Frequency, determinants and impact of overcrowding in emergency departments in Canada: a national survey

Several reports have documented the prevalence and severity of emergency department (ED) overcrowding at specific hospitals or cities in Canada; however, no study has examined the issue at a national level. A 54-item, self-administered, postal and web-based questionnaire was distributed to 243 ED directors in Canada to collect data on the frequency, impact and factors associated with ED overcrowding. The survey was completed by 158 (65% response rate) ED directors, 62% of whom reported overcrowding as a major or severe problem during the past year. Directors attributed overcrowding to a variety of issues including a lack of admitting beds (85%), lack of acute care beds (74%) and the increased length of stay of admitted patients in the ED (63%). They perceived ED overcrowding to have a major impact on increasing stress among nurses (82%), ED wait times (79%) and the boarding of admitted patients in the ED while waiting for beds (67%). Overcrowding is not limited to large urban centres; nor is it limited to academic and teaching hospitals. The perspective of ED directors reinforces the need for further examination of effective policies and interventions to reduce ED overcrowding.

The use of health care policy to facilitate evidence-based knowledge translation in emergency medicine

Health care policy can facilitate emergency medicine knowledge translation (KT). Because of this, the 2007 Academic Emergency Medicine Consensus Conference on KT identified a specific theme regarding issues of health care policy and KT. Six months before the Consensus Conference, international experts in the area were invited to communicate on health care policies regarding all areas of KT via e-mail and "Google groups." From this communication, and using available evidence, specific recommendations and research questions were developed. At the Consensus Conference, additional comments were incorporated. This report summarizes the results of this collaborative effort and provides a set of recommendations and accompanying research questions to guide development, implementation, and evaluation of health care policies intended to promote KT in emergency medicine. The recommendations are to 1a) involve appropriate stakeholders in the health care policy process; 1b) collaborate with policy makers when health care policy focus areas are being developed; 2) use previously validated clinical practice guideline development tools; 3) address implementation issues during the development of health care policies; 4) monitor outcomes with performance measures appropriate to different practice environments; and 5) plan periodic reviews to uncover new clinical evidence, new methods to improve KT, and new technologies. To advance the further development of these recommendations, a research agenda is proposed.

Development of the capacity necessary to perform and promote knowledge translation research in emergency medicine

Knowledge translation (KT) research in emergency medicine (EM) is in its infancy, and few EM investigators have the skills needed to perform KT research. Furthermore, the capacity to perform such KT research is underdeveloped in the field of EM. This consensus group used an iterative process to set forth initial recommendations and suggest methods for the development of EM KT research capacity. We have emphasized the need to form sustainable linkages, particularly between EM researchers and KT scientists, and to educate EM researchers in KT research methods to help create and sustain a culture of KT in our field. EM KT researchers must also engage local and national organizations and stakeholders to fund and promote KT research. Finally, we see the need to further develop and support EM research networks, as these networks will be both the clinical laboratories in which to perform the KT research and the incubators for the development of EM KT research experts.

Impact of a standardized communication system on continuity of care between family physicians and the emergency department

OBJECTIVE

It has been suggested that continuity of care is hampered because of the lack of communication between emergency departments (EDs) and primary care providers. A web-based, standardized communication system (SCS) that enables family physicians (FPs) to visualize information regarding their patients' ED visits was developed. This paper aims to evaluate the impact of this SCS on continuity of care.

METHODS

We conducted an open, 4-period crossover, cluster-randomized controlled trial of 23 FP practices. During the intervention phase, FPs received detailed reports via SCS, while in the control phase they received mailed copies of the ED notes. Continuity of care was evaluated with a web questionnaire completed by FPs 21 days after the ED visit. The primary measures of continuity of care were knowledge of ED visit (quality and quantity), patient management and follow-up rate.

RESULTS

We analyzed a total of 2022 ED visits (1048 intervention and 974 control). The intervention group received information regarding the ED visit more often (odds ratio [OR] 3.14, 95% confidence interval [CI] 2.6-3.79), found the information more useful (OR 5.1, 95% CI 3.49-7.46), possessed a better knowledge of the ED visit (OR 6.28, 95% CI 5.12-7.71), felt they could better manage patients (OR 2.46, 95% CI 2.02-2.99) and initiated actions more often following receipt of information (OR 1.62, 95% CI 1.36-1.93). However, there was no significant difference in the follow-up rate at FPs offices (OR 1.25, 95% CI 0.97-1.61).

CONCLUSION

The use of SCS between an ED and FPs led to significant improvements in continuity of care by increasing the usefulness of transferred information and by improving FPs' perceived patient knowledge and patient management.

Underutilization of acetylsalicylic acid for acute coronary syndromes in the emergency department

OBJECTIVE

Acetylsalicylic acid (ASA) is a simple and cost-effective treatment for acute coronary syndromes (ACS). Our objectives were to determine the frequency of ASA administration in the emergency department (ED) for patients with acute myocardial infarction or unstable angina, and to identify patient characteristics associated with its administration.

METHODS

This is a retrospective chart review of patients discharged with a final diagnosis of ACS. Data on age, gender, mode of presentation, presence of chest pain at triage, administration of ASA or not in the ED, dosage and form of ASA received, timing of administration, presence of contraindications to ASA and use of regular ASA prior to ED presentation were recorded.

RESULTS

Six hundred and one charts were analyzed. Five hundred and fifty patients (91.5%) received ASA. Only 444 (73.9%) of these 550 patients were administered the ASA appropriately, according to the American Heart Association / American College of Cardiology (AHA/ACC) guidelines. Univariate analysis showed that chart notes "Transport by ambulance," "Allergy to ASA" and "Gastrointestinal bleed" were associated with a lower probability of the patient being administered ASA. If a patient was noted as taking ASA regularly, it increased the chance of this patient being administered ASA in the ED.

CONCLUSION

Although the study ED performed well, administering ASA to 91.5% of patients with ACS, only 73.9% of the patients who received ASA were administered the ASA appropriately, as recommended in the AHA/ACC guidelines. Educational strategies and system changes are necessary to increase the proportion of eligible ACS patients who receive appropriate ASA therapy.

The in-hospital interval: a description of EMT time spent in the emergency department

OBJECTIVE

We conducted a time-motion study of emergency medical technician (EMT) flow in an urban, academic emergency department (ED). Our objective was to describe the activity of the EMTs during their time in the ED. Secondary objectives included the association of time of day, age, and triage code with the various time intervals.

METHODS

In this descriptive study, we combined information from two databases: prospectively collected time-motion data of EMTs presenting to one ED and an electronically collected prehospital call database of time data. The pretriage, triage, and posttriage time intervals were calculated, as well as total time spent in the ED as a proportion of total call time. Mean times with 95% confidence intervals (CIs) were reported. Analysis of variance was performed to examine the associations of time of day, age, and triage code with time intervals.

RESULTS

Data were available for 152 calls. The mean pretriage interval was 8.79 (95% CI, 7.55-10.04) minutes, the mean triage interval was 5.14 (95% CI, 4.49-5.79) minutes, and the mean posttriage interval was 31.33 (95% CI, 29.08-33.58) minutes. The proportion of the total call time that was spent in the ED was 45%. Subgroup analysis showed significant differences only between total time spent in the ED in the 7:30-10:00 AM period as compared with the other periods.

CONCLUSIONS

More time was spent in the pretriage and posttriage intervals as compared with the triage interval. Further time-motion studies in the ED will be necessary to plan interventions aimed at decreasing the time spent in-hospital by EMTs.

Delays to reperfusion therapy in acute ST-segment elevation myocardial infarction: results from the AMI-QUEBEC Study

BACKGROUND

Through the AMI-QUEBEC Study we sought to describe delays to reperfusion therapy for ST-segment elevation myocardial infarction (STEMI) and to identify factors associated with prolonged delays.

METHODS

We reviewed the charts of all consecutive patients with STEMI admitted to 17 hospitals in the province of Quebec in 2003 to obtain data on the time from presentation to reperfusion therapy. Data were available for 1189 (83.0%) of 1432 patients.

RESULTS

The median delay to reperfusion therapy was 32 minutes (first and third quartile [Q1, Q3] 20, 49) for 535 patients who received fibrinolytic therapy, 109 minutes (Q1, Q3 79, 150) for 455 patients who underwent primary percutaneous coronary intervention (PCI) at the initial hospital of presentation and 142 minutes (Q1, Q3 115, 194) for 199 patients who underwent primary PCI after an interhospital transfer. Patients who presented outside daytime working hours, those who received primary PCI and those who required interhospital transfer for primary PCI were less likely to receive reperfusion therapy within current recommended times (odds ratios [ORs] 0.49, 0.56 and 0.15, respectively). Increased age was associated with prolonged delays only among patients who received fibrinolytic therapy (OR for each 10-year increase in age 0.95, 95% credible interval [CrI] 0.93-0.99 for fibrinolytic therapy and 0.99, 95% CrI 0.95-1.05, for primary PCI).

INTERPRETATION

In 2003, many patients with STEMI in Quebec were not treated within the recommended times. Delays may be reduced by reorganizing pre-and in-hospital care for patients with STEMI to expedite delivery of reperfusion therapy.

Prospective multicenter study of acute asthma in younger versus older adults presenting to the emergency department

OBJECTIVES

To describe acute asthma in younger versus older adults presenting to the emergency department (ED).

DESIGN

Prospective cohort study. Asthmatic adults were divided into three age groups: 18 to 34, 35 to 54, and 55 and older. The analysis was restricted to never smokers and smokers with fewer than 10 pack-years.

SETTING

ED.

PARTICIPANTS

Two thousand sixty-four patients aged 18 and older with a physician diagnosis of asthma.

MEASUREMENTS

Medications and peak expiratory flow.

RESULTS

There were 1,158 (56%) subjects aged 18 to 34; 777 (37%) aged 35 to 54; and 129 (6%) aged 55 and older. Older patients were most likely to have a primary care provider (65%, 74%, and 91%, respectively; P<.001); most were not taking inhaled corticosteroids (39%, 55%, and 48%, respectively; P<.001). Older patients reported fewer ED visits for asthma (2, 2, and 1, respectively; P=.001) but were more likely to report asthma hospitalization (24%, 31%, and 37%, respectively; P<.001). All groups had severe exacerbations (initial percentage predicted peak flow: 47, 47, and 47, respectively; P=.50), but older patients were least likely to report severe symptoms (72%, 79%, and 67%, respectively; P=.001). Older patients did not respond as well to bronchodilators, even after controlling for other demographic factors, markers of asthma severity, and ED management (change between initial and final peak expiratory flow, using subjects aged 18 to 34 as reference: aged 35-54, beta=-0.7 (95% CI=-9.4-8.0); aged > or = 55, beta=-18.4 (-31.9 to -4.9)). The smaller change in peak expiratory flow contributed most to older patients' greater likelihood of hospitalization.

CONCLUSION

Older asthma patients were less responsive to emergency bronchodilation. This may reflect chronic undertreatment with inhaled corticosteroids.

Impact of an electronic link between the emergency department and family physicians: a randomized controlled trial

BACKGROUND

Electronic information exchange is believed to improve efficiency and reduce resource utilization. We developed a Web-based standardized communication system (SCS) that enables family physicians to receive detailed reports of their patients' care in the emergency department. We sought to determine the impact of the SCS on measures of resource utilization in the emergency department and family physician offices.

METHODS

We used an open 4-period crossover cluster-randomized controlled design. During 2 separate 10-week intervention phases, family physicians received detailed reports of their patients' emergency department visits over the Internet, and in the alternating control phases they received a 1-page copy of the emergency department notes by mail. The primary outcome was the number of repeat visits to the emergency department within 14 days of the initial visit. Secondary outcomes included duplication of test and specialty consultation requests by the emergency and family physician. Outcomes were measured using the hospital database and questionnaires sent to the family physicians.

RESULTS

A total of 2022 patient visits to the emergency department from 23 practices were used in the study. Use of the SCS failed to reduce the number of repeat visits to the emergency department within 14 days (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.8-1.51) and 28 days (OR 1.01, 95% CI 0.8-1.27). There was no significant duplication of requests for diagnostic tests between the emergency and family physician during the intervention and control phases (24 v. 22, p = 0.93), but there was significantly greater duplication in specialty consultation requests in the intervention phase than in the control phase (20 v. 8, p = 0.049).

INTERPRETATION

An electronic link between emergency and family physicians did not result in a significant reduction in resource utilization at either service point. Investments in improved electronic information exchange between emergency departments and family physician offices may not be substantiated by a reduction in resource utilization.

Successful implementation of a combined pneumococcal and influenza vaccination program in a Canadian emergency department

OBJECTIVES

To determine the proportion of patients vaccinated with pneumococcal (PVAX) and influenza (IVAX) vaccines under an emergency department (ED) vaccination program, that would not otherwise have been vaccinated by other primary care resources.

METHODS

This prospective cohort study was performed in a tertiary care academic centre. A questionnaire was administered to all consenting ED patients who met screening eligibility criteria to receive either IVAX or PVAX. Eligible unvaccinated patients who did not plan on receiving vaccination elsewhere were offered one or both of the vaccines and, if agreeable, were immunized in the ED.

RESULTS

During the 4-week study period, 754 patients (36% of all presenting ED patients) were eligible for vaccination with one or both vaccines. Of these 525 (70%) consented to participate in the study and completed a questionnaire. Of the 525 participants, 289 (55% of IVAX eligible patients; 95% confidence interval [CI], 51%-59%) were unvaccinated against influenza that year and did not plan on being vaccinated elsewhere and 277 (60% of PVAX eligible patients; 95% CI, 56%-64%) were unvaccinated against pneumococcus and did not plan on being vaccinated elsewhere. IVAX was administered to 187 patients (65% penetration; 95% CI, 59%-70%), and PVAX was administered to 165 patients (60% penetration; 95% CI, 54%-65%). Overall vaccine penetration was 46% (95% CI, 42%-50%) in the study participants and 32% (95% CI, 29%-35%) for the entire ED screened and eligible group. Reasons for vaccination refusal included concerns about benefit, side effects, and the desire to discuss vaccination with their primary care physician.

CONCLUSIONS

An ED-based program can result in the vaccination of a significant proportion of patients eligible for IVAX and/or PVAX who would otherwise likely go unprotected.

Emergency physician recognition of adverse drug-related events in elder patients presenting to an emergency department

OBJECTIVES

The authors examined the ability of emergency physicians (EPs) to recognize adverse drug-related events (ADREs) in elder patients presenting to the emergency department (ED).

METHODS

This was a prospective observational study of patients at least 65 years of age who presented to the ED. ADREs were identified using a validated, standardized scoring system. EP recognition of ADREs was assessed through physician interview and subsequent chart review.

RESULTS

A total of 161 patients were enrolled in the study. Thirty-seven ADREs were identified, which occurred in 26 patients (16.2%; 95% confidence interval [CI] = 10.5% to 22.0%). The treating EPs recognized 51.2% (95% CI = 35.2% to 67.4%) of all ADREs. There was better recognition of those ADREs related to the patient's chief complaint (91%; 95% CI = 74.1% to 100%) as compared with recognition of ADREs that were not associated with the chief complaint (32.1%; 95% CI = 14.8% to 49%). EPs recognized six of seven severe ADREs (85.7%), 13 of 23 moderate ADREs (56.5%; 95% CI = 36.8% to 77%), and none of the mild ADREs. Recognition of ADREs varied with medication class.

CONCLUSIONS

EP performance was superior at identifying severe ADREs relating to the patients' chief complaints. However, EP performance was suboptimal with respect to identifying ADREs of lower severity, having missed a significant number of ADREs of moderate severity as well as ones unrelated to the patients' chief complaints. ADRE detection methods need to be developed for the ED to aid EPs in detecting those ADREs that are most likely to be missed.

An emergency department-based nurse discharge coordinator for elder patients: does it make a difference?

OBJECTIVES

To evaluate the impact of an emergency department (ED)-based nurse discharge plan coordinator (NDPC) on unscheduled return visits within 14 days of discharge, satisfaction with discharge recommendations, adherence with discharge instructions, and perception of well-being of elder patients discharged from the ED.

METHODS

Patients aged 75 years and older discharged from the ED of the Sir Mortimer B. Davis-Jewish General Hospital were recruited in a pre/post study. During the pre (control) phase, study patients (n = 905) received standard discharge care. Patients in the post (intervention) phase (n = 819) received the intervention of an ED-based NDPC. The intervention included patient education, coordination of appointments, patient education, telephone follow-up, and access to the NDPC for up to seven days following discharge.

RESULTS

Patients in the two groups were similar with respect to gender and age. However, the patients managed by the ED NDPC appeared to be, at baseline, less autonomous, frailer, and sicker. The unadjusted relative risk for unscheduled return visits within 14 days of discharge was 0.79 (95% confidence interval [95% CI] = 0.62 to 1.02). A relative risk reduction of 27% (95% CI = 0% to 44%) for unscheduled return visits was observed for up to eight days postdischarge, and a relative risk reduction of 19% (95% CI = -2% to 36%) for unscheduled return visits was observed for up to 14 days postdischarge. Significant increases in satisfaction with the clarity of discharge information and perceived well-being were also noted.

CONCLUSIONS

An ED-based NDPC, dedicated specifically to the discharge planning care of elder patients, reduces the proportion of unscheduled ED return visits and facilitates the transition from ED back home and into the community health care network.

Nonurgent emergency department patient characteristics and barriers to primary care

OBJECTIVE

Nonurgent (NU) emergency department (ED) use is at the forefront of medico-political agendas, and diversion of NU patients has been entertained as a management strategy. Before policy changes are implemented, this population should be better understood with respect to their characteristics and reasons for not presenting to primary care providers (PCPs) instead of EDs. This study compares NU with urgent and semiurgent (USU) patients and describes the NU patients' reasons for not seeking care with a PCP before presenting to the ED.

METHODS

This was a secondary analysis from a cross-sectional study with sequential sampling in the EDs of five Quebec tertiary care hospitals (October 19, 1999, to May 26, 2000). Data on medical history, social support, awareness and utilization of health care, ED visits, referrals, activities of daily living, and sociodemographics were obtained. The NU group included patients with triage code 5 and the USU group included patients with triage codes 2, 3, and 4 using the Canadian Triage and Acuity Scale. Patient characteristics were structured into the Andersen behavioral model for health care utilization.

RESULTS

Of 2,348 patients approached, 1,783 patients (77%) were eligible and agreed to participate. NU patients (n = 454) were younger than USU patients (n = 1,329) (mean age, 43 [SD +/- 18.1] vs. 49 [SD +/- 20.1] years). Patients in the NU group had better health (number of prior conditions, 3.1 vs. 3.9), were less likely to arrive by ambulance (5% vs. 22%), and were less often admitted from the ED (4% vs. 24%). While 70% of NU compared with 75% of USU patients were followed up by a PCP, only 22% of NU and 27% of USU patients sought PCP care before presenting to the ED. The reasons given by NU patients for not seeking PCP care were accessibility (32%), perception of need (22%), referral/follow-up to the ED (20%), familiarity with the ED (11%), trust of the ED (7%), and no reason (7%).

CONCLUSIONS

NU ED patients are different from USU patients and have multiple reasons for not seeking primary care before going to the ED. This may help explain why various diversion strategies have been unsuccessful and indicate that a multifaceted approach may be better suited to this group of patients. The design of new interventions, however, will benefit from further research that clarifies the impact of NU patients on the health care system.

Impact of ambulance transportation on resource use in the emergency department

OBJECTIVE

To determine how ambulance transportation is associated with resource use in the emergency department (ED).

METHODS

A retrospective administrative database review of patient visits to a Montreal tertiary care hospital ED in one year (April 2000-March 2001). Measures of resource use included ED length of stay, admission to the hospital, and whether consultations and radiology/imaging tests (excluding plain-film x-rays) were ordered from the ED.

RESULTS

During the study period, 39,674 patients made 59,142 visits to the ED. Ambulance transportation was used for 15.6% of these ED visits. Compared with non-ambulance visits, ambulance visits were more likely to be made by older patients (mean age: 68 vs. 47 years), to be made by females (59% vs. 55%), to have a greater triage urgency score (mean on 1-5 scale, with 1 most urgent: 2.7 vs. 3.9), and to occur after office hours, 5 PM to 9 AM (47% vs. 43%). Ambulance visits were also more likely than non-ambulance visits to result in: a longer length of stay (mean: 13.3 hours [95% CI = 13.0 to 13.6] vs. 5.9 [95% CI = 5.8 to 6.0]), hospital admission (40% vs. 10%) (odds ratio [OR]: 5.94 [95% CI = 5.59 to 6.33]), consultations (56% vs. 20%) (OR: 5.15 [95% = 4.86 to 5.45]), and radiology/imaging tests (20% vs. 12%) (OR: 1.93 [95% CI = 1.81 to 2.07]). In multivariate models that adjusted for the effects of age, gender, triage urgency, and temporal factors, ambulance transportation maintained its association with greater resource use.

CONCLUSIONS

This preliminary study indicates that patients arriving at the ED by ambulance use significantly more resources than their walk-in counterparts.

Intervention to decrease emergency department crowding: does it have an effect on return visits and hospital readmissions?

STUDY OBJECTIVES

We evaluate the effect of a multifaceted intervention to decrease emergency department crowding on the incidence of return visits to the ED or a hospital ward. The intervention included increased emergency physician coverage, the designation of physician coordinators, and new hospital policies regarding laboratory, consultation, and admission procedures.

METHODS

The incidence of return visits within 7 days of discharge was estimated in samples from 2 populations (ie, patients discharged from the ED and patients discharged from the hospital) and during a 12-month period before and a 12-month period after the implementation of the intervention. Return visits were categorized into the following groups: (1) scheduled or not and (2) related or not to initial visit. Logistic regression was used in subsamples to assess the effect of the intervention while controlling for potential confounders. By using information from the provincial medical services database, variation between the periods before and after implementation of the intervention in the incidence of return visits to any ED was compared between the study hospital and 2 external control hospitals.

RESULTS

No difference was found in the incidence of return visits between the periods before and after implementation of the intervention, either for patients discharged from the ED (all returns: 11.0% versus 12.4%, 95% confidence interval on difference [CID] -1.5% to 4.3%; unscheduled-related returns: 6.5% versus 5.8%, 95% CID -2.8% to 1.6%) or the hospital (all returns: 6.8% versus 6.6%, 95% CID -2.5% to 2.1%; unscheduled-related returns: 4.2% versus 4.0%, 95% CID -2.0% to 1.7%). This lack of effect remained even after controlling for potential confounders. Variation between the periods before and after implementation of the intervention in the incidence of return to any ED was similar in the 3 hospitals examined.

CONCLUSION

Our successful hospital intervention to decrease crowding reduced the mean length of stay for patients discharged from the ED from 13.8 to 5.9 hours, without resulting in increased return visits to the ED or hospital readmission.

Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department

STUDY OBJECTIVES

We sought to document the degree of polypharmacy, the frequency of adverse drug-related events (ADREs) leading to emergency department presentation that were recognized by emergency physicians, and the frequency of potential adverse drug interactions (PADIs) in medication regimens of elderly patients in the ED.

METHODS

We conducted a retrospective chart review on 300 randomly selected ED visits made by patients 65 years of age and older between January 1 and December 31, 1998. ADREs were defined according to a standardized algorithm. PADIs were identified by using the drug interaction database PharmVigilance.

RESULTS

After excluding 17 patient visits with inadequate documentation, 283 were left for review. Of these, 257 (90.8%) patients were taking 1 or more medications (prescribed or over the counter). The number of medications consumed ranged from 0 to 17 and averaged 4.2 (SD+/-3.1) drugs per patient. ADREs accounted for 10.6% of all ED visits in our patient group. The most frequently implicated classes of medications were nonsteroidal anti-inflammatory drugs, antibiotics, anticoagulants, diuretics, hypoglycemics, beta-blockers, calcium-channel blockers, and chemotherapeutic agents. Thirty-one percent of all patients in our group had at least 1 PADI in their medication list. Among patients who presented because of an ADRE, 50% had at least 1 PADI in their medication list that was unrelated to the ADRE with which they presented.

CONCLUSION

ADREs are an important cause of ED presentation in the elderly. PADIs are found in a significant proportion of medication lists. Emergency physicians must be vigilant in monitoring elderly patients for medication-related problems.