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Heslin SM, Henry M, Litvak E, Singer AJ, Thode H, Viccellio P. An Analysis of New York Data: Fluctuations in Hospital Capacity Are Driven by Variability in Elective Admissions and Discharge Activity. Cureus 2024; 16:e58404. [PMID: 38756272 PMCID: PMC11098058 DOI: 10.7759/cureus.58404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 05/18/2024] Open
Abstract
Background Hospital overcrowding compromises patient safety. The contribution of variability in admissions and discharges to overall hospital capacity needs to be quantified. This study describes the statewide day-to-day fluctuation in the volume of hospitalized patients, the variability and pattern of hospital admissions and discharges throughout the week, and the contribution of Emergency Department (ED) vs. elective (non-ED) admissions and discharges to the overall variability in the system across the week. Methodology This is a retrospective analysis of the New York State Statewide Planning and Research Cooperative System database, in which all New York healthcare facilities submit patient-level data monthly. The study period was from January 01 to December 31, 2015. Outcomes included total volumes of admissions and discharges and length of stay sorted by patient origin (ED vs. non-ED admits (elective)) and service type (medicine vs. surgery) by day of the week. Results We studied 1,692,090 hospital admissions. Admissions were highest on Mondays and Tuesdays and steadily decreased throughout the week. There was little variability in the ED admissions throughout the week. Surgical elective admissions had significant variability throughout the week, with higher admissions at the beginning of the week. There was a significant difference (p < 0.01) between admissions on weekdays vs. weekends. Discharges increased from Monday to Friday, with a dramatic drop on the weekends, for both ED and elective pathways. Systemwide, on Monday, hospitals were 21% above the mean volume, and on Fridays, hospitals were 32% below the mean volume. Conclusions Overall hospital capacity shows dramatic variability throughout the week, driven primarily by elective admissions and discharges from any source throughout the week. Because elective admissions are schedulable, hospitals can reduce variability by smoothing scheduling. Increased weekend discharges will also improve capacity.
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Affiliation(s)
- Samita M Heslin
- Emergency Medicine, Stony Brook University, Stony Brook, USA
| | - Mark Henry
- Emergency Medicine, Stony Brook University, Stony Brook, USA
| | - Eugene Litvak
- Healthcare Optimization, Institute for Healthcare Optimization, Newton, USA
| | - Adam J Singer
- Emergency Medicine, Stony Brook University, Stony Brook, USA
| | - Henry Thode
- Emergency Medicine, Stony Brook University, Stony Brook, USA
| | - Peter Viccellio
- Emergency Medicine, Stony Brook University, Stony Brook, USA
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2
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Iozzo P, Spina N, Cannizzaro G, Gambino V, Patinella A, Bambi S, Vellone E, Alvaro R, Latina R. Association between Boarding of Frail Individuals in the Emergency Department and Mortality: A Systematic Review. J Clin Med 2024; 13:1269. [PMID: 38592117 PMCID: PMC10932317 DOI: 10.3390/jcm13051269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/13/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Older patients who attend emergency departments are frailer than younger patients and are at a high risk of adverse outcomes; (2) Methods: To conduct this systematic review, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. We systematically searched literature from PubMed, Embase, OVID Medline®, Scopus, CINAHL via EBSCOHost, and the Cochrane Library up to May 2023, while for grey literature we used Google Scholar. No time restrictions were applied, and only articles published in English were included. Two independent reviewers assessed the eligibility of the studies and extracted relevant data from the articles that met our predefined inclusion criteria. The Critical Appraisal Skills Program (CASP) was used to assess the quality of the studies; (3) Results: Evidence indicates that prolonged boarding of frail individuals in crowded emergency departments (Eds) is associated with adverse outcomes, exacerbation of pre-existing conditions, and increased mortality risk; (4) Conclusions: Our results suggest that frail individuals are at risk of longer ED stays and higher mortality rates. However, the association between the mortality of frail patients and the amount of time a patient spends in exposure to the ED environment has not been fully explored. Further studies are needed to confirm this hypothesis.
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Affiliation(s)
- Pasquale Iozzo
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Via Montpellier, 1, 00133 Rome, Italy; (E.V.); (R.A.)
| | - Noemi Spina
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria Policlinico “Paolo Giaccone”, Via del Vespro, 129, 90127 Palermo, Italy; (N.S.); (G.C.); (V.G.); (A.P.)
| | - Giovanna Cannizzaro
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria Policlinico “Paolo Giaccone”, Via del Vespro, 129, 90127 Palermo, Italy; (N.S.); (G.C.); (V.G.); (A.P.)
| | - Valentina Gambino
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria Policlinico “Paolo Giaccone”, Via del Vespro, 129, 90127 Palermo, Italy; (N.S.); (G.C.); (V.G.); (A.P.)
| | - Agostina Patinella
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria Policlinico “Paolo Giaccone”, Via del Vespro, 129, 90127 Palermo, Italy; (N.S.); (G.C.); (V.G.); (A.P.)
| | - Stefano Bambi
- Department of Health Sciences, University of Florence, Viale GB Morgagni, 48, 50134 Florence, Italy;
| | - Ercole Vellone
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Via Montpellier, 1, 00133 Rome, Italy; (E.V.); (R.A.)
- Department of Nursing and Obstetrics, Wroclaw Medical University, 51-618 Wrocław, Poland
| | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Via Montpellier, 1, 00133 Rome, Italy; (E.V.); (R.A.)
| | - Roberto Latina
- Department of Health Promotion Science, Maternal and Infant Care, Internal Medicine, and Medical Specialities (PROMISE), University of Palermo, Piazza delle Cliniche, 2, 90127 Palermo, Italy;
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3
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Reardon A, Lushington K, Junge A, Crichton J, Agostini A. Boarding versus day-students: A mixed-methods analysis of sleep and its relationship with psychological distress. Br J Educ Psychol 2023; 93:1146-1170. [PMID: 37409726 DOI: 10.1111/bjep.12624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/21/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Boarding students face unique challenges when entering school, including: adapting to a novel environment, where they are separated from family, friends and culture, for up to 40 weeks per year. A particular challenge is sleep. A further challenge is coping with the demands of boarding with its potential impact on psychological well-being. AIMS To explore how boarders' sleep differs from that of their day-student peers, and how this relates to psychological well-being. SAMPLE AND METHODS 309 students (59 boarding students and 250 day-students, at one Adelaide school) completed the School Sleep Habits Survey, Depression-Anxiety-Stress-Scale-21 (DASS-21), and Flourishing Scale. Boarding students additionally completed the Utrecht Homesickness Scale. Thirteen boarding students described experiences of sleeping in boarding through focus groups. RESULTS Boarding students, compared to day-students reported 40 minutes more sleep per weeknight (p < .001), with earlier sleep onset (p = .026), and later wake-up (p = .008) times. No significant differences were observed between boarding' and day-students' DASS-21 scores. Hierarchical regression revealed longer total weekday sleep time predicted higher psychological well-being in both boarding and day-students. Additionally, in boarding students, low homesickness-loneliness and homesickness-ruminations further predicted psychological well-being. Thematic analysis of boarding students' focus group responses revealed that night-time routine, and restricting technology use at night facilitated sleep. CONCLUSIONS This study supports - in both boarding and day-students - the importance of sleep for adolescent well-being. Sleep hygiene can play an important role in boarding student sleep, especially: regular night-time routine and restricting technology use at night. Finally, these findings suggest that poor sleep and homesickness have an adverse effect on boarding student psychological well-being. This study highlights the importance of strategies which promote sleep hygiene and minimize homesickness, in boarding school students.
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Affiliation(s)
| | - Kurt Lushington
- University of South Australia, Adelaide, South Australia, Australia
| | - Andrew Junge
- University of South Australia, Adelaide, South Australia, Australia
| | | | - Alex Agostini
- University of South Australia, Adelaide, South Australia, Australia
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4
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Feuer V, Mooneyham GC, Malas NM. Addressing the Pediatric Mental Health Crisis in Emergency Departments in the US: Findings of a National Pediatric Boarding Consensus Panel. J Acad Consult Liaison Psychiatry 2023; 64:501-511. [PMID: 37301325 PMCID: PMC10709524 DOI: 10.1016/j.jaclp.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 05/15/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND In 2021, several professional organizations declared a national state of emergency in child and adolescent mental health. Rising volume and acuity of pediatric mental health emergencies, coupled with reduced access to inpatient psychiatric care, has caused tremendous downstream pressures on EDs resulting in long lengths of stay, or "boarding", for youth awaiting psychiatric admission. Nationally, boarding times are highly heterogeneous, with medical / surgical patients experiencing much shorter boarding times compared to patients with primary mental health needs. There is little guidance on best practices in the care of the pediatric patient with significant mental health need "boarding" in the hospital setting. OBJECTIVE There is a significant increase in the practice of "boarding" pediatric patients within emergency departments and inpatient medical floors while awaiting psychiatric admission. This study aims to provide consensus guidelines for the clinical care of this population. METHODS Twenty-three panel participants of fifty-five initial participants (response rate 41.8%) committed to completing four successive rounds of questioning using Delphi consensus gathering methodology. Most (70%) were child psychiatrists and represented 17 health systems. RESULTS Thirteen participants (56%) recommended maintaining boarded patients in the emergency department, while 78% indicated a temporal limit on boarding in the emergency department should prompt transfer to an inpatient pediatric floor. Of this group, 65% recommended a 24-hour threshold. Most participants (87%) recommended not caring for pediatric patients in the same space as adults. There was unanimous agreement that emergency medicine or hospitalists maintain primary ownership of patient care, while 91% agreed that child psychiatry should maintain a consultative role. Access to social work was deemed most important for staffing, followed by behavioral health nursing, psychiatrists, child life, rehabilitative services, and lastly, learning specialists. There was unanimous consensus that daily evaluation is necessary with 79% indicating vitals should be obtained every 12 hours. All agreed that if a child psychiatric provider is not available on-site, a virtual consultation is sufficient to provide mental health assessment. CONCLUSIONS This study highlights findings of the first national consensus panel regarding the care of youth boarding in hospital-based settings and provides promising beginnings to standardizing clinical practice while informing future research efforts.
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Affiliation(s)
- Vera Feuer
- Department of Psychiatry and Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY
| | - GenaLynne C Mooneyham
- Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health (NIMH), Bethesda, MD
| | - Nasuh M Malas
- Department of Psychiatry and Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI.
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5
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Tolentino AP, Gaus KS, Gao Y, Chronowski KJ, Brice JH, Quackenbush EB. Transition of care from the emergency department to skilled nursing facility: Retrospective case-control study. J Am Coll Emerg Physicians Open 2023; 4:e13022. [PMID: 37662441 PMCID: PMC10472214 DOI: 10.1002/emp2.13022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 09/05/2023] Open
Abstract
Objective The primary objective of this study is to describe associations between emergency department (ED)-to-skilled nursing facility (SNF) transition and ED length-of-stay (LOS). The secondary objective is to explore how social determinants of health (SDOH) influence ED-to-SNF transition visit parameters. In 2020, The Centers for Medicare & Medicaid Services issued the "COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers" eliminating the requirement of a 3-day qualifying hospital stay before SNF placement. The waiver allowed ED patients to be transitioned directly to an SNF from the ED. Methods We conducted a descriptive retrospective case-control study of adult patients who sought care in the University of North Carolina Hospitals (UNCH) ED between March 1, 2020, and March 1, 2022, lived in a non-SNF residence before their ED visit, and were transitioned directly to an SNF from the ED (n 1 = 27), compared with a group seen in the ED and admitted to hospital for SNF placement (n 2 = 54). Results The ED-to-SNF group experienced a significantly longer ED LOS compared to the ED-to-Inpatient-to-SNF group: 72.8 hours (95% confidence interval [CI], 59.2-86.4) compared to 14.5 hours (95% CI, 12.1-16.9). We found no significant differences in SDOH between the ED-to-SNF group and the ED-to-Inpatient-to-SNF group. Conclusion Patients who transition from the ED to an SNF experience long ED stays that may adversely affect health and well-being. Transitioning directly from the ED to an SNF may contribute to ED boarding and overcrowding.
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Affiliation(s)
- Alec P. Tolentino
- Department of Emergency MedicineSchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Kelli S. Gaus
- Department of EpidemiologyGillings School of Global Public HealthUniversity of North Carolina Chapel HillChapel HillNorth CarolinaUSA
| | - Yingqiu Gao
- School of NursingUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Kevin J Chronowski
- Department of Emergency MedicineSchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Jane Helen Brice
- Department of Emergency MedicineSchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Eugenia B. Quackenbush
- Department of Emergency MedicineSchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Monahan AC, Feldman SS. The Utility of Predictive Modeling and a Systems Process Approach to Reduce Emergency Department Crowding: A Position Paper. Interact J Med Res 2023; 12:e42016. [PMID: 37428536 PMCID: PMC10366955 DOI: 10.2196/42016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/12/2023] [Accepted: 05/10/2023] [Indexed: 07/11/2023] Open
Abstract
Emergency department (ED) crowding and its main causes, exit block and boarding, continue to threaten the quality and safety of ED care. Most interventions to reduce crowding have not been comprehensive or system solutions, only focusing on part of the care procession and not directly affecting boarding reduction. This position paper proposes that the ED crowding problem can be optimally addressed by applying a systems approach using predictive modeling to identify patients at risk of being admitted to the hospital and uses that information to initiate the time-consuming bed management process earlier in the care continuum, shortening the time during which patients wait in the ED for an inpatient bed assignment, thus removing the exit block that causes boarding and subsequently reducing crowding.
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Affiliation(s)
| | - Sue S Feldman
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
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7
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DeMaranville J, Wongpakaran T, Wongpakaran N, Wedding D. The Mediating Role of Precepts and Meditation on Attachment and Depressive Symptoms in Adolescents. Healthcare (Basel) 2023; 11:1923. [PMID: 37444756 DOI: 10.3390/healthcare11131923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/24/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
Research shows that Buddhist precept adherence (i.e., abstaining from killing, stealing, sexual misconduct, lying, and intoxicant use) and meditation practice influence mental health outcomes. This study investigated how Buddhist precept adherence and meditation practice influenced the relationship between insecure attachment and depressive symptoms among Thai adolescents. A total of 453 Thai boarding-school students from 10th-12th grade were recruited from five boarding schools (two purposively selected Buddhist schools and three conveniently selected secular schools). They completed these tools: Experiences in Close Relationships Questionnaire-revised-18, Outcome-Inventory-21: Depression Subscale, Precept Practice Questionnaire, and Inner-Strength-Based Inventory: Meditation. A parallel mediation model analyzed the indirect effects of attachment anxiety and attachment avoidance on depression through precept adherence and meditation practice. The participants' demographics were 16.35 ± 0.96 years, 88% female, and 89.4% Buddhist. The mean scores for attachment anxiety were 2.7 ± 1.1; attachment avoidance, 2.78 ± 1.2; overall regular precept adherence, 20.1 ± 4.4; regular but not daily meditation, 2.94 ± 1.3; and low depressive symptoms, 3.75 ± 3.4. The standardized indirect effects for attachment anxiety (β = 0.042, 95% CI = 0.022, 0.070) and avoidance (β = 0.024, 95% CI = 0.009, 0.046) on depressive symptoms through meditation and precept adherence were significant. Meditation practice had a significantly higher indirect effect size than precept adherence.
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Affiliation(s)
| | - Tinakon Wongpakaran
- Graduate School, Chiang Mai University, Chiang Mai 50200, Thailand
- Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Nahathai Wongpakaran
- Graduate School, Chiang Mai University, Chiang Mai 50200, Thailand
- Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Danny Wedding
- Graduate School, Chiang Mai University, Chiang Mai 50200, Thailand
- Department of Clinical and Humanistic Psychology, Saybrook University, Pasadena, CA 91103, USA
- Department of Psychology, University of Missouri-Saint Louis, St. Louis, MO 63121, USA
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8
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Moynihan M, Anton G. Evaluation of the impact of a pharmacist-run antimicrobial report in reducing delays in subsequent antibiotic administration in patients in the emergency department. Am J Health Syst Pharm 2023; 80:543-550. [PMID: 36680794 DOI: 10.1093/ajhp/zxad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Indexed: 01/22/2023] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To determine whether the implementation of a pharmacist-run, real-time electronic health record (EHR) antimicrobial report reduces the frequency of delays in subsequent antibiotic medication administration timing in patients in the emergency department (ED). METHODS A single-center, retrospective, pre-and-post quasi-experimental study was conducted between July and December 2021 following the implementation of an antimicrobial EHR report of adult patients presenting to the ED who were continued on antibiotic therapy after receiving a one-time dose of an antibiotic in the ED. The primary objective was to determine the impact of the pharmacist-run, real-time EHR antibiotic dosing report in the ED on reducing the number of major delays in subsequent antibiotic administration times. A subanalysis of the primary outcome was performed to evaluate differences in major delays based on specific dosing intervals of 6, 8, and 12 hours. RESULTS A total of 521 subsequent antibiotic dosing orders from 273 patient encounters were analyzed, with major delays in subsequent antibiotic dosing administration times identified in 20% of the intervention group compared to 27% of the control group (P = 0.047). Major delays were also significantly decreased in the intervention group compared to the control group for antibiotics dosed at 8-hour intervals (18% vs 32%; P = 0.026). No significant difference in delays was observed between the groups for antibiotics dosed at 6-hour intervals (18% vs 27%) or 12-hour intervals (29% vs 21%). CONCLUSION Implementing a real-time EHR antimicrobial report run by pharmacists in the ED was associated with significantly fewer major delays in subsequent antibiotic dosing following a first dose.
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Affiliation(s)
- Meghin Moynihan
- University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Greta Anton
- University of North Carolina Medical Center, Chapel Hill, NC, USA
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9
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Burleson SL, Butler J, Gostigian G, Parr MS, Kelly MP. A Rare Cause of Headache and an Unorthodox Transfer: A Case Report. Clin Pract Cases Emerg Med 2023; 7:24-28. [PMID: 36859324 PMCID: PMC9983335 DOI: 10.5811/cpcem.2022.10.57491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/03/2022] [Indexed: 02/25/2023] Open
Abstract
INTRODUCTION Emergency department (ED) crowding and hospital diversion times are increasing nationwide, with negative effects on patient safety and an association with increased mortality. Crowding in referral centers makes transfer of complex or critical patients by rural emergency physicians (EP) more complicated and difficult. We present a case requiring an unorthodox transfer method to navigate extensive hospital diversion and obtain life-saving neurosurgical care. CASE REPORT We present the case of a previously healthy 21-year-old male with two hours of headache and rapid neurologic decompensation en route to and at the ED. Computed tomography revealed obstructive hydrocephalus recognized by the EP, who medically managed the increased intracranial pressure (ICP) and began the transfer process for neurosurgical evaluation and management. After refusal by six referral centers in multiple states, all of which were on diversion, the EP initiated an unorthodox transfer procedure to the institution at which he trained, ultimately transferring the patient by air. Bilateral external ventricular drains were placed in the receiving ED, and the patient ultimately underwent neurosurgical resection of an obstructive colloid cyst. CONCLUSION First, our case illustrates the difficulties faced by rural EPs when attempting to transfer critical patients when large referral centers are refusing transfers and the need for improvements in facilitating timely transfers of critically ill, time-sensitive patients. Second, EPs should be aware of colloid cysts as a rare but potentially catastrophic cause of rapid neurologic decline due to increased ICP, and the ED management thereof, which we review.
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Affiliation(s)
- Samuel L. Burleson
- University of Alabama at Birmingham, Department of Emergency Medicine, Birmingham, Alabama
| | - Joe Butler
- Baptist Memorial Hospital – Golden Triangle, Department of Emergency Medicine, Columbus, Mississippi
| | - Gabrielle Gostigian
- University of Alabama at Birmingham, Department of Emergency Medicine, Birmingham, Alabama
| | - Matthew S. Parr
- University of Alabama at Birmingham, Department of Neurosurgery, Birmingham, Alabama
| | - Matthew P. Kelly
- University of Alabama at Birmingham, Department of Emergency Medicine, Birmingham, Alabama
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10
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Kim I, Bukhman AK, Chen PC, Shah SB, Schmelzer NA, Baymon DE, Sanchez LD, Baugh CW, Im DD. Psychiatric care in the emergency department: Converting boarding time to treatment time. Acad Emerg Med 2022; 29:1512-1514. [PMID: 36006174 DOI: 10.1111/acem.14586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/06/2022] [Accepted: 08/23/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Inkyu Kim
- Department of Emergency Medicine, Harvard Affiliated Emergency Medicine Residency, Mass General Brigham, Boston, Massachusetts, USA
| | - Alice K Bukhman
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paul C Chen
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sejal B Shah
- Division of Medical Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Naomi A Schmelzer
- Division of Medical Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Da'Marcus E Baymon
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Leon D Sanchez
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dana D Im
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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11
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Napoli AM, Ali S, Baird J, Jouriles N. A quantitative assessment of emergency department boarding and its association with decreases in operational efficiency: A multicenter nationwide study. Acad Emerg Med 2022; 29:1135-1137. [PMID: 35834481 DOI: 10.1111/acem.14560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/20/2022] [Accepted: 07/08/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Anthony M Napoli
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Shihab Ali
- Department of Emergency Medicine, HCA Houston Healthcare Northwest, Houston, Texas, USA
| | - Janette Baird
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nick Jouriles
- Department of Emergency Medicine, Northeast Ohio Medical University Department of Emergency Medicine, Rootstown, Ohio, USA
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12
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O Saggaf AM, Mugharbel A, Aboalola A, Mulla A, Alasiri M, Alabbasi M, Bakhsh A. Emergency Department Boarding of Mechanically Ventilated Patients. Cureus 2022; 14:e23990. [PMID: 35547457 PMCID: PMC9084916 DOI: 10.7759/cureus.23990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2022] [Indexed: 11/05/2022] Open
Abstract
Background and objective The boarding of critically ill patients in the emergency department (ED) has been on the rise over the past few years. Emergency physicians now frequently encounter critically ill patients who require rapid resuscitation and stabilization and they provide extended care in the ED. This study aimed to evaluate the association between the boarding duration of mechanically ventilated patients in the ED and outcomes in such patients. Methods This was a retrospective study conducted during the period 2018-2019 at an academic institution; it included adult patients who were mechanically ventilated, requiring and awaiting admission to the ICU from the ED. Results We included a total of 388 out of 537 patients in the analysis. Patients were stratified into three groups as follows: 93 (24%) were admitted to the ICU within six hours; 126 (32.5%) were admitted to the ICU within 6-24 hours; and 169 (43.6%) were admitted to the ICU after 24 hours. Patients admitted to the ICU within six hours were significantly younger; the mean age of the patients was 55 ± 16.30 years in group 1, 61.96 ± 17.73 years in group 2, and 62.65 ± 16.62 years in group 3 (p=0.001). The ICU mortality in group 1 was lower than in other groups, and mortality increased with increasing boarding time [28 (30.1%), 51 (40.5%), 79 (46.7%), respectively, p=0.032]. Boarding time in the ED was associated with an increased risk of ICU mortality in group 3 compared with group 1 (0.1664 ± 0.063, p=0.009). The logistic regression analysis showed higher mortality rates in groups 2 [adjusted odds ratio: 3.29; 95% confidence interval (CI): 1.95-5.55, p<0.01] and 3 (adjusted odds ratio: 1.98; 95% CI: 1.17-3.35, p=0.01). Conclusion Based on our findings from this small-sample, single-center study, ED boarding of mechanically ventilated patients is associated with higher ICU mortality rates.
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Affiliation(s)
| | - Abdullah Mugharbel
- Department of Emergency Medicine, King Abdulaziz University, Jeddah, SAU
| | | | - Albarra Mulla
- Department of Emergency Medicine, King Abdulaziz University, Jeddah, SAU
| | - Meshal Alasiri
- Family Medicine, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | | | - Abdullah Bakhsh
- Department of Emergency Medicine, King Abdulaziz University, Jeddah, SAU
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Badr S, Nyce A, Awan T, Cortes D, Mowdawalla C, Rachoin JS. Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List. Open Access Emerg Med 2022; 14:5-14. [PMID: 35018125 PMCID: PMC8742612 DOI: 10.2147/oaem.s338079] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.
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Affiliation(s)
- Samer Badr
- Division of Hospital Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Andrew Nyce
- Department of Emergency Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Taha Awan
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Dennise Cortes
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Cyrus Mowdawalla
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jean-Sebastien Rachoin
- Division of Hospital Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA.,Division of Critical Care, Cooper University Health Care, Camden, NJ, USA
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Weiner SG, Salmasian H, Mendu ML. The glaring omission in hospital ranking and quality grading programs: emergency department boarding. Int J Qual Health Care 2021; 33:6444463. [PMID: 34849973 DOI: 10.1093/intqhc/mzab156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 10/31/2021] [Accepted: 11/26/2021] [Indexed: 11/15/2022] Open
Abstract
Hospitals in the United States are assessed and ranked by several agencies and services, including U.S. News & World Report. Frequently, though, the key hospital throughput metric of inpatient boarding time in the emergency department (ED) is not considered when ranking hospitals. As a result, there is a discordance in which highly ranking hospitals may be poor performers in boarding of patients, a practice with known adverse safety effects. This article outlines the rationale for considering ED boarding in hospital ranking and quality assessments.
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Affiliation(s)
- Scott G Weiner
- Department of Emergency Medicine, Division of Health Policy and Public Health, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Hojjat Salmasian
- Department of Quality and Safety, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Mallika L Mendu
- Department of Medicine, Nephrology Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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15
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Appold B, Soniega-Sherwood J, Persaud R, Moss R, Ramnarine M, LaVine SP, Bhansali R, Ahn S, Richman M. Reining in Unnecessary Admission EKGs: A Successful Interdepartmental High-Value Care Initiative. Cureus 2021; 13:e18351. [PMID: 34722095 PMCID: PMC8552818 DOI: 10.7759/cureus.18351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Unnecessary "admission electrocardiograms (EKGs)" on admitted patients waiting ("boarding") in the emergency department (ED) are often ordered. We introduced evidence-based EKG ordering guidelines and determined changes in the percent of patients with "preadmission" and "admission" EKGs ordered before vs. after guideline introduction and which patient characteristics predicted EKG ordering. Methods In 2016, our ED, cardiology, and hospitalist services implemented EKG ordering guidelines to reduce unnecessary ED EKGs ordered after disposition. We compared pre- vs. post-guideline EKG ordering to determine whether guidelines were associated with changes in "preadmission" or "admission EKG" ordering. Patients with an admission diagnosis unrelated to cardiac or pulmonary systems were included. An EKG was "admission" if the order time was after disposition time. The numerator was the number of "admission EKGs" ordered; the denominator was the total number of such admissions; those with "preadmission EKGs" were excluded from this analysis. Variables that might influence EKG ordering were explored. The chi-square test with Bonferroni adjustment was used to compare 2015 vs. 2016 percentages of patients with an "admission EKG." Results There was a decrease in unwarranted "admission EKGs" among ED boarding patients (44.1% pre-implementation to 27.5% by two years post-implementation) and an increase in unwarranted "preadmission EKGs" (66.1% pre-implementation to 72.8% post-implementation). Age ≥40 and past medical history independently predicted EKG ordering. Discussion The decrease in the ordering of "admission EKGs" but "preadmission EKGs" suggests the decline reflects a true change in ordering and not a general environmental/ecologic decline in ordering. This highlights the importance of careful guideline development and implementation.
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Affiliation(s)
- Brendan Appold
- Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, USA
| | | | - Riaad Persaud
- Emergency Medicine, Northwell Health Long Island Jewish Medical Center, New Hyde Park, USA
| | - Rachel Moss
- Emergency Medicine, Northwell Health Long Island Jewish Medical Center, New Hyde Park, USA
| | | | - Sean P LaVine
- Internal Medicine, Northwell Health Long Island Jewish Medical Center, New Hyde Park, USA
| | - Rohan Bhansali
- Cardiology, Northwell Health Long Island Jewish Medical Center, New Hyde Park, USA
| | - Seungjun Ahn
- Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, USA.,Department of Biostatistics, University of Florida, Gainesville, USA
| | - Mark Richman
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City, USA
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Monahan AC, Feldman SS. Models Predicting Hospital Admission of Adult Patients Utilizing Prehospital Data: Systematic Review Using PROBAST and CHARMS. JMIR Med Inform 2021; 9:e30022. [PMID: 34528893 PMCID: PMC8485197 DOI: 10.2196/30022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/27/2021] [Accepted: 07/28/2021] [Indexed: 12/23/2022] Open
Abstract
Background Emergency department boarding and hospital exit block are primary causes of emergency department crowding and have been conclusively associated with poor patient outcomes and major threats to patient safety. Boarding occurs when a patient is delayed or blocked from transitioning out of the emergency department because of dysfunctional transition or bed assignment processes. Predictive models for estimating the probability of an occurrence of this type could be useful in reducing or preventing emergency department boarding and hospital exit block, to reduce emergency department crowding. Objective The aim of this study was to identify and appraise the predictive performance, predictor utility, model application, and model utility of hospital admission prediction models that utilized prehospital, adult patient data and aimed to address emergency department crowding. Methods We searched multiple databases for studies, from inception to September 30, 2019, that evaluated models predicting adult patients’ imminent hospital admission, with prehospital patient data and regression analysis. We used PROBAST (Prediction Model Risk of Bias Assessment Tool) and CHARMS (Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies) to critically assess studies. Results Potential biases were found in most studies, which suggested that each model’s predictive performance required further investigation. We found that select prehospital patient data contribute to the identification of patients requiring hospital admission. Biomarker predictors may add superior value and advantages to models. It is, however, important to note that no models had been integrated with an information system or workflow, operated independently as electronic devices, or operated in real time within the care environment. Several models could be used at the site-of-care in real time without digital devices, which would make them suitable for low-technology or no-electricity environments. Conclusions There is incredible potential for prehospital admission prediction models to improve patient care and hospital operations. Patient data can be utilized to act as predictors and as data-driven, actionable tools to identify patients likely to require imminent hospital admission and reduce patient boarding and crowding in emergency departments. Prediction models can be used to justify earlier patient admission and care, to lower morbidity and mortality, and models that utilize biomarker predictors offer additional advantages.
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Affiliation(s)
- Ann Corneille Monahan
- Department of Epidemiology & Public Health, School of Public Health, University College Cork, Cork, Ireland
| | - Sue S Feldman
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
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Keverline KJ, Mow SJ, Cyr JM, Platts-Mills T, Brice JH. Barriers to Discharge in Geriatric Long Staying Inpatient and Emergency Department Admissions: A Descriptive Study. Geriatrics (Basel) 2021; 6:78. [PMID: 34449655 DOI: 10.3390/geriatrics6030078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/05/2021] [Accepted: 08/07/2021] [Indexed: 11/23/2022] Open
Abstract
Background: This study describes long length of stay during emergency department (ED) visits and hospital admissions, barriers to discharge, and discharge solutions for geriatric patients. Methods: We conducted a retrospective medical record review of a random sample of 150 ED patients and 150 inpatients with long length of stay (LOS) encounters. Cohorts were characterized by demographics, social determinants of health (e.g., health insurance, housing), medical comorbidities at admission, discharge care coordination, and final disposition. Results: In the ED, the primary barrier to discharge was inadequate inpatient bed availability (63%). In the inpatient setting, barriers to discharge were predominantly due to a demonstrated medical requirement for continued hospitalization (55%), followed by difficulty with coordinating discharge to a skilled nursing facility or rehabilitation center (22%). Discussion: Among long LOS ED patients, discharge delays were often the result of unavailable inpatient beds and services. Reducing the LOS for ED patients may require further investigation as to which hospital services are most frequently utilized by geriatric patients and structuring inpatient bed allocation to prevent extended patient boarding in the ED. Reducing long inpatient LOS may require early identification of high-risk patients and strengthening of relationships with community-based services.
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do Nascimento Rocha HM, da Costa Farre AGM, de Santana Filho VJ. Adverse Events in Emergency Department Boarding: A Systematic Review. J Nurs Scholarsh 2021; 53:458-467. [PMID: 33792131 DOI: 10.1111/jnu.12653] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Overcrowding in emergency departments (EDs) is a worldwide challenge. As a result of the increased demand for EDs, slow internal patient flow, and unavailability of hospital beds, patients are kept in the corridors, causing a boarding effect. Studies have associated boarding in EDs with unfavorable clinical outcomes and adverse events. Thus, the purpose of this systematic review was to describe the effects of ED boarding on the occurrence of adverse events. DESIGN We followed the Meta-Analysis of Observational Studies in Epidemiology checklist and registered this systematic review with PROSPERO (CRD42020117915). METHODS Literature searches were performed using the databases PubMed, Scopus, Latin American and Caribbean Center on Health Sciences Information (LILACS), Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane, as well as Google Scholar, OpenThesis, and the Brazilian Digital Library of Theses and Dissertations from September to November 2019. Cohort or case control studies that evaluated the occurrence of adverse events in patients who remained in an ED, waiting for a hospital bed, were included in the review. RESULTS Seven studies met our eligibility criteria. Boarding in EDs may be related to a reduction in the quality of care, resulting in unfavorable clinical outcomes and adverse events. CONCLUSIONS Boarding in EDs may be related to increases in adverse incidents and events. CLINICAL RELEVANCE The evidence in this review suggests that ED boarding increases the occurrence of unfavorable outcomes and identifies important considerations for future research.
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Martin AJ, Burns EC, Kennett R, Pearson J, Munro-Smith V. Boarding and Day School Students: A Large-Scale Multilevel Investigation of Academic Outcomes Among Students and Classrooms. Front Psychol 2021; 11:608949. [PMID: 33469438 PMCID: PMC7813993 DOI: 10.3389/fpsyg.2020.608949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/02/2020] [Indexed: 11/17/2022] Open
Abstract
Boarding school is a major educational option for many students (e.g., students living in remote areas, or whose parents are working interstate or overseas, etc.). This study explored the motivation, engagement, and achievement of boarding and day students who are educated in the same classrooms and receive the same syllabus and instruction from the same teachers (thus a powerful research design to enable unique comparisons). Among 2,803 students (boarding n = 481; day n = 2,322) from 6 Australian high schools and controlling for background attributes and personality, we found predominant parity between boarding and day students in their motivation, engagement, and achievement. We also found that classroom-average motivation, engagement, and achievement was not significantly affected by the number of boarders (relative to day students) in the classroom. In addition, the effects of boarding were generally not moderated by students’ background or personality attributes. We conclude that boarders have academic opportunities and outcomes that are comparable to their day student counterparts. Implications for students, teachers, and parents are discussed.
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Affiliation(s)
- Andrew J Martin
- School of Education/School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Emma C Burns
- Department of Educational Studies, Macquarie University, Macquarie Park, NSW, Australia
| | - Roger Kennett
- School of Education/School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Joel Pearson
- School of Education/School of Psychology, University of New South Wales, Sydney, NSW, Australia
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Rantala A, Nordh S, Dvorani M, Forsberg A. The Meaning of Boarding in a Swedish Accident & Emergency Department: A Qualitative Study on Patients' Experiences of Awaiting Admission. Healthcare (Basel) 2021; 9:healthcare9010066. [PMID: 33445751 PMCID: PMC7828189 DOI: 10.3390/healthcare9010066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/04/2021] [Accepted: 01/10/2021] [Indexed: 01/10/2023] Open
Abstract
The number of in-hospital beds in Sweden has decreased during recent decades, resulting in the smallest number (2.2 available beds/1000 inhabitants) within the European Union. At the same time, the number of patients attending Accident and Emergency (A&E) departments has increased, resulting in overcrowding and boarding. The aim of this study was to explore the meaning of being subjected to boarding at an A&E department, as experienced by patients. A phenomenological-hermeneutic approach was chosen to interpret and understand the meaning of boarding at A&E. The study was carried out at a hospital in the south of Sweden. Seventeen participants with a mean age of 64 years (range: 35-86 years) were interviewed. The thematic structural analysis covers seven themes: Being in a state of uncertainty, Feeling abandoned, Fearing death, Enduring, Adjusting to the circumstances, Being a visitor in an unsafe place, and Acknowledging the staff, all illustrating that the participants were in a state of constant uncertainty and felt abandoned with no guidance or support from the clinicians. The conclusion is that the situation where patients are forced to wait in A&E, i.e., boarding, violates all conditions for professional ethics, presumably causing profound ethical stress in the healthcare professionals involved. Thus, boarding should be avoided.
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Affiliation(s)
- Andreas Rantala
- Department of Health Sciences, Lund University, SE-221 00 Lund, Sweden;
- Emergency Department, Helsingborg General Hospital, SE-251 87 Helsingborg, Sweden;
- Centre of Interprofessional Cooperation within Emergency Care (CICE), Linnaeus University, SE-251 95 Växjö, Sweden
- Correspondence:
| | - Sören Nordh
- Emergency Department, Helsingborg General Hospital, SE-251 87 Helsingborg, Sweden;
| | - Mergime Dvorani
- Premedic AB, Ambulance Service Hässleholm, SE-281 25 Hässleholm, Sweden;
| | - Anna Forsberg
- Department of Health Sciences, Lund University, SE-221 00 Lund, Sweden;
- Department of Cardiothoracic Surgery, Skåne University Hospital, SE-224 42 Lund, Sweden
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21
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Valipoor S, Hatami M, Hakimjavadi H, Akçalı E, Swan WA, De Portu G. Data-Driven Design Strategies to Address Crowding and Boarding in an Emergency Department: A Discrete-Event Simulation Study. HERD 2020; 14:161-177. [PMID: 33176477 DOI: 10.1177/1937586720969933] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To address prolonged lengths of stay (LOS) in a Level 1 trauma center, we examined the impact of implementing two data-driven strategies with a focus on the physical environment. BACKGROUND Crowding in emergency departments (EDs) is a widely reported problem leading to increased service times and patients leaving without being seen. METHODS Using ED historical data and expert estimates, we created a discrete-event simulation model. We analyzed the likely impact of initiating care and boarding patients in the hallway (hallway care) instead of the exam rooms and adding a dedicated triage space for patients who arrive by emergency medical services (EMS triage) to decrease hallway congestion. The scenarios were compared in terms of LOS, time spent in exam rooms and hallway spaces, service time, blocked time, and utilization rate. RESULTS The hallway care scenario resulted in significantly lower LOS and exam room time only for EMS patients but when implemented along with the EMS triage scenario, a significantly lower LOS and exam room time was observed for all patients (EMS and walk-in). The combination of two simulated scenarios resulted in significant improvements in other flow metrics as well. CONCLUSIONS Our findings discourage boarding of admitted patients in ED exam rooms. If space limitations require that admitted patients be placed in ED hallways, designers and planners should consider enabling hallway spaces with features recommended in this article. Alternative locations for boarding should be prioritized in or out of the ED. Our findings also encourage establishing a triage area dedicated to EMS patients in the ED.
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Affiliation(s)
- Shabboo Valipoor
- Department of Interior Design, College of Design, Construction & Planning, 3463University of Florida, Gainesville, FL, USA
| | - Mohsen Hatami
- M. E. Rinker, Sr. School of Construction Management, College of Design, Construction & Planning, 3463University of Florida, Gainesville, FL, USA
| | - Hesamedin Hakimjavadi
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, 3463University of Florida, Gainesville, FL, USA
| | - Elif Akçalı
- Department of Industrial & Systems Engineering, Herbert Wertheim College of Engineering, 3463University of Florida, Gainesville, FL, USA
| | | | - Giuliano De Portu
- Department of Emergency Medicine, College of Medicine, 3463University of Florida, Gainesville, FL, USA
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Abstract
PURPOSE This paper examines the effect of boarding on obesity among middle school students at boarding schools. DESIGN Quantitative, cross-sectional study. SETTING Data from the China Education Panel Survey (CEPS) were analyzed. The CEPS samples middle school students from 7th grade to 9th grade in China. SUBJECTS The final sample included 3,892 observations of boarding school students. MEASURES Measures included body mass index (BMI) that determined obesity, boarding status, demographic information, and instruments for boarding status. ANALYSIS The instrumental variables approach based on the 2 stage least squares (2SLS) methodology was utilized. The endogenous models and the extended probit models were also applied to the data to confirm the robustness of the results. RESULTS Boarding has a significant negative effect on obesity for middle school boys but a smaller negative effect on obesity for middle school girls. Boarding was estimated to reduce obesity by roughly 14% (p < 0.01) among middle school boys and 6% (p > 0.1) among middle school girls. The overall estimated effect based on the pooled sample was about 10% (p < 0.01). CONCLUSION School or government policies that encourage boarding at school can reduce obesity among middle school students, at least for middle school boys. Boarding at school can be a positive factor in preventing and controlling obesity among middle school students.
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Affiliation(s)
- Linyue Yu
- School of Economics and Management, 47829Beijing Jiaotong University, Haidian District, Beijing, China
| | - Wei Chen
- Department of Economics, 6963Lewis University, Romeoville, IL, USA
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Mohr NM, Wessman BT, Bassin B, Elie‐Turenne M, Ellender T, Emlet LL, Ginsberg Z, Gunnerson K, Jones KM, Kram B, Marcolini E, Rudy S. Boarding of critically Ill patients in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:423-431. [PMID: 33000066 PMCID: PMC7493502 DOI: 10.1002/emp2.12107] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Emergency department boarding is the practice of caring for admitted patients in the emergency department after hospital admission, and boarding has been a growing problem in the United States. Boarding of the critically ill has achieved specific attention because of its association with poor clinical outcomes. Accordingly, the Society of Critical Care Medicine and the American College of Emergency Physicians convened a Task Force to understand the implications of emergency department boarding of the critically ill. The objective of this article is to review the U.S. literature on (1) the frequency of emergency department boarding among the critically ill, (2) the outcomes associated with critical care patient boarding, and (3) local strategies developed to mitigate the impact of emergency department critical care boarding on patient outcomes. DATA SOURCES AND STUDY SELECTION Review article. DATA EXTRACTION AND DATA SYNTHESIS Emergency department-based boarding of the critically ill patient is common, but no nationally representative frequency estimates has been reported. Boarding literature is limited by variation in the definitions used for boarding and variation in the facilities studied (boarding ranges from 2% to 88% of ICU admissions). Prolonged boarding in the emergency department has been associated with longer duration of mechanical ventilation, longer ICU and hospital length of stay, and higher mortality. Health systems have developed multiple mitigation strategies to address emergency department boarding of critically ill patients, including emergency department-based interventions, hospital-based interventions, and emergency department-based resuscitation care units. CONCLUSIONS Emergency department boarding of critically ill patients was common and was associated with worse clinical outcomes. Health systems have generated a number of strategies to mitigate these effects. A definition for emergency department boarding is proposed. Future work should establish formal criteria for analysis and benchmarking of emergency department-based boarding overall, with subsequent efforts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.
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Affiliation(s)
- Nicholas M. Mohr
- Department of Emergency Medicine and Department of AnesthesiaUniversity of Iowa Carver College of MedicineIowa CityIA
| | - Brian T. Wessman
- Department of Anesthesiology and Department of Emergency MedicineWashington University School of MedicineSt. LouisMO
| | - Benjamin Bassin
- Department of Emergency MedicineDivision of Critical CareUniversity of MichiganAnn ArborMI
| | - Marie‐Carmelle Elie‐Turenne
- Department of Emergency Medicine and Department of MedicineCritical Care MedicinePalliative and Hospice MedicineUniversity of FloridaGainesvilleFL
| | - Timothy Ellender
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIN
| | - Lillian L. Emlet
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPA
| | - Zachary Ginsberg
- Kettering Health SystemDepartment of Emergency & Critical Care MedicineDaytonOH
| | - Kyle Gunnerson
- Department of Emergency MedicineDivision of Critical CareUniversity of MichiganAnn ArborMI
| | - Kevin M. Jones
- Program in TraumaR. Adams Cowley Shock Trauma Center, Department of Emergency MedicineUniversity of Maryland School of MedicineBaltimoreMA
| | | | - Evie Marcolini
- Section of Emergency MedicineDepartment of MedicineGeisel School of Medicine at DartmouthHanoverNH
| | - Susanna Rudy
- Department of NursingVanderbilt UniversityNashvilleTN
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Mahmood A, Wyant DK, Kedia S, Ahn S, Powell MP, Jiang Y, Bhuyan SS. Self-Check-In Kiosks Utilization and Their Association With Wait Times in Emergency Departments in the United States. J Emerg Med 2020; 58:829-840. [PMID: 31924466 DOI: 10.1016/j.jemermed.2019.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 10/30/2019] [Accepted: 11/10/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Delayed care in emergency departments (EDs) is a serious problem in the United States. Patient wait time is considered a critical measure of delayed care in EDs. Several strategies have been employed by EDs to reduce wait time, including implementation of self-check-in kiosks. However, the effect of kiosks on wait time in EDs is understudied. OBJECTIVES To assess the association between patient wait time and utilization of self-check-in kiosks in EDs. To investigate a series of other patient-, ED-, and hospital-level predictors of wait time in EDs. METHODS Using data from the 2015 and 2016 National Hospital Ambulatory Medical Care Survey, we analyzed 40,528 ED visits by constructing a multivariable linear regression model of the log-transformed wait time data as an outcome, then computing percent changes in wait times. RESULTS During the study period, about 9% of EDs in the United States implemented kiosks. In our linear regression model, the wait time in EDs with kiosk self-check-in services was 56.8% shorter (95% confidence interval ̶ 130% to ̶ 6.4%, p < 0.05) compared with EDs without kiosk services. In addition to kiosks, patients' day of visit, arrival time, triage assessment, arrival by ambulance, chronic medical conditions, ED boarding, hospitals' full-capacity protocol, and hospitals' location were significant predictors of wait time. CONCLUSIONS Self-check-in kiosks are associated with shorter ED wait time in the United States. However, prolonged ED wait time continues to be a system-wide problem, and warrants multilayered interventions to address this challenge for those who are in acute need of immediate care.
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Affiliation(s)
- Asos Mahmood
- Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, Tennessee
| | - David K Wyant
- The Jack C. Massey Graduate School of Business, Belmont University, Nashville, Tennessee
| | - Satish Kedia
- Division of Social and Behavioral Sciences, School of Public Health, The University of Memphis, Memphis, Tennessee
| | - SangNam Ahn
- Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, Tennessee
| | - M Paige Powell
- Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, Tennessee
| | - Yu Jiang
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, The University of Memphis, Memphis, Tennessee
| | - Soumitra S Bhuyan
- Edward J. Bloustein School of Planning and Public Policy, Rutgers University, New Brunswick, New Jersey
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Smith JL, De Nadai AS, Petrila J, Storch EA. Factors Associated With Length of Stay in Emergency Departments for Pediatric Patients With Psychiatric Problems. Pediatr Emerg Care 2019; 35:716-21. [PMID: 31593981 DOI: 10.1097/PEC.0000000000001651] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Length of stay (LOS) and boarding for pediatric psychiatric patients presenting in the emergency department (ED) have been understudied, despite evidence that children with psychiatric disorders experience longer LOS relative to those without. This investigation examined correlates of LOS and boarding among youth with psychiatric disorders presenting to the ED in a large, statewide database. METHODS Using the 2010 to 2013 Florida ED discharge database, generalized linear mixed models were used to examine for associations between LOS and patient and hospital characteristics among pediatric patients (<18 years) who presented with a primary psychiatric diagnosis (N = 44,328). RESULTS Patients had an overall mean ± SD ED LOS of 5.96 ± 8.64 hours. Depending on the definition used (ie, 12 or 6 hours), between 23% and 58% of transferred patients were boarded. Patient characteristics associated with a longer LOS included female sex, being 15 to 17 years old, Hispanic ethnicity, having Medicaid or VA/TriCare insurance, having impulse control problems, having mood or psychotic disorders, and exhibiting self-harm behaviors. Patient transfer, large hospital size, and rural designation were associated with longer LOS. Teaching hospital status and profit status were not significantly associated with LOS. CONCLUSIONS These data suggest that LOS for pediatric psychiatry patients in the ED varies significantly by psychiatric presentation, patient disposition, and hospital factors. Such findings have implications for quality of care, patient safety, and health outcomes.
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Xiong Y, Gates RS, Green-Miller AR. Factors Affecting Trailer Thermal Environment Experienced by Market Pigs Transported in the US. Animals (Basel) 2018; 8:ani8110203. [PMID: 30423983 PMCID: PMC6262555 DOI: 10.3390/ani8110203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 11/05/2018] [Accepted: 11/06/2018] [Indexed: 12/02/2022] Open
Abstract
Simple Summary Transport conditions can be a challenge for pigs being transported to market. In this study, 40 trips of commercial market pigs transported from the farms to an abattoir were monitored for thermal conditions including temperature and relative humidity in order to better understand thermal variability within the trailer during transport. Variation in thermal environment inside the pig transport trailer was used as an indicator of ventilation pattern during various weather conditions. During cold weather, the front top and bottom zones were warmer than in the rest of the trailer, indicating less ventilation toward the front of the trailer. Conditions were more uniform throughout the trailer for hot temperatures, indicating sufficient ventilation to limit temperature rise. Misting showed the potential to alleviate high temperatures, but resulted in higher THI conditions. No effect of boarding and bedding combination was observed for spatial distribution of trailer interior temperatures. Abstract Extreme weather conditions challenge pig thermoregulation during transport and are addressed by the National Pork Board (NPB) Transport Quality Assurance® (TQA) program that provides guidelines for trailer boarding, bedding, and misting. These guidelines are widely applied, yet very little is known about the microenvironment within the trailer. In this study, TQA guidelines (V4) were evaluated via extensive thermal environment measurements during transport in order to evaluate spatial variability and implications on ventilation pattern. Effects of trailer management strategies including bedding, boarding, and misting were examined and the trailer was monitored for interior temperature rise and THI responses within six separate zones. The trailer thermal environment was not uniformly distributed in the colder trips with the top front and bottom zones were the warmest, indicating these zones had the majority of outlet openings and experienced air with accumulated sensible and latent heat of the pigs. Relatively enhanced thermal environment uniformity was observed during hot trips, suggesting that ventilation patterns and ventilation rate were different for colder vs. warmer weather conditions. Misting applied prior to transport cooled interior air temperature, but also created high THI conditions in some cases. Neither boarding and bedding combinations in the TQA nor boarding position showed impacts on trailer interior temperature rise or spatial distribution of temperature inside the trailer.
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Affiliation(s)
- Yijie Xiong
- Agricultural and Biological Engineering, University of Illinois at Urbana-Champaign, 1304 W. Pennsylvania Ave, Urbana, IL 61801, USA.
| | - Richard S Gates
- Agricultural and Biological Engineering, University of Illinois at Urbana-Champaign, 1304 W. Pennsylvania Ave, Urbana, IL 61801, USA.
| | - Angela R Green-Miller
- Agricultural and Biological Engineering, University of Illinois at Urbana-Champaign, 1304 W. Pennsylvania Ave, Urbana, IL 61801, USA.
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Kroll DS, Karno J, Mullen B, Shah SB, Pallin DJ, Gitlin DF. Clinical Severity Alone Does Not Determine Disposition Decisions for Patients in the Emergency Department with Suicide Risk. Psychosomatics 2017; 59:388-393. [PMID: 29336787 DOI: 10.1016/j.psym.2017.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/05/2017] [Accepted: 12/05/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Boarding of patients with suicide risk in emergency departments (EDs) negatively affects both patients and society. Factors other than clinical severity may frequently preclude safe outpatient dispositions among suicidal patients boarding for psychiatric admission in the ED. OBJECTIVE To determine the extent to which nonclinical factors preclude safe outpatient discharge from the ED among patients boarding for psychiatric admission based on suicide risk. METHODS A survey regarding the importance of 13 clinical and 19 nonclinical barriers to safe outpatient disposition was administered in the ED to 40 adults who were determined by psychiatrists to require inpatient level of psychiatric care due to suicide risk. A second survey regarding whether addressing the nonclinical factors would have enabled a safe outpatient disposition in each case was administered to the psychiatrists who evaluated each patient participant. RESULTS Out of 40 patient participants, 39 cited at least one nonclinical factor that could have enabled a safe outpatient disposition had it been correctable in the ED. According to the psychiatrists who made the decision to hospitalize, 10 (25%) of the patient participants could have been discharged had social support become available. CONCLUSION Both clinical and nonclinical factors affect disposition from the ED after an evaluation for suicide risk. Attention to nonclinical factors should be considered in programmatic efforts to reduce ED boarding of patients with suicide risk.
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Affiliation(s)
- David S Kroll
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA.
| | - Jennifer Karno
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA; Division of Social Work, Brigham and Women's Hospital, Boston, MA
| | - Brian Mullen
- Brigham Digital Innovation Hub, Brigham Health, Boston, MA
| | - Sejal B Shah
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - David F Gitlin
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
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Han CY, Lin CC, Goopy S, Hsiao YC, Barnard A, Wang LH. Waiting and hoping: a phenomenographic study of the experiences of boarded patients in the emergency department. J Clin Nurs 2016; 26:840-848. [PMID: 27805751 DOI: 10.1111/jocn.13621] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2016] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To understand the experiences and concerns of patients in the emergency department during inpatient boarding. BACKGROUND Boarding in the emergency department is an increasingly common phenomenon worldwide. Emergency department staff, patients and their families become more stressed as the duration of boarding in the emergency department increases. Yet, there is limited knowledge of the experiences and concerns of boarded patients. DESIGN The qualitative approach of phenomenography was used in the study. METHODS The phenomenographic study was conducted in one emergency department that treats approximately 15,000 patients each month. Twenty emergency department boarding patients were recruited between July-September 2014. Semi-structured interviews were used for data collection. The seven steps of qualitative data analysis for a phenomenographic study - familiarisation, articulation, condensation, grouping, comparison, labelling and contrasting - were employed to develop an understanding of participants' experiences and concerns during their inpatient boarding in the emergency department. RESULTS The perceptions that emerged from the data were collected into four categories of description of the phenomenon of emergency department boarding patients: a helpless choice; loyalty to specific hospitals and doctors; an inevitable challenge of life; and distrust of the healthcare system. The outcome space for the emergency department boarding patients was waiting and hoping for a cure. CONCLUSION The experiences and concerns of emergency department boarding patients include physical, psychological, spiritual and health system dimensions. It is necessary to develop an integrated model of care for these patients. RELEVANCE TO CLINICAL PRACTICE Understanding the experiences and concerns of patients who are placed on boarding status in the ED will help emergency healthcare professionals to improve the quality of emergency care. There is a need to develop a care model and associated intervention measures for emergency department patients during the boarding process. The results of this study will help health regulatory authorities to develop an appropriate emergency department boarding system so that patients receive better emergency care.
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Affiliation(s)
- Chin-Yen Han
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.,Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Chun-Chih Lin
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.,Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Suzanne Goopy
- Faculty of Nursing, University of Calgary, Calgary, Canada
| | - Ya-Chu Hsiao
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.,Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Alan Barnard
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Li-Hsiang Wang
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan
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Khanna S, Boyle J, Good N, Bell A, Lind J. Analysing the emergency department patient journey: Discovery of bottlenecks to emergency department patient flow. Emerg Med Australas 2016; 29:18-23. [PMID: 27862986 DOI: 10.1111/1742-6723.12693] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/28/2016] [Accepted: 09/17/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Despite significant workflow reform to comply with the federally mandated National Emergency Access Target (NEAT), Australian public hospitals continue to face significant barriers in achieving good ED patient flow. This study was undertaken to identify and analyse the impact of individual waypoints on an ED patient's journey and identify which waypoints act as bottlenecks to a hospital's 4 h ED disposition performance. METHODS This study involves retrospective analysis and simulation employing 2 years of ED administrative data from a sample of two major and two large metropolitan hospitals in Queensland, Australia. The main outcome measures included waypoint wait times (Treatment Delay and Departure Delay), ED length of stay (EDLOS) and compliance with the NEAT target, measured for all (overall NEAT) and admitted (Admitted NEAT) patients. Variations in outcome measures were analysed as functions of hour of day, day of week, departure status and triage category. Simulations identified the impact of potential ED workflow changes in the context of NEAT performance. RESULTS Departure Delay accounted for 60 and 20% of EDLOS across large and major metropolitan hospitals, respectively. Higher gains in NEAT compliance are associated with improvements in departure delay rather than treatment delay. Simulation identified that halving Departure Delay improves Admitted NEAT by up to 22 and 4% at large and major metropolitan hospitals, respectively. CONCLUSIONS The results reinforces the need for a whole-of-hospital effort to address flow bottlenecks, and identify moving a patient from emergency to inpatient care as the critical bottleneck in ED system performance.
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Affiliation(s)
- Sankalp Khanna
- CSIRO Australian e-Health Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Justin Boyle
- CSIRO Australian e-Health Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Norm Good
- CSIRO Australian e-Health Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Anthony Bell
- Department of Emergency Medicine, Critical Care and Clinical Support Services, Metro North Hospital and Health Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - James Lind
- Healthcare Improvement Unit, Healthcare and Innovation Branch, Clinical Excellence Division, Department of Health, Queensland Government, Brisbane, Queensland, Australia
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Smith JL, De Nadai AS, Storch EA, Langland-Orban B, Pracht E, Petrila J. Correlates of Length of Stay and Boarding in Florida Emergency Departments for Patients With Psychiatric Diagnoses. Psychiatr Serv 2016; 67:1169-1174. [PMID: 27364809 PMCID: PMC6176481 DOI: 10.1176/appi.ps.201500283] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Length of stay (LOS) and boarding in the emergency department (ED) for psychiatric patients have been the subject of concern, given the problems with crowding and excessive wait times in EDs. This investigation examined correlates of LOS and boarding in Florida EDs for patients presenting with psychiatric complaints from 2010 to 2013. METHODS Utilizing the Florida ED discharge database, the authors examined the association of LOS and boarding with hospital and encounter factors for adult patients presenting with a primary psychiatric diagnosis (N=597,541). RESULTS The mean LOS was 7.77 hours. Anxiety disorders were the most frequent psychiatric complaint and were associated with the lowest mean LOS compared with other diagnoses (p<.05). Patient encounters resulting in a presentation of intentional self-harm and suicidality or schizophrenia were associated with significantly longer stays compared with other psychiatric diagnoses. Commercial insurance was associated with the shortest average LOS. African Americans, Hispanics, and patients age 45 and older were associated with a longer average LOS. Smaller hospital size, for-profit ownership, and rural designation were associated with a shorter average LOS. Teaching status was not associated with LOS. Furthermore, 73% of encounters resulting in transfers qualified as episodes of boarding (a stay of more than six or more hours in the ED). CONCLUSIONS Extended LOS was endemic for psychiatric patients in Florida EDs.
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Affiliation(s)
- Joseph L Smith
- With the exception of Mr. De Nadai, the authors are with the Department of Health Policy and Management, University of South Florida, Tampa (e-mail: ). Dr. Storch is also with Rogers Behavioral Health-Tampa Bay. Mr. De Nadai is with the Department of Psychology, University of South Florida, Tampa
| | - Alessandro S De Nadai
- With the exception of Mr. De Nadai, the authors are with the Department of Health Policy and Management, University of South Florida, Tampa (e-mail: ). Dr. Storch is also with Rogers Behavioral Health-Tampa Bay. Mr. De Nadai is with the Department of Psychology, University of South Florida, Tampa
| | - Eric A Storch
- With the exception of Mr. De Nadai, the authors are with the Department of Health Policy and Management, University of South Florida, Tampa (e-mail: ). Dr. Storch is also with Rogers Behavioral Health-Tampa Bay. Mr. De Nadai is with the Department of Psychology, University of South Florida, Tampa
| | - Barbara Langland-Orban
- With the exception of Mr. De Nadai, the authors are with the Department of Health Policy and Management, University of South Florida, Tampa (e-mail: ). Dr. Storch is also with Rogers Behavioral Health-Tampa Bay. Mr. De Nadai is with the Department of Psychology, University of South Florida, Tampa
| | - Etienne Pracht
- With the exception of Mr. De Nadai, the authors are with the Department of Health Policy and Management, University of South Florida, Tampa (e-mail: ). Dr. Storch is also with Rogers Behavioral Health-Tampa Bay. Mr. De Nadai is with the Department of Psychology, University of South Florida, Tampa
| | - John Petrila
- With the exception of Mr. De Nadai, the authors are with the Department of Health Policy and Management, University of South Florida, Tampa (e-mail: ). Dr. Storch is also with Rogers Behavioral Health-Tampa Bay. Mr. De Nadai is with the Department of Psychology, University of South Florida, Tampa
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Abstract
This study addressed delays to involuntary mental health examinations experienced by individuals in emergency departments (EDs). Florida statute specifies that involuntary mental health examinations shall take place only at state-designated facilities "without unnecessary delay"-no longer than 12 h until transfer-for individuals in hospital EDs. Individuals in EDs needing involuntary mental health examinations sometimes wait for admission to inpatient units because of unavailability of mental health services. Data collectors at two hospitals reviewed the records of 170 randomly selected ED patients requiring involuntary mental health examinations. Nearly one-half (48.8%) of participants waited longer than the 12-h maximum allowed by Florida law for transfer to an authorized facility. Factors that associated with prolonged waits were being male, increased age, being a Medicare beneficiary, and being intoxicated. State agencies responsible for the regulation of hospitals and mental health facilities should use this data and engage front-line caregivers to identify statutory remedies.
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Affiliation(s)
- Laura Brennaman
- Florida Community Health Action Information Network (CHAIN), FL, USA
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McGlone J, Sapkota A, Johnson A, Kephart R. Establishing Trailer Ventilation ( Boarding) Requirements for Finishing Pigs during Transport. Animals (Basel) 2014; 4:515-23. [PMID: 26480321 DOI: 10.3390/ani4030515] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 07/25/2014] [Accepted: 07/28/2014] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Transport is an inevitable process in the modern swine industry due to the multiple-site approach to raising pigs and transport can be a significant source of stress to the animals, which raises a welfare concern. Maintaining the environment inside the transport trailer is crucial for pig comfort. This study aims to determine the amount of ventilation, or varied side-wall boarding, required to keep pigs within their thermal comfort zone. Examination of 302 trailers transporting 48,143 pigs found that pig losses were highest when low boarding levels (open sides) were used in cold air temperatures (<5 °C). In mild air temperatures (5 to 26 °C), boarding levels had little impact on pig losses. Abstract Specifically, this study aimed to establish the effects on mortality and morbidity of boarding levels (amount of side-wall trailer ventilation) for finishing pigs in mild weather (8.80 ± 0.30 °C, 71.70% ± 1.12% humidity). Pigs from commercial finishing sites were transported in 302 pot-bellied trailers to commercial processing plants. Measures collected at the processing plant were rates of dead on arrival (DOA), non-ambulatory, non-injured (NANI), non-ambulatory, injured (NAI), and total dead and down (D&D). Boarding levels (% that side walls were closed off with inserted boards) were divided into 3 bins: low, medium, and high, and outside temperature was divided into 4 bins <5 °C, 5.10–10 °C, and 10.10–15 °C and >15 °C. Average rates of DOA, NANI, NAI, and D&D were approximately 0.30%, 0.12%, 0.04%, and 0.46%, respectively. The D&D was highest when boarding level was low with temperatures <5 °C (p < 0.05). However, variations in boarding level (medium and high boarding) in the temperature range of 5.10 °C to 23.30 °C did not affect pig losses.
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Stephens RJ, White SE, Cudnik M, Patterson ES. Factors associated with longer length of stay for mental health emergency department patients. J Emerg Med 2014; 47:412-9. [PMID: 25074781 DOI: 10.1016/j.jemermed.2014.04.040] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 01/30/2014] [Accepted: 04/22/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mental health patients can experience long lengths of stay in the emergency department (ED). Reducing boarding times for mental health patients might improve care for all ED patients. OBJECTIVE The objective of this study was to identify patient factors that are correlated with extremely long lengths of stay (EL-LOS) for mental health patients in the ED. METHODS A retrospective, case-control study compared mental health patients experiencing lengths of stay longer than 24 h to those with lengths of stay <24 h. The study was conducted at an urban, academic ED and Level I trauma center. Sequential chi-squared tests were used to detect significant differences on the outcome measure. Logistic regression was used to determine factors that made significant contributions to predicting EL-LOS. The outcome measure was patients' length of stay in the ED. The factors analyzed were patient demographics, insurance status, day of arrival and departure, placement (admitted locally, admitted remotely, or discharged), chief complaint, and diagnostic category. RESULTS Patient-level factors associated with EL-LOS were self-pay status, admission to inpatient care, transfer to a remote facility, and suicidal ideation. Admission to inpatient care and self-pay status made significant nonredundant contributions to predicting EL-LOS. In addition, mental health patients arriving on a weekday were significantly more likely to be admitted to inpatient care than those arriving on weekends. CONCLUSIONS Factors were identified that correlated with long lengths of stay in the ED for mental health patients. Increasing timely access to inpatient beds for mental health patients, in particular by improving access to insurance that covers inpatient psychiatric care and eliminating unique mental health requirements to obtain prior authorization for placement, would likely reduce these patients' lengths of stay.
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Affiliation(s)
- Robert J Stephens
- Department of Integrated Systems Engineering, Ohio State University, Columbus, Ohio
| | - Susan E White
- School of Health and Rehabilitation Sciences, College of Medicine, Ohio State University, Columbus, Ohio
| | - Michael Cudnik
- Department of Emergency Medicine, Ohio State University, Columbus, Ohio
| | - Emily S Patterson
- School of Health and Rehabilitation Sciences, College of Medicine, Ohio State University, Columbus, Ohio
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Viccellio P, Zito JA, Sayage V, Chohan J, Garra G, Santora C, Singer AJ. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med 2013; 45:942-6. [PMID: 24063879 DOI: 10.1016/j.jemermed.2013.07.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 07/02/2013] [Accepted: 07/20/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Boarding of admitted patients in the emergency department (ED) is a major cause of crowding. One alternative to boarding in the ED, a full-capacity protocol where boarded patients are redeployed to inpatient units, can reduce crowding and improve overall flow. OBJECTIVE Our aim was to compare patient satisfaction with boarding in the ED vs. inpatient hallways. METHODS We performed a structured telephone survey regarding patient experiences and preferences for boarding among admitted ED patients who experienced boarding in the ED hallway and then were subsequently transferred to inpatient hallways. Demographic and clinical characteristics, as well as patient preferences, including items related to patient comfort and safety using a 5-point scale, were recorded and descriptive statistics were used to summarize the data. RESULTS Of 110 patients contacted, 105 consented to participate. Mean age was 57 ± 16 years and 52% were female. All patients were initially boarded in the ED in a hallway before their transfer to an inpatient hallway bed. The overall preferred location after admission was the inpatient hallway in 85% (95% confidence interval 75-90) of respondents. In comparing ED vs. inpatient hallway boarding, the following percentages of respondents preferred inpatient boarding with regard to the following 8 items: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED. CONCLUSIONS Patients overwhelmingly preferred the inpatient hallway rather than the ED hallway when admitted to the hospital.
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Affiliation(s)
- Peter Viccellio
- Department of Emergency Medicine, Stony Brook University, Stony Brook, New York
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