The impact of the improvement in internal medicine consultation process on ED length of stay

A time-motion study on impact of spatial separation for empiric airborne precautions in emergency department length of stay

AIMS

To evaluate the impact of spatial separation on patient flow in the emergency department.

DESIGN

This was a retrospective, time-and-motion analysis conducted from 15 to 22 August, 2022 at the emergency department of a tertiary hospital in Kuala Lumpur, Malaysia. During this duration, spatial separation was implemented in critical and semi-critical zones to separate patients with symptoms of respiratory infections into respiratory area, and patients without into non-respiratory area. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

METHODS

Patients triaged to critical and semi-critical zones were included in this study. Timestamps of patient processes in emergency department until patient departure were documented.

RESULTS

The emergency department length-of-stay was longer in respiratory area compared to non-respiratory area; 527 min (381-698) versus 390 min (285-595) in critical zone and 477 min (312-739) versus 393 min (264-595) in semi-critical zone. In critical zone, time intervals of critical flow processes and compliance to hospital benchmarks were similar in both areas. More patients in respiratory area were managed within the arrival-to-contact ≤30 min benchmark and more patients in non-respiratory area had emergency department length-of-stay ≤8 h.

CONCLUSIONS

The implementation of spatial separation in infection control should address decision-to-departure delays to minimise emergency department length of stay.

IMPACT

The study evaluated the impact of spatial separation on patient flow in the emergency department. Emergency department length-of-stay was significantly prolonged in the respiratory area. Hospital administrators and policymakers can optimise infection control protocols measures in emergency departments, balancing infection control measures with efficient patient care delivery.

REPORTING METHOD

STROBE guidelines.

NO PATIENT OR PUBLIC CONTRIBUTION

None.

TRIAL AND PROTOCOL REGISTRATION

The study obtained ethics approval from the institution's Medical Ethics Committee (MREC ID NO: 20221113-11727).

STATISTICAL ANALYSIS

The author has checked and make sure our submission has conformed to the Journal's statistical guideline. There is a statistician on the author team (Noor Azhar).

Impact of a general medicine consultant-led ward round in the emergency department

BACKGROUND

Patients requiring admission to the general medicine wards in a public hospital are usually assessed by a medical registrar. This study is based at a metropolitan public hospital in Melbourne where the majority of general medicine patients in the emergency department (ED) are not seen by a consultant physician until they are transferred to the ward.

AIMS

To assess the impact of general medicine consultant-led ward rounds (CWRs) in the ED on patient length of stay (LOS).

METHODS

One-month audit was conducted of all patients admitted to general medicine and awaiting transfer to ward from ED at a metropolitan public hospital in Melbourne. A general medicine CWR was then implemented in the ED, followed by another 1-month audit, with the primary outcome being LOS and the secondary outcome being 30-day readmission rate. Additionally, admitting medical registrars were invited to complete a survey before and after the implementation of CWRs to assess satisfaction rate.

RESULTS

Data from electronic medical records were analysed for 162 patients (90 preimplementation group and 72 postimplementation group). The median LOS was 6 days in the preimplementation group and 4 days in the postimplementation group (P = 0.014). There was no significant difference in 30-day readmission rates. Surveys showed admitting medical registrars reported a reduced level of stress and fewer barriers to seeking consultant input following implementation.

CONCLUSIONS

A CWR in the ED has led to decreased LOS for general medicine patients and improved satisfaction among junior medical staff.

Novel Electronic Health Records-Based Consultation Workflow Improves Time to Operating Room for Vascular Surgery Patients in an Acute Setting

BACKGROUND

Inefficient clinical workflows can have downstream effects of increased costs, poor resource utilization, and worse patient outcomes. The surgical consultation process can be complex with unclear communication, potentially delaying care for patients requiring time-sensitive intervention in an acute setting. A novel electronic health records (EHR)-based workflow was implemented to improve the consultation process. After implementation, we assessed the impact of this initiative in patients requiring vascular surgery consultation.

METHODS

An EHR-driven consultation workflow was implemented at a single institution, standardizing the process across all consulting services. This order-initiated workflow automated notification to clinicians of consult requests, communication of patient data, patient addition to consultants' lists, and tracking consult completion. Preimplementation (1/1/2020-1/31/2022) and postimplementation (2/1/2022-12/4/2022) vascular surgery consultation cohorts were compared to evaluate the impact of this initiative on timeliness of care.

RESULTS

There were 554 inpatient vascular surgery consultations (255 preimplementation and 299 postimplementation); 45 and 76 consults required surgery before and after implementation, respectively. The novel workflow resulted in placement of a consult note 32 min faster than preimplementation (preimplementation: 462 min, postimplementation: 430 min, P = 0.001) for all vascular surgery consults. Furthermore, vascular surgery patients with ASA class III or IV status requiring an urgent or emergent operation were transported to the operating room 63.3% faster after implementation of the workflow (preimplementation: 284 min, postimplementation: 180 min, P = 0.02). There were no differences in procedure duration, postoperative disposition, or intraoperative complication rates.

CONCLUSIONS

We implemented a novel workflow utilizing the EHR to standardize and automate the consultation process in the acute inpatient setting. This institutional initiative significantly improved timeliness of care for vascular surgery patients, including decreased time to operation. Innovations such as this can be further disseminated across shared EHR platforms across institutions, representing a powerful tool to increase the value of care in vascular surgery and healthcare overall.

Interventions to improve consultations in the emergency department: A systematic review

OBJECTIVES

Emergency department (ED) consultations with specialists are necessary for safe and effective patient care. Delays in the ED consultation process, however, have been shown to increase ED length of stay (LOS) and contribute to ED crowding. This review aims to describe and evaluate the effectiveness of interventions to improve the ED consultation process.

METHODS

Eight primary literature databases and the gray literature were searched to identify comparative studies assessing ED-based interventions to improve the specialist consultation process. Two independent reviewers identified eligible studies, assessed study quality, and extracted data. Individual or pooled meta-analysis for continuous outcomes were calculated as mean differences (MDs) with 95% confidence intervals (CIs) using a random-effects model was conducted.

RESULTS

Thirty-five unique comparative intervention studies were included. While the interventions varied, four common components/themes were identified including interventions to improve consultant responsiveness (n = 11), improve access to consultants in the ED (n = 9), expedite ED consultations (n = 8), and bypass ED consultations (n = 7). Studies on interventions to improve consult responsiveness consistently reported a decrease in consult response times in the intervention group with percent changes between 10% and 71%. Studies implementing interventions to improve consult responsiveness (MD -2.55, 95% CI -4.88 to -0.22) and interventions to bypass ED consultations (MD -0.99, 95% CI -1.43 to -0.56) consistently reported a decrease in ED LOS; however, heterogeneity was high (I²  = 99%). Evidence on whether any of the interventions were effective at reducing the proportion of patients consulted or subsequently admitted varied.

CONCLUSIONS

The various interventions impacting the consultation process were predominately successful in reducing ED LOS, with evidence suggesting that interventions improving consult responsiveness and improving access to consultants in the ED also improve consult response times. Health care providers looking to implement interventions to improve the ED consultation process should identify key areas in their setting that could be targeted.

Modelling Granular Process Flow Information to Reduce Bottlenecks in the Emergency Department

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.

Availability, timeliness, documentation and quality of consultations among hospital departments: a prospective, comparative study

Background

Many in-patients require care from practitioners in various disciplines. Consultations most probably have significant implications for hospitalization outcomes.

Purpose

To determine key aspects of consultations provided by various departments to formulate an optimal policy.

Methods

This study comprised two methods: first, a questionnaire was completed in 2019 by 127 physicians interns, residents and senior doctors) from the medical and surgical departments (64 from the surgical wards, 43 from the medical wards and 22 from the emergency room and General ICU) regarding the availability, timeliness and documentation rate of the consultations they received from different disciplines. The investigators rounded through the various departments that were included in the study and they accosted a sample of interns, residents and attending physicians, who were then asked to fill the questionnaire. Overall compliance of filling the questionnaire was 95%. Residents accounted for 72% of the filled questionnaires, seniors and interns accounted for 15 and 13% respectively. Second, a convenience sample of 300 electronic records of hospitalized patients (135 from the surgical wards, 129 from the Medical wards and 36 from the emergency room and General ICU) of actually carried out consultations was reviewed for validated indicators of quality for both the consultation request and response. We used a 5-point Likert scale, ranging from poor (1) to superb (5), to grade the measured parameters.

Results

The availability, timeliness and documentation rate for medical consultations were 4 ± 0.9, 4.1 ± 0.9 and 4.3 ± 0.9 respectively, as compared with surgical consultations 3.2 ± 1.1, 3.4 ± 1.2 and 3.6 ± 1.2 respectively (P < 0.001). The mean time (in hours) from the consultation request till documentation (of the requested consultation) by consultants in the medical and surgical departments was 3.9 ± 5.9 and 10.0 ± 15.6, respectively (P < 0.001). The quality of requests of consultations from the medical and surgical departments was 3.4 ± 1.1 and 2.8 ± 1.2, respectively (P < 0.001). Two different models of consultations are employed: while each medical department adopts several departments for medical consultations, each day’s on-call surgeon provides all the hospital’s surgical consultations.

Conclusion

We detected significant differences in key aspects of consultations provided by the departments. The medical model of consultations, in which each medical department adopts several other wards to which it provides consulting services upon request, should probably be adopted as a major policy decision by hospitals directors to enhance inter-departmental consultations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-021-00446-0.

Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative

INTRODUCTION

Emergency department (ED) wait time is an important health system quality indicator. Prolonged consult to decision time (CTDT), the time it takes to reach a disposition decision after receiving a specialty consultation request, can contribute to increased overall length of stay in the ED.

OBJECTIVE

To identify delays in the consultation process for general internal medicine (GIM) and trial interventions to reduce CTDT.

METHODS

The study was conducted at a large tertiary teaching hospital with GIM inpatient wards at two campuses. Four interventions were trialed over sequential Plan-Do-Study-Act cycles: (1) process mapping, (2) resident education sessions, (3) audit and feedback of CTDT, and (4) adding a swing shift during peak consult volume.

MEASUREMENTS

The primary outcome measures were mean CTDT for patients admitted to GIM and the proportion of admitted patients with CTDT of less than 3 hours.

RESULTS

Mean CTDT decreased from 4.61 hours before intervention to 4.18 hours after intervention (p < .0001). The proportion of GIM patients with CTDT less than 3 hours increased from 25% to 33% (p < .0001).

CONCLUSIONS

The interventions trialed led to a sustained reduction in CTDT over a 12-month period and demonstrated the effectiveness of education in influencing physician performance.

Interventions to reduce emergency department consultation time: A systematic review of the literature

OBJECTIVES

Overcrowding in the emergency department (ED) is associated with increased morbidity and mortality. Studies have shown that consultation to decision time, defined as the time when a consultation has been accepted by a specialty service to the time when disposition decision is made, is one important contributor to the overall length of stay in the ED.The primary objective of this review is to evaluate the impact of workflow interventions on consultation to decision time and ED length of stay in patients referred to consultant services in teaching centres, and to identify barriers to reducing consultation to decision time.

METHODS

This systematic review was performed in accordance with the PRISMA guidelines. An electronic search was conducted to identify relevant studies from MEDLINE, EMBASE, Cochrane Central, and CINAHL databases. Study screening, data extraction, and quality assessment were carried out by two independent reviewers.

RESULTS

A total of nine full text articles were included in the review. All studies reported a decrease in consultation to decision time post intervention, and two studies reported cost savings. Interventions studied included short messaging service (SMS) messaging, education with audit and feedback, standardization of the admission process, implementation of institutional guideline, modification of the consultation process, and staffing schedules. Overall study quality was fair to poor.

CONCLUSIONS

The limited evidence suggests that audit and feedback in the form of SMS messaging, direct consultation to senior physicians, and standardization of the admission process may be the most effective and feasible interventions. Additional high-quality studies are required to explore sustainable interventions aimed at reducing consultation to decision time.

Emergency department crowding: A systematic review of causes, consequences and solutions

BACKGROUND

Emergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions.

AIM

The aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A structured search of four databases (Medline, CINAHL, EMBASE and Web of Science) was undertaken to identify peer-reviewed research publications aimed at investigating the causes or consequences of, or solutions to, emergency department crowding, published between January 2000 and June 2018. Two reviewers used validated critical appraisal tools to independently assess the quality of the studies. The study protocol was registered with the International prospective register of systematic reviews (PROSPERO 2017: CRD42017073439).

RESULTS

From 4,131 identified studies and 162 full text reviews, 102 studies met the inclusion criteria. The majority were retrospective cohort studies, with the greatest proportion (51%) trialling or modelling potential solutions to emergency department crowding. Fourteen studies examined causes and 40 investigated consequences. Two studies looked at both causes and consequences, and two investigated causes and solutions.

CONCLUSIONS

The negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. This review identified a mismatch between causes and solutions. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Solutions aimed at the introduction of whole-of-system initiatives to meet timed patient disposition targets, as well as extended hours of primary care, demonstrated promising outcomes. While the review identified increased presentations by the elderly with complex and chronic conditions as an emerging and widespread driver of crowding, more research is required to isolate the precise local factors leading to ED crowding, with system-wide solutions tailored to address identified causes.