1
|
Wretborn J, Wilhelms DB, Ekelund U. Emergency department crowding and mortality: an observational multicenter study in Sweden. Front Public Health 2023; 11:1198188. [PMID: 37559736 PMCID: PMC10407086 DOI: 10.3389/fpubh.2023.1198188] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/05/2023] [Indexed: 08/11/2023] Open
Abstract
Background Emergency department (ED) crowding is a serious problem worldwide causing decreased quality of care. It is reasonable to assume that the negative effects of crowding are at least partially due to high staff workload, but previous crowding metrics based on high workload have not been generalisable to Swedish EDs and have not been associated with increased mortality, in contrast to, e.g., occupancy rate. We recently derived and validated the modified Skåne Emergency Department Assessment of Patient Load model (mSEAL) that measures crowding based on staff workload in Swedish EDs, but its ability to identify situations with increased mortality is unclear. In this study, we aimed to investigate the association between ED crowding measured by mSEAL model, or occupancy rate, and mortality. Methods All ED patients from 2017-01-01 to 2017-06-30 from two regional healthcare systems (Skåne and Östergötland Counties with a combined population of approximately 1.8 million) in Sweden were included. Exposure was ED- and hour-adjusted mSEAL or occupancy rate. Primary outcome was mortality within 7 days of ED arrival, with one-day and 30-day mortality as secondary outcomes. We used Cox regression hazard ratio (HR) adjusted for age, sex, arrival by ambulance, hospital admission and chief complaint. Results We included a total of 122,893 patients with 168,900 visits to the six participating EDs. Arriving at an hour with a mSEAL score above the 95th percentile for that ED and hour of day was associated with an non-significant HR for death at 7 days of 1.04 (95% CI 0.96-1.13). For one- and 30-day mortality the HR was non-significant at 1.03 (95% CI 0.9-1.18) and 1.03 (95% CI 0.97-1.09). Similarly, occupancy rate above the 95th percentile with a HR of 1.04 (95% CI 0.9-1.19), 1.03 (95%CI 0.95-1.13) and 1.04 (95% CI 0.98-1.11) for one-, 7- and 30-day mortality, respectively. Conclusion In this multicenter study in Sweden, ED crowding measured by mSEAL or occupancy rate was not associated with a significant increase in short-term mortality.
Collapse
Affiliation(s)
- Jens Wretborn
- Department of Emergency Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Daniel B. Wilhelms
- Department of Emergency Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Ulf Ekelund
- Department of Clinical Sciences Lund, Emergency Medicine, Faculty of Medicine, Lund University, Lund, Sweden
| |
Collapse
|
2
|
Amissah M, Lahiri S. Modelling Granular Process Flow Information to Reduce Bottlenecks in the Emergency Department. Healthcare (Basel) 2022; 10:healthcare10050942. [PMID: 35628079 PMCID: PMC9140672 DOI: 10.3390/healthcare10050942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/25/2022] [Accepted: 05/10/2022] [Indexed: 02/01/2023] Open
Abstract
Increasing demand and changing case-mix have resulted in bottlenecks and longer waiting times in emergency departments (ED). However, many process improvement efforts addressing the bottlenecks have limitations, as they lack accurate models of the real system as input accounting for operational complexities. To understand the limitation, this research modelled granular procedural information, to analyse processes in a Level-1 ED of a 1200-bed teaching hospital in the UK. Semi-structured interviews with 21 clinicians and direct observations provided the necessary information. Results identified Majors as the most crowded area, hence, a systems modelling technique, role activity diagram, was used to derive highly granular process maps illustrating care in Majors which were further validated by 6 additional clinicians. Bottlenecks observed in Majors included awaiting specialist input, tests outside the ED, awaiting transportation, bed search, and inpatient handover. Process mapping revealed opportunities for using precedence information to reduce repeat tests; informed alerting; and provisioning for operational complexity into ED processes as steps to potentially alleviate bottlenecks. Another result is that this is the first study to map care processes in Majors, the area within the ED that treats complex patients whose care journeys are susceptible to variations. Findings have implications on the development of improvement approaches for managing bottlenecks.
Collapse
|
3
|
Jeyaraman MM, Alder RN, Copstein L, Al-Yousif N, Suss R, Zarychanski R, Doupe MB, Berthelot S, Mireault J, Tardif P, Askin N, Buchel T, Rabbani R, Beaudry T, Hartwell M, Shimmin C, Edwards J, Halas G, Sevcik W, Tricco AC, Chochinov A, Rowe BH, Abou-Setta AM. Impact of employing primary healthcare professionals in emergency department triage on patient flow outcomes: a systematic review and meta-analysis. BMJ Open 2022; 12:e052850. [PMID: 35443941 PMCID: PMC9058787 DOI: 10.1136/bmjopen-2021-052850] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 02/26/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To identify, critically appraise and summarise evidence on the impact of employing primary healthcare professionals (PHCPs: family physicians/general practitioners (GPs), nurse practitioners (NP) and nurses with increased authority) in the emergency department (ED) triage, on patient flow outcomes. METHODS We searched Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) (inception to January 2020). Our primary outcome was the time to provider initial assessment (PIA). Secondary outcomes included time to triage, proportion of patients leaving without being seen (LWBS), length of stay (ED LOS), proportion of patients leaving against medical advice (LAMA), number of repeat ED visits and patient satisfaction. Two independent reviewers selected studies, extracted data and assessed study quality using the National Institute for Health and Care Excellence quality assessment tool. RESULTS From 23 973 records, 40 comparative studies including 10 randomised controlled trials (RCTs) and 13 pre-post studies were included. PHCP interventions were led by NP (n=14), GP (n=3) or nurses with increased authority (n=23) at triage. In all studies, PHCP-led intervention effectiveness was compared with the traditional nurse-led triage model. Median duration of the interventions was 6 months. Study quality was generally low (confounding bias); 7 RCTs were classified as moderate quality. Most studies reported that PHCP-led triage interventions decreased the PIA (13/14), ED LOS (29/30), proportion of patients LWBS (8/10), time to triage (3/3) and repeat ED visits (5/6), and increased the patient satisfaction (8/10). The proportion of patients LAMA did not differ between groups (3/3). Evidence from RCTs (n=8) as well as other study designs showed a significant decrease in ED LOS favouring the PHCP-led interventions. CONCLUSIONS Overall, PHCP-led triage interventions improved ED patient flow metrics. There was a significant decrease in ED LOS irrespective of the study design, favouring the PHCP-led interventions. Evidence from well-designed high-quality RCTs is required prior to widespread implementation. PROSPERO REGISTRATION NUMBER CRD42020148053.
Collapse
Affiliation(s)
- Maya M Jeyaraman
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rachel N Alder
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Leslie Copstein
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nameer Al-Yousif
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Roger Suss
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ryan Zarychanski
- Department of Medical Oncology and Hematology, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Malcolm B Doupe
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Simon Berthelot
- Centre de recherche du CHU de Québec-Université Laval, Axe Santé des populations et Pratiques optimales en santé, Laval, Quebec, Canada
| | - Jean Mireault
- HEC Pôle santé, Université de Montréal, Montreal, Quebec, Canada
| | - Patrick Tardif
- Department of Emergency Medicine, Cité de la santé de Laval, Laval, Quebec, Canada
| | - Nicole Askin
- WRHA Virtual Library, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tamara Buchel
- Manitoba College of Family Physicians, Winnipeg, Manitoba, Canada
| | - Rasheda Rabbani
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Thomas Beaudry
- Patient and Public Engagement Collaborative Partnership, George & Fay Yee Center for Healthcare Innovation, Winnipeg, Manitoba, Canada
| | - Melissa Hartwell
- Primary and Integrated Health care Innovation Network, Edmonton, Alberta, Canada
| | - Carolyn Shimmin
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jeanette Edwards
- Community Health Quality and Learning, Shared Health Manitoba, Winnipeg, Manitoba, Canada
| | - Gayle Halas
- Manitoba Primary and Integrated Health care Innovation Network, Winnipeg, Manitoba, Canada
| | - William Sevcik
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, St. Michael's Hospital Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Alecs Chochinov
- Department of Emergency Medicine, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmed M Abou-Setta
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
4
|
Wretborn J, Ekelund U, B. Wilhelms D. Differentiating properties of occupancy rate and workload to estimate crowding: A Swedish national cross-sectional study. J Am Coll Emerg Physicians Open 2022; 3:e12648. [PMID: 35079734 PMCID: PMC8769068 DOI: 10.1002/emp2.12648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/25/2021] [Accepted: 12/21/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Emergency department (ED) crowding causes increased patient morbidity and mortality. ED occupancy rate (OR; patients by treatment beds) is a common measure of crowding, but the comparability of ORs between EDs is unknown. The objective of this investigation was to investigate differences in ORs between EDs using staff-perceived workload as reference. METHODS This was a national cross-sectional study in Sweden. EDs provided data on census, treatment beds, staffing, and workload (1-6) at 5 time points. A baseline patient turnover was calculated as the average daily census by treatment beds, denoted turnover per treatment bed (TTB), for each ED. A census ratio (CR), current by daily census, was calculated to adjust for differences in the number of treatment beds. RESULTS Data were returned from 37 (51%) EDs. TTB varied considerably (mean = 4, standard deviation = 1.6; range, 2.1-9.2), and the OR was higher in EDs with TTB >4 compared with ≤4, 0.86 versus 0.43 (0.43; 95% confidence interval [CI], 0.27-0.59), but not workload, 2.75 versus 2.52 (0.23; 95% CI, -0.19 to 0.64). After adjusting for confounders, both TTB (k = -0.3; 95% CI, -0.49 to -0.14) and OR (k = 3.4; 95% CI, 1.76-5.03) affected workload. Correlation with workload was better for CR than for OR (r = 0.75 vs 0.60, respectively). CONCLUSION OR is affected by patient-to-treatment bed ratios that differ significantly between EDs and should be accounted for when measuring crowding. CR is not affected by baseline treatment beds and is a better comparable measure of crowding compared with OR in this national comparator study.
Collapse
Affiliation(s)
- Jens Wretborn
- Department of Emergency MedicineLocal Health Care Services in Central Östergötland, Region ÖstergötlandLinköpingSweden
- Department of Clinical Sciences LundEmergency MedicineFaculty of MedicineLund UniversityLundSweden
| | - Ulf Ekelund
- Department of Clinical Sciences LundEmergency MedicineFaculty of MedicineLund UniversityLundSweden
| | - Daniel B. Wilhelms
- Department of Emergency MedicineLocal Health Care Services in Central Östergötland, Region ÖstergötlandLinköpingSweden
- Department of Medical and Health SciencesFaculty of Health SciencesLinköping UniversityLinköpingSweden
| |
Collapse
|
5
|
Chou SC, Chang YSC, Chen PC, Schuur JD, Weiner SG. Hospital Occupancy and its Effect on Emergency Department Evaluation. Ann Emerg Med 2021; 79:172-181. [PMID: 34756449 DOI: 10.1016/j.annemergmed.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 08/12/2021] [Accepted: 08/23/2021] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To examine whether hospital occupancy was associated with increased testing and treatment during emergency department (ED) evaluations, resulting in reduced admissions. METHODS We analyzed the electronic health records of an urban academic ED. We linked data from all ED visits from October 1, 2010, to May 29, 2015, with daily hospital occupancy (inpatients/total staffed beds). Outcome measures included the frequency of laboratory testing, advanced imaging, medication administration, and hospitalizations. We modeled each outcome using multivariable negative binomial or logistic regression, as appropriate, and examined their association with daily hospital occupancy quartiles, controlling for patient and visit characteristics. We calculated the adjusted outcome rates and relative changes at each daily hospital occupancy quartile using marginal estimating methods. RESULTS We included 270,434 ED visits with a mean patient age of 48.1 (standard deviation 19.8) years; 40.1% were female, 22.8% were non-Hispanic Black, and 51.5% were commercially insured. Hospital occupancy was not associated with differences in laboratory testing, advanced imaging, or medication administration. Compared with the first quartile, the third and fourth quartiles of daily hospital occupancy were associated with decreases of 1.5% (95% confidence interval [CI] -2.9 to -0.2; absolute change -0.6 percentage points [95% CI -1.2 to -0.1]) and 4.6% (95% CI -6.0 to -3.2; absolute change -1.9 percentage points [95% CI -2.5 to -1.3]) in hospitalizations, respectively. CONCLUSION The lack of association between hospital occupancy and laboratory testing, advanced imaging, and medication administration suggest that changes in ED testing or treatment did not facilitate the decrease in admissions during periods of high hospital occupancy.
Collapse
Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI.
| | - Yeu-Shin C Chang
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Paul C Chen
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| |
Collapse
|
6
|
Cerezo-Espinosa de los Monteros J, Castro-Torres A, Gómez-Salgado J, Fagundo-Rivera J, Gómez-Salgado C, Coronado-Vázquez V. Administration of Strategic Agreements in Public Hospitals: Considerations to Enhance the Quality and Sustainability of Mergers and Acquisitions. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4051. [PMID: 33921426 PMCID: PMC8069692 DOI: 10.3390/ijerph18084051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 11/16/2022]
Abstract
Merger processes between hospitals have high benefit potential for patients, staff and managers. This integration of health centres can improve the quality and safety in patient care. Additionally, cooperative processes enhance the sustainability of the health system, by increasing team spirit, giving innovative ideas and improving staff satisfaction. In this article, the critical factors for successful hospital mergers and acquisitions in the Public Health System were considered to develop a brief guide to help with the organisation of a merger process. Five sections were designed: Strategic administration and objectives, Staff management, New hospital complex structure, Processes and Results. This guide facilitates the communication between a variety of stakeholders, thus improving the engagement between all members of the new healthcare system. This could be particularly important for countries with large regional variance in the organisation of health care and resources.
Collapse
Affiliation(s)
| | | | - Juan Gómez-Salgado
- Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, 21007 Huelva, Spain
- Safety and Health Postgraduate Program, Universidad Espíritu Santo, Guayaquil 091650, Ecuador
| | - Javier Fagundo-Rivera
- Health Sciences Doctorate School, University of Huelva, 21007 Huelva, Spain;
- Centro Universitario de Enfermería Cruz Roja, University of Seville, 41009 Seville, Spain
| | | | - Valle Coronado-Vázquez
- Illescas Health Centre, Castilla-La Mancha Health Service, 45200 Toledo, Spain;
- Health Science Institute of Aragon, 50009 Zaragoza, Spain
- Department of Health Sciences, Santa Teresa de Jesus Catholic University of Avila, 05005 Avila, Spain
| |
Collapse
|
7
|
Kreindler SA, Star N, Hastings S, Winters S, Johnson K, Mallinson S, Brierley M, Goertzen LN, Anwar MR, Aboud Z. "Working Against Gravity": The Uphill Task of Overcapacity Management. Health Serv Insights 2020; 13:1178632920929986. [PMID: 32587459 PMCID: PMC7294368 DOI: 10.1177/1178632920929986] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/04/2020] [Indexed: 11/17/2022] Open
Abstract
While most health systems have implemented interventions to manage situations in which patient demand exceeds capacity, little is known about the long-term sustainability or effectiveness of such interventions. A large multi-jurisdictional study on patient flow in Western Canada provided the opportunity to explore experiences with overcapacity management strategies across 10 diverse health regions. Four categories of interventions were employed by all or most regions: overcapacity protocols, alternative locations for emergency patients, locations for discharge-ready inpatients, and meetings to guide redistribution of patients. Two mechanisms undergirded successful interventions: providing a capacity buffer and promoting action by inpatient units by increasing staff accountability and/or solidarity. Participants reported that interventions demanded significant time and resources and the ongoing active involvement of middle and senior management. Furthermore, although most participants characterized overcapacity management practices as effective, this effectiveness was almost universally experienced as temporary. Many regions described a context of chronic overcapacity, which persisted despite continued intervention. Processes designed to manage short-term surges in demand cannot rectify a long-term mismatch between capacity and demand; solutions at the level of system redesign are needed.
Collapse
Affiliation(s)
- Sara A Kreindler
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg Regional Health Authority/University of Manitoba, Winnipeg, MB, Canada
| | - Noah Star
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Stephanie Hastings
- Health Systems Evaluation & Evidence, Alberta Health Services, Calgary, AB, Canada
| | - Shannon Winters
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg Regional Health Authority/University of Manitoba, Winnipeg, MB, Canada
| | - Keir Johnson
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg Regional Health Authority/University of Manitoba, Winnipeg, MB, Canada
| | - Sara Mallinson
- Health Systems Evaluation & Evidence, Alberta Health Services, Calgary, AB, Canada
| | - Meaghan Brierley
- Health Systems Evaluation & Evidence, Alberta Health Services, Calgary, AB, Canada
| | | | | | - Zaid Aboud
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| |
Collapse
|
8
|
Lynch B, Browne J, Buckley CM, Healy O, Corcoran P, Fitzgerald AP. An interrupted time-series analysis of the impact of emergency department reconfiguration on regional emergency department trolley numbers in Ireland from 2005 to 2015. BMJ Open 2019; 9:e029261. [PMID: 31530599 PMCID: PMC6756467 DOI: 10.1136/bmjopen-2019-029261] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To understand the impact of emergency department (ED) reconfiguration on the number of patients waiting for hospital beds on trolleys in the remaining EDs in four geographical regions in Ireland using time-series analysis. SETTING EDs in four Irish regions; the West, North-East, South and Mid-West from 2005 to 2015. PARTICIPANTS All patients counted as waiting on trolleys in an ED for a hospital bed in the study hospitals from 2005 to 2015. INTERVENTION The system intervention was the reconfiguration of ED services, as determined by the Department of Health and Health Service Executive. The timing of these interventions varied depending on the hospital and region in question. RESULTS Three of the four regions studied experienced a significant change in ED trolley numbers in the 12-month post-ED reconfiguration. The trend ratio before and after the intervention for these regions was as follows: North-East incidence rate ratio (IRR) 2.85 (95% CI 2.04 to 3.99, p<0.001), South IRR 0.68 (95% CI 0.51 to 0.89, p=0.006) and the Mid-West IRR 0.03 (95% 1.03 to 2.03, p=0.03). Two of these regions, the South and the Mid-West, displayed a convergence between the observed and expected trolley numbers in the 12-month post-reconfiguration. The North-East showed a much steeper increase, one that extended beyond the 12-month period post-ED reconfiguration. CONCLUSIONS Findings suggest that the impacts of ED reconfiguration on regional level ED trolley trends were either non-significant or caused a short-term shock which converged on the pre-reconfiguration trend over the following 12 months. However, the North-East is identified as an exception due to increased pressures in one regional hospital, which caused a change in trend beyond the 12-month post reconfiguration.
Collapse
Affiliation(s)
- Brenda Lynch
- School of Public Health, University College Cork, Cork, Ireland
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | | | - Orla Healy
- Department of Public Health, HSE South, Cork, Ireland
| | - Paul Corcoran
- National Suicide Research Foundation (NSRF), University College Cork, Cork, Ireland
| | | |
Collapse
|
9
|
Mentzoni I, Bogstrand ST, Faiz KW. Emergency department crowding and length of stay before and after an increased catchment area. BMC Health Serv Res 2019; 19:506. [PMID: 31331341 PMCID: PMC6647148 DOI: 10.1186/s12913-019-4342-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/11/2019] [Indexed: 11/10/2022] Open
Abstract
Background Emergency department (ED) crowding and prolonged length of stay (LOS) are associated with delays in treatment, adverse outcomes and decreased patient satisfaction. Hospital restructuring and mergers are often associated with increased ED crowding. The aim of this study was to explore ED crowding and LOS in Norway’s largest ED before and after an increased catchment area. Methods The catchment area of Akershus University Hospital increased by approximately 150,000 inhabitants in 2011, from 340,000 to 490,000. In this retrospective study, admissions to the ED during a six-year period, from Jan 1st 2010 to Dec 31st 2015 were included and analyzed. Results A total of 179,989 admissions were included (51.0% men). The highest occupancy rate was in the age group 70–79 years. Following the increase in the catchment area, the annual ED admissions increased by 8343 (40.9%) from 2010 to 2011, and peaked in 2013 (34,002). Mean LOS increased from 3:59 h in 2010 to 4:17 in 2012 (highest), and decreased to 3:45 h in 2015 after staff, capacity and organizational measures. In 2010, 37.9% of the ED patients experienced crowding, and this proportion increased to between 52.9–77.6% in 2011–2015. Crowding peaked between 4 and 5 PM. Conclusions LOS increased and crowding was more frequent after a major increase in the hospital’s catchment area in Norway’s largest emergency department. Even after 5 years, the LOS was higher than before the expansion, mainly because of the throughput and output components, which were not properly adapted to the changes in input. Electronic supplementary material The online version of this article (10.1186/s12913-019-4342-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Ida Mentzoni
- Emergency Department, Akershus University Hospital, Lørenskog, Norway.,Lovisenberg Diaconal University College, Oslo, Norway
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Section of Drug Abuse Research, Oslo University Hospital, Oslo, Norway.,Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Kashif Waqar Faiz
- Health Services Research Unit, Akershus University Hospital, PO Box 1000, N-1478, Lørenskog, Norway. .,Department of Neurology, Akershus University Hospital, Lørenskog, Norway.
| |
Collapse
|
10
|
Jones P, Athaullah W, Harper A, Wells S, LeFevre J, Stewart J, Curtis E, Reid P, Ameratunga S. Time to CT head in adult patients with suspected traumatic brain injury: Association with the 'Shorter Stays in Emergency Departments' health target in Aotearoa New Zealand. Injury 2018; 49:1680-1686. [PMID: 29853326 DOI: 10.1016/j.injury.2018.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/22/2018] [Accepted: 05/18/2018] [Indexed: 02/02/2023]
Abstract
A national health target for length of stay in emergency departments (ED) was introduced in 2009 to reduce crowding and improve quality of care. We aimed to determine whether the target was associated with changes in time to CT and appropriateness of CT imaging, as markers of care quality for suspected acute traumatic brain injury (TBI). We undertook a retrospective review of the case records of a random sample of people aged ≥15 years presenting to the ED with TBI from 2006 to 2013. General linear models were used to investigate changes in outcomes along with routine process times before and after the introduction of the target. Among 501 eligible cases the median (IQR) time to CT was 136 (76-247) pre target versus 119 (59-209) minutes post target, p = 0.014. The proportion of appropriate imaging was similar between periods: 77.9% (95% CI 71-83%) versus 76.6% (95%CI 72-81%), p = 0.825. Interactions suggested that the time to CT and appropriateness of imaging before and after the introduction of the target varied by ethnicity, although the changes were not clinically important. Time to assessment and length of stay did not change importantly. We found no evidence of a clinically important change in time to CT or appropriateness of imaging for suspected TBI in association with the introduction of the SSED time target. Additional research with larger cohorts of Māori and Pacific participants is recommended to understand our observed patterns by ethnicity.
Collapse
Affiliation(s)
- Peter Jones
- Adult Emergency Department, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand; Department of Surgery, University of Auckland, Auckland, New Zealand.
| | - Waheedah Athaullah
- Adult Emergency Department, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand.
| | - Alana Harper
- Adult Emergency Department, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand.
| | - Susan Wells
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand.
| | - James LeFevre
- Adult Emergency Department, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand.
| | - Joanna Stewart
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand.
| | - Elana Curtis
- Te Kupenga Hauora Māori, University of Auckland, Auckland, New Zealand.
| | - Papaarangi Reid
- Te Kupenga Hauora Māori, University of Auckland, Auckland, New Zealand.
| | - Shanthi Ameratunga
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand.
| |
Collapse
|
11
|
Kuek BJW, Li H, Yap S, Ng MXR, Ng YY, White AE, Ong MEH. Characteristics of Frequent Users of Emergency Medical Services in Singapore. PREHOSP EMERG CARE 2018; 23:215-224. [PMID: 30118627 DOI: 10.1080/10903127.2018.1484969] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This study aims to describe frequent users of Emergency Medical Services (EMS) conveyed to a Singapore tertiary hospital, focusing on a comparison between younger users (age <65) and older users in diagnoses and admission rates. METHODS All patients conveyed by EMS to a tertiary hospital 4 times or more over a 1-year period in 2015 had their EMS ambulance charts and Emergency Department (ED) electronic records retrospectively analyzed (n = 243), with admission the primary outcome. RESULTS The 243 frequent users were analyzed with a combined total of 1,705 visits, out of a total of 10,183 patients with 12,839 visits conveyed by EMS to Singapore General Hospital (SGH) in 2015. Younger frequent users (<65 years age) were found to be predominantly male (79.6%, p = 0.001) and were on average responsible for more visits than elderly frequent users (8.6 vs. 5.7, p = 0.004). Medical co-morbidities were significantly more prevalent in older users. Younger frequent users were more likely to be smokers (60.2% vs. 22.3%), heavy drinkers (51.3% vs. 8.5%), substance abusers (12.4% vs. 0.8%), and bad debtors (49.6% vs. 20.0%, p < 0.001). A larger proportion presented with altered mental states (11.7% vs. 5.4%, p < 0.001) and alcohol related diagnoses (34.7% vs. 5.3%, p < 0.001). Many were picked up from public areas (45.5% vs. 19.6%, p < 0.001), and had lower acuity triage scores at both EMS (p < 0.001) and ED (p = 0.001). They had lower admission rates (40.5% vs. 78.7%, p < 0.001) and shorter length of stay (4.3 vs. 5.9 days, p < 0.001). Univariable and multivariable analysis showed alcohol related diagnoses, history of alcohol abuse and lower triage scores were less likely to require admissions. CONCLUSION Frequent EMS users consume a disproportionate amount of healthcare resources. Two broad subgroups of patients were identified: younger patients with social issues and older patients with multiple medical conditions. EMS usage by older patients was significantly associated with higher rates of admission.
Collapse
|
12
|
Emergency Overcrowding Impact on the Quality of Care of Patients Presenting with Acute Stroke. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2017; 2:e3. [PMID: 31172066 PMCID: PMC6548098 DOI: 10.22114/ajem.v0i0.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: Emergency overcrowding is defined as when the amount of care required for patients overcomes the available amount. This can cause delays in delivering critical care in situations like stroke. Objective: The aim of this study was to assess the possible impact of emergency department (ED) crowding on the quality of care for acute stroke patients. Methods: In this cross-sectional prospective study, all patients with symptoms of acute stroke presenting to the ED of educational hospitals were enrolled. All patients were assessed and examined by the emergency medicine (EM) residents on shift and a questionnaire was filled out for them. The amount of time that passed from the first triage to performing the required interventions and delivering health services were recorded by the triage nurse. ED crowding was measured by the occupancy rate. Then, the correlation between all of the variables and ED crowding level were calculated. Results: The average daily bed occupancy rate was 184.9 ± 54.3%. The median time passed from the first triage to performing the interventions were as follows: the first EM resident visit after 34 min, the first neurologic visit after 138 min, head CT after 134 min, ECG after 104 min and ASA administration after 210 min. There was no statistically significant relationship between the ED occupancy rate and the time elapsed before different required health services in the management of stroke patients either throughout an entire day or during each 8-hour interval (p > 0.05). Conclusion: In the current study, the ED occupancy rate was not significantly correlated with the time frame associated with management of admitted acute stroke patients.
Collapse
|
13
|
Mustonen K, Kantonen J, Kauppila T. The effect on the patient flow in local health care services after closing a suburban primary care emergency department: a controlled longitudinal follow-up study. Scand J Trauma Resusc Emerg Med 2017; 25:116. [PMID: 29183366 PMCID: PMC5706306 DOI: 10.1186/s13049-017-0460-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 11/20/2017] [Indexed: 11/10/2022] Open
Abstract
Background It has not been studied what happens to patient flow to EDs and other parts of local health care system if distances to ED services are manipulated as a part of health policy in urban areas. Methods The present work was an observational and quasi-experimental study with a control and it was based on before-after comparisons. The impact of terminating a geographically distant suburban primary care ED on patient flow to doctors in local public primary care EDs, office-hour primary care, secondary care EDs and in private primary care was studied. The effect of this intervention was compared with a primary care system where no similar intervention was performed. The number of monthly visits to doctors in different departments of health care was scored as the main measure of the study in each department studied (e.g. in primary care EDs, secondary care ED, office-hour public primary care and private primary care). Monthly mortality rates were also recorded. Results Increasing the distance to ED services by terminating a peripheral ED did not cause an increase in the use of local office-hour services in those areas whose local ED was terminated, although use of ED services decreased by 25% in these areas (P < 0.001). The total use of primary care doctor services rather decreased - if anything - after this intervention while use of doctor services in secondary care ED remained unaffected. Doctor visits to the complementary private primary care increased but this was probably not associated with the intervention because a simultaneous increase in this parameter was observed in the control. There was no increased mortality in any age groups. Conclusion Manipulating distances to ED services can be used to direct patient flows to different parts of the health care system. The correlation between distance to ED and the tendency to use ED by inhabitants is negative. If secondary care ED was available there were no life-threatening side-effects at the level of general public health when a minor ED was closed in a primary care ED system.
Collapse
Affiliation(s)
- Katri Mustonen
- Department of Primary Health Care Laboratory Services, Helsinki University Central Hospital, Laboratory Services (HUSLAB), Topeliuksenkatu 32, 00029 HUS, Helsinki, Finland
| | - Jarmo Kantonen
- Primary Health Care, City of Vantaa, Peltolantie 2D, 01300, Vantaa, Finland
| | - Timo Kauppila
- Primary Health Care, City of Vantaa, Peltolantie 2D, 01300, Vantaa, Finland. .,Department of General Practice and Primary Health Care, Clinicum of Faculty of Medicine, University of Helsinki, (Tukholmankatu 8B), -00014, Helsinki, SF, Finland.
| |
Collapse
|
14
|
Eggart MD, Greene C, Fannin ES, Roberts OA. A 14-Year Review of Socioeconomics and Sociodemographics Relating to Intracerebral Abscess, Subdural Empyema, and Epidural Abscess in Southeastern Louisiana. Neurosurgery 2017; 79:265-9. [PMID: 26909804 DOI: 10.1227/neu.0000000000001225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Secondary intracranial infections are a persistent health concern despite advancements in medicine and improvements in surgical care. Previous studies have reported on the incidence of infection and outcomes in the immunocompromised patient, yet few studies have investigated demographic elements linked to contracting a secondary intracranial infection, a preventable disease. OBJECTIVE The aim of this study was to uniquely describe immunocompetent pediatric patients with secondary intracranial infections and further examine the socioeconomic and sociodemographic factors that may put them at higher risk of acquiring an infection. METHODS A retrospective review was conducted for patients presenting with intracranial infections to the regional Children's Hospital between 2001 and 2014. Patients with a previous history of neurosurgical disease or procedure were excluded. A Z test for proportions was performed to detect significant variations between demographic groups. RESULTS A total of 41 patients were included in the study sample. From 2001 to 2014, 63.4% of patients diagnosed with intracranial infections were white, and 36.5% were other/nonwhite. This incidence of infection varied significantly between white and nonwhite (P = .015). At Children's Hospital, 19.5% of patients were privately insured and 80.5% had public health insurance. The most notable variation of a secondary intracranial infection was health insurance; 51% of Louisiana children carry public insurance, yet they represent more than 80% of disease incidence (P < .001). CONCLUSION Improving access to care and treatment for underinsured populations may contribute to a decrease in secondary intracranial infection cases. ABBREVIATIONS CHD, congenital heart diseaseED, emergency departmentICD-9, International Classification of Diseases, Ninth RevisionRR, relative risk.
Collapse
Affiliation(s)
- M Daniel Eggart
- *Department of Neurosurgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana; ‡Department of Neurosurgery, Children's Hospital New Orleans, New Orleans, Louisiana
| | | | | | | |
Collapse
|
15
|
Yarmohammadian MH, Rezaei F, Haghshenas A, Tavakoli N. Overcrowding in emergency departments: A review of strategies to decrease future challenges. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2017; 22:23. [PMID: 28413420 PMCID: PMC5377968 DOI: 10.4103/1735-1995.200277] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/07/2016] [Accepted: 11/29/2016] [Indexed: 01/20/2023]
Abstract
Emergency departments (EDs) are the most challenging ward with respect to patient delay. The goal of this study is to present strategies that have proven to reduce delay and overcrowding in EDs. In this review article, initial electronic database search resulted in a total of 1006 articles. Thirty articles were included after reviewing full texts. Inclusion criteria were assessments of real patient flows and implementing strategies inside the hospitals. In this study, we discussed strategies of team triage, point-of-care testing, ideal ED patient journey models, streaming, and fast track. Patients might be directed to different streaming channels depending on clinical status and required practitioners. The most comprehensive strategy is ideal ED patient journey models, in which ten interrelated substrategies are provided. ED leaders should apply strategies that provide a continuous care process without deeply depending on external services.
Collapse
Affiliation(s)
- Mohammad H Yarmohammadian
- Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Rezaei
- Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abbas Haghshenas
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Nahid Tavakoli
- Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
16
|
Unwin M, Kinsman L, Rigby S. Why are we waiting? Patients’ perspectives for accessing emergency department services with non-urgent complaints. Int Emerg Nurs 2016; 29:3-8. [DOI: 10.1016/j.ienj.2016.09.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/29/2016] [Accepted: 09/11/2016] [Indexed: 11/28/2022]
|
17
|
Mauritzon IC, Blom M, Borna C, Ivarsson K. Attending physicians believe that hospitalized patients are treated at the appropriate level of care: A qualitative study. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2016. [DOI: 10.1179/2047971915y.0000000021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
18
|
Increased door to admission time is associated with prolonged throughput for ED patients discharged home. Am J Emerg Med 2016; 34:1783-7. [PMID: 27431738 DOI: 10.1016/j.ajem.2016.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 05/09/2016] [Accepted: 06/01/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Emergency Department (ED) service evaluations are typically based on surveys of discharged patients. Physicians/administrators benefit from data that quantifies system-based factors that adversely impact the experience of those who represent the survey cohort. OBJECTIVE While investigators have established that admitted patient boarding impacts overall ED throughput times, we sought to specifically quantify the relationship between throughput times for patients admitted (EDLOS) versus discharged home from the ED (DCLOS). METHODS We performed a prospective analysis of consecutive patient encounters at an inner-city ED. Variables collected: median daily DCLOS for ED patients, ED daily census, left without being seen (LWBS), median door to doctor, median room to doctor, and daily number admitted. Admitted patients divided into 2 groups based on daily median EDLOS for admits (<6 hours, ≥6 hours). Continuous variables analyzed by t-tests. Multivariate regression utilized to identify independent effects of the co-variants on median daily DCLOS. RESULTS We analyzed 24,127 patient visits. ED patient DCLOS was longer for patients seen on days with prolonged EDLOS (193.7 minutes, 95%CI 186.7-200.7 vs. 152.8, 144.9-160.5, P< .0001). Variables that were associated with increased daily median EDLOS for admits included: daily admits (P= 0.01), room to doctor time (P< .01), number of patients that left without being seen (P< .01). When controlling for the covariate daily census, differences in DCLOS remained significant for the ≥6 hours group (189.4 minutes, 95%CI 184.1-194.7 vs. 164.8, 155.7-173.9 (P< .0001). CONCLUSION Prolonged ED stays for admitted patients were associated with prolonged throughput times for patients discharged home from the ED.
Collapse
|
19
|
Aguado-Correa F, Herrera-Carranza M, Padilla-Garrido N. Variability and Overcrowding Management. JOURNAL OF HEALTH MANAGEMENT 2016. [DOI: 10.1177/0972063416637697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Emergency department (ED) overcrowding has become a common situation with significant negative effects on the quality of care. The aim of this study is to detail the flow of patients and their variability and determine the existence of stable patterns that allow better planning of resources. We performed a retrospective descriptive observational study of emergencies attended from 2008 to 2010 in the ‘Juan Ramón Jiménez’ General Hospital (Huelva, Spain), with a sample of 343,233 visits. The time between consecutive arrivals of patients and the arrival patterns according to severity and clinical area was calculated using Microsoft Excel and Stat::Fit. Quarterly differences were determined using the Kruskal–Wallis test. The mean value of the inter-arrival time, independent of the quarter ( p < 0.05), was 2–4 minutes from 10:00 am to 10:00 pm and 15–20 minutes from midnight to 8:00 am. The Priority (P) I Patients arrived every 119.05 ± 136.71 minutes, the PII patients every 75.96 ± 97.58 minutes, the PIII patients every 22.62 ± 33.47 minutes and the PIV patients every 6.37 ± 10.53 minutes. PIV had a fluctuating pattern. The arrival rate peaks at 1:00 pm on Monday in the medical–surgical area, at 10:00 pm on Monday for the trauma area, and at 1:00 pm on Sunday for the paediatric area. The study shows that inter-arrival times and average arrival rates of patients have a defined and reproducible pattern for each level of severity and clinical area, which forces us to rethink the fixed capacity model and oriented towards flexibility of resources to reduce the overcrowding.
Collapse
Affiliation(s)
| | | | - Nuria Padilla-Garrido
- Department of Quantitative Methods for Business and Economics, University of Huelva, Huelva, Spain
| |
Collapse
|
20
|
Dresden SM, Feinglass JM, Kang R, Adams JG. Ambulatory Care Sensitive Hospitalizations Through the Emergency Department by Payer: Comparing 2003 and 2009. J Emerg Med 2015; 50:135-42. [PMID: 26281808 DOI: 10.1016/j.jemermed.2015.02.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 01/08/2015] [Accepted: 02/17/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ambulatory care sensitive hospitalizations (ACSHs) are hospitalizations that may have been preventable with timely and effective outpatient care. Approximately 75% of all ACSHs occur through the emergency department (ED). ACSHs through the ED (ED ACSHs) have significant implications for costs and ED crowding. OBJECTIVE This study compares rates of ED ACSHs for 2003 and 2009 among patients 18 to 64 years of age with private insurance, Medicaid, or no insurance. METHODS Nationally representative estimates of ED ACSHs, defined by the Agency for Healthcare Research and Quality (AHRQ) prevention quality indicators (PQIs), were generated from the 2003 and 2009 Nationwide Inpatient Samples. Census data were used to calculate direct age- and sex-standardized ACSH rates by non-Medicare payers for both years. RESULTS Between 2003 and 2009, the overall rate of ED ACSHs decreased from 7.6 (95% confidence interval [CI] 7.57-7.75) to 7.3 (95% CI 7.2-7.4) per 1000 18- to 64-year-old non-Medicare patients. ED ASCH rates declined significantly from 42.4 (95% CI 42.0-42.8) to 25.3 (95% CI 25.0-25.6) per 1000 patients with Medicaid, and declined modestly from 3.8 (95% CI 3.8-3.9) to 3.3 (95% CI 3.2-3.4) per 1000 patients with private insurance. However, the ED ACSH rate increased for the uninsured population from 5.4 (95% CI 5.2-5.7) to 6.2 (95% CI 5.9-6.4) per 1000 patients. CONCLUSION Expansion of Medicaid over the study period was not associated with an increase in ED ACSHs for Medicaid patients. However, an increase in the uninsured population was associated with an increase in the rate of ED ACSH for uninsured patients.
Collapse
Affiliation(s)
- Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joseph M Feinglass
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raymond Kang
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - James G Adams
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
21
|
Elder E, Johnston AN, Crilly J. Review article: systematic review of three key strategies designed to improve patient flow through the emergency department. Emerg Med Australas 2015. [PMID: 26206428 DOI: 10.1111/1742-6723.12446] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To explore the literature regarding three key strategies designed to promote patient throughput in the ED. CINAHL, Medline, PubMed, Scopus and Australian Government databases were searched for articles published between 1980 and 2014 using the key search terms ED flow/throughput, ED congestion, crowding, overcrowding, models of care, physician-assisted triage, medical assessment units, nurse practitioner, did not wait (DNW) and ED length of stay (LOS). Abstracts and articles not published in English and articles published before 1980 were excluded from the review. Quantitative and qualitative studies were considered for inclusion. The National Health Medical Research Council (NHMRC) Level of Evidence Hierarchy (2009) was applied to included studies. Twenty-one articles met criteria for review. The level of evidence assessed using the NHMRC guidelines of studies ranged from I to IV, with the majority falling into the Level II-2 (n = 6) and III-3 (n = 9) range. ED LOS was the outcome most often reported. Study quality was limited with few studies adjusting for confounding factors. Only one level I systematic review was included in this review. Advanced practice nursing roles, physician-assisted triage and medical assessment units are models of care that can positively impact ED throughput. They have been shown to decrease ED LOS and DNW rates. Confounding factors, such as site specific staffing requirements, patient acuity and rest-of-hospital processes, can also impact on patient throughput through the ED.
Collapse
Affiliation(s)
- Elizabeth Elder
- School of Nursing and Midwifery, Griffith Health, Gold Coast Campus, Griffith University, Brisbane, Queensland, Australia
| | - Amy Nb Johnston
- Department of Emergency Medicine and Griffith Health Institute, Gold Coast Hospital and Health Service and Griffith University, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Department of Emergency Medicine and Griffith Health Institute, Gold Coast Hospital and Health Service and Griffith University, Gold Coast, Queensland, Australia
| |
Collapse
|
22
|
|
23
|
Understanding hospital and emergency department congestion: an examination of inpatient admission trends and bed resources. CAN J EMERG MED 2015; 12:18-26. [DOI: 10.1017/s1481803500011970] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjective:Patients in the emergency department (ED) who have been admitted to hospital (inpatient “boarders”) are associated with ED overcrowding. They are also a symptom of a hospital-wide imbalance between demand and supply of resources. We analyzed the trends of inpatient admissions, ED boarding volumes, lengths of stay and bed resources of 3 major admitting services at our teaching institution.Methods:We used hospital databases from Jan. 1, 2004, to Dec. 31, 2007, to analyze ED visits that resulted in admission to hospital.Results:During the study period, 21 986 ED patients were admitted to hospital. The percentage of cancer-related admissions to the oncology admitting service decreased from 48% in 2004 to 24% in 2007, and admissions to general internal medicine (GIM) increased nearly 2-fold, from 28% in 2004 to 54% in 2007. In addition, GIM admitted about 10% more myocardial infarction and heart failure patients than did cardiology. General internal medicine constituted the majority of ED boarders and had a median boarding length of stay of approximately 15 hours. Inpatient beds on oncology and cardiology services remained static.Conclusion:Without bed capacity to admit more patients, our specialty services relied on GIM to serve as a safety net. At the same time, GIM was cited as a main source of ED congestion as their patients occupied more ED beds for longer periods than any other admitting service. The data presented in this study has helped effect positive change within our institution. Other hospitals running at or near capacity and faced with similar ED congestion may apply the methods we used in this study to analyze the cause and nature of their situation.
Collapse
|
24
|
|
25
|
Groll D, Henry B. Can a universal influenza immunization program reduce emergency department volume? CAN J EMERG MED 2015; 4:245-51. [PMID: 17608986 DOI: 10.1017/s1481803500007466] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACT:Objectives:In 2000 the Ontario Minister of Health and Long-Term Care announced a universal influenza immunization program for Ontario, Canada. The 2 objectives of this $38-million program were to decrease seasonal impact of influenza on emergency department (ED) visits and to decrease the number and severity of influenza cases. This paper examines the correlation between population influenza rates and ED visits in 5 tertiary care hospitals in Ontario over a 5-year period (1996–2001).Methods:In this retrospective, observational study, we determined the total number of ED visits during the study period, by month, at 5 tertiary care hospitals in 3 Ontario cities Kingston, London and Ottawa). Detailed ED diagnoses were captured for Kingston, and provincial and national population-based influenza rates were obtained from Health Canada for the 5-year study period. Correlation and regression analyses were used to determine the relationship of influenza rates and ED volumes. “Influenza season” is defined in this study as November 1st to March 31st of each year.Results:There was no significant correlation between influenza rates and ED volumes, with Pearson correlation coefficients (r) of 0.22 (p= 0.72), 0.33 (p= 0.59) and 0.27 (p= 0.66) at the Kingston, London and Ottawa study sites, respectively. Data from the Kingston hospitals showed that, during influenza season, acute respiratory diagnoses accounted for only 4.4% of ED visits and influenza for only 0.34% of visits. Multiple linear regression analysis showed that the ED diagnosis of influenza was not significantly related to ED volume. During the influenza season after the universal immunization campaign, ED visits increased at all sites.Conclusion:Based on this study, a universal influenza immunization campaign is unlikely to affect ED volume.
Collapse
Affiliation(s)
- Dianne Groll
- ICU Research Group, Queen's University, Kingston, Ontario, Canada
| | | |
Collapse
|
26
|
Borg MA, Suda D, Scicluna E. Time-Series Analysis of the Impact of Bed Occupancy Rates on the Incidence of Methicillin-Resistant Staphylococcus aureus Infection in Overcrowded General Wards. Infect Control Hosp Epidemiol 2015; 29:496-502. [DOI: 10.1086/588157] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.We investigated the impact of bed occupancy, particularly overcrowding, on the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infection in general ward settings.Methods.We performed a time-series and mixed-model analysis of variance of monthly incidence of MRSA infection and corresponding bed occupancy rates, over 65 months, in the medicine and surgical wards within St. Luke's Hospital, a 900-bed tertiary care facility in Malta.Results.In the medicine wards, significant periodic fluctuations in bed demand were evident during the study period, with peaks of occupancy greater than 120% during the winter months. Cross-correlation analysis between the rate of bed occupancy and the rate of MRSA infection displayed an oscillatory configuration, with a periodicity of 12, similar to the periodicity evident in the autocorrelation bed-occupancy pattern. Further statistical analysis by means of analysis of variance confirmed that the months with excessive overcrowding tended to coincide with a significant increase in the rate of MRSA infection, occurring after a lag of approximately 2 months. Identical analysis of equivalent data from the surgical wards also revealed significant fluctuation in the rate of bed occupancy; however, occupancy never exceeded 100%. No cross-correlational relationship with MRSA infection incidence was present.Conclusion.The study data suggest that, in our setting, simple fluctuations in the rate of bed occupancy did not have a direct impact on the incidence of MRSA infection as long as the rate of bed occupancy was within designated levels. Rather, it was episodes of significant overcrowding, with occupancy levels in excess of designated numbers, that triggered increases in infection incidence rates.
Collapse
|
27
|
Fu CY, Huang HC, Chen RJ, Tsuo HC, Tung HJ. Implementation of the acute care surgery model provides benefits in the surgical treatment of the acute appendicitis. Am J Surg 2014; 208:794-799. [PMID: 25441600 DOI: 10.1016/j.amjsurg.2013.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 04/05/2013] [Accepted: 04/29/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND Several reports have indicated the benefits of the acute care surgery (ACS) model in surgical outcomes. We tried to delineate the impact of the ACS model on surgical efficiency and quality. METHODS Before the ACS model was implemented, abdominal surgical emergencies were evaluated by an on-call nontrauma general surgeon (pre-ACS model). An in-house trauma surgeon treated all patients with trauma or nontrauma abdominal surgical emergencies after the ACS model. Patients with acute appendicitis who underwent appendectomies were included. We conducted a pre- and poststudy to compare the time patients were in the emergency department and surgical qualities. RESULTS There were 146 and 159 patients enrolled in the pre-ACS model and ACS model, respectively. The overall ED length of stay in the ACS model was significantly shorter than that in the pre-ACS model (300.3 ± 61.7 vs 719.1 ± 339.0 minutes, P < .001). Hospital LOS was also significantly shorter in the ACS model than in the pre-ACS model (2.44 ± 1.39 vs 3.83 ± 2.21 days, P = .022). CONCLUSION The ACS model may improve abdominal surgical efficiency and quality. Our study results echoed the benefits of the implementation of the ACS model shown in North America.
Collapse
Affiliation(s)
- Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Hung-Chang Huang
- Department of Trauma and Emergency Surgery, Taipei Medical University-Wan Fang Hospital, Taipei Medical University, No 111, Sec 3, Xinglong Rd, Taipei 11696, Taiwan
| | - Ray-Jade Chen
- Department of Trauma and Emergency Surgery, Taipei Medical University-Wan Fang Hospital, Taipei Medical University, No 111, Sec 3, Xinglong Rd, Taipei 11696, Taiwan.
| | - Hsun-Chung Tsuo
- School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Jung Tung
- School of Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
28
|
Melon KA, White D, Rankin J. Beat the clock! Wait times and the production of 'quality' in emergency departments. Nurs Philos 2014; 14:223-37. [PMID: 23745663 DOI: 10.1111/nup.12022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Emergency care in large urban hospitals across the country is in the midst of major redesign intended to deliver quality care through improved access, decreased wait times, and maximum efficiency. The central argument in this paper is that the conceptualization of quality including the documentary facts and figures produced to substantiate quality emergency care is socially organized within a powerful ruling discourse that inserts the interests of politics and economics into nurses' work. The Canadian Triage and Acuity Scale figures prominently in the analysis as a high-level organizer of triage work and knowledge production that underpins the way those who administer the system define, measure and evaluate emergency care processes, and then use this information for restructuring. Managerial targets and thinking not only dominate the way emergency work is understood, determined, and controlled but also subsume the actual work of health-care providers in spaces called 'wait times', where it is systematically rendered 'unknowable'. The analysis is supported with evidence from an extensive institutional ethnography that shows what nurses actually do to manage the safe passage of patients through their emergency care process starting with the work of triage nurses.
Collapse
Affiliation(s)
- Karen A Melon
- Alberta Health Services, 351 Rundlelawn Road NE, Calgary, Alberta, Canada.
| | | | | |
Collapse
|
29
|
Razavi SA, Johnson JO, Kassin MT, Applegate KE. The impact of introducing a no oral contrast abdominopelvic CT examination (NOCAPE) pathway on radiology turn around times, emergency department length of stay, and patient safety. Emerg Radiol 2014; 21:605-13. [DOI: 10.1007/s10140-014-1240-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 05/14/2014] [Indexed: 12/29/2022]
|
30
|
Bergs J, Verelst S, Gillet JB, Vandijck D. Evaluating implementation of the emergency severity index in a Belgian hospital. J Emerg Nurs 2014; 40:592-7. [PMID: 24629665 DOI: 10.1016/j.jen.2014.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 12/06/2013] [Accepted: 01/10/2014] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Triage aims to categorize patients based on their clinical need and the available departmental resources. To accomplish this goal, one needs to ensure that the implemented triage system is reliable and that staff use it correctly. Therefore this study assessed the ability of Belgium nurses to apply the Emergency Severity Index (ESI), version 4, to hypothetical case scenarios after an educational intervention. METHODS An ESI educational intervention was implemented in accordance with the ESI manual. Using paper case scenarios, nurses' interrater agreement was assessed by comparing triage nurse ESI levels with the reference answers noted in the implementation manual. Interrater agreement was measured by the percentage of agreement and Cohen's κ coefficient using different weighting schemes. RESULTS Overall, 77.5% of the scenario cases were coded according the ESI guidelines, resulting in a good interrater agreement (κ = 0.72, linear weighted κ = 0.84, quadratic weighted κ = 0.92, and triage-weighted scheme = 0.79). Interrater agreement varied when evaluating each ESI level separately. Undertriage was more common than overtriage. The highest misclassification range (37.8%) occurred in ESI level 2 scenarios, with 99.2% of the misclassifications being undertriaged. DISCUSSION Implementation of the ESI into a novel setting guided by a locally developed training program resulted in suboptimal interrater agreement. Existing weighted κ schemes overestimated the interrater agreement between the triage nurse-assigned ESI level and the reference standard. By providing an aggregated measure of agreement, which allows partial agreement, clinically significant misclassification was masked by a misleading "good" interrater agreement.
Collapse
|
31
|
Krall SP, Cornelius AP, Addison JB. Hospital factors impact variation in emergency department length of stay more than physician factors. West J Emerg Med 2014; 15:158-64. [PMID: 24672604 PMCID: PMC3966443 DOI: 10.5811/westjem.2013.12.6860] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 11/11/2011] [Accepted: 12/19/2013] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION To analyze the correlation between the many different emergency department (ED) treatment metric intervals and determine if the metrics directly impacted by the physician correlate to the "door to room" interval in an ED (interval determined by ED bed availability). Our null hypothesis was that the cause of the variation in delay to receiving a room was multifactorial and does not correlate to any one metric interval. METHODS We collected daily interval averages from the ED information system, Meditech©. Patient flow metrics were collected on a 24-hour basis. We analyzed the relationship between the time intervals that make up an ED visit and the "arrival to room" interval using simple correlation (Pearson Correlation coefficients). Summary statistics of industry standard metrics were also done by dividing the intervals into 2 groups, based on the average ED length of stay (LOS) from the National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary. RESULTS Simple correlation analysis showed that the doctor-to-discharge time interval had no correlation to the interval of "door to room (waiting room time)", correlation coefficient (CC) (CC=0.000, p=0.96). "Room to doctor" had a low correlation to "door to room" CC=0.143, while "decision to admitted patients departing the ED time" had a moderate correlation of 0.29 (p <0.001). "New arrivals" (daily patient census) had a strong correlation to longer "door to room" times, 0.657, p<0.001. The "door to discharge" times had a very strong correlation CC=0.804 (p<0.001), to the extended "door to room" time. CONCLUSION Physician-dependent intervals had minimal correlation to the variation in arrival to room time. The "door to room" interval was a significant component to the variation in "door to discharge" i.e. LOS. The hospital-influenced "admit decision to hospital bed" i.e. hospital inpatient capacity, interval had a correlation to delayed "door to room" time. The other major factor affecting department bed availability was the "total patients per day." The correlation to the increasing "door to room" time also reflects the effect of availability of ED resources (beds) on the patient evaluation time. The time that it took for a patient to receive a room appeared more dependent on the system resources, for example, beds in the ED, as well as in the hospital, than on the physician.
Collapse
Affiliation(s)
- Scott P. Krall
- Texas A&M University System Health Science Center College of Medicine, Department of Emergency Medicine, Corpus Christi, Texas
| | | | | |
Collapse
|
32
|
Koks DRJC, Zonderland ME, Heringhaus C. Development of an observational instrument to determine variations in the patient care process and patient flow among emergency physicians and internists at the emergency department. Int J Emerg Med 2013; 6:1. [PMID: 23317313 PMCID: PMC3560181 DOI: 10.1186/1865-1380-6-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 12/10/2012] [Indexed: 11/16/2022] Open
Abstract
Background The increasing demand for acute care and restructuring of hospitals resulting in emergency department (ED) closures and fewer inpatient beds are reasons to improve ED efficiency. The approach towards the patient care process varies among doctors. The objective of this study was to determine variations in the patient care process and patient flow among emergency physicians (EP’s) and internists at the ED of Leiden University Medical Centre (LUMC), the Netherlands. Methods An observational instrument was developed during a pilot study at the LUMC ED, following observations of activities performed by EP’s and internists. The instrument divides all different types of activities a clinician can perform on the ED into eight categories. Using the observational instrument, their activities were observed and registered for 10 separate days. Primary outcomes were defined as the time spend on the eight separate activity categories, the total length of stay (LOS) and the number of patients seen during an interval. Secondary outcomes were general observations of working routine features that determine patient flow at the ED. The obtained data were analyzed into SPSS. Results Ten doctors were observed during a total of ± 36 hours in which 42 patients were seen. Although EP’s were observed for a shorter period of time than internists (13:48 vs. 22:10 hrs, -38%), they saw more patients (26 vs. 16, +62%). EP’s tended to spend a higher proportion of their time on patient contact than internists (27.2% vs. 17.3%, p = 0.06). Both groups dedicated the highest proportion of their time to documentation (31.5% and 33.4%, p = 0.75) and had little communication with ED nurses (3.7% and 2.4% p = 0.57). The average LOS of internal patients was higher than that of EP’s patients (5.25 ± sd 1:33 and 2.26 ± sd 1:32 hours). Internists occupied more treatment rooms at the same time (2.41 vs. 2.08, p < 0.00) and followed a more sequential working routine. Conclusions This paper describes the determination of variations in the ED care process and patient flow among EP’s and internists by an observational instrument. A pilot study with the instrument showed variations in the patient care process and patient flow among the two groups at the LUMC ED.
Collapse
|
33
|
Schull MJ, Slaughter PM, Redelmeier DA. Urban emergency department overcrowding: defining the problem and eliminating misconceptions. CAN J EMERG MED 2012; 4:76-83. [PMID: 17612424 DOI: 10.1017/s1481803500006163] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
STUDY OBJECTIVE To develop an operational definition and a parsimonious list of postulated determinants for urban emergency department (ED) overcrowding. METHODS A panel was formed from clinical and administrative experts in pre-hospital, ED and hospital domains. Key studies and reports were reviewed in advance by panel members, an experienced health services researcher facilitated the panel's discussions, and a formal content analysis of audiotaped recordings was conducted. RESULTS The panel considered community, patient, ED and hospital determinants of overcrowding. Of 46 factors postulated in the literature, 21 were not retained by the experts as potentially important determinants of overcrowding. Factors not retained included access to primary care services and seasonal influenza outbreaks. Key determinants retained included admitted patients awaiting beds and patient characteristics. Ambulance diversion was considered to be an appropriate operational definition and proxy measure of ED overcrowding. CONCLUSION These results help to clarify the conceptual framework around ED overcrowding, and may provide a guide for future research. The relative importance of the determinants must be assessed by prospective studies.
Collapse
Affiliation(s)
- Michael J Schull
- Clinical Epidemiology Unit, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | | | | |
Collapse
|
34
|
Atzema CL, Stefan RA, Saskin R, Michlik G, Austin PC. Does ED crowding decrease the number of procedures a physician in training performs? A prospective observational study. Am J Emerg Med 2012; 30:1743-8. [PMID: 22657395 DOI: 10.1016/j.ajem.2012.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 01/27/2012] [Accepted: 01/28/2012] [Indexed: 10/28/2022] Open
Abstract
PURPOSE The aim of the study was to determine whether the number of procedures performed by residents and medical students in the emergency department (ED) is affected by ED crowding. METHODS In this single-center, prospective, observational study, standardized data collection forms were completed by both trainees and supervising emergency physicians (EPs) at the end of each ED shift from August 2009 to March 2010. Shifts with no trainees were excluded. All procedures that were offered to a trainee were recorded as well as the number of potential ED procedures that were, instead, referred to a consulting service. Emergency department crowding was measured in 2 ways: ED length of stay (LOS) and the EP's assessment of crowding during the shift. Poisson regression was used to assess the adjusted effect of ED crowding on the number of trainee procedures performed as well as on the number of procedures given away. RESULTS There were 804 procedures performed by 113 trainees during 647 trainee shifts. Medical students comprised 51% of trainees. Median number of procedures performed per shift was 1.0 (Fine interquartile range, 0-2.0). Emergency department crowding was not associated with the adjusted number of procedures trainees performed using either the EP's assessment of crowding (P = .52) or ED LOS (P = .84). Emergency department crowding was associated with an adjusted 256% increase in the mean number of procedures given away (P = .02) when measured using physician assessment but was not associated with crowding when assessed using ED LOS (P = .06). CONCLUSIONS Crowding was not significantly associated with the number of procedures availed to ED trainees. In patients being considered for admission, however, when the managing EP felt that it was crowded, there was an association with giving procedures to consulting services.
Collapse
Affiliation(s)
- Clare L Atzema
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada M4N 3M5.
| | | | | | | | | |
Collapse
|
35
|
Forero R, Hillman KM, McCarthy S, Fatovich DM, Joseph AP, Richardson DB. Access block and ED overcrowding. Emerg Med Australas 2012; 22:119-35. [PMID: 20534047 DOI: 10.1111/j.1742-6723.2010.01270.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20-30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998-1999) to 2.4 beds per 1000 (2002-2007) in 2002, and has remained steady at between 2.5-2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998-1999 rates, the number of available beds in 2006-2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.
Collapse
Affiliation(s)
- Roberto Forero
- Simpson Centre for Health Services Research Affiliated with The Australian Institute of Health Innovation, University of New South Wales, Kensington, New South Wales, Australia.
| | | | | | | | | | | |
Collapse
|
36
|
Abstract
Ontario is Canada's most populous province, with approximately 12 million people and 130 emergency departments (EDs). Canada has a national single-payer universal health care system, but provinces are responsible for administration. After years of problems and failed attempts to address chronic ED overcrowding, in April 2008 Ontario embarked on an ambitious program to improve system performance through targeted investments (initially CAN$500 million over 3 years) and realigned incentives. Supporting the program were requirements for hospitals to submit timely data and targets for length of stay (LOS) and annual improvements; results are publicly reported. The program has been continued this year. While not all our provincial level targets have been met as yet, major improvements have been made, especially in access to care and LOS in the ED for patients eventually discharged home. The greatest improvements were made among the cohort of mainly urban, high-volume EDs that had the worst performance at baseline. This presentation will highlight some of the controversies and challenges and key lessons learned. Overall, the Ontario experience suggests ED overcrowding is a soluble problem, but requires a system-level intervention.
Collapse
Affiliation(s)
- Howard Ovens
- Schwartz/Reisman Emergency Centre, Mount Sinai Hospital, Ontario, Canada.
| |
Collapse
|
37
|
McCarthy ML, Ding R, Pines JM, Zeger SL. Comparison of methods for measuring crowding and its effects on length of stay in the emergency department. Acad Emerg Med 2011; 18:1269-77. [PMID: 22168190 DOI: 10.1111/j.1553-2712.2011.01232.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This consensus conference presentation article focuses on methods of measuring crowding. The authors compare daily versus hourly measures, static versus dynamic measures, and the use of linear or logistic regression models versus survival analysis models to estimate the effect of crowding on an outcome. METHODS Emergency department (ED) visit data were used to measure crowding and completion of waiting room time, treatment time, and boarding time for all patients treated and released or admitted to a single ED during 2010 (excluding patients who left without being seen). Crowding was characterized according to total ED census. First, total ED census on a daily and hourly basis throughout the 1-year study period was measured, and the ratios of daily and hourly census to the ED's median daily and hourly census were computed. Second, the person-based ED visit data set was transposed to person-period data. Multiple records per patient were created, whereby each record represented a consecutive 15-minute interval during each patient's ED length of stay (LOS). The variation in crowding measured statically (i.e., crowding at arrival or mean crowding throughout the shift in which the patient arrived) or dynamically (every 15 minutes throughout each patient's ED LOS) were compared. Within each phase of care, the authors divided each individual crowding value by the median crowding value of all 15-minute intervals to create a time-varying ED census ratio. For the two static measures, the ratio between each patient's ED census at arrival and the overall median ED census at arrival was computed, as well as the ratio between the mean shift ED census (based on the shift in which the patient arrived) and the study ED's overall mean shift ED census. Finally, the effect of crowding on the probability of completing different phases of emergency care was compared when estimated using a log-linear regression model versus a discrete time survival analysis model. RESULTS During the 1-year study period, for 9% of the hours, total ED census was at least 50% greater than the median hourly census (median, 36). In contrast, on none of the days was total ED census at least 50% greater than the median daily census (median, 161). ED census at arrival and time-varying ED census yielded greater variation in crowding exposure compared to mean shift census for all three phases of emergency care. When estimating the effect of crowding on the completion of care, the discrete time survival analysis model fit the observed data better than the log-linear regression models. The discrete time survival analysis model also determined that the effect of crowding on care completion varied during patients' ED LOS. CONCLUSIONS Crowding measured at the daily level will mask much of the variation in crowding that occurs within a 24-hour period. ED census at arrival demonstrated similar variation in crowding exposure as time-varying ED census. Discrete time survival analysis is a more appropriate approach for estimating the effect of crowding on an outcome.
Collapse
Affiliation(s)
- Melissa L McCarthy
- Center for Healthcare Quality, Departments of Health Policy and Emergency Medicine, George Washington University, Washington, DC, USA.
| | | | | | | |
Collapse
|
38
|
Cooney DR, Millin MG, Carter A, Lawner BJ, Nable JV, Wallus HJ. Ambulance Diversion and Emergency Department Offload Delay: Resource Document for the National Association of EMS Physicians Position Statement. PREHOSP EMERG CARE 2011; 15:555-61. [DOI: 10.3109/10903127.2011.608871] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
39
|
Correlation of measures of patient acuity with measures of crowding in a pediatric emergency department. Pediatr Emerg Care 2011; 27:706-9. [PMID: 21811200 DOI: 10.1097/pec.0b013e318226c7dd] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Emergency department (ED) crowding is an increasingly common problem in the United States. Crowding can lead to ED closure and diversion, poor patient satisfaction, and patient safety issues. The purpose of this study was to examine measures of ED census and measures of crowding to determine if a correlation exists in a pediatric ED setting. METHODS Arkansas Children's Hospital is a major pediatric referral center. Measures of ED acuity (including total census, admission rate, total number of admissions, and proportion of triage category nonurgent patients) and measures of throughput (left-without-being-seen [LWBS] rate and ED length of stay [LOS]) data for 11 years (1996-2006) were plotted, and correlation coefficients were calculated. RESULTS Annual ED census varied between 35,415 and 40,711 during the 11-year study period. The total number of admissions increased from 4179 in 1996 to 6539 in 2006. When total census was plotted against LWBS rate and ED LOS, a poor correlation was found (R² = 0.007 for total census vs LWBS rate). However, a strong correlation was found when the relationship between the total number of admissions and LWBS rate was examined (R² = 0.89). Similarly, a strong relationship between the admission rate and LWBS rate was seen (R² = 0.75). In addition, a strong correlation was seen between admissions (total and percentage) versus ED LOS. CONCLUSIONS There is a strong correlation between the number of patients admitted and measures of overcrowding in this pediatric ED, but there is a poor correlation between the total census and overcrowding measures. Targeting process improvement on hospital-wide patient flow may help reduce ED crowding.
Collapse
|
40
|
Qureshi A, Smith A, Wright F, Brenneman F, Rizoli S, Hsieh T, Tien HC. The impact of an acute care emergency surgical service on timely surgical decision-making and emergency department overcrowding. J Am Coll Surg 2011; 213:284-93. [PMID: 21601487 DOI: 10.1016/j.jamcollsurg.2011.04.020] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 04/20/2011] [Accepted: 04/20/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study evaluated how implementation of an acute care emergency surgery service (ACCESS) affected key determinants of emergency department (ED) length of stay, and particularly, surgical decision time. Also, we analyzed how ACCESS affected ED overcrowding. STUDY DESIGN We conducted a before and after study of all ED patients referred to ACCESS from January 1, 2007 to June 30, 2009. ACCESS was implemented on July 1, 2008. The primary outcome was surgical decision time; the secondary outcome was a measure of overall ED overcrowding: "time-to-stretcher" for all ED patients. The control groups were patients referred to internal medicine or urology. Patients with appendicitis were studied in order to analyze the impact on patient outcomes and to determine barriers to efficient ED patient flow. RESULTS Of 2,510 patients, 1,448 patients were pre-ACCESS, and 1,062 were after ACCESS implementation. Implementation of ACCESS was associated with a 15% reduction in surgical decision time (12.6 hours vs 10.8 hours, p < 0.01). During the same period, there were no significant changes in decision time for our control groups. Also, the mean time-to-stretcher for all ED patients decreased by 20%. In patients with appendicitis, we found that patient flow could be further improved by a timely request for surgical consultation and expedited imaging. Finally, we found that patients with nonperforated appendicitis with a fecalith on CT imaging were more likely to suffer perforation while waiting for surgery. CONCLUSIONS ACCESS reduced surgical decision time for surgical patients. Also, ACCESS improved overall ED crowding, as measured by time-to-stretcher for ED patients. Further improvements could be made by improving time to imaging. Patients referred for nonperforated appendicitis with a fecalith on CT should have expedited surgery.
Collapse
Affiliation(s)
- Adnan Qureshi
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | |
Collapse
|
41
|
Forero R, McCarthy S, Hillman K. Access block and emergency department overcrowding. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:216. [PMID: 21457507 PMCID: PMC3219412 DOI: 10.1186/cc9998] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Roberto Forero
- The Simpson Center for Health Systems Research, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.
| | | | | |
Collapse
|
42
|
Hsia RY, Asch SM, Weiss RE, Zingmond D, Liang LJ, Han W, McCreath H, Sun BC. Hospital determinants of emergency department left without being seen rates. Ann Emerg Med 2011; 58:24-32.e3. [PMID: 21334761 DOI: 10.1016/j.annemergmed.2011.01.009] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 12/15/2010] [Accepted: 01/11/2011] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE The proportion of patients who leave without being seen in the emergency department (ED) is an outcome-oriented measure of impaired access to emergency care and represents the failure of an emergency care delivery system to meet its goals of providing care to those most in need. Little is known about variation in the amount of left without being seen or about hospital-level determinants. Such knowledge is necessary to target hospital-level interventions to improve access to emergency care. We seek to determine whether hospital-level socioeconomic status case mix or hospital structural characteristics are predictive of ED left without being seen rates. METHODS We performed a cross-sectional study of all acute-care, nonfederal hospitals in California that operated an ED in 2007, using data from the California Office of Statewide Health Planning and Development database and the US census. Our outcome of interest was whether a visit to a given hospital ED resulted in left without being seen. The proportion of left without being seen was measured by the number of left without being seen cases out of the total number of visits. RESULTS We studied 9.2 million ED visits to 262 hospitals in California. The percentage of left without being seen varied greatly over hospitals, ranging from 0% to 20.3%, with a median percentage of 2.6%. In multivariable analyses adjusting for hospital-level socioeconomic status case mix, visitors to EDs with a higher proportion of low-income and poorly insured patients experienced a higher risk of left without being seen. We found that the odds of an ED visit resulting in left without being seen increased by a factor of 1.15 for each 10-percentage-point increase in poorly insured patients, and odds of left without being seen decreased by a factor of 0.86 for each $10,000 increase in household income. When hospital structural characteristics were added to the model, county ownership, trauma center designation, and teaching program affiliation were positively associated with increased probability of left without being seen (odds ratio 2.09; 1.62, and 2.14, respectively), and these factors attenuated the association with insurance status. CONCLUSION Visitors to different EDs experience a large variation in their probability of left without being seen, and visitors to hospitals serving a high proportion of low-income and poorly insured patients are at disproportionately higher risk of leaving without being seen. Our findings suggest that there is room for substantial improvement in this outcome, and regional interventions can be targeted toward certain at-risk hospitals to improve access to emergency care.
Collapse
Affiliation(s)
- Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, CA, USA.
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Vertesi L. Does the Canadian Emergency Department Triage and Acuity Scale identify non-urgent patients who can be triaged away from the emergency department? CAN J EMERG MED 2010; 6:337-42. [PMID: 17381991 DOI: 10.1017/s1481803500009611] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Non-urgent visits comprise a significant proportion of visits to most emergency departments (EDs). Given the severe overcrowding issues faced by many EDs, the use of the Canadian Emergency Department Triage and Acuity Scale (CTAS) to identify patients who could be managed elsewhere seems to be an obvious way to reduce the pressure on the ED and "solve" the overcrowding problem. OBJECTIVE To quantify the resource implications, in terms of stretcher use and waiting times, related to non-urgent patient visits and to estimate the potential impact on ED flow of redirecting these patients to alternate primary care settings. METHODS Retrospective database audit in an urban referral hospital ED. For this study, patients triaged as either CTAS Levels IV or V were considered "non-urgent." RESULTS Non-urgent patients comprised 30% of ED visits, but less than 5% of all those needing stretchers, along with their associated nursing resources. The longer waits consisted almost entirely of waits for available stretchers and would therefore have remained essentially unaffected. In spite of being labelled "non-urgent" by CTAS criteria, 7.3% of all patients requiring admission came from this group. CONCLUSIONS Non-urgent patients consume a small fraction of the ED stretchers and acute-care resources; therefore, strategies aimed at diverting non-urgent patients are unlikely to improve access for more urgent patients. Using the CTAS to identify patients for diversion away from the ED is measurably unsafe and will lead to inappropriate refusal of care for many patients requiring hospital treatment.
Collapse
Affiliation(s)
- Les Vertesi
- Institute for Health Research and Education, Simon Fraser University, Burnaby BC, Canada.
| |
Collapse
|
44
|
Abstract
OBJECTIVE Emergency department (ED) visits continue to climb in the United States despite numerous primary care initiatives. A variety of staffing models including the utilization of nurse practitioners (NPs) and physician assistants (PAs) and the use of fast-track or express care are alternative methods of caring for the ED patients with less acute illness. Our objectives were to determine the prevalence of NPs in pediatric EDs (PEDs) and fast-track areas and to identify common procedures performed by NPs in PEDs. METHODS Two telephone surveys were conducted. The first survey was performed with the ED charge nurse at all 205 hospitals in the United States participating in the National Association of Children's Hospitals and Related Institutions. The second survey consisted of an interview with NPs working in those PEDs. Both descriptive data as well as the procedures performed by NPs in the PED were collected. RESULTS A total of 198 hospitals completed the first survey (97% response rate), representing 41 states. Fifty-one percent of respondents reported using NPs in the ED, contrasted with only 36% who reported using PAs (P < 0.01). The use of NPs was found to be distributed across all geographical regions, whereas the use of PAs was statistically more likely in the Northeast and Midwest regions (P < 0.01). Freestanding children's hospitals were more likely to use NPs than children's hospital within general hospitals (P < 0.01). Procedures such as fluorescein staining of the cornea were performed by all NPs, whereas only 65% of NPs performed repair of a finger-tip amputation. CONCLUSIONS The use of NPs in the PED is common. Nurse practitioners in the PED perform a number of different procedures. Future studies analyzing practice patterns and effectiveness of the NP role in the PED are needed.
Collapse
|
45
|
Stiell IG, Clement CM, O'Connor A, Davies B, Leclair C, Sheehan P, Clavet T, Beland C, MacKenzie T, Wells GA. Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. CMAJ 2010; 182:1173-9. [PMID: 20457772 DOI: 10.1503/cmaj.091430] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES The Canadian C-Spine Rule for imaging of the cervical spine was developed for use by physicians. We believe that nurses in the emergency department could use this rule to clinically clear the cervical spine. We prospectively evaluated the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses. METHODS We conducted this three-year prospective cohort study in six Canadian emergency departments. The study involved adult trauma patients who were alert and whose condition was stable. We provided two hours of training to 191 triage nurses. The nurses then assessed patients using the Canadian C-Spine Rule, including determination of neck tenderness and range of motion, reapplied immobilization and completed a data form. RESULTS Of the 3633 study patients, 42 (1.2%) had clinically important injuries of the cervical spine. The kappa value for interobserver assessments of 498 patients with the Canadian C-Spine Rule was 0.78. We calculated sensitivity of 100.0% (95% confidence interval [CI] 91.0%-100.0%) and specificity of 43.4% (95% CI 42.0%-45.0%) for the Canadian C-Spine Rule as interpreted by the investigators. The nurses classified patients with a sensitivity of 90.2% (95% CI 76.0%-95.0%) and a specificity of 43.9% (95% CI 42.0%-46.0%). Early in the study, nurses failed to identify four cases of injury, despite the presence of clear high-risk factors. None of these patients suffered sequelae, and after retraining there were no further missed cases. We estimated that for 40.7% of patients, the cervical spine could be cleared clinically by nurses. Nurses reported discomfort in applying the Canadian C-Spine Rule in only 4.8% of cases. CONCLUSION Use of the Canadian C-Spine Rule by nurses was accurate, reliable and clinically acceptable. Widespread implementation by nurses throughout Canada and elsewhere would diminish patient discomfort and improve patient flow in overcrowded emergency departments.
Collapse
Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Department of Nursing, Ottawa Hospital, Ottawa, Ontario.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Bittencourt RJ, Hortale VA. Intervenções para solucionar a superlotação nos serviços de emergência hospitalar: uma revisão sistemática. CAD SAUDE PUBLICA 2009; 25:1439-54. [PMID: 19578565 DOI: 10.1590/s0102-311x2009000700002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 01/22/2009] [Indexed: 11/22/2022] Open
Abstract
Esta revisão discute as intervenções voltadas para solucionar o problema da superlotação dos Serviços de Emergência Hospitalar (SEH), como evidência de baixa efetividade organizacional. Em bases de dados eletrônicas de livre acesso e acesso restrito, os descritores buscados foram "superlotação; emergência; medicina; pronto-socorro". O levantamento identificou 66 citações de intervenções, agrupadas em 47 intervenções afins. A maioria dos trabalhos teve como desenho os estudos observacionais que avaliaram os resultados das intervenções antes e depois. As mais citadas: implantação da unidade de observação dos pacientes graves; implantação do serviço de enfermagem dedicado à admissão, alta e transferência do paciente; instituição de protocolos de saturação operacional e implantação da unidade de pronto-atendimento. Na análise das 21 intervenções para solucionar a superlotação nos SEH, que tiveram resultados favoráveis no evento principal - tempo de permanência no SEH -, 15 tinham relação com a melhoria do fluxo no próprio SEH ou nos setores do hospital, interferindo ativa e positivamente no fluxo interno dos pacientes. As intervenções que aumentaram as barreiras de acesso aos SEH, ou que apenas melhoram a estrutura dos SEH não foram efetivas.
Collapse
|
47
|
The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med 2009; 54:663-671.e1. [PMID: 19394111 DOI: 10.1016/j.annemergmed.2009.03.008] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Revised: 01/20/2009] [Accepted: 03/04/2009] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting. METHODS We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury. RESULTS The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The kappa value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule. CONCLUSION This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.
Collapse
|
48
|
Jones SS, Evans RS, Allen TL, Thomas A, Haug PJ, Welch SJ, Snow GL. A multivariate time series approach to modeling and forecasting demand in the emergency department. J Biomed Inform 2009; 42:123-39. [DOI: 10.1016/j.jbi.2008.05.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 05/06/2008] [Accepted: 05/12/2008] [Indexed: 10/22/2022]
|
49
|
Ong MEH, Ho KK, Tan TP, Koh SK, Almuthar Z, Overton J, Lim SH. Using demand analysis and system status management for predicting ED attendances and rostering. Am J Emerg Med 2009; 27:16-22. [PMID: 19041529 DOI: 10.1016/j.ajem.2008.01.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 01/07/2008] [Accepted: 01/07/2008] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION It has been observed that emergency department (ED) attendances are not random events but rather have definite time patterns and trends that can be observed historically. OBJECTIVES To describe the time demand patterns at the ED and apply systems status management to tailor ED manpower demand. METHODS Observational study of all patients presenting to the ED at the Singapore General Hospital during a 3-year period was conducted. We also conducted a time series analysis to determine time norms regarding physician activity for various severities of patients. RESULTS The yearly ED attendances increased from 113387 (2004) to 120764 (2005) and to 125773 (2006). There was a progressive increase in severity of cases, with priority 1 (most severe) increasing from 6.7% (2004) to 9.1% (2006) and priority 2 from 33.7% (2004) to 35.1% (2006). We noticed a definite time demand pattern, with seasonal peaks in June, weekly peaks on Mondays, and daily peaks at 11 to 12 am. These patterns were consistent during the period of the study. We designed a demand-based rostering tool that matched doctor-unit-hours to patient arrivals and severity. We also noted seasonal peaks corresponding to public holidays. CONCLUSION We found definite and consistent patterns of patient demand and designed a rostering tool to match ED manpower demand.
Collapse
Affiliation(s)
- Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, 169608 Singapore.
| | - Khoy Kheng Ho
- Department of Emergency Medicine, Singapore General Hospital, 169608 Singapore
| | - Tiong Peng Tan
- Department of Emergency Medicine, Singapore General Hospital, 169608 Singapore
| | - Seoh Kwee Koh
- Department of Emergency Medicine, Singapore General Hospital, 169608 Singapore
| | - Zain Almuthar
- Service Operations Department, Singapore General Hospital, Singapore
| | | | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital, 169608 Singapore
| |
Collapse
|
50
|
ALaRMED: adverse events in low-risk chest pain patients receiving continuous ECG monitoring in the emergency department: a survey of Canadian emergency physicians. CAN J EMERG MED 2008; 10:413-9. [PMID: 18826728 DOI: 10.1017/s1481803500010472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Current guidelines suggest that most patients who present to an emergency department (ED) with chest pain should be placed on a continuous electrocardiographic monitoring (CEM) device. We surveyed emergency physicians to determine their perception of current occupancy rates of CEM and to assess their attitudes toward prescribing monitors for low-risk chest pain patients in the ED. METHODS We conducted a cross-sectional, self-administered Internet and mail survey of a random sample of 300 members of the Canadian Association of Emergency Physicians. Main outcome measures included the perceived frequency of fully occupied monitors in the ED and physicians' willingness to forgo CEM in certain chest pain patients. RESULTS The response rate was 66% (199 respondents). The largest group of respondents (43%; 95% confidence interval [CI] 36%-50%) indicated that monitors were fully occupied 90%-100% of the time during their most recent ED shift. When asked how often they were forced to choose a patient for monitor removal because of the limited number of monitors, 52% (95% CI 45%-60%) of respondents selected 1-3 times per shift. Ninety percent (95% CI 84%-93%) of respondents indicated that they would forgo CEM in certain cardiac chest pain patients if there was good evidence that the risk of a monitor-detected adverse event was very low. CONCLUSION Emergency physicians report that monitors are often fully occupied in Canadian EDs, and most are willing to forgo CEM in certain chest pain patients. A large prospective study of CEM in low-risk chest pain patients is warranted.
Collapse
|