Effect of emergency department fast track on emergency department length of stay: a case-control study

Fast-Track Training in Emergency Department During the COVID-19 Pandemic: Evaluation of a Hybrid Education Model

INTRODUCTION

Emergency department (ED) fast track (FT) for the ambulatory, minor injury patient cohort requires rapid patient assessment, treatment, and turnover, yet specific nursing education is limited. The study aimed to test the feasibility and staff satisfaction of an education program to expand nursing skills and knowledge of managing FT patients during the COVID-19 pandemic.

METHODS

This quasi-experimental study, including self-rating surveys and interviews, assessed the pre- and postimplementation of an education program for nurses working in FT in a metropolitan hospital ED in Australia. Hybrid (face-to-face and Teams) education sessions on 10 topics of staff-perceived limited knowledge were delivered over 8 months.

RESULTS

Participants demonstrated higher knowledge scores after the implementation of short online education sessions to cover the core facets of minor injury management. Overall staff satisfaction with the program was high. Interview discussions involved three key themes, including "benefits to staff learning," "positive impact on patient care and flow," and "preferred mode of delivery."

CONCLUSIIONS

Recorded education sessions on minor injury topics for nurses working in FT have proved effective, and this program has now become a core facet of ED education in our hospital.

Which low urgent triaged febrile children are suitable for a fast track? An observational European study

BACKGROUND

The number of paediatric patients visiting the ED with non-urgent problems is increasing, leading to poor patient flow and ED crowding. Fast track aims to improve the efficiency of evaluation and discharge of low acuity patients. We aimed to identify which febrile children are suitable for a fast track based on presenting symptoms and management.

METHODS

This study is part of the Management and Outcome of Fever in children in Europe study, which is an observational study including routine data of febrile children <18 years attending 12 European EDs. We included febrile, low urgent children (those assigned a triage acuity of either 'standard' or 'non-urgent' using the Manchester Triage System) and defined children as suitable for fast track when they have minimal resource use and are discharged home. Presenting symptoms consisted of neurological (n=237), respiratory (n=8476), gastrointestinal (n=1953) and others (n=3473, reference group). Multivariable logistic regression analyses regarding presenting symptoms and management (laboratory blood testing, imaging and admission) were performed with adjustment for covariates: patient characteristics, referral status, previous medical care, previous antibiotic use, visiting hours and ED setting.

RESULTS

We included 14 139 children with a median age of 2.7 years (IQR 1.3-5.2). The majority had respiratory symptoms (60%), viral infections (50%) and consisted of self-referrals (69%). The neurological group received imaging more often (adjusted OR (aOR) 1.8, 95% CI 1.1 to 2.9) and were admitted more frequently (aOR 1.9, 95% CI 1.4 to 2.7). The respiratory group had fewer laboratory blood tests performed (aOR 0.6, 95% CI 0.5 to 0.7), were less frequently admitted (aOR 0.6, 95% CI 0.5 to 0.7), but received imaging more often (aOR 1.8, 95% CI 1.6 to 2.0). Lastly, the gastrointestinal group had more laboratory blood tests performed (aOR 1.2. 95% CI 1.1 to 1.4) and were admitted more frequently (aOR 1.4, 95% CI 1.2 to 1.6).

CONCLUSION

We determined that febrile children triaged as low urgent with respiratory symptoms were most suitable for a fast track. This study provides evidence for which children could be triaged to a fast track, potentially improving overall patient flow at the ED.

Operations Factors Associated with Emergency Department Length of Stay: Analysis of a National Operations Database

Introduction: Prolonged emergency department (ED) length of stay (LOS) has been shown to adversely affect patient care. We sought to determine factors associated with ED LOS via analysis of a large, national, ED operations database. Methods: We performed retrospective, multivariable, linear regression modeling using the 2019 Emergency Department Benchmarking Alliance survey results to identify associated factors of ED LOS for admitted and discharged patients. Results: A total of 1,052 general and adult-only EDs responded to the survey. Median annual volume was 40,946. The median admit and discharge LOS were 289 minutes and 147 minutes, respectively. R-squared values for the admit and discharge models were 0.63 and 0.56 with out-of-sample R-squared values of 0.54 and 0.59, respectively. Both admit and discharge LOS were associated with academic designation, trauma level designation, annual volume, proportion of ED arrivals occurring via emergency medical services, median boarding, and use of a fast track. Additionally, admit LOS was associated with transfer-out percentage, and discharge LOS was associated with percentage of high Current Procedural Terminology, percentage of patients <18 years old, use of radiographs and computed tomography, and use of an intake physician. Conclusion: Models derived from a large, nationally representative cohort identified diverse associated factors of ED length of stay, several of which were not previously reported. Dominant within the LOS modeling were patient population characteristics and other factors extrinsic to ED operations, including boarding of admitted patients, which was associated with both admitted and discharged LOS. The results of the modeling have significant implications for ED process improvement and appropriate benchmarking.

Implementation of Vertical Split Flow Model for Patient Throughput at a Community Hospital Emergency Department

BACKGROUND

Hospitals have implemented innovative strategies to address overcrowding by optimizing patient flow through the emergency department (ED). Vertical split flow refers to the concept of assigning patients to vertical chairs instead of horizontal beds based on patient acuity.

OBJECTIVE

Evaluate the impact of vertical split flow implementation on ED Emergency Severity Index (ESI) level 3, patient length of stay, and throughput at a community hospital.

METHODS

Retrospective cohort study of all ESI level 3 patients presenting to a community hospital ED over a 3-month period prior to and after vertical split flow implementation between 2018 and 2019.

RESULTS

In total, data were collected from 10,638 patient visits: 5262 and 5376 patient visits pre- and postintervention, respectively. There was a significant reduction in mean overall length of stay when ESI-3 patients were triaged with vertical split flow (251 min vs 283 min, p < 0.001).

CONCLUSIONS

Community hospital ED implementation of vertical split flow for ESI level 3 patients was associated with a significant reduction in overall length of stay and improved throughput. This model provides a solution to increase the number of patients that can be simultaneously cared for in the ED without increasing staffing or physical space.

Quality Improvement: Implementing Nurse Standard Work in Emergency Department Fast-Track Area to Reduce Patient Length of Stay

Introduction

The average length of stay of a fast-track area of a large urban hospital was excessively long, which affected the patient experience and the rate at which patients left without being seen. One approach to reducing average length of stay is to create nurse standard work. Nurse standard work was a defined set of process and procedures that reduce variability within a nurse’s workflow.

Methods

Nurse standard work was created by a team of nurses assisted by management engineering using lean methodology and A3 problem solving. Data were gathered about average length of stay and left without being seen for patients in the emergency department fast-track area of an urban emergency department from October 2018 to June 2020. This period includes 5 months before the intervention start, 4 months during nurse standard work implementation, 9 months using nurse standard work before the unit was repurposed during COVID-19, and 3 months during COVID-19.

Results

Nurse standard work helped reduce average length of stay in the emergency department fast-track area from 205 minutes before project initiation to 150.4 minutes in the 7 months after implementing nurse standard work. The time spent walking for supplies was reduced from 422 and 272 seconds before nurse standard work to 25 and 30 seconds for the nurse technician and nurse, respectively, after nurse standard work. Left without being seen was decreased from 4.7% in October of 2018 to 0.7% by March of 2020.

Discussion

Nurse standard work reduced the amount of time that nurses spent performing support tasks and reduced delays in providing patient care, which then allowed more time for nurses to interact directly with patients. Nurse standard work provides a clear task sequence that eliminates delays in treating patients, but it also allows for fast identification of delays that do occur and simplifies problem solving to eliminate reoccurrence of delays. Therefore, nurse standard work is an essential component of efforts to reduce patient average length of stay in health care processes and reduce left without being seen to the national standard of less than 2%.

Machine learning-based triage to identify low-severity patients with a short discharge length of stay in emergency department

BACKGROUND

Overcrowding in emergency departments (ED) is a critical problem worldwide, and streaming can alleviate crowding to improve patient flows. Among triage scales, patients labeled as "triage level 3" or "urgent" generally comprise the majority, but there is no uniform criterion for classifying low-severity patients in this diverse population. Our aim is to establish a machine learning model for prediction of low-severity patients with short discharge length of stay (DLOS) in ED.

METHODS

This was a retrospective study in the ED of China Medical University Hospital (CMUH) and Asia University Hospital (AUH) in Taiwan. Adult patients (aged over 20 years) with Taiwan Triage Acuity Scale level 3 were enrolled between 2018 and 2019. We used available information during triage to establish a machine learning model that can predict low-severity patients with short DLOS. To achieve this goal, we trained five models-CatBoost, XGBoost, decision tree, random forest, and logistic regression-by using large ED visit data and examined their performance in internal and external validation.

RESULTS

For internal validation in CMUH, 33,986 patients (75.9%) had a short DLOS (shorter than 4 h), and for external validation in AUH, there were 13,269 (82.7%) patients with short DLOS. The best prediction model was CatBoost in internal validation, and area under the receiver operating cha racteristic curve (AUC) was 0.755 (95% confidence interval (CI): 0.743-0.767). Under the same threshold, XGBoost yielded the best performance, with an AUC value of 0.761 (95% CI: 0.742- 0.765) in external validation.

CONCLUSIONS

This is the first study to establish a machine learning model by applying triage information alone for prediction of short DLOS in ED with both internal and external validation. In future work, the models could be developed as an assisting tool in real-time triage to identify low-severity patients as fast track candidates.

Queueing Problems in Emergency Departments: A Review of Practical Approaches and Research Methodologies

Problems related to patient scheduling and queueing in emergency departments are gaining increasing attention in theory, in the fields of operations research and emergency and healthcare services, and in practice. This paper aims to provide an extensive review of studies addressing queueing-related problems explicitly related to emergency departments. We have reviewed 229 articles and books spanning seven decades and have sought to organize the information they contain in a manner that is accessible and useful to researchers seeking to gain knowledge on specific aspects of such problems. We begin by presenting a historical overview of applications of queueing theory to healthcare-related problems. We subsequently elaborate on managerial approaches used to enhance efficiency in emergency departments. These approaches include bed management, fast-track, dynamic resource allocation, grouping/prioritization of patients, and triage approaches. Finally, we discuss scientific methodologies used to analyze and optimize these approaches: algorithms, priority models, queueing models, simulation, and statistical approaches.

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

OBJECTIVE

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

DESIGN

Prospective, observational, clinical study.

SETTING

Emergency department of an urban, tertiary referral veterinary hospital.

ANIMALS

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

MEASUREMENT AND MAIN RESULTS

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

CONCLUSIONS

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

Interventions and strategies involving primary healthcare professionals to manage emergency department overcrowding: a scoping review

OBJECTIVES

To conduct a scoping review to identify and summarise the existing literature on interventions involving primary healthcare professionals to manage emergency department (ED) overcrowding.

DESIGN

A scoping review.

DATA SOURCES

A comprehensive database search of Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) databases was conducted (inception until January 2020) using peer-reviewed search strategies, complemented by a search of grey literature sources.

ELIGIBILITY CRITERIA

Interventions and strategies involving primary healthcare professionals (PHCPs: general practitioners (GPs), nurse practitioners (NPs) or nurses with expanded role) to manage ED overcrowding.

METHODS

We engaged and collaborated, with 13 patient partners during the design and conduct stages of this review. We conducted this review using the JBI guidelines. Two reviewers independently selected studies and extracted data. We conducted descriptive analysis of the included studies (frequencies and percentages).

RESULTS

From 23 947 records identified, we included 268 studies published between 1981 and 2020. The majority (58%) of studies were conducted in North America and were predominantly cohort studies (42%). The reported interventions were either 'within ED' (48%) interventions (eg, PHCP-led ED triage or fast track) or 'outside ED' interventions (52%) (eg, after-hours GP clinic and GP cooperatives). PHCPs involved in the interventions were: GP (32%), NP (26%), nurses with expanded role (16%) and combinations of the PHCPs (42%). The 'within ED' and 'outside ED' interventions reported outcomes on patient flow and ED utilisation, respectively.

CONCLUSIONS

We identified many interventions involving PHCPs that predominantly reported a positive impact on ED utilisation/patient flow metrics. Future research needs to focus on conducting well-designed randomized controlled trials (RCTs) and systematic reviews to evaluate the effectiveness of specific interventions involving PHCPs to critically appraise and summarise evidence on this topic.

A rapid clinic-based service for an emergency department of a tertiary teaching hospital during a dengue outbreak

The 2015 dengue outbreak in southern Taiwan turned into a public health emergency, resulting in a large-scale mobilization of personnel from the emergency department (ED) services operating in and near full capacity to assist with the outbreak. This study aimed to assess a rapid independent clinic-based service (RCS), which was set up and designed to relieve the overcrowding of the regular ambulatory and emergency services during an epidemic of dengue.This is a retrospective cross-sectional study.National Cheng Kung University Hospital, Tainan, Taiwan.Patients with positive test results were enrolled and reviewed to evaluate the efficacy of RCS implementation between August and October 2015. The case-treatment rates stratified by length of stay (LOS) were used to examine the performance of the RCS that was set up outside the ED and designed to relieve the overcrowding of the regular ambulatory and emergency services.Patients with dengue-like illnesses may arrive at the hospital and require optimal ED triage and management thereafter. Although the outbreak resulted in a shortage of spare space in the ED, a proper response from the hospital administration would ameliorate the work overload of the staff and would not decrease the quality of care for critical patients.An early and restrictive intensive intervention was beneficial to health care facilities during a dengue outbreak. Further planning and training of the RCS could be crucial for hospital preparedness for infectious disease outbreaks.

Quantifying Dynamic Flow of Emergency Department (ED) Patient Managements: A Multistate Model Approach

Background

Emergency department (ED) crowding and prolonged lengths of stay continue to be important medical issues. It is difficult to apply traditional methods to analyze multiple streams of the ED patient management process simultaneously. The aim of this study was to develop a statistical model to delineate the dynamic patient flow within the ED and to analyze the effects of relevant factors on different patient movement rates.

Methods

This study used a retrospective cohort available with electronic medical data. Important time points and relevant covariates of all patients between January and December 2013 were collected. A new five-state Markov model was constructed by an expert panel, including three intermediate states: triage, physician management, and observation room and two final states: admission and discharge. A day was further divided into four six-hour periods to evaluate dynamics of patient movement over time.

Results

A total of 149,468 patient records were analyzed with a median total length of stay being 2.12 (interquartile range = 6.51) hours. The patient movement rates between states were estimated, and the effects of the age group and triage level on these movements were also measured. Patients with lower acuity go home more quickly (relative rate (RR): 1.891, 95% CI: 1.881–1.900) but have to wait longer for physicians (RR: 0.962, 95% CI: 0.956–0.967) and admission beds (RR: 0.673, 95% CI: 0.666–0.679). While older patients were seen more quickly by physicians (RR: 1.134, 95% CI: 1.131–1.139), they spent more time waiting for the final state (for admission RR: 0.830, 95% CI: 0.821–0.839; for discharge RR: 0.773, 95% CI: 0.769–0.776). Comparing the differences in patient movement rates over a 24-hour day revealed that patients wait longer before seen by physicians during the evening and that they usually move from the ED to admission afternoon. Predictive dynamic illustrations show that six hours after the patients' entry, the probability of still in the ED system ranges from 28% in the evening to 38% in the morning.

Conclusions

The five-state model well described the dynamic ED patient flow and analyzed the effects of relevant influential factors at different states. The model can be used in similar medical settings or incorporate different important covariates to develop individually tailored approaches for the improvement of efficiency within the health professions.

Implementation and validation of a new method to model voluntary departures from emergency departments. Running Title: Modeling Voluntary departures from emergency departments

In the literature, several organizational solutions have been proposed for determining the probability of voluntary patient discharge from the emergency department. Here, the issue of self-discharge is analyzed by Markov theory-based modeling, an innovative approach diffusely applied in the healthcare field in recent years. The aim of this work is to propose a new method for calculating the rate of voluntary discharge by defining a generic model to describe the process of first aid using a "behavioral" Markov chain model, a new approach that takes into account the satisfaction of the patient. The proposed model is then implemented in MATLAB and validated with a real case study from the hospital "A. Cardarelli" of Naples. It is found that most of the risk of self-discharge occurs during the wait time before the patient is seen and during the wait time for the final report; usually, once the analysis is requested, the patient, although not very satisfied, is willing to wait longer for the results. The model allows the description of the first aid process from the perspective of the patient. The presented model is generic and can be adapted to each hospital facility by changing only the transition probabilities between states.

Does Telemedicine Reduce Emergency Room Congestion? Evidence from New York State

Overcrowding in emergency rooms (ERs) is a common yet nagging problem. It not only is costly for hospitals but also compromises care quality and patient experience. Our paper provides solid evidence that telemedicine can significantly improve ER care delivery, especially in the presence of demand and supply fluctuations. We believe such findings are critical for ERs, due to the special setting of unscheduled arrivals leading to high unpredictability of patient traffic. Additional evidence suggests that the efficiency gained from telemedicine does not come at the expense of lower care quality or higher medical expenditure, which points to telemedicine as a feasible solution to the ER overcrowding problem. For healthcare practitioners, our paper highlights the general applicability of telemedicine through the “hub and spoke” architecture. Besides increasing patients’ access to more immediate care from specialists who were not available otherwise, telemedicine enables flexible resource allocation for any hospitals, regardless of where hospitals are located. Our research also provides ground for policymakers to incentivize hospitals to adopt telemedicine in ER, which we believe is critical given the relatively low adoption rate, the lack of direct evidence on its effectiveness, and the current inflexibility of reimbursement policies regarding the application of ER telemedicine.

Is the fast-track process efficient and safe for older adults admitted to the emergency department?

BACKGROUND

The efficiency of the fast-track (FT) process in the management of patients in Emergency Departments is well demonstrated, but there is a lack of research focused on older adults. The aim of our study was to verify whether the FT process is efficient and safe for older adults admitted to ED.

METHODS

Observational case-control single-centre study.

RESULTS

Five hundred four cases and 504 controls were analysed. The mean age was 75 years, and there was a predominance of women. In total 96% of subjects were classified with a "less-urgent" tag. The length of stay was significantly lower in the fast-track group than in the control group (median 178 min, interquartile range 184 min, and 115 min, interquartile range 69 min, respectively, p < 0.001), as well as the time spent between the ED physician's visit and patient discharge (median 78 min, interquartile range 120 min, and median 3 min, interquartile range 6 min, respectively, p < 0.001). There weren't any increases in the number of unplanned readmissions within 48 h, 7 days and 30 days.

CONCLUSIONS

The fast-track appears to be an efficient and safe strategy to improve the management of older adults admitted to the ED with minor complaints.

Adjusting Daily Inpatient Bed Allocation to Smooth Emergency Department Occupancy Variation

Study Objective: Overcrowding in emergency departments (ED) is an increasingly common problem in Taiwanese hospitals, and strategies to improve efficiency are in demand. We propose a bed resource allocation strategy to overcome the overcrowding problem. Method: We investigated ED occupancy using discrete-event simulation and evaluated the effects of suppressing day-to-day variations in ED occupancy by adjusting the number of empty beds per day. Administrative data recorded at the ED of Taichung Veterans General Hospital (TCVGH) in Taiwan with 1500 beds and an annual ED volume of 66,000 visits were analyzed. Key indices of ED quality in the analysis were the length of stay and the time in waiting for outward transfers to in-patient beds. The model is able to analyze and compare several scenarios for finding a feasible allocation strategy. Results: We compared several scenarios, and the results showed that by reducing the allocated beds for the ED by 20% on weekdays, the variance of daily ED occupancy was reduced by 36.25% (i.e., the percentage of reduction in standard deviation). Conclusions: This new allocation strategy was able to both reduce the average ED occupancy and maintain the ED quality indices.

The Influence of Visibility on Medical Teamwork in Emergency Departments: A Mixed-Methods Study

AIM

This mixed-methods study delivers empirical evidence on the influence of visibility on healthcare teamwork in Emergency Departments (EDs). This study researchers hypothesized that with changes of visibility in EDs, teamwork among medical staff members will be impacted.

BACKGROUND

Prior research results suggest that visibility can influence health-setting efficacy. Teamwork is one of the components of each healthcare system that can be supported by environmental design.

METHOD

Visibility in four subject sites from the same healthcare system was objectively measured by morphology plan analyses. Teamwork among medical staff members was the behavioral variable of interest and explored through field observations, interviews, and surveys.

RESULTS

The qualitative outcomes demonstrated that teamwork can be enhanced by improved visibility, while the quantitative findings supported the idea that some specific measures of visibility were correlated with teamwork.

CONCLUSION

This study provides a model for future research on the association between healthcare staff behavior and ED plan configuration. The enhancement of ED design, considering the significance of visibility, enhances the perceptions of nurses and physicians in terms of teamwork.

Prediction of emergency department patient disposition decision for proactive resource allocation for admission

We investigate the capability of information from electronic health records of an emergency department (ED) to predict patient disposition decisions for reducing "boarding" delays through the proactive initiation of admission processes (e.g., inpatient bed requests, transport, etc.). We model the process of ED disposition decision prediction as a hierarchical multiclass classification while dealing with the progressive accrual of clinical information throughout the ED caregiving process. Multinomial logistic regression as well as machine learning models are built for carrying out the predictions. Utilizing results from just the first set of ED laboratory tests along with other prior information gathered for each patient (2.5 h ahead of the actual disposition decision on average), our model predicts disposition decisions with positive predictive values of 55.4%, 45.1%, 56.9%, and 47.5%, while controlling false positive rates (1.4%, 1.0%, 4.3%, and 1.4%), with AUC values of 0.97, 0.95, 0.89, and 0.84 for the four admission (minor) classes, i.e., intensive care unit (3.6% of the testing samples), telemetry unit (2.2%), general practice unit (11.9%), and observation unit (6.6%) classes, respectively. Moreover, patients destined to intensive care unit present a more drastic increment in prediction quality at triage than others. Disposition decision classification models can provide more actionable information than a binary admission vs. discharge prediction model for the proactive initiation of admission processes for ED patients. Observing the distinct trajectories of information accrual and prediction quality evolvement for ED patients destined to different types of units, proactive coordination strategies should be tailored accordingly for each destination unit.

Emergency department visits by patients with an internal medicine specialist: understanding the role of specialists in reducing ED crowding

As emergency department (ED) crowding continues to worsen, many visits are at academic referral hospitals. As a result, engaging specialty services will be essential to decompressing the ED. To do this, it will be important to understand which specialties to focus interventions on for the greatest impact. To characterize the ED utilization of non-surgical adult patients with an ambulatory specialist who were seen and discharged from the ED. Retrospective cohort study of all consecutive patients currently under the care from a specialist presenting to an urban, university affiliated hospital between 01 January 2015 and 31 December 2016. The identification of ED visits attributable to specialists was based on the primary diagnosis of ED visits and the frequency of visit with specialists within a given timeframe. Only patients who were discharged directly from the ED were included in the analysis. There were 29,853 ED visits by patients currently under the care of a specialist during the study period. 17.76% of these visits were related to the medical specialty of the specialist. Of these visits, 41.73% occurred during office hours, and 24.81% occurred during weekends. The specialties with the largest proportion of ED visits related to their specialty was cardiology, gastroenterology, and pulmonary, respectively. Nearly 18% of all patients that have a specialist and are treated and discharged from the ED present with a diagnosis related to their specialist's practice. This may indicate that there is a role for specialty service to play in decreasing some ED utilization that may be appropriate for the out-patient clinical setting. By focusing attention on specific specialties and interventions targeted during office hours, there may be an opportunity to decrease ED utilization.

Interprofessional teamwork versus fast track streaming in an emergency department-An observational cohort study of two strategies for enhancing the throughput of orthopedic patients presenting limb injuries or back pain

Objective

To compare two strategies, interprofessional teams versus fast track streaming, for orthopedic patients with limb injuries or back pain, the most frequent orthopedic complaints in an emergency department.

Methods

An observational before-and-after study at an adult emergency department from May 2012 to Nov 2015. Patients who arrived on weekdays from 8 am to 9 pm and presented limb injury or back pain during one year of each process were included, so that 11,573 orthopedic presentations were included in the fast track period and 10,978 in the teamwork period. Similarly, another 11,020 and 10,760 arrivals presenting the six most frequent non-orthopedic complaints were included in the respective periods, altogether 44,331 arrivals. The outcome measures were the time to physician (TTP) and length of stay (LOS). The LOS was adjusted for predictors, including imaging times, by using linear regression analysis.

Results

The overall median TTP was shorter in the teamwork period, 76.3 min versus 121.0 min in the fast track period (-44.7 min, 95% confidence interval (CI): -47.3 to -42.6). The crude median LOS for orthopedic presentations was also shorter in the teamwork period, 217.0 min versus 230.0 min (-13.0 min, 95% CI: -18.0 to -8.0), and the adjusted LOS was 22.8 min shorter (95% CI: -26.9 to -18.7). For non-orthopedic presentations, the crude median LOS did not differ significantly between the periods (2.0 min, 95% CI: -3.0 to 7.0). However, the adjusted LOS was shorter in the teamwork period (-20.1 min, 95% CI: -24.6 to -15.7).

Conclusions

The median TTP and LOS for orthopedic presentations were shorter in the teamwork period. For non-orthopedic presentations, the TTP and adjusted LOS were also shorter in the teamwork period. Therefore, interprofessional teamwork may be an alternative approach to improve the patient flow in emergency departments.

Impact of the implementation of a fast-track on emergency department length of stay and quality of care indicators in the Champagne-Ardenne region: a before-after study

OBJECTIVES

We aimed to evaluate the effect of the implementation of a fast-track on emergency department (ED) length of stay (LOS) and quality of care indicators.

DESIGN

Adjusted before-after analysis.

SETTING

A large hospital in the Champagne-Ardenne region, France.

PARTICIPANTS

Patients admitted to the ED between 13 January 2015 and 13 January 2017.

INTERVENTION

Implementation of a fast-track for patients with small injuries or benign medical conditions (13 January 2016).

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of patients with LOS ≥4 hours and proportion of access block situations (when patients cannot access an appropriate hospital bed within 8 hours). 7-day readmissions and 30-day readmissions.

RESULTS

The ED of the intervention hospital registered 53 768 stays in 2016 and 57 965 in 2017 (+7.8%). In the intervention hospital, the median LOS was 215 min before the intervention and 186 min after the intervention. The exponentiated before-after estimator for ED LOS ≥4 hours was 0.79; 95% CI 0.77 to 0.81. The exponentiated before-after estimator for access block was 1.19; 95% CI 1.13 to 1.25. There was an increase in the proportion of 30 day readmissions in the intervention hospital (from 11.4% to 12.3%). After the intervention, the proportion of patients leaving without being seen by a physician decreased from 10.0% to 5.4%.

CONCLUSIONS

The implementation of a fast-track was associated with a decrease in stays lasting ≥4 hours without a decrease in access block. Further studies are needed to evaluate the causes of variability in ED LOS and their connections to quality of care indicators.

Comparison of emergency physiotherapy practitioner prescribers versus existing emergency department prescribers for musculoskeletal injuries

OBJECTIVE

The scope of selected emergency physiotherapy practitioners (EPP) in this Australian non-tertiary ED has recently extended to include the prescription of a limited drug formulary, including paracetamol, some NSAIDs and opioids, an anti-emetic, a benzodiazepine and nitrous oxide. Although there are large-scale studies investigating prescription errors made by doctors, there is a lack of data on prescribing practices of physiotherapists in the ED setting. The aim of present study is to compare the prescribing practices of EPP to their medical and nursing colleagues within the setting of treating musculoskeletal injuries in the ED.

METHODS

One hundred retrospective National Inpatient Medication Chart (NIMC) audits of adult patients presenting primarily with musculoskeletal complaints were undertaken using the standardised NIMC audit tool, with patient demographics, and NIMC audit results compared between groups.

RESULTS

Fifty medication charts were audited for each group, with a total of 212 drug orders. EPP demonstrated higher completion rates for patient identification, patient weight and medication history compared to medical and nursing staff. Legibility of drug names and route of administration appeared equivalent, whereas EPP had higher completion rates for legible drug doses and signatures compared to medical and nursing staff.

CONCLUSION

In the management of ED patients with musculoskeletal complaints, prescription-trained EPP appear to perform similarly if not better than their medical and nursing colleagues with regards to NIMC audit tool results.

Reliability and validity of emergency department triage tools in low- and middle-income countries: a systematic review

OBJECTIVE

Despite the universal acknowledgment that triage is necessary to prioritize emergency care, there is no review that provides an overview of triage tools evaluated and utilized in resource-poor settings, such as low- and middle-income countries (LMICs). We seek to quantify and evaluate studies evaluating triage tools in LMICs.

METHODS

We performed a systematic review of the literature between 2000 and 2015 to identify studies that evaluated the reliability and validity of triage tools for adult emergency care in LMICs. Studies were then evaluated for the overall quality of evidence using the GRADE criteria.

RESULTS

Eighteen studies were included in the review, evaluating six triage tools. Three of the 18 studies were in low-income countries and none were in rural hospitals. Two of the six tools had evaluations of reliability. Each tool positively predicted clinical outcomes, although the variety in resource environments limited ability to compare the predictive nature of any one tool. The South African Triage Scale had the highest quality of evidence. In comparison with high-income countries, the review showed fewer studies evaluating reliability and presented a higher number of studies with small sample sizes that decreased the overall quality of evidence.

CONCLUSION

The quality of evidence supporting any single triage tool's validity and reliability in LMICs is moderate at best. Research on triage tool applicability in low-resource environments must be targeted to the actual clinical environment where the tool will be utilized, and must include low-income countries and rural, primary care settings.

The French Emergency National Survey: A description of emergency departments and patients in France

INTRODUCTION

Some major changes have occurred in emergency department (ED) organization since the early 2000s, such as the establishment of triage nurses and short-track systems. The objectives of this study were to describe the characteristics of French EDs organization and users, based on a nationwide cross-sectional survey.

METHODS

The French Emergency Survey was a nationwide cross-sectional survey. All patients presenting to all EDs during a 24-hr period of June 2013 were included. Data collection concerned ED characteristics as well as patient characteristics.

RESULTS

Among the 736 EDs in France, 734 were surveyed. Triage nurses and short-track systems were respectively implemented in 73% and 41% of general EDs. The median proportion of patients aged > 75 years was 14% and median hospitalisation rate was 20%. During the study period, 48,711 patients presented to one of the 734 EDs surveyed. Among them, 7% reported having no supplementary health or universal coverage (for people with lower incomes). Overall, 50% of adult patients had been seen by the triage nurse in less than 5 minutes, 74% had a time to first medical contact shorter than one hour and 55% had an ED length of stay shorter than 3 hours.

CONCLUSION

The French Emergency Survey is the first study to provide data on almost all EDs in France. It underlines how ED organization has been redesigned to face the increase in the annual census. French EDs appear to have a particular role for vulnerable people: age-related vulnerability and socio-economic vulnerability with an over-representation of patients without complementary health coverage.

Adjusting patients streaming initiated by a wait time threshold in emergency department for minimizing opportunity cost

Purpose Two different systems for streaming patients were considered to improve efficiency measures such as waiting times (WTs) and length of stay (LOS) for a current emergency department (ED). A typical fast track area (FTA) and a fast track with a wait time threshold (FTW) were designed and compared effectiveness measures from the perspective of total opportunity cost of all patients' WTs in the ED. The paper aims to discuss these issues. Design/methodology/approach This retrospective case study used computerized ED patient arrival to discharge time logs (between July 1, 2009 and June 30, 2010) to build computer simulation models for the FTA and fast track with wait time threshold systems. Various wait time thresholds were applied to stream different acuity-level patients. National average wait time for each acuity level was considered as a threshold to stream patients. Findings The fast track with a wait time threshold (FTW) showed a statistically significant shorter total wait time than the current system or a typical FTA system. The patient streaming management would improve the service quality of the ED as well as patients' opportunity costs by reducing the total LOS in the ED. Research limitations/implications The results of this study were based on computer simulation models with some assumptions such as no transfer times between processes, an arrival distribution of patients, and no deviation of flow pattern. Practical implications When the streaming of patient flow can be managed based on the wait time before being seen by a physician, it is possible for patients to see a physician within a tolerable wait time, which would result in less crowded in the ED. Originality/value A new streaming scheme of patients' flow may improve the performance of fast track system.

Why do 'fast track' patients stay more than four hours in the emergency department? An investigation of factors that predict length of stay

OBJECTIVE

Low-acuity 'fast track' patients represent a large portion of Australian EDs' workload and must be managed efficiently to meet the National Emergency Access Target. The current study determined the relative importance and estimated marginal effects of patient and system-related variables in predicting ED fast track patients who stayed longer than 4 h in the ED.

METHODS

Data for ED presentations between 1 July 2014 and 30 June 2015 were collected from a large regional Australian public hospital. Only 'fast track' patients were included in the analysis. A gradient boosting machine was used to predict which patients would have an ED length of stay greater or less than 4 h. The performance of the final model was tested using a validation data set that was withheld from the initial analysis. A total of 27 variables were analysed.

RESULTS

The model's performance was very good (area under receiver operating characteristic curve 0.89, where 1.0 is perfect prediction). The five most important variables for predicting length of stay were time-dependent and system-related (not patient-related); these were the amount of time taken from when the patient arrived at the ED to: (i) order imaging; (ii) order pathology; (iii) request admission to hospital; (iv) allocate a clinician to care for the patient; and (v) handover a patient between ED clinicians.

CONCLUSIONS

We identified the most important variables for predicting length of stay greater than 4 h for fast track patients in our ED. Identifying factors that influence length of stay is a necessary step towards understanding ED patient flow and identifying improvement opportunities.

Holiday Fast-Track Reduced Medical Cost and Length of Emergency Department Stay: Preliminary Report from a Single Secondary Care Hospital

Introduction

The aims of this study were to compare the effect of a Holiday Fast-Track (HFT) unit on medical costs and emergency department (ED) length of stay (LOS) associated with low acuity patients attended during the same timeframe in two consecutive years in a single secondary care hospital ED.

Methods

Two groups (non-HFT vs. HFT), before and after the fast-track unit was implemented, were compared. The HFT unit was operated to improve the flow of low acuity patients, which were defined as the patients classified as level 4 or 5 by the modified Canadian Triage and Acuity Scale. Data were collected from March 1 to April 30, 2011 for the non-HFT group and during the same period in 2012 for the HFT group.

Results

A total of 894 (431 for non-HFT period and 463 for HFT period) patients of acuity level 4 or 5 visited the ED during the study period. Compared to the non-HFT group, the ED LOS of the HFT group decreased by 27 min and 3.5 min in the patients with acuity levels 4 and 5, respectively (p=0.005 and p=0.003, respectively). Furthermore, total medical costs and laboratory fees were also reduced significantly in the HFT group (p<0.001, p=0.038). However, there was no difference in the other variables between those two groups.

Conclusions

The HFT system decreases the medical costs and LOS in low acuity patients visiting the ED of a secondary care hospital. (Hong Kong j.emerg.med. 2015;22:84-92)

The Impact of Visibility on Teamwork, Collaborative Communication, and Security in Emergency Departments: An Exploratory Study

The aim of this study was to examine the influence of visibility on teamwork, collaborative communication, and security issues in emergency departments (EDs). This research explored whether with high visibility in EDs, teamwork and collaborative communication can be improved while the security issues will be reduced. Visibility has been regarded as a critical design consideration and can be directly and considerably impacted by ED's physical design. Teamwork is one of the major related operational outcomes of visibility and involves nurses, support staff, and physicians. The collaborative communication in an ED is another important factor in the process of care delivery and affects efficiency and safety. Furthermore, security is a behavioral factor in ED designs, which includes all types of safety including staff safety, patient safety, and the safety of visitors and family members. This qualitative study investigated the impact of visibility on teamwork, collaborative communication, and security issues in the ED. One-on-one interviews and on-site observation sessions were conducted in a community hospital. Corresponding data analysis was implemented by using computer plan analysis, observation and interview content, and theme analyses. The findings of this exploratory study provided a framework to identify visibility as an influential factor in ED design. High levels of visibility impact productivity and efficiency of teamwork and communication and improve the chance of lowering security issues. The findings of this study also contribute to the general body of knowledge about the effect of physical design on teamwork, collaborative communication, and security.

Comparison of Emergency Department Wait Times in Adults with Sickle Cell Disease Versus Other Painful Etiologies

Sickle cell disease is characterized by intermittent painful crises often requiring treatment in the emergency department (ED). Past examinations of time-to-provider (TTP) in the ED for patients with sickle cell disease demonstrated that these patients may have longer TTP than other patients. Here, we examine TTP for patients presenting for emergency care at a single institution, comparing patients with sickle cell disease to both the general population and to those with other painful conditions, with examination of both institutional and patient factors that might affect wait times. Our data demonstrated that at our institution patients with sickle cell disease have a slightly longer average TTP compared to the general ED population (+16 min.) and to patients with other painful conditions (+4 min.) However, when confounding factors were considered, there was no longer a significant difference between TTP of patients with sickle cell disease and the general population nor between patients with sickle cell disease and those with other painful conditions. Multivariate analyses demonstrated that gender, race, age, high utilizer status, fast track use, time of presentation, acuity and insurance type, were all independently associated with TTP, with acuity, time of presentation and use of fast track having the greatest influence. We concluded that the longer TTP observed in patients with sickle cell disease can at least partially be explained by institutional factors such as the use of fast track protocols. Further work to reduce TTP for sickle cell disease and other patients is needed to optimize care.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Analyzing Factors Affecting Emergency Department Length of Stay-Using a Competing Risk-accelerated Failure Time Model

Emergency department (ED) length of stay (LOS) is associated with ED crowding and related complications. Previous studies either analyzed single patient disposition groups or combined different endpoints as a whole. The aim of this study is to evaluate different effects of relevant factors affecting ED LOS among different patient disposition groups.This is a retrospective electronic data analysis. The ED LOS and relevant covariates of all patients between January 2013 and December 2013 were collected. A competing risk accelerated failure time model was used to compute endpoint type-specific time ratios (TRs) for ED LOS.A total of 149,472 patients was included for analysis with an overall medium ED LOS of 2.15 [interquartile range (IQR) = 6.51] hours. The medium LOS for discharged, admission, and mortality patients was 1.46 (IQR = 2.07), 11.3 (IQR = 33.2), and 7.53 (IQR = 28.0) hours, respectively. In multivariate analysis, age (TR = 1.012, P < 0.0001], higher acuity (triage level I vs level V, TR = 2.371, P < 0.0001), pediatric nontrauma (compared with adult nontrauma, TR = 3.084, P < 0.0001), transferred patients (TR = 2.712, P < 0.0001), and day shift arrival (compared with night shift, TR = 1.451, P < 0.0001) were associated with prolonged ED LOS in the discharged patient group. However, opposite results were noted for higher acuity (triage level I vs level V, TR = 0.532, P < 0.0001), pediatric nontrauma (TR = 0.375, P < 0.0001), transferred patients (TR = 0.852, P < 0.0001), and day shift arrival (TR = 0.88, P < 0.0001) in the admission patient group.Common influential factors such as age, patient entity, triage acuity level, or arrival time may have varying effects on different disposition groups of patients. These findings and the suggested model could be used for EDs to develop individually tailored approaches to minimize ED LOS and further improve ED crowding status.

Effect of an emergency department fast track on Press-Ganey patient satisfaction scores

Introduction

Mandated patient surveys have become an integral part of Medicare remuneration, putting hundreds of millions of dollars in funding at risk. The Centers for Medicare & Medicaid Services (CMS) recently announced a patient experience survey for the emergency department (ED). Development of an ED Fast Track, where lower acuity patients are rapidly seen, has been shown to improve many of the metrics that CMS examines. This is the first study examining if ED Fast Track implementation affects Press-Ganey scores of patient satisfaction.

Methods

We analyzed returned Press-Ganey questionnaires from all ESI 4 and 5 patients seen 11AM – 1PM, August–December 2011 (pre-fast track), and during the identical hours of fast track, August–December 2012. Raw ordinal scores were converted to continuous scores for paired student t-test analysis. We calculated an odds ratio with 100% satisfaction considered a positive response.

Results

An academic ED with 52,000 annual visits had 140 pre-fast track and 85 fast track respondents. Implementation of a fast track significantly increased patient satisfaction with the following: wait times (68% satisfaction to 88%, OR 4.13, 95% CI [2.32–7.33]), doctor courtesy (90% to 95%, OR 1.97, 95% CI [1.04–3.73]), nurse courtesy (87% to 95%, OR 2.75, 95% CI [1.46–5.15]), pain control (79% to 87%, OR 2.13, 95% CI [1.16–3.92]), likelihood to recommend (81% to 90%, OR 2.62, 95% CI [1.42–4.83]), staff caring (82% to 91%, OR 2.82, 95% CI [1.54–5.19]), and staying informed about delays (66% to 83%, OR 3.00, 95% CI [1.65–5.44]).

Conclusion

Implementation of an ED Fast Track more than doubled the odds of significant improvements in Press-Ganey patient satisfaction metrics and may play an important role in improving ED performance on CMS benchmarks.

Improvement of clinical quality indicators through reorganization of the acute care by establishing an emergency department-a register study based on data from national indicators

Background

The Emergency Departments (EDs) reorganization process in Denmark began in 2007 and includes creating a single entrance for all emergency patients, establishing triage, having a specialist in the front and introducing the use of electronic overview boards and electronic patient files. The aim of this study was to investigate the quality of acute care in a re-organized ED based on national indicator project data in a pre and post reorganizational setting.

Methods

Quasi experimental design was used to examine the effect of the health care quality in relation to the reorganization of an ED. Patients admitted at Nykøbing Falster Hospital in 2008 or 2012 were included in the study and data reports from the national databases (RKKP) regarding stroke, COPD, heart failure, bleeding and perforated ulcer or hip fracture were analysed. Holbæk Hospital works as a control hospital.

Chi-square test was used for analysing significant differences from pre-and post intervention and Z-test to compare the experimental groups to the control group (HOL). P < 0.05 was considered statistically significant.

Results

We assessed 4584 patient cases from RKKP. A significant positive change was seen in all of the additional eight indicators related to stroke at NFS (P < 0.001); however, COPD indicators were unchanged in both hospitals. In NFS two of eight heart failure indicators were significantly improved after the reorganization (p < 0.01). In patients admitted with a bleeding ulcer 2 of 5 indicators were significantly improved after the reorganization in NFS and HOL (p < 0.01). Both compared hospitals showed significant improvements in the two indicators concerning hip fracture (p < 0.001). Significant reductions in the 30 day-mortality in patients admitted with stroke were seen when the pre- and the post-intervention data were compared for both NFS and HOL (p = 0.024).

Conclusions

During the organisation of the new EDs, several of the indicators improved and the overall 30 days mortality decreased in the five diseases. The development of a common set of indicators for monitoring acute treatment at EDs in Denmark is recommended.

Improving process quality for pediatric emergency department

PURPOSE

Overcrowding in emergency departments (EDs) leads to longer waiting times and results in higher number of patients leaving the ED without being seen by a physician. EDs need to improve quality for patients' waiting time and length of stay (LoS) from the perspective of process and flow control management. The paper aims to discuss these issues.

DESIGN/METHODOLOGY/APPROACH

The retrospective case study was performed using the computerized ED patient time logs from arrival to discharge between July 1, 2009 and June 30, 2010. Patients were divided into two groups either adult or pediatric with a cutoff age of 18. Patients' characteristics were measured by arrival time periods, waiting times before being seen by a physician, total LoS and acuity levels. A discrete event simulation was applied to the comparison of quality performance measures.

FINDINGS

Statistically significant differences were found between the two groups in terms of arrival times, acuity levels, waiting time stratified for various arrival times and acuity levels. The process quality for pediatric patients could be improved by redesign of patient flow management and medical resource.

RESEARCH LIMITATIONS/IMPLICATIONS

The results are limited to a case of one community and ED. This study did not analyze the characteristic of leaving the ED without being seen by a physician.

PRACTICAL IMPLICATIONS

Separation of pediatric patients from adult patients in an ED can reduce the waiting time before being seen by a physician and the total staying time in the ED for pediatric patients. It can also lessen the chances for pediatric patients to leave the ED without being seen by a physician.

ORIGINALITY/VALUE

A process and flow control management scheme based on patient group characteristics may improve service quality and lead to a better patient satisfaction in ED.

Patient perceptions of emergency department fast track: a prospective pilot study comparing two models of care

BACKGROUND

Emergency department (ED) fast track has been shown to improve patient flow for low complexity presentations.(1) The optimal model of care and service delivery for fast track patients has not been established.

AIMS

The objective of this pilot study was to compare patient satisfaction using two models of ED fast track - one in a tertiary hospital emergency department staffed by doctors and the other in a nearby urban district hospital staffed by nurse practitioners. We also wanted to determine the proportion of fast track patients who would prefer to see a General Practitioner (GP) instead of presenting to the ED. This pilot study was the foundation for subsequent studies later conducted by Dinh et al.(2,3) METHODS: This was an observational study using a convenience sample of patients. Eligible fast track patients were asked to complete a standardised satisfaction survey. Presenting problems and waiting times of patients were collected using patient information systems. Primary outcome measure was satisfaction rating using a 5-point Likert scale. Secondary outcomes were surrogate satisfaction measures encompassing questions on likelihood of returning to ED. A multivariate analysis was performed to obtain odds ratio for higher satisfaction scores.

RESULTS

In total, 353 patients were recruited: 212 patients in the doctor treated group (DR) and 141 were in the nurse practitioner treated group (NP). The two groups had similar baseline characteristics in terms of age, gender, referral source and waiting times. Overall, 320/353(86%) patients rated their care as either very good or excellent, with only 0.6% rating their care as poor. Satisfaction scores in the NP group were higher than those in the DR group (median score 4 vs. 3, p<0.01). A greater proportion of patients in the NP group reported that they would return to the ED for a similar problem (99% vs. 91% p<0.01). Overall, 175/353 (50%) of patients indicated that they would prefer to see a general practitioner for a similar problem if available nearby. These numbers were slightly lower in the NP group (43% vs. 53%, p=0.05).

CONCLUSIONS

Most patients were satisfied with ED fast track, irrespective of model of care. Patient satisfaction was greater in the group of patients using the nurse practitioner model of care. Around half of the fast track patients would prefer to see a general practitioner for a similar problem if available nearby.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Decreasing length of stay in the emergency department with a split emergency severity index 3 patient flow model

OBJECTIVES

There has been a steady increase in emergency department (ED) patient volume and wait times. The desire to maintain or decrease costs while improving throughput requires novel approaches to patient flow. The break-out session "Interventions to Improve the Timeliness of Emergency Care" at the June 2011 Academic Emergency Medicine consensus conference "Interventions to Assure Quality in the Crowded Emergency Department" posed the challenge for more research of the split Emergency Severity Index (ESI) 3 patient flow model. A split ESI 3 patient flow model divides high-variability ESI 3 patients from low-variability ESI 3 patients. The study objective was to determine the effect of implementing a split ESI 3 flow model has on patient length of stay (LOS) for discharged patients.

METHODS

This was a retrospective chart review at an urban academic ED seeing over 70,000 adult patients a year. Cases consisted of adults who presented from 9 a.m. to 11 p.m. from June 1, 2011, to December 31, 2011, and were discharged. Controls were patients who presented on the same times and days, but in 2010. Visit descriptors included age, race, sex, ESI score, and first diagnosis. The first diagnosis was coded based on methods used by the Agency for Healthcare Research and Quality to codify International Classification of Diseases, ninth version, into disease groups. Linear models compared log-transformed LOS for cases and controls. A front-end ED redesign involved creating guidelines to split ESI 3 patients into low and high variability, a hybrid sort/triage registered nurse, an intake area consisting of an internal results waiting room, and a treatment area for patients after initial assessment. The previous low-acuity area (ESI 4s and 5s) began to see low-variability ESI 3 patients as well. This was done without additional beds. The intake area was staffed with an attending emergency physician (EP), a physician assistant (PA), three nurses, two medical technicians, and a scribe.

RESULTS

There was a 5.9% decrease, from 2.58 to 2.43 hours, in the geometric mean of LOS for discharged patients from 2010 to 2011 (95% confidence interval CI = 4.5% to 7.2%; 2010, n = 20,215; 2011, n = 20,653). Abdominal pain was the most common diagnostic grouping (2010, n = 2,484; 2011, n = 2,464) with a reduction in LOS of 12.9%, from 4.37 to 3.8 hours (95% CI = 10.3% to 15.3%).

CONCLUSIONS

A split ESI 3 patient flow model improves door-to-discharge LOS in the ED.

Improvement in emergency department length of stay using an early senior medical assessment and streaming model of care: A cohort study

OBJECTIVE

Australian EDs are required to conform to the National Emergency Access Target (NEAT): patients must be discharged within 4 h of arrival. The aim of the present study was to determine if a model of care called Senior Assessment and Streaming (SAS) would increase the proportion of patients achieving NEAT.

METHODS

Stable, ambulant patients considered to have problems that early consultant-level assessment was likely to improve processing efficiency were streamed through a dedicated clinical area staffed by an ED physician, intern and nurse. The proportion of patients achieving NEAT were compared between days with or without SAS, adjusted for confounding variables.

RESULTS

The 18 962 patients presented during the study, 6828 on days with SAS, 12 134 on days without. On days with SAS, there were more presentations, more admissions, lower access to ward beds and fewer staff working hours. After controlling for confounding, the odds of meeting NEAT on days with SAS was 15% higher compared with days without (odds ratio, 1.15; 95% confidence interval [CI], 1.07-1.24; P < 0.001). For the subgroups of patients admitted, discharged, triage category 3, 4, 5, or presentation 12.00-18.00 the odds of meeting NEAT on days with SAS was, respectively, 1.10 (95% CI, 0.98-1.23; P = 0.10), 1.17 (95% CI, 1.07-1.28; P < 0.001), 1.17 (95% CI, 1.08-1.27; P < 0.001) and 1.19 (95% CI, 1.06-1.35; P = 0.003). The odds of a patient not waiting to be seen on days with SAS was 28% lower compared with days without (odds ratio, 0.72; 95% CI, 0.58-0.90; P = 0.003).

CONCLUSION

Through the introduction of SAS, the present study has demonstrated that providing early senior medical assessment can improve an ED's ability to meet NEAT.

Effect of patient sex on triage for ischaemic heart disease and treatment onset times: A retrospective analysis of Australian emergency department data

Time between emergency department (ED) presentation and treatment onset is an important, but little-researched phase within the revascularization process for ischaemic heart disease (IHD).

OBJECTIVE

To determine if sex influences triage score allocation and treatment onset for patients with IHD in the ED.

METHODS

Retrospective data for patients 18-85 years presenting to EDs from 2005 to 2010 for acute myocardial infarction (AMI), unstable and stable angina, and chest pain were analysed collectively and separately for AMI.

RESULTS

Proportionately more men (61% of males) were triaged correctly for AMI than women (51.4% of females; P<0.001). Across all triage categories, average treatment time was faster for men than women with AMI (P<0.001). When incorrectly triaged for AMI, treatment time for men was faster than for women (P=0.04). When correctly triaged for AMI, there was no difference in mean treatment time between men and women (P=0.538).

CONCLUSIONS

Substantial undertriage of AMI occurred for both sexes, but was worse in women. Incorrect triage led to prolonged treatment times for AMI, with women's treatment delays longer than men's. When triaged correctly, both sexes were treated early for AMI, emphasising the need for all patients to be accurately triaged for this time-sensitive disease.

Analysis of three advanced practice roles in emergency nursing

BACKGROUND

There are many Emergency Department (ED) demand management systems that include advanced practice emergency nursing roles. The aim of this study is to examine and compare three advanced emergency nursing practice roles: ED Fast Track, Clinical Initiatives Nurse (CIN) and Rapid Intervention and Treatment Zone (RITZ).

METHOD

A descriptive exploratory approach was used to conduct this study at an urban district hospital in Melbourne, Australia. The study participants were patients managed in each of the three systems with advanced practice emergency nursing roles: Fast Track, CIN and RITZ.

RESULTS

There were a total of 551 patients: 195 Fast Track patients, 163 CIN managed patients and 193 RITZ patients. CIN managed patients were older (p<0.001), with higher levels of clinical urgency (p<0.001), and higher hospital admission rates (p<0.001). CIN managed patients had shorter waiting time for nursing care (p=0.001) and lower incidence of medical assessment within the time associated with their triage category (p<0.0001). ED LOS for discharged patients was significantly longer for CIN managed patients (p<0.001). CIN managed patients had a significantly higher incidence of electrocardiography (p<0.001), blood glucose measurement (p<0.001), intravenous cannulation (p<0.001), pathology testing (p<0.001), and analgesia administration (p<0.001) when compared to Fast Track and RITZ patients.

CONCLUSIONS

Advanced practice roles in emergency nursing can have different applications in the ED context. Clarity about role intent and scope of practice is important and should inform educational preparation and teams within which these roles operate.

A new after-hours clinic model provides cost-saving, faster care compared with a pediatric emergency department

OBJECTIVE

The objective of this study was to compare the charges and length of stay of demographically and clinically matched nonemergent patients managed in a new After-Hours Clinic (AHC) model versus a pediatric emergency department (PED).

METHODS

Retrospective cross-sectional study conducted in a tertiary-care urban academic children's hospital. The AHC was off-site from the children's hospital emergency department. After-Hours Clinic patients were matched with PED patients for age, date and time of presentation, and chief complaint. The 95% confidence intervals for the difference in the means were used to compare the outcome variables of charges and length of stay.

RESULTS

Of 471 patients seen at AHC in January 2008, 130 were matched to PED patients for date and time of presentation, age, and chief complaint, giving 260 study patients. There was no significant difference between AHC and PED patients in relationship to date and time of presentation, sex, age, and chief complaint. Comparing the length of stay and charges between AHC and PED patients revealed a significant difference in each. The patient-visit length-of-stay mean time for the AHC was 81.2 minutes less than the mean time for the PED (95.6 vs 176.8 minutes). The patient-visit mean charge for the AHC was $236.20 less than the mean charge for the PED ($226.00 vs $462.20).

CONCLUSIONS

Our AHC model showed a significant reduction in length of stay and charges in compared demographically and clinically matched PED patients. This may be an effective model to help address emergency department overcrowding and promote patient safety.

Self-referral and serious illness in children with fever

OBJECTIVE

The goal of this study was to evaluate parents' capability to assess their febrile child's severity of illness and decision to present to the emergency department. We compared children referred by a general practitioner (GP) with those self-referred on the basis of illness-severity markers.

METHODS

This was a cross-sectional observational study conducted at the emergency departments of a university and a teaching hospital. GP-referred or self-referred children with fever (aged <16 years) who presented to the emergency department (2006-2008) were included. Markers for severity of illness were urgency according to the Manchester Triage System, diagnostic interventions, therapeutic interventions, and follow-up. Associations between markers and referral type were assessed by using logistic regression analysis. Subgroup analyses were performed for patients with the most common presenting problems that accompanied the fever (ie, dyspnea, gastrointestinal complaints, neurologic symptoms, fever without specific symptoms).

RESULTS

Thirty-eight percent of 4609 children were referred by their GP and 62% were self-referred. GP-referred children were classified as high urgency (immediate/very urgent categories) in 46% of the cases and self-referrals in 45%. Forty-three percent of GP referrals versus 27% of self-referrals needed extensive diagnostic intervention, intravenous medication/aerosol treatment, hospitalization, or a combination of these (odds ratio: 2.0 [95% confidence interval: 1.75-2.27]). In all subgroups, high urgency was not associated with referral type. GP-referred and self-referred children with dyspnea had similar frequencies of illness-severity markers.

CONCLUSIONS

Although febrile self-referred children were less severely ill than GP-referred children, many parents properly judged and acted on the severity of their child's illness. To avoid delayed or missed diagnoses, recommendations regarding interventions that would discourage self-referral to the emergency department should be reconsidered.

Emergency medicine: an operations management view

Operations management (OM) is the science of understanding and improving business processes. For the emergency department (ED), OM principles can be used to reduce and alleviate the effects of crowding. A fundamental principle of OM is the waiting time formula, which has clear implications in the ED given that waiting time is fundamental to patient-centered emergency care. The waiting time formula consists of the activity time (how long it takes to complete a process), the utilization rate (the proportion of time a particular resource such a staff is working), and two measures of variation: the variation in patient interarrival times and the variation in patient processing times. Understanding the waiting time formula is important because it presents the fundamental parameters that can be managed to reduce waiting times and length of stay. An additional useful OM principle that is applicable to the ED is the efficient frontier. The efficient frontier compares the performance of EDs with respect to two dimensions: responsiveness (i.e., 1/wait time) and utilization rates. Some EDs may be "on the frontier," maximizing their responsiveness at their given utilization rates. However, most EDs likely have opportunities to move toward the frontier. Increasing capacity is a movement along the frontier and to truly move toward the frontier (i.e., improving responsiveness at a fixed capacity), we articulate three possible options: eliminating waste, reducing variability, or increasing flexibility. When conceptualizing ED crowding interventions, these are the major strategies to consider.

'Hospital-at-Night' expedites review of trauma patients without affecting outcome from hip fracture

The UK Hospital at Night (H@N) programme is hypothesised to improve efficiency of out-of-hours care. No studies have assessed a surgical programme or mechanisms of effect. This prospective study aimed to do so in a trauma and orthopaedic department over 10 weeks. Senior house officers recorded night shift activity. Mean time to attend referrals reduced from 29 to 15 minutes as a result of the programme (p = 0.007). Workload and 30 day mortality and morbidity for hip fracture remained unchanged. The mechanisms underlying improvements are unclear, but may represent central organisation of workload.