Predicting ambulance diversion in an adult Emergency Department using a Gaussian process

When the Emergency Department (ED) reaches a critical level of overcrowding, it diverts ambulances to other hospitals. We evaluated the accuracy of a Gaussian process for prediction of ambulance diversion using March 1, 2005 November 30, 2005 data. The area under the receiver operating curve (AUC) for 120 minutes in advance was 0.93 (SE: 0.19). The instrument demonstrated a high AUC and may be used to alert ED managers earlier of a diversion episode.

Leaving critical care: facilitating a smooth transition

Patient transfers from one area to another occur frequently within the inpatient healthcare environment. During transfers, nurses pass on information about patients to one another in a variety of ways. This article discusses the types of patient transfers, the problems that can occur throughout the transfer process, and strategies to decrease the identified problems. The perspectives of both the nursing staff and patients/families illustrate concerns related to patient transfers. The most important aspect of the patient transfer is systematically communicating necessary information to the receiving nurse in such a way that patient safety is not compromised and continuity of care is enhanced.

The Effect of Referral and Transfer Patients on Hospital Funding in a Capitated Health Care Delivery System

OBJECTIVES

(1) To investigate whether inpatients referred or transferred between facilities result in increased financial loss compared with those admitted directly, in a health care delivery system funded by capitation methods. (2) To determine whether the higher cost of those patients transferred or referred is fairly compensated by a diagnosis-based risk adjustment system, and whether tertiary care facilities bear an unfair financial burden for such patients in a capitated financing environment.

METHODS

The study cohort included all Veterans Affairs (VA) beneficiaries who received inpatient care during fiscal year (FY) 2004. Referral was defined as an outpatient visit to 1 facility followed by an admission to another facility. Transfers were consecutive inpatient stays at different hospitals. We defined loss as cost minus the share of budget determined by a Diagnostic Cost Group-based allocation. Both t tests and linear regression were used to compare the effect on cost and loss for patients transferred or not and referred or not.

RESULTS

Mean loss to a facility for patients transferred in was 1231 dollars more than for those not transferred. Mean loss for referred patients was 3341 dollars more than for those not referred, controlling for disease burden. For tertiary hospitals, the difference in losses for transfer patients was less than for other hospitals but greater for referral patients.

CONCLUSIONS

Patients referred or transferred from other facilities are more costly than those who are not. The difference may not be compensated by a diagnosis-based allocation system. A capitated health care system may consider additional funding to cover the cost of such patients.

Innovative Approach to the Aims for Improvement

Los Angeles County is in crisis with its emergency ambulatory care. Many barriers exist at the hospital level that affect patient throughput. A case study is presented for St. Francis Medical Center, a 384-bed hospital in southeast Los Angeles. Its governing board has put out a call to have its emergency department oversee intraprocess and interprocess improvements to enhance patient movement through the system. These innovative front- and back-end initiatives are examined using the Institute of Medicine's Six Aims for Improvement. Details on each of the initiatives are provided along with how the leadership monitors the progress.

Patient navigators show the way to faster flow

Nurses or physician assistants designated as patient navigators can ease the burden on the rest of the staff, improve relations with outside physicians, and improve patient flow in your ED. Provide them with separate phone numbers that primary care physicians can call to check on the condition of referred patients. Make them an integral part of your bed flow team, and have them serve as liaisons to admitting. Navigators also can be used to check with radiology when test results appear to be delayed.

Advanced statistics: developing a formal model of emergency department census and defining operational efficiency

BACKGROUND

Emergency department (ED) crowding has been a frequent topic of investigation, but it is a concept without an objective definition. This has limited the scope of research and progress toward the development of consistent and meaningful operational responses.

OBJECTIVES

To develop a straightforward model of ED census that incorporates concepts of ED crowding, daily patient surge, throughput time, and operational efficiency.

METHODS

Using 2005-2006 patient encounter data at a Level 1 urban trauma center, a set of three stylized facts describing daily patterns of ED census was observed. These facts guided the development of a formal, mathematical model of ED census. Using this model, a metric of ED operational efficiency and a forecast of ED census were developed.

RESULTS

The three stylized facts of daily ED census were 1) ED census is cyclical, 2) ED census exhibits an input-output relationship, and 3) unexpected shocks have long-lasting effects. These were represented by a three-equation system. This system was solved for the following expression, Census(t) = A(.) + B(.) cos(vT + epsilon) + a(e(t)), that captured the time path of ED census. Using nonlinear estimation, the parameters of this expression were estimated and a forecasting tool was developed.

CONCLUSIONS

The basic pattern of ED census can be represented by a straightforward expression. This expression can be quickly adapted to a variety of inquiries regarding ED crowding, daily surge, and operational efficiency.

Easing the Strain on a Pediatric Tertiary Care Center

OBJECTIVE

To evaluate the ability of a regionalized system to safely transfer patients requiring admission from a referral center to either regional or community hospitals.

DESIGN

Cohort study of children requiring admission. Following transfer, a questionnaire was administered to eligible caregivers. Subsequent emergency department (ED) use was assessed by comparing children who were transferred with those who were not.

SETTING

The Hospital for Sick Children, Toronto, Ontario, Canada, from April 1, 2003, through March 31, 2004.

PARTICIPANTS

Caregivers of 371 children who underwent transfer from a tertiary care center ED to either a regional or a community hospital were eligible; 344 were contacted. Two hundred fifty-three children for whom transfer was considered but was not performed served as a comparison group. Intervention Questionnaire administered to caregivers, combined with database review.

MAIN OUTCOME MEASURES

Failure of the transfer process, caregiver satisfaction, and future tertiary care center ED use.

RESULTS

Five children experienced intravenous access problems, and 4 children experienced delayed antibiotic administration. Caregiver satisfaction was 92.3% with the transfer process and 84.4% with the care at the receiving hospital. Forty-seven percent of caregivers indicated that they would agree to a similar transfer in the future. Two years later, fewer transferred children (39.9%) than those who were not transferred (49.6%) had revisited the tertiary care center ED (odds ratio, 1.52; 95% confidence interval, 1.10-2.10). The mean number of visits was unchanged (95% confidence interval of the difference, -0.44 to 0.21 visits).

CONCLUSIONS

Although we found the redistribution program to be safe, caregivers stated a preference not to be transferred again. The redistribution system did not substantially alter tertiary care center ED use.

Predictors of Mortality Following Involuntary Interinstitutional Relocation

Relocation is traumatic for older adults. There is a paucity of literature about the characteristics of individuals who are most susceptible to negative effects of relocation. Residents of a nursing home that closed were compared with residents of a control institution to determine whether relocation had a significant effect on mortality and to identify risk factors for death. The difference in mortality was significant. A Cox regression model demonstrated that the only variable to achieve significance in predicting mortality was the relocation itself. Research must evaluate strategies that will reduce the negative effects of involuntary relocation.

Decisionmaking in Hospital Earthquake Evacuation: Does Distance From the Epicenter Matter?

STUDY OBJECTIVE

Over large expanses, the risk for hospital damage from an earthquake attenuates as the distance from the epicenter increases, which may not be true within the immediate disaster zone (near field), however. The following study examines the impact of epicenter distance and ground motion on hospital evacuation and closure for those structures near the epicenter of the 1994 Northridge Earthquake and the implications for patient evacuation.

METHODS

This is a retrospective case-control study of all hospitals reporting off-site evacuations or permanent closure because of damage from the January 17, 1994, earthquake in Northridge, CA. Control hospitals were randomly identified from those facilities that did not evacuate patients. Distances from the epicenter and peak ground accelerations were calculated for each hospital from Trinet ShakeMap data and compared.

RESULTS

Eight hospitals evacuated patients (study group); 4 of these hospitals were condemned. These were compared to 8 hospitals that did not evacuate patients (control group). The median epicenter-to-hospital distance for evacuated facilities was 8.1 miles (interquartile range [IQRs] 4.0 to 17.2 miles), whereas that for nonevacuated facilities was 14.1 miles (IRQ 10.5 to 17.0 miles). The difference in the median distances was 6.0 miles (95% confidence interval -4.8 to 11.9 miles). The peak ground acceleration had a median of 0.77 g (IQR 0.53 to 0.85 g) for study hospitals and a median of 0.36 g (IQR 0.24 to 0.50 g) for control hospitals, where 1 g equals the force of gravity. The difference in median acceleration of 0.41 g (95% CI 0.14 to 0.55 g) was significant (P=.009).

CONCLUSION

The distances from the epicenter for evacuated or condemned facilities and control hospitals do not appear to differ in the near field. Peak ground acceleration is a superior indicator of the risk for hospital damage and evacuation. Physicians can obtain these data in real time from the Internet and should transfer patients to facilities in areas of lower recorded peak ground acceleration regardless of distance from the epicenter.

Lessons from Hurricane Rita: the University of Texas Medical Branch Hospital's evacuation

In September 2005, the University of Texas Medical Branch at Galveston (UTMB) was threatened by Hurricane Rita, a category five storm. Abandoning its historic practice of clearing the hospital of all but the sickest patients, UTMB rapidly organized and conducted the first total evacuation in its 114-year history. The authors report how this was accomplished and lessons learned. Specific factors were crucial for success, including identifying an incident commander with sole authority to make decisions, developing and communicating a set of guiding principles, setting patient safety as our top priority, establishing an incident command center that consolidated vital institutional functions, avoiding delays in deciding to evacuate, identifying strategic partners, selecting essential personnel who would not be distracted by personal concerns during the emergency, and conducting periodic trial runs of emergency preparedness. Complex demands for communication were not met as well as was hoped. Technical problems were encountered with some communication devices that proved inoperable; trial runs would have probably revealed these problems in advance. Also, in-transit communication could be improved-not always knowing which patients were where, what vehicles were mired in stalled traffic, and what relocations occurred impeded optimal communication with patients' family members. Finally, a system ensuring that the recipients of UTMB's electronic records had the proper software to receive them would have facilitated communication and helped record keeping. The authors encourage physicians, as essential members of the health care team, to become better prepared to respond to disasters.

What Do We Really Know About the Transition to Adult-Centered Health Care? A Focus on Cerebral Palsy and Spina Bifida

OBJECTIVES

To address the lack of synthesis regarding the factors, processes, and outcomes specific to the transition from child-centered to adult-centered health care for people with cerebral palsy (CP) and spina bifida (SB); more specifically, to identify barriers, to outline key elements, to review empirical studies, and to make clinical and research recommendations.

DATA SOURCES

We searched Medline and CINAHL databases from 1990 to 2006 using the key words: transition, health care transition, pediatric health care, adult health care, health care access, health care use, chronic illness, special health care needs, and physical disability. The resulting studies were reviewed with a specific focus on clinical transition for persons with CP and SB, and were supplemented with key information from other diagnostic groups.

STUDY SELECTION

All studies meeting the inclusion criteria were included.

DATA EXTRACTION

Each article classified according to 5 criteria: methodology, diagnostic group, country of study, age group, and sample size.

DATA SYNTHESIS

We identified 149 articles: 54 discussion, 21 case series, 28 database or register, 25 qualitative, and 34 survey articles (some included multiple methods). We identified 5 key elements that support a positive transition to adult-centered health care: preparation, flexible timing, care coordination, transition clinic visits, and interested adult-centered health care providers. There was, however, limited empirical evidence to support the impact of these elements.

CONCLUSIONS

This review summarizes key factors that must be considered to support this critical clinical transition and sets the foundation for future research. It is time to apply prospective study designs to evaluate transition interventions and determine long-term health outcomes.

Reforming the acute phase of the inpatient journey

The medical admissions unit (MAU) of the Royal Free Hospital, London, should receive all acute accident and emergency (A&E) medical admissions. The unit aims to discharge 60% of patients and to transfer the remainder to a base ward within 48 hours of admission. This study tracked the patient journey from admission to A&E through the MAU during two parallel weeks, one year apart. Key bottlenecks were identified in the first audit and reforms implemented prior to the second. These reforms included improved transfer to base wards, improved weekend work patterns and improved access to investigation, specialist teams and pharmacy. The reforms served to facilitate the patient journey. A greater proportion of acute medical admissions were managed on the MAU and the number of patients exceeding a 48-hour stay fell from 55% to 10%. Both study periods demonstrated a peak in transfer activity from A&E in the 20 minutes before the four-hour target.

Case managers optimize patient safety by facilitating effective care transitions

In this new era of patient safety, the case manager, as an advocate and facilitator of care, has a pivotal role on the front line of healthcare delivery. Effective communication and collaboration between disciplines is key to the promotion of patient safety, and ultimately the avoidance of life-threatening medical errors. Across the healthcare continuum and within hospitals in particular, patients are routinely transferred from one service to another, from one level of care to another, or from one provider to another. As patients are stabilized and transitioned through the hospital system, there are multiple hand-offs of care or care transitions that can often expose the patient to fragmented service and increase the risk of communication breakdown. Ineffective hand-offs can result in a disruption of continuity between one level of care and the next. In a culture that places a strong emphasis on patient safety, case managers can facilitate opportunities that ease care transitions whereby a change in venue is no longer perceived as a disruption in the flow of care but rather is viewed as a coordinated changeover where cautious and comprehensive communication sets the tone for the continued delivery of safe and effective healthcare.

Expedited transfer for primary percutaneous coronary intervention: a program evaluation

BACKGROUND

A shorter time from symptom onset to reperfusion is associated with improved outcomes for patients with ST-segment elevation myocardial infarction (MI). Primary percutaneous coronary intervention is a favourable method of reperfusion if performed effectively and expeditiously. We sought to evaluate the impact of an expedited pre-hospital diagnosis and transfer pathway developed by a multidisciplinary team on the door-to-balloon time in a large urban community.

METHODS

We included all patients with ST-segment elevation MI who presented within 12 hours after symptom onset and who sought medical attention through Emergency Medical Services within the boundaries of the city of Calgary in the 16 months following the introduction of the pathway in June 2004. The primary aim was to determine the proportion of patients who received percutaneous coronary intervention within the recommended door-to-balloon time of 90 minutes.

RESULTS

The 358 patients (268 men) in the study cohort had a mean age of 63.2 (standard deviation 12.7) years; 140 (39.1%) had an anterior MI; and 23 (6.4%) had cardiogenic shock. The introduction of the pathway resulted in a median door-to-balloon time of 62 (interquartile range 45-84) minutes. A door-to-balloon time within 60 minutes and within the currently recommended 90 minutes was achieved in 48.9% and 78.8% of the patients respectively. The in-hospital and 30-day mortality rates were both 3.1%.

INTERPRETATION

In a community with multiple regional hospitals and a single facility for percutaneous coronary intervention, the implementation of a multidisciplinary pre-hospital diagnosis and transfer pathway was feasible and resulted in most patients in the study cohort receiving primary percutaneous coronary intervention within the recommended door-to-balloon time of 90 minutes.

Emergency Department Physician Activation of the Catheterization Laboratory and Immediate Transfer to an Immediately Available Catheterization Laboratory Reduce Door-to-Balloon Time in ST-Elevation Myocardial Infarction

Background— Consensus guidelines and hospital quality-of-care programs recommend that ST-elevation myocardial infarction patients achieve a door-to-balloon time of ≤90 minutes. However, there are limited prospective data on specific measures to significantly reduce door-to-balloon time.

Methods and Results— We prospectively determined the impact on median door-to-balloon time of a protocol mandating (1) emergency department physician activation of the catheterization laboratory and (2) immediate transfer of the patient to an immediately available catheterization laboratory by an in-house transfer team consisting of an emergency department nurse, a critical care unit nurse, and a chest pain unit nurse. We collected door-to-balloon time for 60 consecutive ST-elevation myocardial infarction patients undergoing emergency percutaneous intervention within 24 hours of presentation from October 1, 2004, through August 31, 2005, and compared this group with 86 consecutive ST-elevation myocardial infarction patients from September 1, 2005, through June 26, 2006, after protocol implementation. Median door-to-balloon time decreased overall (113.5 versus 75.5 minutes; P <0.0001), during regular hours (83.5 versus 64.5 minutes; P =0.005), during off-hours (123.5 versus 77.5 minutes; P <0.0001), and with transfer from an outside affiliated emergency department (147 versus 85 minutes; P =0.0006). Treatment within 90 minutes increased from 28% to 71% ( P <0.0001). Mean infarct size decreased (peak creatinine kinase, 2623±3329 versus 1517±1556 IU/L; P =0.0089), as did hospital length of stay (5±7 versus 3±2 days; P =0.0097) and total hospital costs per admission ($26 826±29 497 versus $18 280±8943; P =0.0125).

Conclusions— Emergency department physician activation of the catheterization laboratory and immediate transfer of the patient to an immediately available catheterization laboratory reduce door-to-balloon time, leading to a reduction in myocardial infarct size, hospital length of stay, and total hospital costs.