101
|
The adverse effect of emergency department crowding on compliance with the resuscitation bundle in the management of severe sepsis and septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R224. [PMID: 24093643 PMCID: PMC4055965 DOI: 10.1186/cc13047] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 08/27/2013] [Indexed: 01/20/2023]
Abstract
Introduction The aim of this study is to evaluate the effects of emergency department (ED) crowding on the implementation of tasks in the early resuscitation bundle during acute care of patients with severe sepsis and septic shock, as recommended by the Surviving Sepsis Campaign guidelines. Methods We analyzed the sepsis registry from August 2008 to March 2012 for patients presenting to an ED of a tertiary urban hospital and meeting the criteria for severe sepsis or septic shock. The ED occupancy rate, which was defined as the total number of patients in the ED divided by the total number of ED beds, was used for measuring the degree of ED crowding. It was categorized into three groups (low; intermediate; high crowding). The primary endpoint was the overall compliance with the entire resuscitation bundle. Results A total of 770 patients were enrolled. Of the eligible patients, 276 patients were assigned to the low crowding group, 250 patients to the intermediate crowding group, and 244 patients to the high crowding group (ED occupancy rate: ≤ 115; 116–149; ≥ 150%). There was significant difference in compliance rates among the three groups (31.9% in the low crowding group, 24.4% in the intermediate crowding group, and 16.4% in the high crowding group, P < 0.001). In a multivariate model, the high crowding group had a significant association with lower compliance (adjusted odds ratio (OR), 0.44; 95% confidence interval (CI), 0.26 to 0.76; P = 0.003). When the ED occupancy rate was included as a continuous variable in the model, it had also a negative correlation with the overall compliance (OR of 10% increase of the ED occupancy rate, 0.90; 95% CI, 0.84 to 0.96, P = 0.002). Conclusions ED crowding was significantly associated with lower compliance with the entire resuscitation bundle and decreased likelihood of the timely implementation of the bundle elements.
Collapse
|
102
|
Watts H, Nasim MU, Sweis R, Sikka R, Kulstad E. Further characterization of the influence of crowding on medication errors. J Emerg Trauma Shock 2013; 6:264-70. [PMID: 24339659 PMCID: PMC3841533 DOI: 10.4103/0974-2700.120370] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 08/28/2013] [Indexed: 11/29/2022] Open
Abstract
STUDY OBJECTIVES Our prior analysis suggested that error frequency increases disproportionately with Emergency department (ED) crowding. To further characterize, we measured this association while controlling for the number of charts reviewed and the presence of ambulance diversion status. We hypothesized that errors would occur significantly more frequently as crowding increased, even after controlling for higher patient volumes. MATERIALS AND METHODS We performed a prospective, observational study in a large, community hospital ED from May to October of 2009. Our ED has full-time pharmacists who review orders of patients to help identify errors prior to their causing harm. Research volunteers shadowed our ED pharmacists over discrete 4- hour time periods during their reviews of orders on patients in the ED. The total numbers of charts reviewed and errors identified were documented along with details for each error type, severity, and category. We then measured the correlation between error rate (number of errors divided by total number of charts reviewed) and ED occupancy rate while controlling for diversion status during the observational period. We estimated a sample size requirement of at least 45 errors identified to allow detection of an effect size of 0.6 based on our historical data. RESULTS During 324 hours of surveillance, 1171 charts were reviewed and 87 errors were identified. Median error rate per 4-hour block was 5.8% of charts reviewed (IQR 0-13). No significant change was seen with ED occupancy rate (Spearman's rho = -.08, P = .49). Median error rate during times on ambulance diversion was almost twice as large (11%, IQR 0-17), but this rate did not reach statistical significance in univariate or multivariate analysis. CONCLUSIONS Error frequency appears to remain relatively constant across the range of crowding in our ED when controlling for patient volume via the quantity of orders reviewed. Error quantity therefore increases with crowding, but not at a rate greater than the expected baseline error rate that occurs in uncrowded conditions. These findings suggest that crowding will increase error quantity in a linear fashion.
Collapse
Affiliation(s)
- Hannah Watts
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Muhammad Umer Nasim
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Rolla Sweis
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Rishi Sikka
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Erik Kulstad
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| |
Collapse
|
103
|
Husain N, Bein KJ, Green TC, Veillard AS, Dinh MM. Real time shift reporting by emergency physicians predicts overall ED performance. Emerg Med J 2013; 32:130-3. [PMID: 24022112 DOI: 10.1136/emermed-2013-203051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate factors associated with emergency physician perception of the shift and to determine whether these perceptions were predictors of overall daily emergency department (ED) performance indicators. METHODS This was an observational study conducted at an inner city ED in New South Wales. Shift reports completed by the emergency physician in charge at clinical handover times between February and July 2012 were included. Variables collected by the shift report included (1) total number of patients in ED, (2) number of patients in the ED with length of stay (LOS) greater than 4 h, (3) number of admitted patients, (4) number of patients waiting to be seen by a doctor and (5) medical staffing levels. Outcomes of interest for this study were shift perception scores (1=very poor to 5=very good) and daily ED performance measures. Performance measures were the proportion of patients admitted or discharged from ED within 4 h (National Emergency Access Target, NEAT) and the percentage of inpatient admissions leaving ED within 8 h of ED arrival time. RESULTS The number of patients in ED with LOS >4 h (OR 0.83, 95% CI 0.79 to 0.87, p value <0.001) and number of patients waiting to be seen (OR 0.92, 95% CI 0.88 to 0.95, p value <0.001) were the factors most strongly associated with shift perception score. After adjustment, the mean NEAT performance improved 6% for each incremental increase in average shift perception score (β=0.06 95% CI 0.04 to 0.07, p<0.001). CONCLUSIONS Shift reports and shift perceptions by emergency physicians may be used to predict overall ED performance.
Collapse
Affiliation(s)
- Nadia Husain
- Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kendall J Bein
- Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Timothy C Green
- Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | | | - Michael M Dinh
- Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
104
|
Montgomery P, Godfrey M, Mossey S, Conlon M, Bailey P. Emergency department boarding times for patients admitted to intensive care unit: Patient and organizational influences. Int Emerg Nurs 2013; 22:105-11. [PMID: 23978577 DOI: 10.1016/j.ienj.2013.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 06/17/2013] [Accepted: 06/26/2013] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Critically ill patients can be subject to prolonged stays in the emergency department following receipt of an order to admit to an intensive care unit. The purpose of this study was to explore patient and organizational influences on the duration of boarding times for intensive care bound patients. METHODS This exploratory descriptive study was situated in a Canadian hospital in northern Ontario. Through a six-month retrospective review of three data sources, information was collected pertaining to 16 patient and organizational variables detailing the emergency department boarding time of adults awaiting transfer to the intensive care unit. Data analysis involved descriptive and non-parametric methods. RESULTS The majority of the 122 critically ill patients boarded in the ED were male, 55 years of age or older, arriving by ground ambulance on a weekday, and had an admitting diagnosis of trauma. The median boarding time was 34 min, with a range of 0-1549 min. Patients designated as most acute, intubated, and undergoing multiple diagnostic procedures had statistically significantly shorter boarding times. DISCUSSION The study results provide a profile that may assist clinicians in understanding the complex and site-specific interplay of variables contributing to boarding of critically ill patients.
Collapse
Affiliation(s)
- Phyllis Montgomery
- School of Nursing, Laurentian University, Ramsey Lake Road, Sudbury, Ontario P3E 2C6, Canada.
| | - Michelle Godfrey
- School of Nursing, Laurentian University, Ramsey Lake Road, Sudbury, Ontario P3E 2C6, Canada
| | - Sharolyn Mossey
- School of Nursing, Laurentian University, Ramsey Lake Road, Sudbury, Ontario P3E 2C6, Canada
| | - Michael Conlon
- Epidemiology, Outcomes & Evaluation, Northeast Cancer Centre, Health Sciences North, 41 Ramsey Lake Road, Sudbury, Ontario, Canada
| | - Patricia Bailey
- School of Nursing, Laurentian University, Ramsey Lake Road, Sudbury, Ontario P3E 2C6, Canada
| |
Collapse
|
105
|
Freund Y, Goulet H, Bokobza J, Ghanem A, Carreira S, Madec D, Leroux G, Ray P, Boddaert J, Riou B, Hausfater P. Factors Associated with Adverse Events Resulting From Medical Errors in the Emergency Department: Two Work Better Than One. J Emerg Med 2013; 45:157-62. [DOI: 10.1016/j.jemermed.2012.11.061] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 09/28/2012] [Accepted: 11/02/2012] [Indexed: 10/27/2022]
|
106
|
Ergonomie participative aux urgences — Méthode d’implantation de changements. ANNALES FRANCAISES DE MEDECINE D URGENCE 2013. [DOI: 10.1007/s13341-013-0324-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
107
|
Ergonomie participative aux urgences — Méthode d’implantation de changements. ANNALES FRANCAISES DE MEDECINE D URGENCE 2013. [DOI: 10.1007/s13341-013-0325-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
108
|
Abstract
OBJECTIVES Little is known about how recent system-wide increases in demand for critical care have affected U.S. emergency departments (EDs). This study describes changes in the amount of critical care provided in U.S. EDs between 2001 and 2009. DESIGN Analysis of data from the National Hospital Ambulatory Medical Care Survey for the years 2001-2009. SETTING National multistage probability sample of U.S. ED data. U.S. ED capacity was estimated using the National Emergency Department Inventory-United States. PATIENTS : ED patients admitted a critical care unit. INTERVENTIONS None. MEASUREMENTS Annual hours of ED-based critical care and annual number critical care ED visits. Clinical characteristics, demographics, insurance status, setting, geographic region, and ED length of stay for critically ill ED patients. MAIN RESULTS Annual critical care unit admissions from U.S. EDs increased by 79% from 1.2 to 2.2 million. The proportion of all ED visits resulting in critical care unit admission increased from 0.9% to 1.6% (ptrend < 0.001). Between 2001 and 2009, the median ED length of stay for critically ill patients increased from 185 to 245 minutes (+ 60 min; ptrend < 0.02). For the aggregated years 2001-2009, ED length of stay for critical care visits was longer among black patients (12.6% longer) and Hispanic patients (14.8% longer) than among white patients, and one third of all critical care ED visits had an ED length of stay greater than 6 hrs. Between 2001 and 2009, total annual hours of critical care at U.S. EDs increased by 217% from 3.2 to 10.1 million (ptrend < 0.001). The average daily amount of critical care provided in U.S. EDs tripled from 1.8 to 5.6 hours per ED per day. CONCLUSIONS The amount of critical care provided in U.S. EDs has increased substantially over the past decade, driven by increasing numbers of critical care ED visits and lengthening ED length of stay. Increased critical care burden will further stress an already overcapacity U.S. emergency care system.
Collapse
|
109
|
Varndell W, MacGregor C, Gallagher R, Fry M. Measuring patient dependency—Performance of the Jones Dependency Tool in an Australian Emergency Department. ACTA ACUST UNITED AC 2013; 16:64-72. [DOI: 10.1016/j.aenj.2013.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 04/16/2013] [Accepted: 04/16/2013] [Indexed: 11/28/2022]
|
110
|
Lin YK, Lee WC, Kuo LC, Cheng YC, Lin CJ, Lin HL, Chen CW, Lin TY. Building an ethical environment improves patient privacy and satisfaction in the crowded emergency department: a quasi-experimental study. BMC Med Ethics 2013; 14:8. [PMID: 23421603 PMCID: PMC3616842 DOI: 10.1186/1472-6939-14-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 02/06/2013] [Indexed: 11/22/2022] Open
Abstract
Background To evaluate the effectiveness of a multifaceted intervention in improving emergency department (ED) patient privacy and satisfaction in the crowded ED setting. Methods A pre- and post-intervention study was conducted. A multifaceted intervention was implemented in a university-affiliated hospital ED. The intervention developed strategies to improve ED patient privacy and satisfaction, including redesigning the ED environment, process management, access control, and staff education and training, and encouraging ethics consultation. The effectiveness of the intervention was evaluated using patient surveys. Eligibility data were collected after the intervention and compared to data collected before the intervention. Differences in patient satisfaction and patient perception of privacy were adjusted for predefined covariates using multivariable ordinal logistic regression. Results Structured questionnaires were collected with 313 ED patients before the intervention and 341 ED patients after the intervention. There were no important covariate differences, except for treatment area, between the two groups. Significant improvements were observed in patient perception of “personal information overheard by others”, being “seen by irrelevant persons”, having “unintentionally heard inappropriate conversations from healthcare providers”, and experiencing “providers’ respect for my privacy”. There was significant improvement in patient overall perception of privacy and satisfaction. There were statistically significant correlations between the intervention and patient overall perception of privacy and satisfaction on multivariable analysis. Conclusions Significant improvements were achieved with an intervention. Patients perceived significantly more privacy and satisfaction in ED care after the intervention. We believe that these improvements were the result of major philosophical, administrative, and operational changes aimed at respecting both patient privacy and satisfaction.
Collapse
Affiliation(s)
- Yen-Ko Lin
- Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | | | | |
Collapse
|
111
|
Lee CC, Hsu HC, Chang CM, Hong MY, Ko WC. Atypical presentations of dengue disease in the elderly visiting the ED. Am J Emerg Med 2013; 31:783-7. [PMID: 23399333 DOI: 10.1016/j.ajem.2013.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 01/12/2013] [Accepted: 01/13/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The objective was to compare the clinical characteristics of elderly and young adult patients with dengue in the emergency department (ED). METHODS Demographic characteristics, clinical presentation, disease severity, laboratory characteristics, and outcomes were analyzed prospectively as a case-control study. RESULTS Of the 193 adults with serologically confirmed dengue disease in 2007, 31 (16.1%) were elderly patients (aged ≥65) and 162 were young adults (aged <65). More dengue hemorrhagic fever (12.9% vs 2.5%, P = .02), a longer ED stay (13.3 vs 8.6 hours, P = .004), a longer hospital stay (7.4 vs 3.4 days, P < .001), a higher Simplified Acute Physiology Score II in the ED (29.7 vs 17.4, P < .001), and a higher rate of at least 1 comorbidity (61.8 vs 22.8%, P < .001) were found in the elderly. However, the length of the intensive care unit stay (elderly 0.7 vs young adults 0.3 day, P = .47) and the 14-day mortality rate (0% vs 0.6%, P = 1.00) were similar. Of note, in terms of clinical presentations of dengue in the ED, there were more elderly patients with isolated fever (41.9% vs 17.9%, P = .003) and fewer with typical presentation (41.9% vs 75.9%, P = <.001) than there were young adults. CONCLUSIONS The present study found a higher number of atypical presentations, a longer hospitalization, and a higher degree of clinical illness in elderly patients with dengue.
Collapse
Affiliation(s)
- Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan 704, Taiwan
| | | | | | | | | |
Collapse
|
112
|
Grafstein E, Wilson D, Stenstrom R, Jones C, Tolson M, Poureslami I, Scheuermeyer FX. A regional survey to determine factors influencing patient choices in selecting a particular emergency department for care. Acad Emerg Med 2013; 20:63-70. [PMID: 23570480 DOI: 10.1111/acem.12063] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Revised: 06/12/2012] [Accepted: 07/31/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Increases in regional emergency department (ED) efficiencies might be obtained by shifting patients to less crowded EDs. The authors sought to determine factors associated with a patient's decision to choose a specific regional ED. Based on prior focus group discussions with volunteers, the hypothesis was that distance to a specific ED and perceived ED wait times would be important. METHODS A cross-sectional survey was developed using qualitative focus group methodology. The resulting survey was composed of 17 questions relating to patient decisions in choosing a specific ED and was administered in each of six EDs in a single urban Canadian health region at all hours of the day. Ambulatory patients with a Canadian Triage and Acuity Scale (CTAS) level 3 to 5 and aged ≥19 years were surveyed. The primary outcome was the proportion of patients whose main motivation for attending a specific ED was either distance traveled to reach the ED or perceived ED waiting time. Multivariable logistic regression was performed to assess factors influencing both of these reasons. RESULTS A total of 757 patients were approached and 634 surveys (83.8%) were completed. Distance from the ED (named by 44.0% of respondents as their primary reason) and perceived ED wait times (9.3%) were the main motivations for patients to attend a specific ED. Multivariable analysis of factors associated with choosing distance revealed that ED distance < 10 km (adjusted odds ratio [OR] = 2.20, 95% confidence interval [CI] = 1.45 to 3.33; p = 0.001) and age ≥ 60 years (adjusted OR = 1.58, 95% CI = 1.12 to 2.26; p = 0.04) were significant in choosing a particular ED. Multivariable analysis of factors influencing wait times demonstrated that having a painful complaint (adjusted OR = 1.42, 95% CI = 1.05 to 1.98; p = 0.047) and age < 60 years (OR = 1.47, 95% CI = 1.02 to 2.14; p = 0.049) were significant in choosing a particular ED. CONCLUSIONS In a multicenter survey of patients from an urban health region, distance to a specific ED and perceived ED wait times were the most important reasons for choosing that ED. Younger patients and those with painful conditions appear to place greater priority on wait times.
Collapse
Affiliation(s)
- Eric Grafstein
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia Vancouver; British Columbia Canada
| | - Danielle Wilson
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia Vancouver; British Columbia Canada
| | - Rob Stenstrom
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia Vancouver; British Columbia Canada
| | - Catherine Jones
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia Vancouver; British Columbia Canada
| | - Margreth Tolson
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia Vancouver; British Columbia Canada
| | - Iraj Poureslami
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia Vancouver; British Columbia Canada
| | - Frank Xavier Scheuermeyer
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia Vancouver; British Columbia Canada
| |
Collapse
|
113
|
Kumar GS, Klein R. Effectiveness of case management strategies in reducing emergency department visits in frequent user patient populations: a systematic review. J Emerg Med 2012. [PMID: 23200765 DOI: 10.1016/j.jemermed.2012.08.035] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Case management (CM) is a commonly cited intervention aimed at reducing Emergency Department (ED) utilization by "frequent users," a group of patients that utilize the ED at disproportionately high rates. Studies have investigated the impact of CM on a variety of outcomes in this patient population. OBJECTIVES We sought to examine the evidence of the effectiveness of the CM model in the frequent ED user patient population. We reviewed the available literature focusing on the impact of CM interventions on ED utilization, cost, disposition, and psychosocial variables in frequent ED users. DISCUSSION Although there was heterogeneity across the 12 studies investigating the impact of CM interventions on frequent users of the ED, the majority of available evidence shows a benefit to CM interventions. Reductions in ED visitation and ED costs are supported with the strongest evidence. CONCLUSION CM interventions can improve both clinical and social outcomes among frequent ED users.
Collapse
Affiliation(s)
- Gayathri S Kumar
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | |
Collapse
|
114
|
Abstract
The advent of health care reform means new pressures on American hospitals, which will be forced to do more with less. In the next decade, increased use of "Lean" principles and practices in hospitals can create real value by reducing waste and improving productivity, costs, quality, and the timely delivery of patient care services. In 2010, the Institute of Medicine recommended that nurses lead collaborative quality improvement efforts and assume a major role in redesigning health care in the United States. In this article, we provide an overview of the use of Lean techniques in health care and 2 case studies of successful, nurse-directed Lean initiatives at the Robert Wood Johnson University Hospital. The article concludes with some lessons we have learned and implications for nursing education in the future that must include the concepts, tools, and skills required for adapting Lean to the patient care environment.
Collapse
|
115
|
Khanna S, Boyle J, Good N, Lind J. Unravelling relationships: Hospital occupancy levels, discharge timing and emergency department access block. Emerg Med Australas 2012; 24:510-7. [DOI: 10.1111/j.1742-6723.2012.01587.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2012] [Indexed: 11/28/2022]
Affiliation(s)
| | - Justin Boyle
- CSIRO Australian e-Health Research Centre; Brisbane
| | - Norm Good
- CSIRO Australian e-Health Research Centre; Brisbane
| | - James Lind
- Queensland Health; Gold Coast; Queensland; Australia
| |
Collapse
|
116
|
Burström L, Nordberg M, Ornung G, Castrén M, Wiklund T, Engström ML, Enlund M. Physician-led team triage based on lean principles may be superior for efficiency and quality? A comparison of three emergency departments with different triage models. Scand J Trauma Resusc Emerg Med 2012; 20:57. [PMID: 22905993 PMCID: PMC3478190 DOI: 10.1186/1757-7241-20-57] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 08/16/2012] [Indexed: 11/26/2022] Open
Abstract
Background The management of emergency departments (EDs) principally involves maintaining effective patient flow and care. Different triage models are used today to achieve these two goals. The aim of this study was to compare the performance of different triage models used in three Swedish EDs. Using efficiency and quality indicators, we compared the following triage models: physician-led team triage, nurse first/emergency physician second, and nurse first/junior physician second. Methods All data of patients arriving at the three EDs between 08:00- and 21:00 throughout 2008 were collected and merged into a database. The following efficiency indicators were measured: length of stay (LOS) including time to physician, time from physician to discharge, and 4-hour turnover rate. The following quality indicators were measured: rate of patients left before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days. Results Data from 147,579 patients were analysed. The median length of stay was 158 minutes for physician-led team triage, compared with 243 and 197 minutes for nurse/emergency physician and nurse/junior physician triage, respectively (p < 0.001). The rate of patients left before treatment was completed was 3.1% for physician-led team triage, 5.3% for nurse/emergency physician, and 9.6% for nurse/junior physician triage (p < 0.001). Further, the rates of unscheduled return within 24 hours were significantly lower for physician-led team triage, 1.0%, compared with 2.1%, and 2.5% for nurse/emergency physician, and nurse/junior physician, respectively (p < 0.001). The mortality rate within 7 days was 0.8% for physician-led team triage and 1.0% for the two other triage models (p < 0.001). Conclusions Physician-led team triage seemed advantageous, both expressed as efficiency and quality indicators, compared with the two other models.
Collapse
Affiliation(s)
- Lena Burström
- Centre for Clinical Research, Uppsala University, Central Hospital, Västerås, Sweden.
| | | | | | | | | | | | | |
Collapse
|
117
|
Characteristics of all, occasional, and frequent emergency department visits due to ambulatory care-sensitive conditions in Florida. J Ambul Care Manage 2012; 35:149-58. [PMID: 22415289 DOI: 10.1097/jac.0b013e318244d222] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We studied characteristics of all, occasional, and frequent emergency department (ED) visits due to ambulatory care-sensitive conditions (ACSCs). We used a cross-sectional, split-sample design with multivariate logistic regressions using encounter-level, all-payer ED data from all Florida hospitals for the year of 2005. We evaluated associations of key patient characteristics, characteristics of ED utilization, and availability of primary care physicians in the area, with ED visits for ACSCs. We concluded that factors associated with ED use for ACSCs were similar for occasional and frequent ED users. Therefore, universal strategies for reduction of ED overutilization by increasing access to, timeliness, and quality of primary care for all patients likely to experience ACSCs should be used.
Collapse
|
118
|
Lee CC, Lee NY, Chuang MC, Chen PL, Chang CM, Ko WC. The impact of overcrowding on the bacterial contamination of blood cultures in the ED. Am J Emerg Med 2012; 30:839-45. [DOI: 10.1016/j.ajem.2011.05.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 05/13/2011] [Accepted: 05/19/2011] [Indexed: 11/29/2022] Open
|
119
|
Lee CC, Lee CH, Hong MY. Risk factors and outcome of Pseudomonas aeruginosa bacteremia among adults visiting the ED. Am J Emerg Med 2012; 30:852-60. [DOI: 10.1016/j.ajem.2011.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Revised: 05/20/2011] [Accepted: 05/22/2011] [Indexed: 10/17/2022] Open
|
120
|
Huang YC, Lin MS, Lin HH. Comparison of emergency physicians and internists regarding core measures of care for admitted emergency department boarders with pneumonia. J Acute Med 2012. [DOI: 10.1016/j.jacme.2012.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
121
|
Chase VJ, Cohn AEM, Peterson TA, Lavieri MS. Predicting emergency department volume using forecasting methods to create a "surge response" for noncrisis events. Acad Emerg Med 2012; 19:569-76. [PMID: 22594361 DOI: 10.1111/j.1553-2712.2012.01359.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study investigated whether emergency department (ED) variables could be used in mathematical models to predict a future surge in ED volume based on recent levels of use of physician capacity. The models may be used to guide decisions related to on-call staffing in non-crisis-related surges of patient volume. METHODS A retrospective analysis was conducted using information spanning July 2009 through June 2010 from a large urban teaching hospital with a Level I trauma center. A comparison of significance was used to assess the impact of multiple patient-specific variables on the state of the ED. Physician capacity was modeled based on historical physician treatment capacity and productivity. Binary logistic regression analysis was used to determine the probability that the available physician capacity would be sufficient to treat all patients forecasted to arrive in the next time period. The prediction horizons used were 15 minutes, 30 minutes, 1 hour, 2 hours, 4 hours, 8 hours, and 12 hours. Five consecutive months of patient data from July 2010 through November 2010, similar to the data used to generate the models, was used to validate the models. Positive predictive values, Type I and Type II errors, and real-time accuracy in predicting noncrisis surge events were used to evaluate the forecast accuracy of the models. RESULTS The ratio of new patients requiring treatment over total physician capacity (termed the care utilization ratio [CUR]) was deemed a robust predictor of the state of the ED (with a CUR greater than 1 indicating that the physician capacity would not be sufficient to treat all patients forecasted to arrive). Prediction intervals of 30 minutes, 8 hours, and 12 hours performed best of all models analyzed, with deviances of 1.000, 0.951, and 0.864, respectively. A 95% significance was used to validate the models against the July 2010 through November 2010 data set. Positive predictive values ranged from 0.738 to 0.872, true positives ranged from 74% to 94%, and true negatives ranged from 70% to 90% depending on the threshold used to determine the state of the ED with the 30-minute prediction model. CONCLUSIONS The CUR is a new and robust indicator of an ED system's performance. The study was able to model the tradeoff of longer time to response versus shorter but more accurate predictions, by investigating different prediction intervals. Current practice would have been improved by using the proposed models and would have identified the surge in patient volume earlier on noncrisis days.
Collapse
Affiliation(s)
- Valerie J Chase
- Industrial and Operations Engineering, College of Engineering, University of Michigan, Ann Arbor, MI, USA
| | | | | | | |
Collapse
|
122
|
Lower mortality in sepsis patients admitted through the ED vs direct admission. Am J Emerg Med 2012; 30:432-9. [DOI: 10.1016/j.ajem.2011.01.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 01/04/2011] [Accepted: 01/09/2011] [Indexed: 01/22/2023] Open
|
123
|
Jo S, Kim K, Lee JH, Rhee JE, Kim YJ, Suh GJ, Jin YH. Emergency department crowding is associated with 28-day mortality in community-acquired pneumonia patients. J Infect 2012; 64:268-75. [DOI: 10.1016/j.jinf.2011.12.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 11/29/2011] [Accepted: 12/02/2011] [Indexed: 12/01/2022]
|
124
|
Serviá L, Badia M, Baeza I, Montserrat N, Justes M, Cabré X, Valdrés P, Trujillano J. Time spent in the emergency department and mortality rates in severely injured patients admitted to the intensive care unit: An observational study. J Crit Care 2012; 27:58-65. [DOI: 10.1016/j.jcrc.2011.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 06/08/2011] [Accepted: 07/07/2011] [Indexed: 02/03/2023]
|
125
|
Ciambrone RM, Zavotsky KE, Souto K, Baron K, Joseph VD, Johnson JE, Mastro KA. Redesign of an urban academic emergency department: action research can make a difference. J Emerg Nurs 2012; 38:531-6. [PMID: 22245398 DOI: 10.1016/j.jen.2011.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 11/01/2011] [Accepted: 11/05/2011] [Indexed: 10/14/2022]
Affiliation(s)
- Regina M Ciambrone
- Emergency Services, Robert Wood Johnson University Hospital, New Brunswick, NJ 08903, USA
| | | | | | | | | | | | | |
Collapse
|
126
|
Easter BD, Fischer C, Fisher J. The use of mechanical ventilation in the ED. Am J Emerg Med 2011; 30:1183-8. [PMID: 22100473 DOI: 10.1016/j.ajem.2011.09.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 09/08/2011] [Accepted: 09/08/2011] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Although EDs are responsible for the initial care of critically ill patients and the amount of critical care provided in the ED is increasing, there are few data examining mechanical ventilation (MV) in the ED. In addition, characteristics of ED-based ventilation may affect planning for ventilator shortages during pandemic influenza or bioterrorist events. The study examined the epidemiology of MV in US EDs, including demographic, clinical, and hospital characteristics; indications for MV; ED length of stay (LOS); and in-hospital mortality. METHODS This study was a retrospective review of the 1993 to 2007 National Hospital Ambulatory Medical Care Survey ED data sets. Ventilated patients were compared with ED patients admitted to the intensive care unit (ICU) and to all other ED visits. RESULTS There were 3.6 million ED MV visits (95% confidence interval [CI], 3.2-4.0 million) over the study period. Sex, age, race, and payment source were similar for mechanically ventilated and ICU patients (P > .05 for all). Approximately 12.5% of ventilated patients underwent cardiopulmonary resuscitation compared with 1.7% of ICU admissions and 0.2% of all other ED visits (P < .0001). Accordingly, in-hospital mortality was significantly higher for ventilated patients (24%; 95% CI, 13.1%-34.9%) than both comparison groups (9.3% and 2.5%, respectively). Median LOS for ventilated patients was 197 minutes (interquartile range, 112-313 minutes) compared with 224 minutes for ICU admissions and 140 minutes for all other ED visits. CONCLUSIONS Patients undergoing ED MV have particularly high in-hospital mortality rates, but their ED LOS is sufficient for implementation of evidence-based ventilator interventions.
Collapse
|
127
|
The Impact of a Temporary Medical Ward Closure on Emergency Department and Hospital Service Delivery Outcomes. Qual Manag Health Care 2011; 20:322-33. [DOI: 10.1097/qmh.0b013e318231355a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
128
|
Richmond C, Merrick E, Green T, Dinh M, Iedema R. Bedside review of patient care in an emergency department: The Cow Round. Emerg Med Australas 2011; 23:600-5. [PMID: 21995475 DOI: 10.1111/j.1742-6723.2011.01440.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Clinical handover is a critical point in medical care in the ED, which can contribute to adverse effects for patient care and staff workloads. Over a 4 and a half months in a tertiary referral hospital ED, a centralized whiteboard handover was performed followed by a multidisciplinary review of each patient. This round was referred to as the 'Cow Round'. METHODOLOGY This observational study used a standardized feedback survey of clinicians leading each Cow Round. The survey asked participants in the round to report issues found, which were not handed over during the centralized whiteboard handover. Data were analysed for the number of issues identified, the type of issue identified, and to determine if there was a relationship between the number of issues reported and patients in the department. RESULTS 204 surveys met inclusion criteria. Clinical issues not handed over at the standard whiteboard round were found in 64% of Cow Rounds. Of the 2411 patients reviewed on Cow Rounds, 14.1% had at least one clinical issue not handed over during the whiteboard round. A mean of 2.2 issues per round (95% CI 1.9-2.5) were found. Pearson correlation found a relationship between the number of issues identified and the total number of patients in the department (r= 0.246 P= 0.005). CONCLUSION Review of patients led by a senior member of medical staff, at the patient bedside enables the timely identification and management of issues not communicated during the whiteboard handover process. This review is important when more patients are receiving treatment in the department.
Collapse
Affiliation(s)
- Clare Richmond
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | | | | | | | | |
Collapse
|
129
|
Arendts G, Sim M, Johnston S, Brightwell R. ParaMED Home: a protocol for a randomised controlled trial of paramedic assessment and referral to access medical care at home. BMC Emerg Med 2011; 11:7. [PMID: 21649935 PMCID: PMC3126720 DOI: 10.1186/1471-227x-11-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 06/08/2011] [Indexed: 11/27/2022] Open
Abstract
Abstract Trial Registration Australian and New Zealand Clinical Trials Registry Number 12610001064099
Collapse
Affiliation(s)
- Glenn Arendts
- Centre for Clinical Research in Emergency Medicine, Western Australian Institute for Medical Research, Australia.
| | | | | | | |
Collapse
|
130
|
Migita R, Del Beccaro M, Cotter D, Woodward GA. Emergency Department Overcrowding: Developing Emergency Department Capacity Through Process Improvement. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011. [DOI: 10.1016/j.cpem.2011.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
131
|
|
132
|
Castillo EM, Vilke GM, Williams M, Turner P, Boyle J, Chan TC. Collaborative to Decrease Ambulance Diversion: The California Emergency Department Diversion Project. J Emerg Med 2011; 40:300-7. [DOI: 10.1016/j.jemermed.2010.02.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 02/03/2010] [Accepted: 02/17/2010] [Indexed: 11/28/2022]
|
133
|
Abstract
BACKGROUND The volume and duration of stay of the critically ill in the emergency department (ED) is increasing and is affected by factors including case-mix, overcrowding, lack of available and staffed intensive care beds and an ageing population. The purpose of this study was to describe the clinical activity associated with these high-acuity patients and to quantify resource utilization by this patient group. METHODS The study was a retrospective review of ED notes from all patients referred directly to the intensive care team over a 6-month period from April to September 2004. We applied a workload measurement tool, Therapeutic Intervention Scoring System (TISS)-28, which has been validated as a surrogate marker of nursing resource input in the intensive care setting. A nurse is considered capable of delivering nursing activities equal to 46 TISS-28 points in each 8-h shift. RESULTS The median score from our 69 patients was 19 points per patient. Applying TISS-28 methodology, we estimated that 3 h 13 min nursing time would be spent on a single critically ill ED patient, with a TISS score of 19. This is an indicator of the high levels of personnel resources required for these patients in the ED. ED-validated models to quantify nursing and medical staff resources used across the spectrum of ED care is needed, so that staffing resources can be planned and allocated to match service demands.
Collapse
|
134
|
Safety of Assessment of Patients With Potential Ischemic Chest Pain in an Emergency Department Waiting Room: A Prospective Comparative Cohort Study. Ann Emerg Med 2010; 56:455-62. [DOI: 10.1016/j.annemergmed.2010.03.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Revised: 03/06/2010] [Accepted: 03/30/2010] [Indexed: 11/22/2022]
|
135
|
Lang ES, Wyer P, Tabas JA, Krishnan JA. Educational and research advances stemming from the Academic Emergency Medicine consensus conference in knowledge translation. Acad Emerg Med 2010; 17:865-9. [PMID: 20670324 DOI: 10.1111/j.1553-2712.2010.00825.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The 2007 Academic Emergency Medicine (AEM) consensus conference "Knowledge Translation in Emergency Medicine" yielded a number of initiatives in both education and research that directly reflected the conference's published objectives and recommendations. One research initiative, CONCERT, is a national consortium of chronic obstructive pulmonary disease (COPD) investigators who set forth an effort designed to optimize COPD care through the identification of gaps between research and practice in diagnosis and management of the chronic and acute care aspects of this disease. In addition to CONCERT, educational programs designed to identify barriers to evidence implementation and to develop solutions to achieve uptake through multidisciplinary collaboration have emerged that reflect the impact of the consensus conference. This article describes these initiatives and highlights the potential for future innovative opportunities.
Collapse
Affiliation(s)
- Eddy S Lang
- Division of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.
| | | | | | | |
Collapse
|
136
|
Briones A, Markoff B, Kathuria N, Jagoda A, Baumlin K, Hill S, Mumm L, Jervis R, Dunn A. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med 2010; 5:360-4. [PMID: 20803676 DOI: 10.1002/jhm.636] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alan Briones
- Department of Medicine, Mount Sinai Medical Center, New York, New York, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
137
|
White BA, Brown DFM, Sinclair J, Chang Y, Carignan S, McIntyre J, Biddinger PD. Supplemented Triage and Rapid Treatment (START) improves performance measures in the emergency department. J Emerg Med 2010; 42:322-8. [PMID: 20554420 DOI: 10.1016/j.jemermed.2010.04.022] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 01/27/2010] [Accepted: 04/13/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency Department (ED) crowding is well recognized, and multiple studies have demonstrated its negative effect on patient care. STUDY OBJECTIVES This study aimed to assess the effect of an intervention, Supplemented Triage and Rapid Treatment (START), on standard ED performance measures. The START program complemented standard ED triage with a team of clinicians who initiated the diagnostic work-up and selectively accelerated disposition in a subset of patients. METHODS This retrospective before-after study compared performance measures over two 3-month periods (September-November 2007 and 2008) in an urban, academic tertiary care ED. Data from an electronic patient tracking system were queried over 12,936 patients pre-intervention, and 14,220 patients post-intervention. Primary outcomes included: 1) overall length of stay (LOS), 2) LOS for discharged and admitted patients, and 3) the percentage of patients who left without complete assessment (LWCA). RESULTS In the post-intervention period, patient volume increased 9% and boarder hours decreased by 1.3%. Median overall ED LOS decreased by 29 min (8%, 361 min pre-intervention, 332 min post-intervention; p < 0.001). Median LOS for discharged patients decreased by 23 min (7%, 318 min pre-intervention, 295 min post-intervention; p < 0.001), and by 31 min (7%, 431 min pre-intervention, 400 min post-intervention) for admitted patients. LWCA was decreased by 1.7% (4.1% pre-intervention, 2.4% post-intervention; p < 0.001). CONCLUSIONS In this study, a comprehensive screening and clinical care program was associated with a significant decrease in overall ED LOS, LOS for discharged and admitted patients, and rate of LWCA, despite an increase in ED patient volume.
Collapse
Affiliation(s)
- Benjamin A White
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | | | | | | | | | | | | |
Collapse
|
138
|
Petrillo-Albarano T, Little WK. When There Are No Inpatient Beds: Providing Pediatric Critical Care for Trauma Patients in the Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2009.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
139
|
Firestone DN, Band RA, Hollander JE, Castillo E, Vilke GM. Use of a urine dipstick and brief clinical questionnaire to predict an abnormal serum creatinine in the emergency department. Acad Emerg Med 2009; 16:699-703. [PMID: 19500077 DOI: 10.1111/j.1553-2712.2009.00421.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Prior data demonstrated that a urine dipstick used alone was a sensitive predictor of abnormal creatinine, but not sufficiently enough to forego screening of serum creatinine prior to administration of contrast for diagnostic studies. The authors hypothesized that a brief historical questionnaire coupled with a urine dipstick would have high sensitivity for renal dysfunction, potentially eliminating the need for a serum creatinine prior to contrast administration. METHODS This was a prospective study of a convenience sample of patients at two academic tertiary-care emergency departments (EDs) during 2006-2007. Subjects included patients who had both a serum creatinine result reported by the laboratory and a urine dipstick result reported in the medical record. Data included triage vital signs, basic demographic data, 14 medical history items, dipstick urinalysis, and serum creatinine results. The main outcome measure was an abnormal serum creatinine, defined as greater than 1.5 mg/dL. RESULTS Complete data sets were collected on 1,354 patient visits. Of these, there were 161 (12%) with a serum creatinine of >1.5 mg/dL. Logistic regression analysis identified the following independent predictors associated with elevated creatinine: age greater than 60 years, known renal insufficiency, diabetes, hypertension, diuretic use, vomiting, and proteinuria. Nearly all patients with abnormal creatinine (98%) had at least one of these seven predictors. A decision tool combining these predictors would have identified 158 of 161 patients with an abnormal creatinine (sensitivity, 98.1%; 95% confidence interval [CI] = 95.8% to 99.9%) and a specificity of 21.2% (95% CI = 18.8% to 23.2%). CONCLUSIONS The absence of six historical factors and absence of proteinuria can be safely used to identify patients who are unlikely to have an abnormal creatinine.
Collapse
Affiliation(s)
- Daniel N Firestone
- Department of Emergency Medicine, University of California-San Diego, San Diego, CA, USA.
| | | | | | | | | |
Collapse
|
140
|
Herring A, Wilper A, Himmelstein DU, Woolhandler S, Espinola JA, Brown DFM, Camargo CA. Increasing length of stay among adult visits to U.S. Emergency departments, 2001-2005. Acad Emerg Med 2009; 16:609-16. [PMID: 19538503 DOI: 10.1111/j.1553-2712.2009.00428.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergency departments (EDs) are traditionally designed to provide rapid evaluation and stabilization and are neither staffed nor equipped to provide prolonged care. Longer ED length of stay (LOS) may compromise quality of care and contribute to delays in the emergency evaluation of other patients. OBJECTIVES The objective was to determine whether ED LOS increased between 2001 and 2005 and whether trends varied by patient and hospital factors. METHODS This was a retrospective analysis of a nationally representative sample of 138,569 adult ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2001 to 2005. ED LOS was measured from registration to discharge. RESULTS Median ED LOS increased 3.5% per year from 132 minutes in 2001 to 154 minutes in 2005 (p-value for trend < 0.001). There was a larger increase among critically ill patients for whom ED LOS increased 7.0% annually from 185 minutes in 2001 to 254 minutes in 2005 (p-value for trend < 0.01). ED LOS was persistently longer for black/African American, non-Hispanic patients (10.6% longer) and Hispanic patients (13.9% longer) than for non-Hispanic white patients, and these differences did not diminish over time. Among factors potentially associated with increasing ED LOS, a large increase was found (60.1%, p-value for trend < 0.001) in the use of advanced diagnostic imaging (computed tomography [CT], magnetic resonance imaging [MR], and ultrasound [US]) and in the proportion of ED visits at which five or more diagnostic or screening tests were ordered (17.6% increase, p-value for trend = 0.001). The proportion of uninsured patients was stable throughout the study period, and EDs with predominately privately insured patients experienced significant increases in ED LOS (4.0% per year from 2001 to 2005, p-value for trend < 0.01). CONCLUSIONS Emergency department LOS in the United States is increasing, especially for critically ill patients for whom time-sensitive interventions are most important. The disparity of longer ED LOS for African Americans and Hispanics is not improving.
Collapse
Affiliation(s)
- Andrew Herring
- Department of Emergency Medicine, Highland General Hospital, Oakland, CA, USA.
| | | | | | | | | | | | | |
Collapse
|
141
|
Abstract
In this article we present a summary of two interactive panel discussions held at the 2008 Council of Emergency Medicine Residency Directors (CORD) annual meeting. Attendees attempted to identify measurable outcomes for resident performance that could be used to evaluate program effectiveness.
Collapse
Affiliation(s)
- Sandra M Schneider
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA.
| | | |
Collapse
|
142
|
Khorram-Manesh A, Hedelin A, Ortenwall P. Hospital-related incidents; causes and its impact on disaster preparedness and prehospital organisations. Scand J Trauma Resusc Emerg Med 2009; 17:26. [PMID: 19493330 PMCID: PMC2700787 DOI: 10.1186/1757-7241-17-26] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2009] [Accepted: 06/03/2009] [Indexed: 11/10/2022] Open
Abstract
Background A hospital's capacity and preparedness is one of the important parts of disaster planning. Hospital-related incidents, a new phenomenon in Swedish healthcare, may lead to ambulance diversions, increased waiting time at emergency departments and treatment delay along with deterioration of disaster management and surge capacity. We aimed to identify the causes and impacts of hospital-related incidents in Region Västra Götaland (western region of Sweden). Methods The regional registry at the Prehospital and Disaster Medicine Center was reviewed (2006–2008). The number of hospital-related incidents and its causes were analyzed. Results There were an increasing number of hospital-related incidents mainly caused by emergency department's overcrowdings, the lack of beds at ordinary wards and/or intensive care units and technical problems at the radiology departments. These incidents resulted in ambulance diversions and reduced the prehospital capacity as well as endangering the patient safety. Conclusion Besides emergency department overcrowdings, ambulance diversions, endangering patient s safety and increasing risk for in-hospital mortality, hospital-related incidents reduces and limits the regional preparedness by minimizing the surge capacity. In order to prevent a future irreversible disaster, this problem should be avoided and addressed properly by further regional studies.
Collapse
|
143
|
Effective Triage Can Ameliorate the Deleterious Effects of Delayed Transfer of Trauma Patients from the Emergency Department to the ICU. J Am Coll Surg 2009; 208:671-8; discussion 678-81. [DOI: 10.1016/j.jamcollsurg.2008.11.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Accepted: 11/26/2008] [Indexed: 11/18/2022]
|
144
|
Lott JP, Iwashyna TJ, Christie JD, Asch DA, Kramer AA, Kahn JM. Critical illness outcomes in specialty versus general intensive care units. Am J Respir Crit Care Med 2009; 179:676-83. [PMID: 19201923 DOI: 10.1164/rccm.200808-1281oc] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE General intensive care units (ICUs) provide care across a wide range of diagnoses, whereas specialty ICUs provide diagnosis-specific care. Risk-adjusted outcome differences across such units are unknown. OBJECTIVES To determine the association between specialty ICU care and the outcome of critical illness. METHODS We conducted a retrospective cohort study design analyzing patients admitted to 124 ICUs participating in the Acute Physiology and Chronic Health Evaluation IV from January 2002 to December 2005. We examined 84,182 patients admitted to specialty and general ICUs with an admitting diagnosis or procedure of acute coronary syndrome, ischemic stroke, intracranial hemorrhage, pneumonia, abdominal surgery, or coronary-artery bypass graft surgery. ICU type was determined by a local data coordinator at each site. Patients were classified by admission to a general ICU, a diagnosis-appropriate ("ideal") specialty ICU, or a diagnosis-inappropriate ("non-ideal") specialty ICU. The primary outcomes were in-hospital mortality and ICU length of stay. MEASUREMENTS AND MAIN RESULTS After adjusting for important confounders, there were no significant differences in risk-adjusted mortality between general versus ideal specialty ICUs for all conditions other than pneumonia. Risk-adjusted mortality was significantly greater for patients admitted to non-ideal specialty ICUs. There was no consistent effect of specialization on length of stay for all patients or for ICU survivors. CONCLUSIONS Ideal specialty ICU care appears to offer no survival benefit over general ICU care for select common diagnoses. Non-ideal specialty ICU care (i.e., "boarding") is associated with increased risk-adjusted mortality.
Collapse
Affiliation(s)
- Jason P Lott
- University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | | | | | | | | | | |
Collapse
|
145
|
Optimizing cardiology capacity to reduce emergency department boarding: a systems engineering approach. Am Heart J 2008; 156:1202-9. [PMID: 19033021 DOI: 10.1016/j.ahj.2008.07.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Accepted: 07/10/2008] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patient safety and emergency department (ED) functionality are compromised when inefficient coordination between hospital departments impedes ED patients' access to inpatient cardiac care. The objective of this study was to determine how bed demand from competing cardiology admission sources affects ED patients' access to inpatient cardiac care. METHODS A stochastic discrete event simulation of hospital patient flow predicted ED patient boarding time, defined as the time interval between cardiology admission request to inpatient bed placement, as the primary outcome measure. The simulation was built and tested from 1 year of patient flow data and was used to examine prospective strategies to reduce cardiology patient boarding time. RESULTS Boarding time for the 1,591 ED patients who were admitted to the cardiac telemetry unit averaged 5.3 hours (median 3.1, interquartile range 1.5-6.9). Demographic and clinical patient characteristics were not significant predictors of boarding time. Measurements of bed demand from competing admission sources significantly predicted boarding time, with catheterization laboratory demand levels being the most influential. Hospital policy required that a telemetry bed be held for each electively scheduled catheterization patient, yet the analysis revealed that 70.4% (95% CI 51.2-92.5) of these patients did not transfer to a telemetry bed and were discharged home each day. Results of simulation-based analyses showed that moving one afternoon scheduled elective catheterization case to before noon resulted in a 20-minute reduction in average boarding time compared to a 9-minute reduction achieved by increasing capacity by one additional telemetry bed. CONCLUSIONS Scheduling and bed management practices based on measured patient transfer patterns can reduce inpatient bed blocking, optimize hospital capacity, and improve ED patient access.
Collapse
|
146
|
Food, shelter and safety needs motivating homeless persons' visits to an urban emergency department. Ann Emerg Med 2008; 53:598-602. [PMID: 18838193 DOI: 10.1016/j.annemergmed.2008.07.046] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 07/16/2008] [Accepted: 07/23/2008] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES We determine whether homeless persons present to the emergency department (ED) for food, shelter, and safety and whether the availability of alternative sites for provision of these needs might decrease their ED presentations. METHODS In July to August 2006 and February to March 2007, adult homeless and control (not homeless) patients, who self-presented (nonambulance) to an urban county ED, were interviewed with a structured instrument. RESULTS One hundred ninety-one homeless and 63 control subjects were enrolled. Homeless persons spent a mean (standard deviation [SD]) of 3.5 (3.0) nights/week sleeping without shelter and ate a mean (SD) of 2.1 (1.1) meals per day; 51% stated they had been assaulted on the street. On an analog scale, in which 0=no problem and 10=worst possible problem in their daily lives, the mean (SD) homeless subject responses for hunger, lack of shelter, and safety were 4.8 (3.7), 6.1 (4.2), and 5.1 (4.0), respectively. More homeless (29% [55/189]) than not homeless (10% [6/63]) persons replied that hunger, safety concerns, and lack of shelter were reasons they came to the ED (Delta=20%; 95% confidence interval 10% to 29%). If offered a place that would provide food, shelter, and safety at all times, 24% of homeless subjects stated they would not have come to the ED. CONCLUSION Homeless persons commonly come to the ED for food, shelter, and safety. Provision of these subsistence needs at all times at another site may decrease their ED presentations.
Collapse
|
147
|
|
148
|
Schneider SM, Asplin BR. Form follows finance: emergency department admissions and hospital operating margins. Acad Emerg Med 2008; 15:959-60. [PMID: 18851718 DOI: 10.1111/j.1553-2712.2008.00253.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
149
|
Shumway M, Boccellari A, O'Brien K, Okin RL. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med 2008; 26:155-64. [PMID: 18272094 DOI: 10.1016/j.ajem.2007.04.021] [Citation(s) in RCA: 155] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2007] [Revised: 04/07/2007] [Accepted: 04/11/2007] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The objective of the study was to test the hypothesis that clinical case management is more cost-effective than usual care for frequent users of the emergency department (ED). METHODS The study is a 24-month randomized trial obtaining data on psychosocial problems through interviews and service usage and cost data from administrative records. RESULTS Two-hundred fifty-two frequent users were randomized (167 to case management, 85 to usual care). Case management was associated with statistically significant reductions in psychosocial problems common among ED frequent users, including homelessness, alcohol use, lack of health insurance and social security income, and financial need. Case management was associated with statistically significant reductions in ED use and cost. Case management and usual care patients did not differ in use or cost of other hospital services. CONCLUSIONS Case management appears cost-effective for ED frequent users because it yields statistically and clinically significant reductions in psychosocial problems at a cost similar to that of usual care.
Collapse
Affiliation(s)
- Martha Shumway
- Department of Psychiatry, San Francisco General Hospital, University of California, San Francisco, CA, USA.
| | | | | | | |
Collapse
|
150
|
Jones AE, Kline JA. Resource Utilization in Patients Undergoing Early Goal-Directed Therapy for Severe Sepsis and Septic Shock: Response. Chest 2008. [DOI: 10.1378/chest.07-2400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|