The effect of physician triage on emergency department length of stay

BACKGROUND

Emergency Department (ED) overcrowding is a serious public health issue, but few solutions exist.

OBJECTIVES

We sought to determine the impact of physician triage on ED length of stay for discharged and admitted patients, left-without-being-seen (LWBS) rates, and ambulance diversion.

METHODS

This was a pre-post study performed using retrospective data at an urban, academic tertiary care, Level I trauma center. On July 11, 2005, physician triage was initiated from 1:00 p.m. to 9:00 p.m., 7 days a week. An additional physician was placed in triage so that the ED diagnostic evaluation and treatment could be started in waiting room patients. Using the hospital information system, we obtained individual patient data, ED and waiting room statistics, and diversion status data from a 9-week pre-physician triage (May 11, 2005 to July 10, 2005) and a 9-week physician triage (July 11, 2005 to September 9, 2005) period.

RESULTS

We observed that overall ED length of stay decreased by 11 min, but this decrease was entirely attributed to non-admitted patients. No difference in ED length of stay was observed in admitted patients. LWBS rates decreased from 4.5% to 2.5%. Total time spent on ambulance diversion decreased from 5.6 days per month to 3.2 days per month.

CONCLUSION

Physician triage was associated with a decrease in LWBS rates, and time spent on ambulance diversion. However, its effect on ED LOS was modest in non-admitted ED patients and negligible in admitted patients.

EMERGENCY DEPARTMENT EVALUATION OF THE CHEST PAIN PATIENT

The emergency physician must have a high degree of suspicion for myocardial ischemia in patients presenting with no obvious for their chest pain. The role of the emergency physician is to determine a relative risk for each patient and to order the appropriate studies to minimize the risk of missed myocardial infarction as well as to recognize acute ischemia or infarction and manage it aggressively. It is not possible to rule out myocardial ischemia or infarction subjectively. It is the opinion of these authors that some form of further testing should be performed on patients in all categories, except those determined to be at very low risk.

Biogenesis and regulation of the Vibrio cholerae toxin-coregulated pilus: analogies to other virulence factor secretory systems

Biogenesis of the toxin-coregulated pilus (TCP) of Vibrio cholerae 01 is essential for successful bacterial colonization of the small intestine. Pilus assembly requires the products of at least seven genes located on the chromosome adjacent to the pilin-encoding gene, tcpA. Previously reported TnphoA insertions in the TCP-assembly-deficient V. cholerae strains, KP2.21 and KP4.2, were isolated from the chromosome for further analysis. Nucleotide sequencing of the tcpE::phoA and tcpF::phoA fusions and corresponding clones of the region containing the intact genes revealed the presence of two open reading frames (ORFs) of 340 and 338 amino acids, designated TcpE and TcpF, respectively. The partial sequence of an ORF downstream from the TcpF coding sequence was determined to correspond to the global virulence regulator, ToxT. Proteins corresponding to the observed ORFs were visualized with the T7 promoter/RNA polymerase expression system. Computer-generated alignment algorithms predict that a homology exists between TcpE and the Klebsiella pneumoniae pullulanase secretion proteins PulD and PulF, the Xanthomonas campestris extracellular enzyme secretion factor XpsF, the Bacillus subtilis DNA competence protein ComG-ORF2, and the Yersinia enterocolitica Yop secretion determinant YscC. These observations provide a model to investigate further the relationship between the secretion mechanisms utilized by these seemingly diverse virulence determinants. Additionally, an extreme C-terminal segment of TcpE shows striking homology to the transmembrane segment of the eukaryotic integrin beta-1 chain, which could imply a role for TcpE in not only TCP secretion, but also host cell interaction.