION The case study results demonstrated the effectiveness of the generic methodology. The research contributions were validated through statistically significant improvements seen in patient throughput and waiting time at the hospital participating in the study.
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Affiliation(s)
- Jomon Aliyas Paul
- Department of Economics, Finance and Quantitative Analysis, Kennesaw State University, Kennesaw, Georgia 30144, USA
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Patwardhan A, Davis J, Murphy P, Ryan SF. Comparison of Waiting and Consultation Times in Convenient Care Clinics and Physician Offices. J Prim Care Community Health 2012; 4:124-8. [DOI: 10.1177/2150131912450030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study measures waiting times and consultation times at convenient care clinics (CCCs), and compares them with equivalent times in traditional, family practice, physician offices. The analysis was limited to conditions most commonly treated at CCCs. It was found that patients using CCCs had significantly shorter waiting times from check-in to seeing a clinician than the equivalent waiting times reported by patients at family practice physicians’ offices and that CCC patients had significantly longer consultation times with the clinician than those reported by family practice patients. Applying a correction factor to adjust for potential differences between real waiting times and perceived waiting times did not substantially alter the conclusions. Shorter waiting times may increase satisfaction and thereby encourage patients to seek care; and spending additional time with the clinician may help ensure that all of a patient’s concerns or questions are addressed. This study provides objective evidence from a large database that CCCs provide prompt, satisfying care.
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MATHEMATICAL MODELING: THE CASE OF EMERGENCY DEPARTMENT WAITING TIMES. Int J Technol Assess Health Care 2012; 28:93-109. [DOI: 10.1017/s0266462312000013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A decision analytic model often comprises a significant part of a health technology assessment. As health technology assessment in the hospital setting evolves, there is an increased need for modeling methods that account for patient care pathways and interactions between patients and their environment. For example, an evaluation of a computed tomography (CT) scanner for a new indication would need to consider the current and increased demand of the machine and how that may affect service in other areas of the hospital. This problem solving approach views “problems” through a systems perspective.
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Sinreich D, Jabali O, Dellaert NP. Reducing emergency department waiting times by adjusting work shifts considering patient visits to multiple care providers. ACTA ACUST UNITED AC 2012. [DOI: 10.1080/0740817x.2011.609875] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Jones P, Chalmers L, Wells S, Ameratunga S, Carswell P, Ashton T, Curtis E, Reid P, Stewart J, Harper A, Tenbensel T. Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol. BMC Health Serv Res 2012; 12:45. [PMID: 22353694 PMCID: PMC3311075 DOI: 10.1186/1472-6963-12-45] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 02/21/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts? METHODS/DESIGN The study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study. DISCUSSION At the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.
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Affiliation(s)
- Peter Jones
- Adult Emergency Department, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
- Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Linda Chalmers
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Susan Wells
- Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Shanthi Ameratunga
- Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Peter Carswell
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Toni Ashton
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Elana Curtis
- Te Kupenga Hauora Māori, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Papaarangi Reid
- Te Kupenga Hauora Māori, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Joanna Stewart
- Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Alana Harper
- Adult Emergency Department, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
| | - Tim Tenbensel
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Abstract
Background: Emergency Department (ED) overcrowding is an important healthcare issue facing increasing public and regulatory scrutiny in Canada and around the world. Many approaches to alleviate excessive waiting times and lengths of stay have been studied. In theory, optimal ED patient flow may be assisted via balancing patient loads between EDs (in essence spreading patients more evenly throughout this system). This investigation utilizes simulation to explore “Crowdinforming” as a basis for a process control strategy aimed to balance patient loads between six EDs within a mid-sized Canadian city. Methods: Anonymous patient visit data comprising 120,000 ED patient visits over six months to six ED facilities were obtained from the region’s Emergency Department Information System (EDIS) to (1) determine trends in ED visits and interactions between parameters; (2) to develop a process control strategy integrating crowdinforming; and, (3) apply and evaluate the model in a simulated environment to explore the potential impact on patient self-redirection and load balancing between EDs. Results: As in reality, the data available and subsequent model demonstrated that there are many factors that impact ED patient flow. Initial results suggest that for this particular data set used, ED arrival rates were the most useful metric for ED ‘busyness’ in a process control strategy, and that Emergency Department performance may benefit from load balancing efforts. Conclusions: The simulation supports the use of crowdinforming as a potential tool when used in a process control strategy to balance the patient loads between EDs. The work also revealed that the value of several parameters intuitively expected to be meaningful metrics of ED ‘busyness’ was not evident, highlighting the importance of finding parameters meaningful within one’s particular data set. The information provided in the crowdinforming model is already available in a local context at some ED sites. The extension to a wider dissemination of information via an Internet web service accessible by smart phones is readily achievable and not a technological obstacle. Similarly, the system could be extended to help direct patients by including future estimates or predictions in the crowdinformed data. The contribution of the simulation is to allow for effective policy evaluation to better inform the public of ED ‘busyness’ as part of their decision making process in attending an emergency department. In effect, this is a means of providing additional decision support insights garnered from a simulation, prior to a real world implementation.
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A time and motion study of patients presenting at the accident and emergency department at Mater Dei Hospital. BMC Res Notes 2011; 4:421. [PMID: 22008520 PMCID: PMC3212980 DOI: 10.1186/1756-0500-4-421] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 10/18/2011] [Indexed: 11/25/2022] Open
Abstract
Background To carry out a time and motion study of patients presenting at the Emergency Department (ED) by measuring waiting times at the ED dept throughout the day. The objectives were: • to determine whether waiting times are prolonged, and • if prolonged, at which station(s) bottlenecks occur most often in terms of duration and frequency. Results will be compared to the United Kingdom guidelines of stay at the emergency department. Methods A group of 11 medical students monitored all patients who attended ED between 0600 hours on the 25th August and 0600 hours on the 1st September 2008. For each 24 hour period, students were assigned to the triage room and the 3 priority areas where they monitored all patient-related activity, movement and waiting times so that length of stay (LOS) could be recorded. The key data recorded included patient characteristics, waiting times at various ED process stages, tests performed, specialist consultations and follow up until admitted, discharged, or referred to another hospital area. Average waiting times were calculated for each priority area. Bottle-necks and major limiting factors were identified. Results were compared against the United Kingdom benchmarks - i.e. 1 hour until first assessment, and 4 hours before admitting/discharge. Results 1779 patients presented to the ED in the week monitored. As expected, patients in the lesser priority areas (i.e. 2 & 3) waited longer before being assessed by staff. Patients requiring laboratory and imaging investigations had a prolonged length of stay, which varied depending on specific tests ordered. Specialty consultation was associated with longer waiting times. A major bottleneck identified was waiting times for inpatient admission. Conclusions In conclusion, it was found that 30.3% of priority 1 patients, 86.3% of priority 2 patients and 76.8% of priority 3 patients waited more than 1 hour for first assessment. We conclude by proposing several changes that may expedite throughput.
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Nugus P, Holdgate A, Fry M, Forero R, McCarthy S, Braithwaite J. Work pressure and patient flow management in the emergency department: findings from an ethnographic study. Acad Emerg Med 2011; 18:1045-52. [PMID: 21996069 DOI: 10.1111/j.1553-2712.2011.01171.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In this hypothesis-generating study, we observe, identify, and analyze how emergency clinicians seek to manage work pressure to maximize patient flow in an environment characterized by delayed patient admissions (access block) and emergency department (ED) crowding. METHODS An ethnographic approach was used, which involved direct observation of on-the-ground behaviors, when and where they happened. More than 1,600 hours over a 12-month period were spent observing approximately 4,500 interactions across approximately 260 emergency physicians and nurses, emergency clinicians, and clinicians from other hospital departments. The authors content analyzed and thematically analyzed more than 800 pages of field notes to identify indicators of and responses to pressure in the day-to-day ED work environment. RESULTS In response to the inability to control inflow, and the reactions of inpatient departments to whom patients might be transferred, emergency clinicians: reconciled urgency and acuity of conditions; negotiated and determined patients' admission-discharge status early in their trajectories; pursued predetermined but coevolving pathways in response to micro- and macroflow problems; and exercised flexibility to reduce work pressure by managing scarce time and space in the ED. CONCLUSIONS To redress the linearity of most literature on patient flow, this study adopts a systems perspective and ethnographic methods to bring to light the dynamic role that individuals play, interacting with their work contexts, to maintain patient flow. The study provides an empirical foundation, uniquely discernible through qualitative research, about aspects of ED work that previously have been the subject only of discussion or commentary articles. This study provides empirical documentation of the moment-to-moment responses of emergency clinicians to work pressure brought about by factors outside much of their control, establishing the relationship between patient flow and work pressure. We conceptualize the ED as a dynamic system, combining socioprofessional influences to reduce and control work pressure in the ED. Interventions in education, practice, policy, and organizational performance evaluations will be supported by this systematic documentation of the complexity of emergency clinical work. Future research involves testing the five findings using systems dynamic modeling techniques.
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Affiliation(s)
- Peter Nugus
- Centre for Clinical Governance Research in Health, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, Australia.
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Divecha HM, Smith RD, Cairns C, Bayer J. Improving patient flow: The impact of consultant work pattern on trauma ward efficiency. Surgeon 2011; 9:175-8. [DOI: 10.1016/j.surge.2010.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 08/19/2010] [Indexed: 10/19/2022]
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Criado-Álvarez JJ, Mirón Pérez IJ, Montero Rubio JC, Linares C. [Effects of thermic extremes on the contingency plans of health systems]. Med Clin (Barc) 2011; 136:602-3. [PMID: 21145081 DOI: 10.1016/j.medcli.2010.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 05/13/2010] [Indexed: 10/18/2022]
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Hwang U, McCarthy ML, Aronsky D, Asplin B, Crane PW, Craven CK, Epstein SK, Fee C, Handel DA, Pines JM, Rathlev NK, Schafermeyer RW, Zwemer FL, Bernstein SL. Measures of crowding in the emergency department: a systematic review. Acad Emerg Med 2011; 18:527-38. [PMID: 21569171 DOI: 10.1111/j.1553-2712.2011.01054.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Despite consensus regarding the conceptual foundation of crowding, and increasing research on factors and outcomes associated with crowding, there is no criterion standard measure of crowding. The objective was to conduct a systematic review of crowding measures and compare them in conceptual foundation and validity. METHODS This was a systematic, comprehensive review of four medical and health care citation databases to identify studies related to crowding in the emergency department (ED). Publications that "describe the theory, development, implementation, evaluation, or any other aspect of a 'crowding measurement/definition' instrument (qualitative or quantitative)" were included. A "measurement/definition" instrument is anything that assigns a value to the phenomenon of crowding in the ED. Data collected from papers meeting inclusion criteria were: study design, objective, crowding measure, and evidence of validity. All measures were categorized into five measure types (clinician opinion, input factors, throughput factors, output factors, and multidimensional scales). All measures were then indexed to six validation criteria (clinician opinion, ambulance diversion, left without being seen (LWBS), times to care, forecasting or predictions of future crowding, and other). RESULTS There were 2,660 papers identified by databases; 46 of these papers met inclusion criteria, were original research studies, and were abstracted by reviewers. A total of 71 unique crowding measures were identified. The least commonly used type of crowding measure was clinician opinion, and the most commonly used were numerical counts (number or percentage) of patients and process times associated with patient care. Many measures had moderate to good correlation with validation criteria. CONCLUSIONS Time intervals and patient counts are emerging as the most promising tools for measuring flow and nonflow (i.e., crowding), respectively. Standardized definitions of time intervals (flow) and numerical counts (nonflow) will assist with validation of these metrics across multiple sites and clarify which options emerge as the metrics of choice in this "crowded" field of measures.
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Affiliation(s)
- Ula Hwang
- Department of Emergency Medicine, Mount Sinai School of Medicine (UH), New York, NY.
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Martin M, Champion R, Kinsman L, Masman K. Mapping patient flow in a regional Australian emergency department: A model driven approach. Int Emerg Nurs 2011; 19:75-85. [DOI: 10.1016/j.ienj.2010.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 03/23/2010] [Accepted: 03/25/2010] [Indexed: 10/19/2022]
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Zia TS, Mohsen R, Riji HM, Abbas E, Mostafa L. Patient Satisfaction with Care Received from Emergency Department of Ali-Ebne-Abitaleb Hospital, Iran. JOURNAL OF HEALTH MANAGEMENT 2011. [DOI: 10.1177/097206341001300101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: A hospital’s Emergency Department (ED) plays a crucial role in the healthcare delivery system. Its operation has an impact on patients’ general and specific satisfaction. Methodology: Through a survey, a study to determine the satisfaction of patients attending the Ali-Ebne-Abitaleb Hospital (ED) was carried out. Out of 12,000 patients who were referred to the ED, 392 patients and 608 of their relatives were included in the study. The data were analysed by SPSS version 14. Results: The findings showed that 191 (19.1 per cent) of the patients were ‘satisfied with medical care’ while 719 (71.9 per cent) were ‘somewhat satisfied’ and 90 (9 per cent) were ‘unsatisfied’. With regard to nursing care in particular, 265 (26.5 per cent) of the patients were ‘satisfied with nursing care’, while 630 (63 per cent) were ‘somewhat satisfied’ and 105 (10.5 per cent) were ‘unsatisfied’. The chi-square tests showed that a statistical significant relationship existed between patient’s satisfaction with medical and nursing care and the shift work. Conclusion and Recommendations: Paying proper attention to the ED patients’ expectations is highly important to make them satisfied. Therefore, it is suggested that more efforts should be made to improve the quality of services within the ED.
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Affiliation(s)
- Tabatabaei Seyed Zia
- Tabatabaei Seyed Zia (corresponding author) is Phd Candidate, Department of Social Medicine, Faculty of Medicine, Rafsanjan University of Medical Sciences, Iran
| | - Rezaeian Mohsen
- Rezaeian Mohsen is Epidemiologist, Associate Professor, Dean, Faculty of Medicine, Rafsanjan, Iran
| | - Haliza Mohd Riji
- Haliza Mohd Riji is Associate Professor, Medical Anthropologist/Sociologist, Department of Community Health, Faculty of Medicine and Health Sciences, University Putra Malaysia, Malaysia
| | - Esmaeili Abbas
- Esmaeili Abbas is Associate Professor in Environmental Health, Chancellor of Rafsanjan University of Medical Sciences, Iran
| | - Langarizadeh Mostafa
- Langarizadeh Mostafa is PhD Candidate in Medical Informatics, Faculty of Medicine and Health Sciences, University Putra Malaysia, Malaysia
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Abstract
Spain has universal public health care coverage. Emergency care provisions are offered to patients in different modalities and levels according to the characteristics of the medical complaint: at primary care centers (PCC), in an extrahospital setting by emergency medical services (EMS) and at hospital emergency departments (ED). We have more than 3,000 PCCs, which are run by family doctors (general practitioners) and pediatricians. On average, there is 1 PCC for every 15,000 to 20,000 inhabitants, and every family doctor is in charge of 1,500 to 2,000 citizens, although less populated zones tend to have lower ratios. Doctors spend part of their duty time in providing emergency care to their own patients. While not fully devoted to emergency medicine (EM) practice, they do manage minor emergencies. However, Spanish EMSs contribute hugely to guarantee population coverage in all situations. These EMS are run by EM technicians (EMT), nurses and doctors, who usually work exclusively in the emergency arena. EDs dealt with more than 25 million consultations in 2008, which implies, on average, that one out of two Spaniards visited an ED during this time. They are usually equipped with a wide range of diagnostic tools, most including ultrasonography and computerized tomography scans. The academic and training background of doctors working in the ED varies: nearly half lack any structured specialty residence training, but many have done specific master or postgraduate studies within the EM field. The demand for emergency care has grown at an annual rate of over 4% during the last decade. This percentage, which was greater than the 2% population increase during the same period, has outpaced the growth in ED capacity. Therefore, Spanish EDs become overcrowded when the system exerts minimal stress. Despite the high EM caseload and the potential severity of the conditions, training in EM is still unregulated in Spain. However, in April 2009 the Spanish Minister of Health announced the imminent approval of an EM specialty, allowing the first EM resident to officially start in 2011. Spanish emergency physicians look forward to the final approval, which will complete the modernization of emergency health care provision in Spain.
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Affiliation(s)
- Òscar Miró
- Emergency Department, Hospital Clinic, Villarroel 170, 08036 Barcelona, Catalonia Spain
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Chiou SJ, Campbell C, Myers L, Culbertson R, Horswell R. Factors influencing inappropriate use of ED visits among type 2 diabetics in an evidence-based management programme. J Eval Clin Pract 2010; 16:1048-54. [PMID: 20630002 DOI: 10.1111/j.1365-2753.2009.01248.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECT This study analyses inappropriate use of emergency department (ED) services among type 2 diabetics under an evidence-based management programme. METHODS Using 1999-2006 databases of Louisiana Health Care Services Division (HCSD) eight public hospitals ED visits among the uninsured and other patients in Louisiana, we termed urgent ED visits appropriate and less-urgent visits inappropriate. Eliminating weekend ED visits, 17,458 urgent and 22,395 less-urgent visits by 8596 patients were analysed, using generalized estimating equation methods. RESULTS Caucasians were 0.82 times (95% CI: 0.751-0.889) less likely to use the ED inappropriately compared with African Americans. Patients with commercial insurance, Medicaid and Medicare used the ED more inappropriately than uninsured, with odds ratios of 1.28, 1.32 and 1.28, respectively. Patients hospitalized the prior year were 0.84 times (95% CI: 1.08-1.31) less likely for inappropriate. Patients in larger hospitals used the ED more inappropriately, with an odds ratio of 1.44 (95% CI: 1.32-1.56). CONCLUSIONS The study suggests that inappropriate use of the ED among diabetic patients in an evidence-based management programme is more likely to occur among African American, patients with insurance coverage and those seeking care in larger hospitals. Reinforcing the regular use of clinic services for diabetes management, providing clinic access in off-hours, and engaging the health plans in providing incentives for more appropriate use of the ED might reduce inappropriate ED visits. Notably, uninsured patients with diabetes from HCSD were more efficient users of the ED.
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Affiliation(s)
- Shang-Jyh Chiou
- Department of Healthcare Administration, College of Health Science, Asia University, Taichung, Taiwan.
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Abstract
OBJECTIVE The purpose of this study was to evaluate the combined effects of focused system changes on several key measures of emergency department (ED) quality (length of stay, waiting time, rate of leaving without being seen, and patient satisfaction) in a children's hospital ED. METHODS System-wide ED changes were made and implemented during a 6-month period. The combined changes are called "be quick"--BEQK. The components were bedside registration, the Bed-ahead program, electronic medical records and tracking board, quick triage, and Kids Express. Three study periods were evaluated: before BEQK (2005) and the 2 periods after BEQK (2006 and 2007). RESULTS The primary outcome measures, namely wait time, length of stay, and leaving without being seen rates, were all decreased during the 2 post-BEQK periods compared with the pre-BEQK period (2005). The mean waiting time was 46 minutes (95% confidence interval [CI], 39-53 minutes) in 2005 and this decreased to 22 minutes (95% CI, 21-23 minutes) and 14 minutes (95% CI, 13-15 minutes) in 2006 and 2007, respectively. The mean length of stay was 151 minutes (95% CI, 139-163 minutes) in 2005 and this decreased to 136 minutes (95% CI, 135-137 minutes) and 115 minutes (95% CI, 114-116 minutes) in 2006 and 2007, respectively. The rate of leaving without being seen was 2.45% of patient visits per month in 2005 and this decreased to 1.67% in 2006 and to 0.92% in 2007. CONCLUSIONS In our pediatric ED, focused system changes significantly decreased wait time, leaving without being seen, and length of stay and improved patient satisfaction.
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Antolín A, Ambrós A, Mangirón P, Alves D, Sánchez M, Miró O. [Grade of knowledge about the advance directive document by the chronic patient who comes to the emergency department]. Rev Clin Esp 2010; 210:379-88. [PMID: 20674892 DOI: 10.1016/j.rce.2010.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Revised: 01/13/2010] [Accepted: 01/25/2010] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the patient's and their caregiver's knowledge of the advance directive document (ADD) in patients with chronic diseases who come to the emergency department due to decompensation and their caregivers. To discover the patient's willingness and associated factors to draw up an ADD. MATERIAL AND METHODS A descriptive cohort study including patients with an acutely decompensated chronic evolving disease attending the ED medicine section at an urban tertiary teaching hospital was performed. The patients' demographic and clinical variables were recorded. After control of their symptoms, an anonymous structured oral interview was also administered. Dependent variables included were previous knowledge of the ADD, and the patient willingness to draw it up. The relationship among independent and dependent variables was analyzed. RESULTS A total of 380 people (190 patients and 190 carers) were analyzed. Compared with patients, carers were more frequently women (76% vs 42%, p<0.001), younger (58+/-15 vs 73+/-12, p<0.001), and had a better knowledge of the disease (88% vs 74%, p<0.001) and of the ADD (28% vs 16%, p<0.001). Only 5% of the patients had received ADD information from their physician. The only factor associated with the patients' previous knowledge of the ADD was to have completed at least secondary school (p<0.05). Forty-six percent of patients were favorable to the drawing up of an ADD. The only variable associated with such a willingness was to be 70 or younger (p<0.05). Eighty-eight percent of the patients were in favor of the distribution of information leaflets in the ED. CONCLUSIONS There is poor patient and carer knowledge regarding the ADD among patients with chronic diseases. Nonetheless, almost half of patients would be willing to draw up an ADD. EDs can contribute to improve the information about it.
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Affiliation(s)
- A Antolín
- Secció d'Urgencias Medicina, Area d'Urgències, Hospital Clínic, Barcelona, España.
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Baumlin KM, Shapiro JS, Weiner C, Gottlieb B, Chawla N, Richardson LD. Clinical Information System and Process Redesign Improves Emergency Department Efficiency. Jt Comm J Qual Patient Saf 2010; 36:179-85. [DOI: 10.1016/s1553-7250(10)36030-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chiou SJ, Campbell C, Horswell R, Myers L, Culbertson R. Use of the emergency department for less-urgent care among type 2 diabetics under a disease management program. BMC Health Serv Res 2009; 9:223. [PMID: 19968871 PMCID: PMC2795752 DOI: 10.1186/1472-6963-9-223] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Accepted: 12/07/2009] [Indexed: 11/25/2022] Open
Abstract
Background This study analyzed the likelihood of less-urgent emergency department (ED) visits among type 2 diabetic patients receiving care under a diabetes disease management (DM) program offered by the Louisiana State University Health Care Services Division (LSU HCSD). Methods All ED and outpatient clinic visits made by 6,412 type 2 diabetic patients from 1999 to 2006 were extracted from the LSU HCSD Disease Management (DM) Evaluation Database. Patient ED visits were classified as either urgent or less-urgent, and the likelihood of a less-urgent ED visit was compared with outpatient clinic visits using the Generalized Estimating Equation methodology for binary response to time-dependent variables. Results Patients who adhered to regular clinic visit schedules dictated by the DM program were less likely to use the ED for less urgent care with odds ratio of 0.1585. Insured patients had 1.13 to 1.70 greater odds of a less-urgent ED visit than those who were uninsured. Patients with better-managed glycated hemoglobin (A1c or HbA1c) levels were 82 times less likely to use less-urgent ED visits. Furthermore, being older, Caucasian, or a longer participant in the DM program had a modestly lower likelihood of less-urgent ED visits. The patient's Charlson Comorbidity Index (CCI), gender, prior hospitalization, and the admitting facility showed no effect. Conclusion Patients adhering to the DM visit guidelines were less likely to use the ED for less-urgent problems. Maintaining normal A1c levels for their diabetes also has the positive impact to reduce less-urgent ED usages. It suggests that successful DM programs may reduce inappropriate ED use. In contrast to expectations, uninsured patients were less likely to use the ED for less-urgent care. Patients in the DM program with Medicaid coverage were 1.3 times more likely to seek care in the ED for non-emergencies while commercially insured patients were nearly 1.7 times more likely to do so. Further research to understand inappropriate ED use among insured patients is needed. We suggest providing visit reminders, a call centre, or case managers to reduce the likelihood of less-urgent ED visit use among DM patients. By reducing the likelihood of unnecessary ED visits, successful DM programs can improve patient care.
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Affiliation(s)
- Shang-Jyh Chiou
- Department of Health Care Administration, College of Health Science, Asia University, 500, Lioufeng Road, Wufeng, Taichung County 41354, Taiwan.
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Crowding and delivery of healthcare in emergency departments: the European perspective. West J Emerg Med 2009; 10:233-9. [PMID: 20046239 PMCID: PMC2791723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2008] [Revised: 08/14/2009] [Accepted: 09/30/2009] [Indexed: 11/24/2022] Open
Abstract
Emergency department (ED) crowding is a multifactorial problem, resulting in increased ED waiting times, decreased patient satisfaction and deleterious domino effects on the entire hospital. Although difficult to define and once limited to anecdotal evidence, crowding is receiving more attention as attempts are made to quantify the problem objectively. It is a worldwide phenomenon with regional influences, as exemplified when analyzing the problem in Europe compared to that of the United States. In both regions, an aging population, limited hospital resources, staff shortages and delayed ancillary services are key contributors; however, because the structure of healthcare differs from country to country, varying influences affect the issue of crowding. The approach to healthcare delivery as a right of all people, as opposed to a free market commodity, depends on governmental organization and appropriation of funds. Thus, public funding directly influences potential crowding factors, such as number of hospital beds, community care facilities, and staffing. Ultimately ED crowding is a universal problem with distinctly regional root causes; thus, any approach to address the problem must be tailored to regional influences.
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Shortening the Wait: A Strategy to Reduce Waiting Times in the Emergency Department. J Emerg Nurs 2009; 35:509-14. [DOI: 10.1016/j.jen.2009.03.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Revised: 02/13/2009] [Accepted: 03/08/2009] [Indexed: 11/22/2022]
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Chung SH, Hwang JI. Patient characteristics associated with length of stay in emergency departments. HEALTH POLICY AND MANAGEMENT 2009. [DOI: 10.4332/kjhpa.2009.19.3.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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50
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Miró Ò. Regarding the adjustment of roster according to ED census. Am J Emerg Med 2009; 27:362; author reply 363. [DOI: 10.1016/j.ajem.2009.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Accepted: 01/05/2009] [Indexed: 11/29/2022] Open
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