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Lin IC, Chiu PW, Lin CH. Impact of the Emergency Procedure Zone on Emergency Care. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050901. [PMID: 37241133 DOI: 10.3390/medicina59050901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/28/2023]
Abstract
Background: Emergency department (ED) overcrowding is a public health crisis that affects patient care quality. Space management in the ED can affect patient flow dynamics and clinical practice. We proposed a novel design of the "emergency procedure zone" (EPZ). The purpose of the EPZ was to provide an isolated area for clinical practice and procedure teaching, to ensure a secure area with adequate equipment and monitors, and safeguard patient privacy and safety. This study aimed to analyze the impact of the EPZ on procedural practice and patient flow dynamics. Methods: This study was conducted at the ED of a tertiary teaching hospital in Taiwan. Data were collected from 1 March 2019 to 31 August 2020 (pre-EPZ period) and from 1 November 2020 to 30 April 2022 (post-EPZ period). Statistical analyses were performed using IBM SPSS Statistics software. This study focused on the number of procedures and length of stay in the emergency department (LOS-ED). Variables were analyzed using the chi-square test and Mann-Whitney U test. Statistical significance was defined as p < 0.05. Results: There were 137,141 (pre-EPZ period) and 118,386 (post-EPZ period) ED visits recorded during this period. The post-EPZ period showed a significant increase in central venous catheter insertion, chest tube or pigtail placement, arthrocentesis, lumbar puncture, and incision and drainage procedures (p < 0.001). For patients who were directly discharged from the ED, the post-EPZ period also had a higher percentage of ultrasound studies performed in the ED and a shorter LOS-ED for patients who were directly discharged from the ED (p < 0.001). Conclusions: The establishment of an EPZ in the ED has a positive impact on procedural efficiency. The EPZ improved diagnosis and disposition efficiency, shortened the length of stay, and provided benefits such as improved management, patient privacy, and teaching opportunities.
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Affiliation(s)
- I-Chen Lin
- Department of Emergency Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan 70403, Taiwan
| | - Po-Wei Chiu
- Department of Emergency Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan 70403, Taiwan
| | - Chih-Hao Lin
- Department of Emergency Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan 70403, Taiwan
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Baumer-Mouradian SH, Gray MP, Wolfgram PM, Kopetsky M, Chang F, Brousseau DC, Frenkel MM, Ferguson CC. Improving Emergency Department Management of Diabetic Ketoacidosis in Children. Pediatrics 2019; 144:peds.2018-2984. [PMID: 31515299 DOI: 10.1542/peds.2018-2984] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Diagnostic delays in the pediatric emergency department (ED) can lead to unnecessary interventions and prolonged ED length of stay (LOS), especially in patients with diabetes mellitus evaluated for diabetic ketoacidosis (DKA). At our institution, baseline DKA determination time (arrival to diagnosis) was 86 minutes, and 61% of patients did not meet DKA criteria. Subsequently, intravenous (IV) placement occurred in 85% of patients without DKA. We aimed to use point-of-care (POC) testing to reduce DKA determination time from 86 to 30 minutes and to reduce IV placements in patients without DKA from 85% to 20% over 18 months. METHODS Four key interventions (POC tests, order panels, provider guidelines, and nursing guidelines) were tested by using plan-do-study-act cycles. DKA determination time was our primary outcome, and secondary outcomes included the percentage of patients receiving IV placement and ED LOS. Process measures included the rate of use of POC testing and order panels. All measures were analyzed on statistical process control charts. RESULTS Between January 2015 and July 2018, 783 patients with diabetes mellitus were evaluated for DKA. After all 4 interventions, DKA determination time decreased from 86 to 26 minutes (P < .001). In patients without DKA, IV placement decreased from 85% to 36% (P < .001). ED LOS decreased from 206 to 186 minutes (P = .009) in patients discharged from the hospital after DKA evaluation. POC testing and order panel use increased from 0% to 98% and 90%, respectively. CONCLUSIONS Using quality-improvement methodology, we achieved a meaningful reduction in DKA determination time, the percentage of IV placements, and ED LOS.
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Affiliation(s)
| | - Matthew P Gray
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Peter M Wolfgram
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Matthew Kopetsky
- Business Intelligence and Data Warehousing, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Franklin Chang
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - David C Brousseau
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Mogen M Frenkel
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Catherine C Ferguson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
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Kankaanpää M, Holma-Eriksson M, Kapanen S, Heitto M, Bergström S, Muukkonen L, Harjola VP. Comparison of the use of comprehensive point-of-care test panel to conventional laboratory process in emergency department. BMC Emerg Med 2018; 18:43. [PMID: 30453888 PMCID: PMC6245706 DOI: 10.1186/s12873-018-0198-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 11/08/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In this study, we hypothesized that point of care testing (POCT) would reduce length of stay (LOS) in emergency department (ED) when compared to central laboratory testing and be a factor in patient discharge destination. METHODS A single centre observational study was performed in ED non-ambulatory patients. Blood testing was performed either with POC instruments for blood gases and chemistry panel, full blood count, and CRP, or at central laboratory, or as a combination of both. Blood draw and POCTs were performed by experienced nurses. RESULTS During the 4-week study period, 1759 patients underwent sample testing (POCT: n = 160, central lab: n = 951; both n = 648). Median waiting time for blood sampling was 19 min less in POCT than central laboratory (0:52 (95% confidence interval (CI) 0:46-1:02) vs. 1:11 (95% CI 1:05-1:14), p < 0.001). POCT results were available faster in both discharge groups, as expected. When imaging was not required, patients in POCT group were discharged home 55 min faster (4:57 (95% CI 3:59-6:17) vs. 5:52 (95% CI 5:21-6:35), p = 0.012) and 1 h 22 min faster when imaging was performed (5:48 (95% CI 5:26-6:18) vs. 7:10 (95% CI 6:47-8:26), p = 0.010). Similar reduction in sampling time and LOS was not seen among those admitted to hospital. CONCLUSIONS POCT shortened the laboratory process and made results available faster than the central lab. This allowed patients to be discharged home quicker. Thus, with proper training and education of the ED care team, POCT can be used as an effective tool for improving patient flow.
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Affiliation(s)
- Meri Kankaanpää
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Haartmaninkatu 4, PL 340, 00029, Helsinki, Finland.
| | - Marika Holma-Eriksson
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Haartmaninkatu 4, PL 340, 00029, Helsinki, Finland
| | - Sami Kapanen
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Haartmaninkatu 4, PL 340, 00029, Helsinki, Finland
| | - Merja Heitto
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Haartmaninkatu 4, PL 340, 00029, Helsinki, Finland
| | - Sari Bergström
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Haartmaninkatu 4, PL 340, 00029, Helsinki, Finland
| | - Leila Muukkonen
- Department of Clinical Chemistry and Haematology, Helsinki University Hospital, HUSLAB, Helsinki, Finland
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Haartmaninkatu 4, PL 340, 00029, Helsinki, Finland
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Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS One 2018; 13:e0203316. [PMID: 30161242 PMCID: PMC6117060 DOI: 10.1371/journal.pone.0203316] [Citation(s) in RCA: 519] [Impact Index Per Article: 86.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/17/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Emergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions. AIM The aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding. METHOD The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A structured search of four databases (Medline, CINAHL, EMBASE and Web of Science) was undertaken to identify peer-reviewed research publications aimed at investigating the causes or consequences of, or solutions to, emergency department crowding, published between January 2000 and June 2018. Two reviewers used validated critical appraisal tools to independently assess the quality of the studies. The study protocol was registered with the International prospective register of systematic reviews (PROSPERO 2017: CRD42017073439). RESULTS From 4,131 identified studies and 162 full text reviews, 102 studies met the inclusion criteria. The majority were retrospective cohort studies, with the greatest proportion (51%) trialling or modelling potential solutions to emergency department crowding. Fourteen studies examined causes and 40 investigated consequences. Two studies looked at both causes and consequences, and two investigated causes and solutions. CONCLUSIONS The negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. This review identified a mismatch between causes and solutions. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Solutions aimed at the introduction of whole-of-system initiatives to meet timed patient disposition targets, as well as extended hours of primary care, demonstrated promising outcomes. While the review identified increased presentations by the elderly with complex and chronic conditions as an emerging and widespread driver of crowding, more research is required to isolate the precise local factors leading to ED crowding, with system-wide solutions tailored to address identified causes.
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Affiliation(s)
- Claire Morley
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Maria Unwin
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
| | - Gregory M. Peterson
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Jim Stankovich
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
| | - Leigh Kinsman
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
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Goldstein L, Wells M, Vincent-Lambert C. A Randomized Controlled Trial to Assess the Impact of Upfront Point-of-Care Testing on Emergency Department Treatment Time. Am J Clin Pathol 2018; 150:224-234. [PMID: 29931184 DOI: 10.1093/ajcp/aqy042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To compare standard emergency department (ED) workflow to a protocolized pathway using upfront point-of-care (POC) tests performed prior to doctor evaluation to determine if this could produce a significant reduction in treatment time. METHODS We performed a prospective, randomized, controlled trial. Patients were randomized to receive the standard of care or one of the enhanced workflow pathways with POC tests. RESULTS There were 1,044 patients enrolled. All workflows, except electrocardiogram and low-dose x-ray (LODOX), exceeded the outcome measure (20% reduction in treatment time). It was significantly shorter compared with the control workflow if the patient received any (i-STAT + CBC)-containing workflows (P = .0001, P = .020, P = .0009, P = .011), as well as the i-STAT + LODOX workflows (P = .0001, P = .034). CONCLUSIONS The full benefit of POC testing can be realized if it is implemented prior to doctor evaluation, as part of a standardized procedure in the ED. This allows for a more rapid availability of investigation results subsequently leading to decreased treatment times.
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Affiliation(s)
- Lara Goldstein
- Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Emergency Medical Care, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Mike Wells
- Department of Emergency Medical Care, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Craig Vincent-Lambert
- Department of Emergency Medical Care, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
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Bargnoux AS, Beaufils O, Oguike M, Lopasso A, Dupuy AM, Sebbane M, Badiou S, Fesler P, Cristol JP. Point-of-care creatinine testing in patients receiving contrast-enhanced computed tomography scan. Clin Chim Acta 2018; 478:111-113. [DOI: 10.1016/j.cca.2017.12.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/17/2017] [Accepted: 12/17/2017] [Indexed: 12/01/2022]
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Kankaanpää M, Raitakari M, Muukkonen L, Gustafsson S, Heitto M, Palomäki A, Suojanen K, Harjola VP. Use of point-of-care testing and early assessment model reduces length of stay for ambulatory patients in an emergency department. Scand J Trauma Resusc Emerg Med 2016; 24:125. [PMID: 27756354 PMCID: PMC5069884 DOI: 10.1186/s13049-016-0319-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 10/09/2016] [Indexed: 11/10/2022] Open
Abstract
Background To assess whether the use of point-of-care testing (POCT) and early assessment team (EAT) model shortens emergency department (ED) length of stay (LOS). Methods This prospective, observational study with comparison between three study periods was performed in three phases in a metropolitan ED with 57,000 annual visits. Data were collected from adult ambulatory patients who were discharged home. Phase 1 served as a control (n = 1559 in one month). In phase 2, a comprehensive POCT panel including complete blood count, sodium, potassium, glucose, C-reactive protein, creatinine, alkaline phosphatase, alanine aminotransferase, bilirubin, amylase, and D-dimer was launched (n = 1442 in one month). In phase 3 (n = 3356 in subsequent two months), POCT approach continued. In addition, the working process was changed by establishing an EAT consisting of an emergency medicine resident and a nurse. The team operated from 12 noon to 10 p.m. was. The primary outcome was LOS (hh:mm) in the ED. Waiting times for patients requiring laboratory testing were analysed also, including time from admission to laboratory blood sampling (A2S interval), time from blood sampling to results ready (S2R interval) and time from results to discharge (R2D interval). Results Median LOS of patients requiring laboratory tests in phase 1 was 3:51 (95 % confidence interval 03:38–04:04). During phase 2, introduction of POCT reduced median LOS by 29 min to 03:22 (03:12–03:31, p = 0.000). In phase 3, the EAT model reduced median LOS further by 17 min to 03:05 (02:59–03:12, p = 0.033). Altogether, the process was expedited by 46 min compared with the phase 1. Surprisingly, A2S interval was unaffected by the interventions among all patients needing laboratory testing. In comparison to phase 1, shortening of S2R interval was observed in phase 2 and 3, and that of R2D interval in all patients with laboratory assessments in phase 3. Discussion The present study included adult ambulatory patients and is the first one to examine the impact of comprehensive POC test panel, first alone and then with additional process change. As a result, LOS was reduced significantly for patients needing laboratory tests. Considerable shortening in LOS came from introduction of POCT, and EAT process decreased the LOS further. We used a comprehensive POC test panel in order to maximise the patient population benefiting from the positive impacts of POC on laboratory turnaround time and length of stay. In EAT, diverse setups exist, and these differences affect the interpretation of results. The process changes in phase 3 were done by rearranging work shifts and no extra resources were added. Regarding to staffing the process improvement was thus cost neutral. Conclusions The advantage of POCT alone compared with central laboratory seemed to lie in shorter waiting times for results and earlier discharge home. Moreover, POCT and EAT model shorten LOS additively compared with conventional processes. However, a longer time is seemingly needed to adopt a new working process in the ED, and to establish its full benefit.
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Affiliation(s)
- Meri Kankaanpää
- University of Helsinki, Helsinki, Finland. .,Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland.
| | - Maria Raitakari
- Department of Clinical Chemistry and Haematology, HUSLAB, Helsinki, Finland
| | - Leila Muukkonen
- Department of Clinical Chemistry and Haematology, HUSLAB, Helsinki, Finland
| | - Siv Gustafsson
- Department of Clinical Chemistry and Haematology, HUSLAB, Helsinki, Finland
| | - Merja Heitto
- University of Helsinki, Helsinki, Finland.,Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Ari Palomäki
- University of Tampere, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Kimmo Suojanen
- University of Helsinki, Helsinki, Finland.,Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Veli-Pekka Harjola
- University of Helsinki, Helsinki, Finland.,Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
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Jarvis PRE. Improving emergency department patient flow. Clin Exp Emerg Med 2016; 3:63-68. [PMID: 27752619 PMCID: PMC5051606 DOI: 10.15441/ceem.16.127] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/02/2016] [Accepted: 03/02/2016] [Indexed: 11/23/2022] Open
Abstract
Emergency departments (ED) face significant challenges in delivering high quality and timely patient care on an ever-present background of increasing patient numbers and limited hospital resources. A mismatch between patient demand and the ED's capacity to deliver care often leads to poor patient flow and departmental crowding. These are associated with reduction in the quality of the care delivered and poor patient outcomes. A literature review was performed to identify evidence-based strategies to reduce the amount of time patients spend in the ED in order to improve patient flow and reduce crowding in the ED. The use of doctor triage, rapid assessment, streaming and the co-location of a primary care clinician in the ED have all been shown to improve patient flow. In addition, when used effectively point of care testing has been shown to reduce patient time in the ED. Patient flow and departmental crowding can be improved by implementing new patterns of working and introducing new technologies such as point of care testing in the ED.
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