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Bergstedt A, Hilliard B, Alabsi S, Usher MG, Peters M, Grace J, Melton GB, Beebe TJ, Pestka DL. Evaluation of a Clinical Decision Support Tool to Guide Adoption of the American Heart Association Telemetry Monitoring Practice Standards. J Am Heart Assoc 2024; 13:e031523. [PMID: 38686881 PMCID: PMC11179861 DOI: 10.1161/jaha.123.031523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 03/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND The objectives of this study were to (1) evaluate telemetry use pre- and postimplementation of clinical decision support tools to support American Heart Association practice standards for telemetry monitoring and (2) understand the factors that may contribute to variation of telemetry monitoring in practice. METHODS AND RESULTS First, we captured overall variability in telemetry use pre- and postimplementation of the clinical decision support intervention. We then conducted semistructured interviews with telemetry-ordering providers to identify key barriers and facilitators to adoption. During the study period, 399 physicians met criteria for inclusion and were divided into excessive and nonexcessive orderers. Distribution of telemetry use was bimodal. Among nonexcessive users, 24.4% of patient days were with telemetry compared with 51.6% among excessive users. On average, both excessive (6.1% reduction) and nonexcessive users (2.8% reduction) decreased telemetry use postimplementation, and these reductions were sustained over a 16-month period. Sixteen interviews were conducted. Physicians believed that the tool was successful because it caused them to more closely consider if telemetry was indicated for each patient. Physicians also voiced frustration with interruptions to their workflow, and some noted that they commonly use telemetry outside of practice standards to monitor patients who were acutely but not critically ill. CONCLUSIONS Embedding telemetry practice standards into the electronic health record in the form of clinical decision support is effective at reducing excess telemetry use. Although the intervention was well received, there are persistent barriers, such as preexisting views on telemetry and existing workflow habits, that may inhibit higher adoption of standards.
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Affiliation(s)
- Allen Bergstedt
- Department of Medicine University of Minnesota Medical School Minneapolis MN
| | - Brian Hilliard
- Department of Medicine University of Minnesota Medical School Minneapolis MN
| | - Sarah Alabsi
- Department of Medicine University of Minnesota Medical School Minneapolis MN
| | - Michael G Usher
- Department of Medicine University of Minnesota Medical School Minneapolis MN
- Center for Learning Health System Sciences University of Minnesota Medical School Minneapolis MN
| | - Maya Peters
- Center for Learning Health System Sciences University of Minnesota Medical School Minneapolis MN
| | - James Grace
- Department of Medicine University of Minnesota Medical School Minneapolis MN
| | - Genevieve B Melton
- Department of Surgery University of Minnesota Medical School Minneapolis MN
- Center for Learning Health System Sciences University of Minnesota Medical School Minneapolis MN
- Institute for Health Informatics University of Minnesota Minneapolis MN
| | - Timothy J Beebe
- Center for Learning Health System Sciences University of Minnesota Medical School Minneapolis MN
- Division of Health Policy Management, School of Public Health University of Minnesota Minneapolis MN
| | - Deborah L Pestka
- Center for Learning Health System Sciences University of Minnesota Medical School Minneapolis MN
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Patel SV, Arcidiacono A, Austin CP, Imburgio S, Heaton J, DiSandro K, Mathur D, Besa R, Angelo E, Walch B, Bakr M, Buccellato V, Frank E, Hossain MA, Asif A. Improving Patient Outcomes Using Measures to Increase Discharge Rates to Home. Cureus 2024; 16:e59738. [PMID: 38841032 PMCID: PMC11151191 DOI: 10.7759/cureus.59738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2024] [Indexed: 06/07/2024] Open
Abstract
Background Post-acute care (PAC) centers are facilities used for recuperation, rehabilitation, and symptom management in an effort to improve the long-term outcomes of patients. PAC centers include skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals. In the 1990s, Medicare payment reforms significantly increased the discharge rates to PAC centers and subsequently increased the length of stay (LOS) among these patient populations. Over the last several years, there have been national initiatives and multidisciplinary approaches to improve safe discharge rates to home. Multiple studies have shown that patients who are discharged to home have decreased rates of 30-day readmissions, reduced short-term mortality, and an improvement in their activities of daily living. Objectives This study aimed to investigate how multidisciplinary approaches could improve a single institution's discharge rates to home. In doing so, we aim to lower hospital readmission rates, hospital length of stay, morbidity and mortality rates, and healthcare-associated costs. Methods A retrospective single-institution cohort study was implemented at Jersey Shore University Medical Center (JSUMC). Data from January 2015 to December 2019 served as the control period, compared to the intervention period from January 2020 to January 2024. Patients were either admitted to JSUMC teaching faculty, hospitalists, or "others," which is composed of various medical and surgical subspecialists. Interventions performed to improve home discharge rates can be categorized into the following: physician education, patient education, electronic medical record (EMR) initiatives, accountability, and daily mobility initiatives. All interventions were performed equally across the three patient populations. The primary endpoint was the proportion of patients discharged to home. Results There were 190,699 patients, divided into a pre-intervention group comprising 98,885 individuals and a post-intervention group comprising 91,814 patients. Within the pre-intervention group, the faculty attended to 8,495 patients, hospitalists cared for 39,145 patients, and others managed 51,245 patients. In the post-intervention period, the faculty oversaw 8,014 patients, hospitalists attended to 35,094 patients, and others were responsible for 48,706 patients. After implementing a series of multidisciplinary interventions, there was a significant increase in the proportion of patients discharged home, rising from 74.9% to 80.2% across the entire patient population. Specifically, patients under the care of the faculty experienced a more substantial improvement, with a discharge rate increasing from 73.6% to 84.4%. Similarly, the hospitalists exhibited a rise from 69.4% to 74.3%, and the others demonstrated an increase from 79.3% to 83.7%. All observed changes yielded a p-value < 0.001. Conclusions By deploying a multifaceted strategy that emphasized physician education, patient education, EMR initiatives, accountability measures, and daily mobility, there was a statistically significant increase in the rate of patient discharges to home. These initiatives proved to be cost-effective and led to a tangible reduction in healthcare-associated costs and patient length of stay. Further studies are required to look into the effect on hospital readmission rates and morbidity and mortality rates. The comprehensive approach showcased its potential to optimize patient outcomes.
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Affiliation(s)
- Swapnil V Patel
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Anne Arcidiacono
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | | | - Steven Imburgio
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Joseph Heaton
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Kristin DiSandro
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Divya Mathur
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Rocel Besa
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Ellen Angelo
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Brian Walch
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Mohamed Bakr
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Vito Buccellato
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Elliot Frank
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Mohammad A Hossain
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Arif Asif
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
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Hti Lar Seng NS, Zeratsion G, Pena Zapata OY, Tufail MU, Jim B. Utility of Cardiac Troponins in Patients With Chronic Kidney Disease. Cardiol Rev 2024; 32:62-70. [PMID: 35617248 DOI: 10.1097/crd.0000000000000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cardiovascular disease is a major cause of death worldwide especially in patients with chronic kidney disease (CKD). Troponin T and troponin I are cardiac biomarkers used not only to diagnose acute myocardial infarction (AMI) but also to prognosticate cardiovascular and all-cause mortality. The diagnosis of AMI in the CKD population is challenging because of their elevated troponins at baseline. The development of high-sensitivity cardiac troponins shortens the time needed to rule in and rule out AMI in patients with normal renal function. While the sensitivity of high-sensitivity cardiac troponins is preserved in the CKD population, the specificity of these tests is compromised. Hence, diagnosing AMI in CKD remains problematic even with the introduction of high-sensitivity assays. The prognostic significance of troponins did not differ whether it is detected with standard or high-sensitivity assays. The elevation of both troponin T and troponin I in CKD patients remains strongly correlated with adverse cardiovascular and all-cause mortality, and the prognosis becomes poorer with advanced CKD stages. Interestingly, the degree of troponin elevation appears to be predictive of the rate of renal decline via unclear mechanisms though activation of the renin-angiotensin and other hormonal/oxidative stress systems remain suspect. In this review, we present the latest evidence of the use of cardiac troponins in both the diagnosis of AMI and the prognosis of cardiovascular and all-cause mortality. We also suggest strategies to improve on the diagnostic capability of these troponins in the CKD/end-stage kidney disease population.
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Affiliation(s)
- Nang San Hti Lar Seng
- From the Division of Nephrology/Department of Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, NY
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Wang KY, Quan T, Kapoor S, Gu A, Best MJ, Kreulen RT, Srikumaran U. The influence of elevated international normalized ratio on complications following total shoulder arthroplasty. Shoulder Elbow 2023; 15:53-64. [PMID: 37692874 PMCID: PMC10492533 DOI: 10.1177/17585732221088974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/16/2022] [Accepted: 02/21/2022] [Indexed: 09/12/2023]
Abstract
Background Identifying preoperative risk factors for complications following total shoulder arthroplasty (TSA) has both clinical and financial implications. The purpose of this study was to determine the influence of different degrees of preoperative INR elevation on complications following TSA. Methods Patients undergoing primary TSA from 2007 to 2018 were identified in a national database. Patients were stratified into 4 cohorts: INR of <1.0, INR of >1.0 to 1.25, INR of >1.25 to 1.5, and INR of >1.5. Postoperative complications were assessed. Multivariate logistic regressions were performed to adjust for differences in demographics and comorbidities among the INR groups. Results Following adjustment and relative to patients with an INR of <1.0, those with INR of >1.0-1.25, >1.25-1.5, and >1.5 had 1.6-times, 2.4-times, and 2.8-times higher odds of having postoperative bleeding requiring transfusion, respectively (p < 0.05 for all). Relative to patients with INR <1.0, those with INR of > 1.25-1.5 and INR of >1.5 had 7.8-times and 7.0-times higher odds of having pulmonary complications, respectively (p < 0.05 for both). Discussion With increasing INR levels, there is an independent and step-wise increase in odd ratios for postoperative complications. Current guidelines for preoperative INR thresholds may need to be adjusted for more predictive risk-stratification for TSA. Level of Evidence III.
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Affiliation(s)
- Kevin Y Wang
- Department of Orthopaedic Surgery, Johns Hopkins, Columbia, MD, USA
| | - Theodore Quan
- Department of Orthopaedic Surgery, George Washington Hospital, Washington, DC, USA
| | - Shrey Kapoor
- Department of Orthopaedic Surgery, Johns Hopkins, Columbia, MD, USA
| | - Alex Gu
- Department of Orthopaedic Surgery, George Washington Hospital, Washington, DC, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins, Columbia, MD, USA
| | | | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins, Columbia, MD, USA
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Cho KK, French JK, Figtree GA, Chow CK, Kozor R. Rapid access chest pain clinics in Australia and New Zealand. Med J Aust 2023; 219:168-172. [PMID: 37544013 DOI: 10.5694/mja2.52043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 08/08/2023]
Abstract
Chest pain is the second most common reason for adult emergency department presentations. Most patients have low or intermediate risk chest pain, which historically has led to inpatient admission for further evaluation. Rapid access chest pain clinics represent an innovative outpatient pathway for these low and intermediate risk patients, and have been shown to be safe and reduce hospital costs. Despite variations in rapid access chest pain clinic models, there are limited data to determine the most effective approach. Developing a national framework could be beneficial to provide sites with evidence, possible models, and business cases. Multicentre data analysis could enhance understanding and monitoring of the service.
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Affiliation(s)
| | | | - Gemma A Figtree
- Royal North Shore Hospital, University of Sydney, Sydney, NSW
- University of Sydney, Sydney, NSW
| | - Clara K Chow
- University of Sydney, Sydney, NSW
- Westmead Applied Research Centre and Westmead Hospital, Sydney, NSW
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Azari L, Turner K, Hong YR, Alishahi Tabriz A. Adoption of emergency department crowding interventions among US hospitals between 2007 and 2020. Am J Emerg Med 2023; 70:127-132. [PMID: 37270852 DOI: 10.1016/j.ajem.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 05/03/2023] [Accepted: 05/23/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND To deal with emergency department (ED) crowding, the American College of Emergency Physicians (ACEP) established a task force to develop a list of low-cost, high-impact solutions. In this study, we report on the trend in the adoption rate of ACEP-recommended ED crowding interventions by US hospitals. METHODS We analyzed the National Hospital Ambulatory Medical Care Survey data from 2007 to 2020 (N = 3874 hospitals). The primary outcome was whether a hospital adopted each of the ACEP-recommended interventions, which were grouped into three overlapping categories: technology-based, flow modifications, and physical-based (e.g., changing ED layout). RESULTS On average, the most frequently adopted intervention was bedside registration (85.1%) and the least frequently adopted intervention was kiosk check-in (8.3%). The adoption of ED crowding interventions increased significantly between 2007 and 2020, except for expanding ED treatment space which declined by 45.0% from 30.3% in 2007 to 15.7% in 2020. The largest adoption rate increase occurred in having a separate operating room for ED cases with a 188.5% increase in adoption rate followed by radio-frequency identification (RFID) tracking (151.2%), and kiosk check-in (144.2%). CONCLUSIONS The adoption rate of ED crowding interventions by hospitals has risen, however most effective ED crowding interventions are still underutilized. The trends for each intervention did not always increase linearly, with certain periods showing greater fluctuations in adoption rate. Hospitals tend to implement technology-based interventions, compared to physical-based interventions and flow modification interventions.
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Affiliation(s)
- Leila Azari
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA; Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Young-Rock Hong
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions University of Florida, Gainesville, FL, USA; UF Health Cancer Center, Gainesville, FL, USA
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA; Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
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Temporal trends in the rate of complications and prolonged length of stay relative to body mass index in patients undergoing total knee arthroplasty from 2012 to 2020. Knee 2023; 41:266-273. [PMID: 36773372 DOI: 10.1016/j.knee.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/13/2022] [Accepted: 01/26/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Elevated body mass index (BMI) is a risk factor for complications following total knee arthroplasty (TKA). Thus, we believe it is important to constantly re-evaluate the relationship between BMI and complication risk following TKA. METHOD Patients undergoing primary TKA were identified in a national database from 2012-2020. Rates of major complications, minor complications, and length of stay (LOS) greater than 2 days were calculated. The prevalence of postoperative outcomes were calculated per unit of BMI and then multiplied by a factor of 10^2 or 10^3 in order to create adjusted-BMI (aBMI). To isolate the effect of aBMI on postoperative outcomes, changes over time were analyzed using linear regression analysis controlling for age, sex, American Society of Anesthesiology (ASA) classification and smoking status. RESULTS 365,333 patients were included. Mean BMI 33 ± 6.8. 10,616 (2.9%) of patients had a major postoperative complication, 9,345 (2.6%) minor complications, 3,277 (0.9%) had a deep or superficial surgical site infection (SSI). 133,563 (37%) of patients had LOS > 2 days. From 2012-2020, the ratio of major complications to aBMI decreased significantly by an average of -2.7% per year. The ratio of patients with LOS > 2 days to aBMI decreased significantly by -27% per year. The ratio of SSI to aBMI increased significantly by 10.8% per year. CONCLUSIONS From 2012 to 2020, the ratio of major complications and extended LOS following TKA as a function of BMI has decreased significantly, while the ratio of SSI as a function of BMI has doubled.
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Song SR, Kim KH, Park JH, Song KJ, Shin SD. Association between prehospital recognition of acute myocardial infarction and length of stay in the emergency department. Clin Exp Emerg Med 2022; 9:323-332. [PMID: 36111415 PMCID: PMC9834821 DOI: 10.15441/ceem.22.330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/31/2022] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE This study aimed to evaluate the association between prehospital recognition of acute myocardial infarction (AMI) and length of stay (LOS) in the emergency department (ED) of emergency medical service (EMS)-transported AMI patients. METHODS A multicenter retrospective observational study was conducted using prehospital and hospital data from three tertiary emergency departments. Patients diagnosed with AMI between January 2015 and December 2018 were enrolled. Study groups were categorized according to prehospital recognition and prehospital 12-lead electrocardiography (ECG) into three groups based on an EMS cardiovascular registry: group A, no prehospital recognition (reference group); group B, prehospital recognition without 12-lead ECG; and group C, prehospital recognition with 12-lead ECG. The primary outcome was an ED LOS of less than 4 hours. RESULTS Among 1,237 study participants, 722 (58.4%) were in group A, 325 (26.3%) were in group B, and 190 (15.4%) were in group C. Multivariable logistic regression showed that groups B and C had a higher likelihood of a short ED LOS (adjusted odds ratio [95% confidence interval]: group B, 1.64 [1.21-2.22] and group C, 1.88 [1.30-2.71]) than group A. There was no significant difference in ED LOS according to whether prehospital 12-lead ECG was conducted. CONCLUSION Prehospital recognition of AMI by EMS personnel, with or without 12-lead ECG, was associated with a short ED LOS.
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Affiliation(s)
- So Ra Song
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea,Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea,Correspondence to: Ki Hong Kim Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea E-mail:
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea,Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, Korea,Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea,Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
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Pehlivanturk-Kizilkan M, Ozsezen B, Batu ED. Factors Affecting Nonurgent Pediatric Emergency Department Visits and Parental Emergency Overestimation. Pediatr Emerg Care 2022; 38:264-268. [PMID: 35507379 DOI: 10.1097/pec.0000000000002723] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Understanding the factors causing nonurgent visits to the pediatric emergency departments (PED) is essential for developing effective interventions. Sociodemographic factors might have a direct effect, or they might be associated with other potential causal factors such as access, perceived severity, and convenience. Therefore, we aimed to evaluate the factors that might have an effect on nonurgent PED visits and parental overestimation of emergency severity. METHODS Data of a total of 974 patients who have been administered to the PED of a district state hospital were collected with a cross-sectional, self-administered survey. Level 5 was accepted as nonurgent cases according to the Pediatric Canadian Triage and Acuity Scale. Parents' assessment of their child's emergency status was assessed along with the age and sex of the child, the number of children, presence of a chronic illness, presence of fever, admission time, parental age, education status and occupation, transportation method, and living distance to emergency department. RESULTS Sixty-eight percent of visits were nonurgent. Among these visits, 51.6% were perceived as urgent, and 11.5% as extremely urgent by the parents. We identified that infancy age group (P = 0.001), father's unemployment status (P = 0.038), presence of a chronic disease (P = 0.020), and a previous visit to the PED in the last week (P = 0.008) are associated with urgent visits. Having a fever (P = 0.002), younger mother (P = 0.046) and father age (P = 0.007), mother not having an income (P = 0.034), and father's lower level of education (P = 0.036) increased the likelihood of overestimating the emergency severity. CONCLUSIONS Nonurgent visits constitute most of the PED admissions. Several factors were found to be associated with nonurgent visits either by causing a direct effect or by indirectly impacting the perceived severity. Health literacy-based interventions targeting common symptoms like fever and especially younger parent groups might be beneficial in lowering the patient burden of PEDs.
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Affiliation(s)
| | | | - Ezgi Deniz Batu
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
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Badr S, Nyce A, Awan T, Cortes D, Mowdawalla C, Rachoin JS. Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:5-14. [PMID: 35018125 PMCID: PMC8742612 DOI: 10.2147/oaem.s338079] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.
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Affiliation(s)
- Samer Badr
- Division of Hospital Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Andrew Nyce
- Department of Emergency Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Taha Awan
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Dennise Cortes
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Cyrus Mowdawalla
- Department of Medical Education, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jean-Sebastien Rachoin
- Division of Hospital Medicine, Cooper University Health Care, Camden, NJ, USA.,Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA.,Division of Critical Care, Cooper University Health Care, Camden, NJ, USA
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Verma A, Shishodia S, Jaiswal S, Sheikh WR, Haldar M, Vishen A, Ahuja R, Khatai AA, Khanna P. Increased Length of Stay of Critically Ill Patients in the Emergency Department Associated with Higher In-hospital Mortality. Indian J Crit Care Med 2021; 25:1221-1225. [PMID: 34866817 PMCID: PMC8608642 DOI: 10.5005/jp-journals-10071-24018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives Emergency department (ED) length of stay (LOS) is defined as the time a patient is registered to the time the patient is shifted to a hospital bed or discharged. Increasing demand for quality emergency care has resulted in increased wait times due to demand and supply mismatch. It is perceived that longer LOS in the ED of critical patients leads to poor outcomes. Our goal was to study the impact of LOS in the ED on the patients who required critical care admissions. Methods This was a retrospective study conducted in the ED of a tertiary center. Data were collected using electronic health records (EHR) for patients admitted to the intensive care units (ICUs). Patient's LOS in ED was divided into 0–4, 4–8, 8–12, 12–24, and >24 hours. ED LOS was calculated from the registration time to the time patient was handed over in the ICU. Patients were divided into four categories (1–4) based on their criticality. LOS in ED, mortality, and total hospital LOS were analyzed in the study. Results Three thousand four hundred and twenty-nine patients were enrolled in the study. Mean age was 62.69 years (95% CI 62.11–63.26). A total of 42.09% (95% CI 40.5–43.8) were Category 1 patients. Overall mortality rate was 52.46% (95% CI 50.79–54.13). LOS of 48.15% (95% CI 46.54–49.88) patients in the ED was between 0 and 4 hours, 19.90% (95% CI 18.62–21.29) between 4 and 8 hours, 8.21% (95% CI 7.35–9.19) between 8 and 12 hours, 15.50% (95% CI 14.34–16.77) between 12 and 24 hours, and 8.13% (95% CI 7.27–9.10) >24 hours. Mortality for LOS of 0–4 hours was 51.30% (95% CI 48.89–53.70), 54.03% (95% CI 50.28–57.73) for 4–8 hours, 48.94% (95% CI 43.16–54.75) for 8–12 hours, 51.50% (95% CI 47.26–55.72) for 12–24 hours, and 60.57% (95% CI 54.73–66.13) for >24 hours. Conclusion We concluded that the longer the critically ill patients are boarded in the ED, the higher is the chance for mortality. Processes should be implemented to ease the throughput from the ED. How to cite this article Verma A, Shishodia S, Jaiswal S, Sheikh WR, Haldar M, Vishen A, et al. Increased Length of Stay of Critically Ill Patients in the Emergency Department Associated with Higher In-hospital Mortality. Indian J Crit Care Med 2021;25(11):1221–1225.
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Affiliation(s)
- Ankur Verma
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Shakti Shishodia
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Sanjay Jaiswal
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Wasil R Sheikh
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Meghna Haldar
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Amit Vishen
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Rinkey Ahuja
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Abbas A Khatai
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
| | - Palak Khanna
- Department of Emergency Medicine, Max Super Speciality Hospital, Delhi, India
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12
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Chu E, Zhang C, Musikantow DR, Turagam MK, Langan N, Sofi A, Choudry S, Syros G, Miller MA, Koruth JS, Whang W, Dukkipati SR, Reddy VY. Barriers and financial impact of same-day discharge after atrial fibrillation ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:711-719. [PMID: 33686695 DOI: 10.1111/pace.14217] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/17/2021] [Accepted: 02/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Same-day discharge (SDD) after atrial fibrillation (AF) ablation is increasingly being considered. This study examined the barriers and financial impact associated with SDD in a contemporary cohort of patients undergoing elective AF ablation. METHODS A single center retrospective review was conducted of the 249 first case-of-the-day outpatient AF ablations performed in 2019 to evaluate the proportion of patients that could have undergone SDD. Barriers to SDD were defined as any intervention that prevented SDD by 8 p.m. The financial impact of SDD was based on savings from avoidance of the overnight hospital stay and revenue related to management of chest pain facilitated by a vacant hospital bed. RESULTS SDD could have occurred in 157 patients (63%) without change in management and in up to 200 patients (80%) if avoidable barriers were addressed. Barriers to SDD included non-clinical logistical issues (43%), prolonged post-procedure recovery (42%) and minor procedural complications (15%). On multivariate analysis, factors associated with barriers to SDD included increasing age (P = .01), left ventricular ejection fraction ≤ 35% (P = .04), and severely dilated left atrium (P = .04). The financial gain from SDD would have ranged from $1,110,096 (assuming discharge of 63% of eligible patients) to $1,480,128 (assuming 80% discharge) over the course of a year. CONCLUSIONS Up to 80% of patients undergoing outpatient AF ablation were amenable to SDD if avoidable delays in care had been anticipated. Based on reduced hospital operating expenses and increased revenue from management of individuals with chest pain, this would translate to a financial savings of ∼$1.5 million.
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Affiliation(s)
- Edward Chu
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chi Zhang
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel R Musikantow
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohit K Turagam
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Noelle Langan
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aamir Sofi
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Subbarao Choudry
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Georgios Syros
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marc A Miller
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jacob S Koruth
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William Whang
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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13
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Rubins D, Boxer R, Landman A, Wright A. Effect of default order set settings on telemetry ordering. J Am Med Inform Assoc 2021; 26:1488-1492. [PMID: 31504592 DOI: 10.1093/jamia/ocz137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/08/2019] [Accepted: 07/13/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To investigate the effects of adjusting the default order set settings on telemetry usage. MATERIALS AND METHODS We performed a retrospective, controlled, before-after study of patients admitted to a house staff medicine service at an academic medical center examining the effect of changing whether the admission telemetry order was pre-selected or not. Telemetry orders on admission and subsequent orders for telemetry were monitored pre- and post-change. Two other order sets that had no change in their default settings were used as controls. RESULTS Between January 1, 2017 and May 1, 2018, there were 1, 163 patients admitted using the residency-customized version of the admission order set which initially had telemetry pre-selected. In this group of patients, there was a significant decrease in telemetry ordering in the post-intervention period: from 79.1% of patients in the 8.5 months prior ordered to have telemetry to 21.3% of patients ordered in the 7.5 months after (χ2 = 382; P < .001). There was no significant change in telemetry usage among patients admitted using the two control order sets. DISCUSSION Default settings have been shown to affect clinician ordering behavior in multiple domains. Consistent with prior findings, our study shows that changing the order set settings can significantly affect ordering practices. Our study was limited in that we were unable to determine if the change in ordering behavior had significant impact on patient care or safety. CONCLUSION Decisions about default selections in electronic health record order sets can have significant consequences on ordering behavior.
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Affiliation(s)
- David Rubins
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA and
| | - Robert Boxer
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA and
| | - Adam Landman
- Harvard Medical School, Boston, Massachusetts, USA and.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Adam Wright
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA and
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14
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El-Hallal M, Shah Y, Nath M, Eksambe P, Theroux L, Amlicke M, Steele F, Krief W, Kothare S. Length of stay linked to neurodiagnostic workup for seizures presenting to the pediatric emergency department. Epilepsy Behav 2021; 115:107639. [PMID: 33378722 DOI: 10.1016/j.yebeh.2020.107639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Patients presenting to the pediatric emergency department (ED) often undergo unnecessary testing that leads to prolonged ED visits. Lower ED length of stay has been linked to improved patient experience and may reduce ED overcrowding, a costly burden on a health system. METHODS This is a retrospective cohort study involving patient records over the period of 6 months at an urban tertiary children's hospital who presented with seizures. Febrile seizures, seizures associated with trauma, and charts of patients who did not present initially through our ED were excluded. RESULTS 328 charts were obtained through this search criteria. Head imaging was performed in 52 (16%) patients and consisted of 81% CT (n = 42) and 19% (n = 10) magnetic resonance imaging (MRI). Obtaining an MRI was associated with a 3.5 h longer ED visit (p = 0.07); obtaining a CT was associated with a 1.5 h longer ED visit (p = 0.005). An Electroencephalogram (EEG) was obtained for 67 (20%) visits and was associated with a 3.0 h longer ED length of stay (p < 0.001). Ten % of the CT scans showed new or progressive findings and 40% of the MRIs done provided useful information for management. Thirty-seven % of EEGs performed in new onset seizure patients revealed epileptiform findings and 5% of EEGs in established seizure patients provided meaningful findings important to management. CONCLUSION Obtaining neurodiagnostic studies significantly prolongs duration of stay in the ED. Electroencephalograms appear to have the greatest yield in new onset seizure patients and can help make a diagnosis of an epilepsy syndrome in children.
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Affiliation(s)
- Maria El-Hallal
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, USA
| | - Yash Shah
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, USA
| | - Manan Nath
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, USA
| | - Padmavati Eksambe
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, USA
| | - Liana Theroux
- Divison of Epilepsy, Department of Neurology, Northwell Health, 300 Community Dr, 9 Tower, Manhasset, NY 11030, USA
| | - Maire Amlicke
- Division of Emergency Medicine, Department of Pediatrics, Cohen Children's Medical Center, 269-01 76th Ave, Queens, NY 11040, USA
| | - Frances Steele
- Division of Emergency Medicine, Department of Pediatrics, Cohen Children's Medical Center, 269-01 76th Ave, Queens, NY 11040, USA
| | - William Krief
- Division of Emergency Medicine, Department of Pediatrics, Cohen Children's Medical Center, 269-01 76th Ave, Queens, NY 11040, USA
| | - Sanjeev Kothare
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, USA.
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15
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A Comparative Analysis of the Aspects and Costs of Emergency Department Visits of Syrian Refugees with Turkish People and Former Refugees (Afghan People). JOURNAL OF CONTEMPORARY MEDICINE 2020. [DOI: 10.16899/jcm.814458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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16
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Cai X, Wu J, Chen J, Sun J, Li P. The "two-step four-level + " pediatric triage method in a medical center in Southern China. J SPEC PEDIATR NURS 2020; 25:e12305. [PMID: 32702207 DOI: 10.1111/jspn.12305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 06/04/2020] [Accepted: 07/09/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Because the quality of medical resources is extremely uneven across China, it is nearly impossible to implement a unified emergency triage program. The aim of the study is to examine triage using the "two-step four-level+ " triage model in a hospital in Southern China, with an emphasis on hand, foot, and mouth disease. DESIGN AND METHODS This was a retrospective study of all patients seen in the pediatric emergency room (ER) between January 1, 2012 and December 31, 2018, at the Guangzhou Women and Children's Medical Center. The "two-step and four-level+ " was manually implemented in 2012, and an electronic triage system was developed and applied since 2015. Emergency quality control indicators were analyzed. RESULTS There were 645,473 patients triaged at the pediatric ER between January 1, 2015 and December 31, 2018. After the first step, 17,444 patients were classified as unstable, including 6546 (1.01%) Level I patients, 10,898 (1.69%) Level II patients, 210,368 (32.5%) Level III patients, and 417,661 (64.8%) Level IV patients. After triage implementation, the stay time of the patient in the pediatric ER decreased each year (all p < .05) and shortened to 20.3 ± 2.2 h in 2018. Compared with 2012-2014, the mortality of 2015-2018 decreased by 21.1%, the rate of unexpected resuscitation was 0%, and the complaints of overcrowding decreased (all p < .05). PRACTICE IMPLICATIONS This "two-step four-level+ " triage method can improve the medical care quality of pediatric ER in China.
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Affiliation(s)
- Xian Cai
- Department of Pediatric Emergency, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jinxia Wu
- Department of Pediatric Emergency, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jiechan Chen
- Department of Pediatric Emergency, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jing Sun
- Department of Pediatric Emergency, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Peiqing Li
- Department of Pediatric Emergency, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
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17
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Schreyer KE. Opportunity Gains Overlooked. Acad Emerg Med 2020; 27:1077. [PMID: 32865851 DOI: 10.1111/acem.14120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kraftin E Schreyer
- Department of Emergency Medicine, Temple University Hospital, Philadelphia, PA, USA
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18
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Hautz WE, Sauter TC, Hautz SC, Kämmer JE, Schauber SK, Birrenbach T, Exadaktylos AK, Stock S, Müller M. What determines diagnostic resource consumption in emergency medicine: patients, physicians or context? Emerg Med J 2020; 37:546-551. [PMID: 32647026 PMCID: PMC7497575 DOI: 10.1136/emermed-2019-209022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 04/15/2020] [Accepted: 04/22/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVES A major cause for concern about increasing ED visits is that ED care is expensive. Recent research suggests that ED resource consumption is affected by patients' health status, varies between physicians and is context dependent. The aim of this study is to determine the relative proportion of characteristics of the patient, the physician and the context that contribute to ED resource consumption. METHODS Data on patients, physicians and the context were obtained in a prospective observational cohort study of patients hospitalised to an internal medicine ward through the ED of the University Hospital Bern, Switzerland, between August and December 2015. Diagnostic resource consumption in the ED was modelled through a multilevel mixed effects linear regression. RESULTS In total, 473 eligible patients seen by one of 38 physicians were included in the study. Diagnostic resource consumption heavily depends on physicians' ratings of case difficulty (p<0.001, z-standardised regression coefficient: 147.5, 95% CI 87.3 to 207.7) and-less surprising-on patients' acuity (p<0.001, 126.0, 95% CI 65.5 to 186.6). Neither the physician per se, nor their experience, the patients' chronic health status or the context seems to have a measurable impact (all p>0.05). CONCLUSIONS Diagnostic resource consumption in the ED is heavily affected by physicians' situational confidence. Whether we should aim at altering physician confidence ultimately depends on its calibration with accuracy.
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Affiliation(s)
- Wolf E Hautz
- Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland.,Center for Educational Measurement, University of Oslo, Oslo, Norway
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland.,Medical Skills Lab, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stephanie C Hautz
- Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland
| | - Juliane E Kämmer
- Center for Adaptive Rationality, Max-Planck-Institut fur Bildungsforschung, Berlin, Germany.,Institute of Health and Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan K Schauber
- Center for Educational Measurement, University of Oslo, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tanja Birrenbach
- Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland
| | | | - Stephanie Stock
- Institute of Health Economics and Clinical Epidemiology, Cologne, University Hospital of Cologne, Cologne
| | - Martin Müller
- Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland .,Institute of Health Economics and Clinical Epidemiology, Cologne, University Hospital of Cologne, Cologne
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19
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Abstract
Emergency department crowding is a multifactorial issue with causes intrinsic to the emergency department and to the health care system. Understanding that the causes of emergency department crowding span this continuum allows for a more accurate analysis of its effects and a more global consideration of potential solutions. Within the emergency department, boarding of inpatients is the most appreciable effect of hospital-wide crowding, and leads to further emergency department crowding. We explore the concept of emergency department crowding, and its causes, effects, and potential strategies to overcome this problem.
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Affiliation(s)
- James F Kenny
- Milstein Adult Emergency Department, NewYork-Presbyterian Hospital, Department of Emergency Medicine, Columbia University Irving Medical Center, 622 West 168th Street, Suite VC2-260, New York, NY 10032, USA.
| | - Betty C Chang
- Milstein Adult Emergency Department, NewYork-Presbyterian Hospital, Department of Emergency Medicine, Columbia University Irving Medical Center, 622 West 168th Street, Suite VC2-260, New York, NY 10032, USA
| | - Keith C Hemmert
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Ground Floor Ravdin, Philadelphia PA 19104, USA
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20
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Joshi AU, Randolph FT, Chang AM, Slovis BH, Rising KL, Sabonjian M, Sites FD, Hollander JE. Impact of Emergency Department Tele-intake on Left Without Being Seen and Throughput Metrics. Acad Emerg Med 2020; 27:139-147. [PMID: 31733003 DOI: 10.1111/acem.13890] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures. METHODS We conducted a before-and-after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele-intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program. RESULTS Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%). CONCLUSIONS Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.
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Affiliation(s)
- Aditi U. Joshi
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
| | - Frederick T. Randolph
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
| | - Anna Marie Chang
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
| | - Benjamin H. Slovis
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
| | - Kristin L. Rising
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
| | - Megan Sabonjian
- JeffConnect Program and National Academic Center for Telehealth Thomas Jefferson University Philadelphia PA
| | - Frank D. Sites
- JeffConnect Program and National Academic Center for Telehealth Thomas Jefferson University Philadelphia PA
| | - Judd E. Hollander
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
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21
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Lee SY, Chinnam RB, Dalkiran E, Krupp S, Nauss M. Prediction of emergency department patient disposition decision for proactive resource allocation for admission. Health Care Manag Sci 2019; 23:339-359. [PMID: 31444660 DOI: 10.1007/s10729-019-09496-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 08/07/2019] [Indexed: 11/27/2022]
Abstract
We investigate the capability of information from electronic health records of an emergency department (ED) to predict patient disposition decisions for reducing "boarding" delays through the proactive initiation of admission processes (e.g., inpatient bed requests, transport, etc.). We model the process of ED disposition decision prediction as a hierarchical multiclass classification while dealing with the progressive accrual of clinical information throughout the ED caregiving process. Multinomial logistic regression as well as machine learning models are built for carrying out the predictions. Utilizing results from just the first set of ED laboratory tests along with other prior information gathered for each patient (2.5 h ahead of the actual disposition decision on average), our model predicts disposition decisions with positive predictive values of 55.4%, 45.1%, 56.9%, and 47.5%, while controlling false positive rates (1.4%, 1.0%, 4.3%, and 1.4%), with AUC values of 0.97, 0.95, 0.89, and 0.84 for the four admission (minor) classes, i.e., intensive care unit (3.6% of the testing samples), telemetry unit (2.2%), general practice unit (11.9%), and observation unit (6.6%) classes, respectively. Moreover, patients destined to intensive care unit present a more drastic increment in prediction quality at triage than others. Disposition decision classification models can provide more actionable information than a binary admission vs. discharge prediction model for the proactive initiation of admission processes for ED patients. Observing the distinct trajectories of information accrual and prediction quality evolvement for ED patients destined to different types of units, proactive coordination strategies should be tailored accordingly for each destination unit.
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Affiliation(s)
- Seung-Yup Lee
- Haskayne School of Business, University of Calgary, 2500 University Dr. NW, Calgary, AB, T2N 1N4, Canada.
| | - Ratna Babu Chinnam
- Department of Industrial & Systems Engineering, Wayne State University, 4815 Fourth St, Detroit, MI, 48202, USA
| | - Evrim Dalkiran
- Department of Industrial & Systems Engineering, Wayne State University, 4815 Fourth St, Detroit, MI, 48202, USA
| | - Seth Krupp
- Department of Emergency Medicine, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
| | - Michael Nauss
- Department of Emergency Medicine, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
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22
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Steren B, Fleming M, Zhou H, Zhang Y, Pei KY. Predictors of Delayed Emergency Department Throughput Among Blunt Trauma Patients. J Surg Res 2019; 245:81-88. [PMID: 31404894 DOI: 10.1016/j.jss.2019.07.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/21/2019] [Accepted: 07/12/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Delayed emergency department (ED) LOS has been associated with increased mortality and increased hospital length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, workup, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED for trauma patients remain unclear. METHODS The Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of ED LOS, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS trauma verification level, geographic region), abbreviated injury scale and comorbid status. RESULTS 412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 y resulted in 0.63 increased minutes in the ED (P < 0.001). In multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status, and northeast region were associated with increased ED LOS. Black and Hispanic patients spent on average 41 and 42 more minutes, respectively, in the ED room when compared with white patients (P < 0.001). Patients seen at University hospitals spent 52 more minutes in the ED when compared with community hospitals, whereas patients at nonteaching hospitals spent 31 fewer minutes (P < 0.001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 45, 36, and 89 more minutes, respectively (P < 0.001). Non-Medicaid patients at level 1 trauma centers and those requiring intensive care admission had significantly decreased ED LOS. Medicaid patients took the longest to move through the ED with Medicare, BlueCross, and Private insurance outpacing them by 17, 23, and 23 min, respectively (P < 0.001). ACS level 1 trauma centers moved patients through the ED fastest, whereas ACS level II trauma centers and level III trauma centers moved patients through 50 and 130 min slower when compared with ACS level 1 trauma centers (P < 0.001). CONCLUSIONS ED LOS varied significantly by patient and hospital characteristics. Medicaid patients and those patients at university hospitals were associated with significantly higher ED LOS, whereas ACS trauma verification level status had strong correlation with ED LOS. These results may allow targeted quality improvement programs to enhance ED LOS.
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Affiliation(s)
- Benjamin Steren
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew Fleming
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Haoran Zhou
- Yale University School of Medicine, Section of Surgical Outcomes and Epidemiology, New Haven, Connecticut
| | - Yawei Zhang
- Yale University School of Medicine, Section of Surgical Outcomes and Epidemiology, New Haven, Connecticut
| | - Kevin Y Pei
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut; Department of Surgery, Texas Tech University of Health Sciences Center, School of Medicine, Lubbock, Texas.
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Del Carlo CH. Rule-out myocardial infarction in the high-sensitivity cardiac troponin era. Int J Cardiol 2019; 288:17-18. [DOI: 10.1016/j.ijcard.2019.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/27/2019] [Accepted: 03/05/2019] [Indexed: 11/17/2022]
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Chrusciel J, Fontaine X, Devillard A, Cordonnier A, Kanagaratnam L, Laplanche D, Sanchez S. Impact of the implementation of a fast-track on emergency department length of stay and quality of care indicators in the Champagne-Ardenne region: a before-after study. BMJ Open 2019; 9:e026200. [PMID: 31221873 PMCID: PMC6588991 DOI: 10.1136/bmjopen-2018-026200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the effect of the implementation of a fast-track on emergency department (ED) length of stay (LOS) and quality of care indicators. DESIGN Adjusted before-after analysis. SETTING A large hospital in the Champagne-Ardenne region, France. PARTICIPANTS Patients admitted to the ED between 13 January 2015 and 13 January 2017. INTERVENTION Implementation of a fast-track for patients with small injuries or benign medical conditions (13 January 2016). PRIMARY AND SECONDARY OUTCOME MEASURES Proportion of patients with LOS ≥4 hours and proportion of access block situations (when patients cannot access an appropriate hospital bed within 8 hours). 7-day readmissions and 30-day readmissions. RESULTS The ED of the intervention hospital registered 53 768 stays in 2016 and 57 965 in 2017 (+7.8%). In the intervention hospital, the median LOS was 215 min before the intervention and 186 min after the intervention. The exponentiated before-after estimator for ED LOS ≥4 hours was 0.79; 95% CI 0.77 to 0.81. The exponentiated before-after estimator for access block was 1.19; 95% CI 1.13 to 1.25. There was an increase in the proportion of 30 day readmissions in the intervention hospital (from 11.4% to 12.3%). After the intervention, the proportion of patients leaving without being seen by a physician decreased from 10.0% to 5.4%. CONCLUSIONS The implementation of a fast-track was associated with a decrease in stays lasting ≥4 hours without a decrease in access block. Further studies are needed to evaluate the causes of variability in ED LOS and their connections to quality of care indicators.
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Affiliation(s)
- Jan Chrusciel
- Department of Medical Information and Performance Evaluation, Centre Hospitalier de Troyes, Troyes, France
- Department of Research and Public Health, University Hospitals of Reims, Reims, France
| | - Xavier Fontaine
- Emergency Department, Manchester Hospital, Charleville-Mézières, France
| | - Arnaud Devillard
- Emergency Department, Centre Hospitalier de Troyes, Troyes, France
| | - Aurélien Cordonnier
- Department of Medical Information, Manchester Hospital, Charleville-Mézières, France
| | - Lukshe Kanagaratnam
- Department of Research and Public Health, University Hospitals of Reims, Reims, France
- Faculty of Medicine, Université de Reims Champagne-Ardenne, Reims, France
| | - David Laplanche
- Department of Medical Information and Performance Evaluation, Centre Hospitalier de Troyes, Troyes, France
| | - Stéphane Sanchez
- Department of Medical Information and Performance Evaluation, Centre Hospitalier de Troyes, Troyes, France
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Huang D, Bastani A, Anderson W, Crabtree J, Kleiman S, Jones S. Communication and bed reservation: Decreasing the length of stay for emergency department trauma patients. Am J Emerg Med 2018; 36:1874-1879. [PMID: 30104090 DOI: 10.1016/j.ajem.2018.08.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 08/07/2018] [Accepted: 08/07/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Prolonged emergency department (ED) length of stay (LOS) is associated with poorer clinical outcomes and patient experience. At our community hospital, trauma patients were experiencing extended ED LOS incommensurate with their clinical status. Our objective was to determine if operational modifications to patient flow would reduce the LOS for trauma patients. METHOD We conducted a retrospective chart review of admitted trauma patients from January 1, 2015 to June 30, 2016 to study two interventions. First, a communication intervention [INT1], which required the ED provider to directly notify the trauma service, was studied. Second, a bed intervention [INT2], which reserved two temporary beds for trauma patients, was added. The primary outcome was the average ED LOS change across three time periods: (1) Baseline data [BASE] collected from January 1, 2015 to June 30, 2015, (2) INT1 data collected from July 1, 2015 to October 18, 2015, and (3) INT2 data collected from October 19, 2015 to June 30, 2016. Data was analyzed using descriptive statistics, two-sample t-tests, and multivariate linear regression. RESULTS A total of 777 trauma patients were reviewed, with 151, 150 and 476 reviewed during BASE, INT1, and INT2 time periods, respectively. BASE LOS for trauma patients was 389 min. After INT1, LOS decreased by 74.35 min (±31.92; p < 0.0001). After INT2 was also implemented, LOS decreased by 164.56 min (±22.97; p < 0.0001) from BASE LOS. CONCLUSION Direct communication with the trauma service by the ED provider and reservation of two temporary beds significantly decreased the LOS for trauma patients.
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Affiliation(s)
- Derrick Huang
- Oakland University William Beaumont School of Medicine, 586 Pioneer Dr, Rochester, MI 48309, United States of America.
| | - Aveh Bastani
- Department of Emergency Medicine, Troy Beaumont Hospital, 44201 Dequindre Rd, Troy, MI 48085, United States of America
| | - William Anderson
- Department of Emergency Medicine, Troy Beaumont Hospital, 44201 Dequindre Rd, Troy, MI 48085, United States of America
| | - Janice Crabtree
- Management Engineering, Beaumont Health System, 44201 Dequindre Rd, Troy, MI 48085, United States of America
| | - Scott Kleiman
- Department of Emergency Medicine, Troy Beaumont Hospital, 44201 Dequindre Rd, Troy, MI 48085, United States of America
| | - Shanna Jones
- Department of Emergency Medicine, Troy Beaumont Hospital, 44201 Dequindre Rd, Troy, MI 48085, United States of America
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Jiang H, Li Y, Mo J, Chen X, Li M, Lin P, Hung KKC, Rainer TH, Graham CA. Comparison of outcomes in emergency department patients with suspected cardiac chest pain: two-centre prospective observational study in Southern China. BMC Cardiovasc Disord 2018; 18:95. [PMID: 29769019 PMCID: PMC5956813 DOI: 10.1186/s12872-018-0814-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 04/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hong Kong (HK) and Guangzhou (GZ) are cities in China with different healthcare systems. This study aimed to compare 30-day and 6-month mortality and characteristics of patients with suspected cardiac chest pain admitted to two emergency departments (ED) in HK and GZ. METHODS A prospective observational study enrolled patients with suspected cardiac chest pain presenting to EDs in the Prince of Wales Hospital (PWH), HK and the Second Affiliated Hospital of Guangzhou Medical University (AHGZMU),GZ. The primary outcome was 30-day and 6-month mortality. RESULTS In total, 996 patients were recruited, 407 cases from GZ and 589 cases from HK.The 30-day and 6-month mortality of chest patients were 3.7% and 4.7% in GZand 0.3% and 1.9% in HK, respectively. Serum creatinine level (Cr) was an independent factor for 30-day mortality whilst Cr and systolic blood pressure (SBP) were independent factors for 6-month mortality. In Cox regression analysis, unadjusted and adjusted hazard ratios for 30-day and 6-month mortality in GZ were significantly increased. CONCLUSION The 30-day and 6-month mortality of patients with suspected cardiac chest pain in Guangzhou were higher than in Hong Kong due to due to different baseline clinical characteristics of patients and different distributions of diagnoses, which were associated with different healthcare systems. Serum creatinine and SBP were independent factors for 30-day and 6-month mortality.
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Affiliation(s)
- Huilin Jiang
- Emergency Department, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yunmei Li
- Emergency Department, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Junrong Mo
- Emergency Department, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaohui Chen
- Emergency Department, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Min Li
- Emergency Department, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Peiyi Lin
- Emergency Department, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Kevin K C Hung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Main Clinical Block and Trauma Centre, Shatin, N.T, Hong Kong, China
| | - Timothy H Rainer
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Main Clinical Block and Trauma Centre, Shatin, N.T, Hong Kong, China
| | - Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Main Clinical Block and Trauma Centre, Shatin, N.T, Hong Kong, China.
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Kim BBJ, Delbridge TR, Kendrick DB. Adjusting patients streaming initiated by a wait time threshold in emergency department for minimizing opportunity cost. Int J Health Care Qual Assur 2018; 30:516-527. [PMID: 28714834 DOI: 10.1108/ijhcqa-10-2016-0155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose Two different systems for streaming patients were considered to improve efficiency measures such as waiting times (WTs) and length of stay (LOS) for a current emergency department (ED). A typical fast track area (FTA) and a fast track with a wait time threshold (FTW) were designed and compared effectiveness measures from the perspective of total opportunity cost of all patients' WTs in the ED. The paper aims to discuss these issues. Design/methodology/approach This retrospective case study used computerized ED patient arrival to discharge time logs (between July 1, 2009 and June 30, 2010) to build computer simulation models for the FTA and fast track with wait time threshold systems. Various wait time thresholds were applied to stream different acuity-level patients. National average wait time for each acuity level was considered as a threshold to stream patients. Findings The fast track with a wait time threshold (FTW) showed a statistically significant shorter total wait time than the current system or a typical FTA system. The patient streaming management would improve the service quality of the ED as well as patients' opportunity costs by reducing the total LOS in the ED. Research limitations/implications The results of this study were based on computer simulation models with some assumptions such as no transfer times between processes, an arrival distribution of patients, and no deviation of flow pattern. Practical implications When the streaming of patient flow can be managed based on the wait time before being seen by a physician, it is possible for patients to see a physician within a tolerable wait time, which would result in less crowded in the ED. Originality/value A new streaming scheme of patients' flow may improve the performance of fast track system.
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Ramkumar S, Tsoi EH, Raghunath A, Dias FF, Li Wai Suen C, Tsoi AH, Mansfield DR. Guideline-based intervention to reduce telemetry rates in a large tertiary centre. Intern Med J 2018; 47:754-760. [PMID: 28401682 DOI: 10.1111/imj.13452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/31/2017] [Accepted: 04/01/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Inappropriate cardiac telemetry use is associated with reduced patient flow and increased healthcare costs. AIM To evaluate the outcomes of guideline-based application of cardiac telemetry. METHODS Phase I involved a prospective audit (March to August 2011) of telemetry use at a tertiary hospital. Data were collected on indication for telemetry and clinical outcomes. Phase II prospectively included patients more than 18 years under general medicine requiring ward-based telemetry. As phase II occurred at a time remotely from phase I, an audit similar to phase I (phase II - baseline) was completed prior to a 3-month intervention (May to August 2015). The intervention consisted of a daily telemetry ward round and an admission form based on the American Heart Association guidelines (class I, telemetry indicated; class II, telemetry maybe indicated; class III, telemetry not indicated). Patient demographics, telemetry data, and clinical outcomes were studied. Primary endpoint was the percentage reduction of class III indications, while secondary endpoint included telemetry duration. RESULTS In phase I (n = 200), 38% were admitted with a class III indication resulting in no change in clinical management. A total of 74 patients was included in phase II baseline (mean ± standard deviation (SD) age 73 years ± 14.9, 57% male), whilst 65 patients were included in the intervention (mean ± SD age 71 years ± 18.4, 35% male). Both groups had similar baseline characteristics. There was a reduction in class III admissions post-intervention from 38% to 11%, P < 0.001. Intervention was associated with a reduction in median telemetry duration (1.8 ± 1.8 vs 2.4 ± 2.5 days, P = 0.047); however, length of stay was similar in both groups (P > 0.05). CONCLUSION Guideline-based telemetry admissions and a regular telemetry ward round are associated with a reduction in inappropriate telemetry use.
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Affiliation(s)
- Satish Ramkumar
- Department of General Medicine, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Edward H Tsoi
- Department of General Medicine, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Ajay Raghunath
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Floyd F Dias
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Christopher Li Wai Suen
- Department of General Medicine, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Andrew H Tsoi
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Darren R Mansfield
- Department of General Medicine, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
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Sandmann FG, Robotham JV, Deeny SR, Edmunds WJ, Jit M. Estimating the opportunity costs of bed-days. HEALTH ECONOMICS 2018; 27:592-605. [PMID: 29105894 PMCID: PMC5900745 DOI: 10.1002/hec.3613] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 09/25/2017] [Accepted: 09/26/2017] [Indexed: 05/28/2023]
Abstract
Opportunity costs of bed-days are fundamental to understanding the value of healthcare systems. They greatly influence burden of disease estimations and economic evaluations involving stays in healthcare facilities. However, different estimation techniques employ assumptions that differ crucially in whether to consider the value of the second-best alternative use forgone, of any available alternative use, or the value of the actually chosen alternative. Informed by economic theory, this paper provides a taxonomic framework of methodologies for estimating the opportunity costs of resources. This taxonomy is then applied to bed-days by classifying existing approaches accordingly. We highlight differences in valuation between approaches and the perspective adopted, and we use our framework to appraise the assumptions and biases underlying the standard approaches that have been widely adopted mostly unquestioned in the past, such as the conventional use of reference costs and administrative accounting data. Drawing on these findings, we present a novel approach for estimating the opportunity costs of bed-days in terms of health forgone for the second-best patient, but expressed monetarily. This alternative approach effectively re-connects to the concept of choice and explicitly considers net benefits. It is broadly applicable across settings and for other resources besides bed-days.
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Affiliation(s)
- Frank G. Sandmann
- London School of Hygiene and Tropical MedicineDepartment of Infectious Disease EpidemiologyLondonUK
- Public Health EnglandModelling and Economics UnitLondonUK
| | | | - Sarah R. Deeny
- Public Health EnglandModelling and Economics UnitLondonUK
- The Health FoundationLondonUK
| | - W. John Edmunds
- London School of Hygiene and Tropical MedicineDepartment of Infectious Disease EpidemiologyLondonUK
| | - Mark Jit
- London School of Hygiene and Tropical MedicineDepartment of Infectious Disease EpidemiologyLondonUK
- Public Health EnglandModelling and Economics UnitLondonUK
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Gardner RM, Friedman NA, Carlson M, Bradham TS, Barrett TW. Impact of revised triage to improve throughput in an ED with limited traditional fast track population. Am J Emerg Med 2018; 36:124-127. [DOI: 10.1016/j.ajem.2017.10.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 09/17/2017] [Accepted: 10/07/2017] [Indexed: 10/18/2022] Open
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Chen S, Palchaudhuri S, Johnson A, Trost J, Ponor I, Zakaria S. Does this patient need telemetry? An analysis of telemetry ordering practices at an academic medical center. J Eval Clin Pract 2017; 23:741-746. [PMID: 28127832 DOI: 10.1111/jep.12708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 12/19/2016] [Accepted: 12/19/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The American Heart Association and Choosing Wisely campaign recommend guideline-based usage of telemetry. Inappropriate use leads to increased costs, alarm fatigue, and inefficient nursing care. This study assesses provider ordering practices for telemetry at a US-based academic hospital. METHODS This retrospective study includes all telemetry orders in the medicine and progressive care units from April 2014 to March 2015. Indications were grouped into categories per American Heart Association guidelines. RESULTS The top 3 cardiac indications included angina/acute coronary syndrome (35.3%), arrhythmias (19.7%), and heart failure (10.2%). However, noncardiac indications accounted for 20.2% of orders, including respiratory conditions (17.4%), infection (17.4%), substance abuse (14.0%), bleeding (12.4%), vital sign monitoring (10.4%), altered mental status (7.0%), and pulmonary embolus/deep vein thrombosis (7.0%). CONCLUSIONS One-fifth of patients were monitored on telemetry for noncardiac indications. We recommend further study on the benefits and risks of telemetry in these patients and systems-based changes for appropriate usage.
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Affiliation(s)
- Stephanie Chen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Providers for Responsible Ordering, Baltimore, MD, USA
| | - Sonali Palchaudhuri
- National Director of Providers for Responsible Ordering, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,National Director of Providers for Responsible Ordering, Providers for Responsible Ordering, Baltimore, MD, USA
| | - Amber Johnson
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeff Trost
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Providers for Responsible Ordering, Baltimore, MD, USA
| | - Ileana Ponor
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sammy Zakaria
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Rizvi W, Munguti CM, Mehta J, Kallail KJ, Youngman D, Antonios S. Reducing Over-Utilization of Cardiac Telemetry with Pop-Ups in an Electronic Medical Record System. Cureus 2017; 9:e1282. [PMID: 28680770 PMCID: PMC5491336 DOI: 10.7759/cureus.1282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Non-invasive cardiac monitoring has well-established indications and protocols. Telemetry is often overused leading to a shortage of tele-beds and an increment of hospital expenses. In some cases, patients are kept on telemetry longer than the indicated length because providers are unaware of its ongoing use. We investigated the effect of reminder pop-ups, incorporated into an electronic medical record (EMR), on minimizing the use of telemetry. Three regional hospitals implemented an electronic pop-up reminder for discontinuing the use of telemetry when no longer indicated. A retrospective analysis of data for patients on telemetry, outside of the intensive care unit (ICU), was conducted and comparisons were drawn from pre- and post-implementation periods. A composite analysis of the number of days on telemetry was calculated using the Kruskal-Wallis test. With the implementation of the pop-up reminder, the median number of days on telemetry was significantly lower in 2016 than in 2015 (2.25 vs 3.61 days, p < 0.0001). Overutilization of telemetry is widely recognized, despite not being warranted in non-ICU hospitalizations. The implementation of a pop-up reminder built into the electronic medical record system reduced the overuse of telemetry by 37% between the two time periods studied.
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Affiliation(s)
- Wajeeha Rizvi
- Internal Medicine, University of Kansas School of Medicine - Wichita
| | - Cyrus M Munguti
- Internal Medicine, University of Kansas School of Medicine - Wichita
| | - Jeet Mehta
- Internal Medicine, University of Kansas School of Medicine - Wichita
| | - K James Kallail
- Internal Medicine, University of Kansas School of Medicine - Wichita
| | | | - Samer Antonios
- Internal Medicine, University of Kansas School of Medicine - Wichita
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Salway RJ, Valenzuela R, Shoenberger JM, Mallon WK, Viccellio A. CONGESTIÓN EN EL SERVICIO DE URGENCIA: RESPUESTAS BASADAS EN EVIDENCIAS A PREGUNTAS FRECUENTES. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.04.009] [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] Open
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EMERGENCY DEPARTMENT (ED) OVERCROWDING: EVIDENCE-BASED ANSWERS TO FREQUENTLY ASKED QUESTIONS. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.04.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Neuenschwander JF, Peacock WF, Migeed M, Hunter SA, Daughtery JC, McCleese IC, Hiestand BC. Safety and efficiency of emergency department interrogation of cardiac devices. Clin Exp Emerg Med 2017; 3:239-244. [PMID: 28168230 PMCID: PMC5292301 DOI: 10.15441/ceem.15.118] [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: 12/19/2015] [Revised: 01/06/2016] [Accepted: 03/08/2016] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Patients with implanted cardiac devices may wait extended periods for interrogation in emergency departments (EDs). Our purpose was to determine if device interrogation could be done safely and faster by ED staff. METHODS Prospective randomized, standard therapy controlled, trial of ED staff device interrogation vs. standard process (SP), with 30-day follow-up. Eligibility criteria: ED presentation with a self-report of a potential device related complaint, with signed informed consent. SP interrogation was by company representative or hospital employee. RESULTS Of 60 patients, 42 (70%) were male, all were white, with a median (interquartile range) age of 71 (64 to 82) years. No patient was lost to follow up. Of all patients, 32 (53%) were enrolled during business hours. The overall median (interquartile range) ED vs. SP time to interrogation was 98.5 (40 to 260) vs. 166.5 (64 to 412) minutes (P=0.013). While ED and SP interrogation times were similar during business hours, 102 (59 to 138) vs. 105 (64 to 172) minutes (P=0.62), ED interrogation times were shorter vs. SP during non-business hours; 97 (60 to 126) vs. 225 (144 to 412) minutes, P=0.002, respectively. There was no difference in ED length of stay between the ED and SP interrogation, 249 (153 to 390) vs. 246 (143 to 333) minutes (P=0.71), regardless of time of presentation. No patient in any cohort suffered an unplanned medical contact or post-discharge adverse device related event. CONCLUSION ED staff cardiac device interrogations are faster, and with similar 30-day outcomes, as compared to SP.
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Affiliation(s)
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Madgy Migeed
- Department Cardiology, Genesis Health Care Systems, Zanesville, OH, USA
| | - Sara A Hunter
- Department of Radiology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - John C Daughtery
- Department of Cell Biology and Physiology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Brian C Hiestand
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Ha BH, Park JY. Triage and Length of Stay in a Cancer Center Emergency Department. ASIAN ONCOLOGY NURSING 2017. [DOI: 10.5388/aon.2017.17.4.246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Bok Hee Ha
- Department of Nursing, National Cancer Center, Goyang, Korea
| | - Jeong Yun Park
- Department of Clinical Nursing, University of Ulsan, Seoul, Korea
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Sharma G, Wong D, Arnaoutakis DJ, Shah SK, O'Brien A, Ashley SW, Ozaki CK. Systematic identification and management of barriers to vascular surgery patient discharge time of day. J Vasc Surg 2017; 65:172-178. [PMID: 27658897 PMCID: PMC5819890 DOI: 10.1016/j.jvs.2016.07.109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 07/24/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Length of stay fails to completely capture the clinical and economic effects of patient progression through the phases of inpatient care, such as admission, room placement, procedures, and discharge. Delayed hospital throughput has been linked to increased time spent in the emergency department and postanesthesia care unit, delayed time to treatment, increased in-hospital mortality, decreased patient satisfaction, and lost hospital revenue. We identified barriers to vascular surgery inpatient care progression and instituted defined measures to positively impact standardized metrics. METHODS The study was divided into three periods: preintervention, "wash-in," and postintervention. During the preintervention phase, barriers to patient flow were quantified by an interdisciplinary team. Suboptimal provider communication emerged as the key barrier. An enhanced communication intervention consisting of face-to-face and mobile application-based education on key patient flow metrics, explicit discussion of individual patient barriers to progression at rounds and interdisciplinary huddles, and communication of projected discharge and potential barriers via e-mail was developed with input from all stakeholders. Following a 4-week wash-in implementation phase, data collection was repeated. RESULTS The pre- and postintervention patient cohorts accounted for 244.3 and 238.1 inpatient days, respectively. Both groups had similar baseline demographic, clinical characteristics, and procedures performed during hospitalization. The postintervention group was discharged 78 minutes earlier (14:00:32 vs 15:18:37; P = .03) with a trend toward increased discharge by noon (94% vs 88%; P = .09). Readmission rates did not differ (P = .44). CONCLUSIONS Implementation of a focused, interdisciplinary, frontline provider-driven, enhanced communication program can be feasibly incorporated into existing specialty surgical workflow. The program resulted in improved timeliness of discharge and projected cost savings, without increasing readmission rates.
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Affiliation(s)
- Gaurav Sharma
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Danny Wong
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Dean J Arnaoutakis
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Samir K Shah
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Alice O'Brien
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Stanley W Ashley
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - C Keith Ozaki
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass.
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Abstract
AbstractPrimary percutaneous intervention (PPCI) is the preferred treatment in patients with ST elevation myocardial infarction (STEMI) if this can be performed in a timely manner. The
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Factors associated with choosing the emergency department as the primary
access point to health care: a Canadian population cross-sectional study. CAN J EMERG MED 2016; 19:271-276. [DOI: 10.1017/cem.2016.350] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Objective
Approximately 4.3 million Canadians are without a primary care physician,
of which 13% choose the emergency department (ED) as their regular access point
to health care. We sought to identify factors associated with preferential ED
use over other health services. We hypothesized that socioeconomic barriers
(i.e., employment, health status, education) to primary care would also prevent
access to ED alternatives.
Methods
Data from the Canadian Community Health Survey, 2007 to 2008, were
analysed (N=134,073; response rate 93.5%). Our study
population comprised 14,091 individuals identified without a primary care
physician. Socioeconomic variables included employment, health, and education.
Covariates included chronic health conditions, immigrant status, gender, age,
and mental health. Prevalence estimates and 95% confidence intervals (CIs) for
each variable were calculated. Weighted logistic regression models were
constructed to evaluate the importance of individual risk factors and their
interactions after adjustment for relevant covariates.
Results
The sample comprised 57.2% males from across Canada. Employment (OR 0.73
[95% CI: 0.59-0.90]), good health (OR 0.73 [95% CI 0.57-0.88]), and
post-secondary education (OR 0.68 [95% CI 0.53-0.88]) reduced respondents use
of the ED. The reduced odds of ED use were independent of chronic conditions,
mental health, gender, poor mobility, province, and age.
Conclusions
Low socioeconomic status dictates preferential ED use in those without a
primary care physician. Specific policy and system development targeting this
at-risk population are indicated to alter ED use patterns in this
population.
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Cha WC, Ahn KO, Shin SD, Park JH, Cho JS. Emergency Department Crowding Disparity: a Nationwide Cross-Sectional Study. J Korean Med Sci 2016; 31:1331-6. [PMID: 27478347 PMCID: PMC4951566 DOI: 10.3346/jkms.2016.31.8.1331] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 04/21/2016] [Indexed: 11/20/2022] Open
Abstract
In this study, we evaluated national differences in emergency department (ED) crowding to identify factors significantly associated with crowding in institutes and communities across Korea. This was a cross-sectional nationwide observational study using data abstracted from the National Emergency Department Information System (NEDIS). We calculated mean occupancy rates to quantify ED crowding status and divided EDs into three groups according to their occupancy rates (cutoffs: 0.5 and 1.0). Factors potentially related to ED crowding were collected from the NEDIS. We performed a multivariate regression analysis to identify variables significantly associated with ED crowding. A total of 120 EDs were included in the final analysis. Of these, 73 were categorized as 'low crowded' (LC, occupancy rate < 0.50), 37 as 'middle crowded' (MC, 0.50 ≤ occupancy rate < 1.00), 10 EDs as 'high crowded' (HC, 1.00 ≤ occupancy rate). The mean ED occupancy rate varied widely, from 0.06 to 2.33. The median value was 0.39 with interquartile ranges (IQRs) from 0.20 to 0.71. Multivariate analysis revealed that after adjustment, ED crowding was significantly associated with the number of visits, percentage of patients referred, number of nurses, and ED disposition. This nationwide study observed significant variety in ED crowding. Several input, throughput, and output factors were associated with crowding.
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Affiliation(s)
- Won Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Seoul, Korea
- Laboratory of Emergency Medical Service, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Ki Ok Ahn
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Service, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Service, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Jeong Ho Park
- Laboratory of Emergency Medical Service, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Jin Sung Cho
- Department of Emergency Medicine, Gachon University Gil Hospital, Incheon, Korea
- Laboratory of Emergency Medical Service, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
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Claret PG, Bobbia X, Olive S, Demattei C, Yan J, Cohendy R, Landais P, de la Coussaye JE. The impact of emergency department segmentation and nursing staffing increase on inpatient mortality and management times. BMC Health Serv Res 2016; 16:279. [PMID: 27430423 PMCID: PMC4950694 DOI: 10.1186/s12913-016-1544-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 07/07/2016] [Indexed: 11/15/2022] Open
Abstract
Background The aim of our study was to investigate the impact of a new organization of our emergency department (ED) on patients’ mortality and management delays. Methods The ED segmentation consisted of the development of a new patient care geographical layout on a pre-existing site and changing the organization of patient flow. It took place on May 10, 2012. We did a before-after study in the ED of a university hospital, “before” (winter 2012) and “after” (summer 2012) reorganization by segmentation into sectors. All ED patients were included. Results Eighty-three thousand three hundred twenty-two patient visits were analyzed, 61,118 in phase “before”, 22,204 during the phase “after”. The overall inpatient mortality was 1.5 % during summer 2011 (“before” period), 1.8 % during winter 2012 (“before” period), 1.3 % during summer 2012 (“after” period) period (summer 2012 vs. winter 2012, OR = 0.72; 95 % CIs [0.61, 0.85], and summer 2012 vs. summer 2011, OR = 0.85; 95 % CIs [0.72, 0.99]). The mean (SD) time to first medical contact was 129 min (±133) during winter 2012 and 104 min (± 95) during summer 2012 (p < .05). Conclusions Our study showed a decrease in mortality and improvement in time to first medical contact after the segmentation of our ED and nursing staffing increase, without an increase in medical personnel. Improving patient care through optimizing ED segmentation may be an effective strategy.
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Affiliation(s)
- Pierre-Géraud Claret
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, 4 Rue du Professeur Robert Debré, 30029, Nîmes, France. .,EA 2415, Clinical Research University Institute, Montpellier University, 641 Avenue du Doyen Gaston Giraud, 34093, Montpellier, France.
| | - Xavier Bobbia
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, 4 Rue du Professeur Robert Debré, 30029, Nîmes, France
| | - Sylvia Olive
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, 4 Rue du Professeur Robert Debré, 30029, Nîmes, France
| | - Christophe Demattei
- Department of Biostatistics, Clinical Research, Clinical Epidemiology, and Public Health, Nîmes University Hospital, 4 Rue du Professeur Robert Debré, 30029, Nîmes, France
| | - Justin Yan
- Division of Emergency Medicine, Department of Medicine, London Health Sciences Centre and The Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada
| | - Robert Cohendy
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, 4 Rue du Professeur Robert Debré, 30029, Nîmes, France.,Montpellier-Nîmes University, 2 rue École de Médecine, 34060, Montpellier, France
| | - Paul Landais
- EA 2415, Clinical Research University Institute, Montpellier University, 641 Avenue du Doyen Gaston Giraud, 34093, Montpellier, France.,Department of Biostatistics, Clinical Research, Clinical Epidemiology, and Public Health, Nîmes University Hospital, 4 Rue du Professeur Robert Debré, 30029, Nîmes, France.,Montpellier-Nîmes University, 2 rue École de Médecine, 34060, Montpellier, France
| | - Jean Emmanuel de la Coussaye
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, 4 Rue du Professeur Robert Debré, 30029, Nîmes, France.,Montpellier-Nîmes University, 2 rue École de Médecine, 34060, Montpellier, France
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Okafor M, Wrenn G, Ede V, Wilson N, Custer W, Risby E, Claeys M, Shelp FE, Atallah H, Mattox G, Satcher D. Improving Quality of Emergency Care Through Integration of Mental Health. Community Ment Health J 2016; 52:332-42. [PMID: 26711094 DOI: 10.1007/s10597-015-9978-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/08/2015] [Indexed: 11/24/2022]
Abstract
The goal of this study was to better integrate emergency medical and psychiatric care at a large urban public hospital, identify impact on quality improvement metrics, and reduce healthcare cost. A psychiatric fast track service was implemented as a quality improvement initiative. Data on disposition from the emergency department from January 2011 to May 2012 for patients impacted by the pilot were analyzed. 4329 patients from January 2011 to August 2011 (pre-intervention) were compared with 4867 patients from September 2011 to May 2012 (intervention). There was a trend of decline on overall quality metrics of time to triage and time from disposition to discharge. The trend analysis of the psychiatric length of stay and use of restraints showed significant reductions. Integrated emergency care models are evidence-based approach to ensuring that patients with mental health needs receive proper and efficient treatment. Results suggest that this may also improve overall emergency department's throughput.
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Affiliation(s)
- Martha Okafor
- Yale University School of Nursing, New Haven, CT, USA.,Division of Behavioral Health in Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, GA, USA
| | - Glenda Wrenn
- Division of Behavioral Health in Satcher Health Leadership Institute, Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Victor Ede
- Division of Behavioral Health in Satcher Health Leadership Institute, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA.
| | - Nana Wilson
- Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - William Custer
- Center for Health Services Research, Institute of Health Administration, Georgia State University, Atlanta, GA, USA
| | - Emile Risby
- Georgia State Department of Behavioral Health and Developmental Disabilities, Atlanta, GA, 30303, USA
| | - Michael Claeys
- Department of Behavioral Health, Grady Health System, Atlanta, GA, USA
| | - Frank E Shelp
- Georgia State Department of Behavioral Health and Developmental Disabilities, Atlanta, GA, 30303, USA.,Good Neighbor Community Services, Richmond, VA, USA
| | - Hany Atallah
- Grady Health System, Atlanta, GA, USA.,Department of Emergency Medicine, Emory University, 531 Asbury Circle, Annex Building, Suite N340, Atlanta, GA, 30322, USA
| | - Gail Mattox
- Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA, 30310, USA
| | - David Satcher
- Satcher Health Leadership Institute, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA, 30310, USA
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Probasco JC, Hawley G, Burnett M, Gibson L, Carter K, Harlow E, Russell H, Huffman L, Adams J, Ziegler T, Sporney H, Levy M, Puttgen HA. Facilitating Early-In-Day Discharge for Multiple Sclerosis Patients Treated With Intravenous Methylprednisolone: A Quality Improvement Project. Neurohospitalist 2015; 5:197-204. [PMID: 26425247 DOI: 10.1177/1941874415576206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Delays in patient hospital discharge affect care value through costs of prolonged length of stay and barriers to patient flow within the hospital. We sought to facilitate early-in-day discharges (EIDDs) without extending length of stay for inpatients with multiple sclerosis admitted for acute exacerbations and treated with intravenous (IV) methylprednisolone. METHODS We developed a standardized admission order set, a provider checklist, and a patient checklist to better coordinate in-hospital care and discharge planning for patients with multiple sclerosis admitted for IV methylprednisolone treatment. The order set allowed providers to enter an accelerated dosing schedule of methylprednisolone, as appropriate, to ensure administration of the final dose of methylprednisolone in the morning on the anticipated day of discharge. We compared a prospective intervention cohort to a retrospective, preintervention baseline cohort. RESULTS At baseline (N = 25), 12.0% of patients were EIDD compared to 40.7% of intervention patients (N = 27; P = .03). In all, 85.2% of intervention patients compared to 64.0% of baseline patients were discharged on the same day as last methylprednisolone treatment (P = .11). No difference was observed in median length of stay and 30-day readmission rate between groups. CONCLUSIONS Use of a standard admission order set as well as provider and patient checklists can facilitate EIDD and hospital bed availability without compromising care quality for a select group of neurology inpatients.
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Affiliation(s)
- John C Probasco
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Gina Hawley
- Department of Neurosciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Margie Burnett
- Department of Neurosciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lorrie Gibson
- Department of Neurosciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kathryn Carter
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth Harlow
- Department of Neurosciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Holly Russell
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Linda Huffman
- Department of Neurosciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jane Adams
- Department of Neurosciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Terry Ziegler
- Department of Medicine and Surgery Social Work, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Hilary Sporney
- Department of Quality Improvement, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Michael Levy
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Hans A Puttgen
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
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Cole G, Stefanus D, Gardner H, Levy MJ, Klein EY. The impact of interruptions on the duration of nursing interventions: a direct observation study in an academic emergency department. BMJ Qual Saf 2015; 25:457-65. [PMID: 26294689 DOI: 10.1136/bmjqs-2014-003683] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 07/29/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Interruptions to nursing workload may contribute to procedural failures and clinical errors impacting quality/safety of care, but the impact of interruptions on the duration of these activities has not been closely scrutinised. This study analyses the effect of interruptions to care provided by nurses and clinical technicians on the length of clinical procedures and interventions (excluding the length of the interruption). METHODS An observational time study of the effect of interruptions on common nursing interventions in the emergency department (ED) of a large academic medical centre was conducted. This study used direct observations of nurses and clinical technicians while delivering care to patients. RESULTS The average time spent on an uninterrupted intervention was 296.47 s (median:185.15, SD:319.05), while interrupted interventions took 682.02 s (median:589.63, SD:504.59). Controlling for intervention type and other potential confounding factors using multiple linear regression found that interrupted interventions were 121.36 s (95% CI 79.57 to 163.15) longer, a 19 percentage point increase (95% CI 11.31 to 26.89), than an intervention without (excluding the length of the interruption). Family/patient interruptions effected duration the most while staff interruptions affected the intervention time the least. DISCUSSION Our findings are consistent with outcomes of studies in non-healthcare domains, but are contrary to a study of ED physicians, suggesting differential responses to interruptions by physicians and nurses. Future studies on interruptions in healthcare should thus be discipline specific. Though the effect of interruptions on intervention length is only about 2 min, in an ED setting, this can increase patient risks and costs. To better focus efforts to reduce interruptions future research should focus on further separation of interruption type (eg, urgent vs routine or unnecessary).
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Affiliation(s)
- Gai Cole
- Emergency Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Dicky Stefanus
- Carey Business School, Johns Hopkins University, Baltimore, Maryland, USA
| | - Heather Gardner
- Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Matthew J Levy
- Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eili Y Klein
- Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Korley FK, George RT, Jaffe AS, Rothman RE, Sokoll LJ, Fernandez C, Falk H, Post WS, Saheed MO, Gerstenblith G, Berkowitz SA, Hill PM. Low high-sensitivity troponin I and zero coronary artery calcium score identifies coronary CT angiography candidates in whom further testing could be avoided. Acad Radiol 2015; 22:1060-7. [PMID: 26049777 DOI: 10.1016/j.acra.2015.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 04/28/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
RATIONALE AND OBJECTIVES Pilot study to determine whether among subjects receiving coronary computed tomography angiography (CTA), the combination of high-sensitivity troponin I (hsTnI) and coronary artery calcium score (CACS) identifies a low-risk population in whom CTA might be avoided. MATERIALS AND METHODS A cross-sectional study of 314 symptomatic patients receiving CTA as part of their acute coronary syndrome evaluation was conducted. hsTnI was measured with Abbott Laboratories' hsTnI assay. CACSs were calculated via the Agatston method. Patients were followed for at least 30 days after discharge for the occurrence of major adverse cardiac events (MACEs; all-cause mortality, acute coronary syndrome, and revascularization). RESULTS Of 314 subjects studied, 213 (67.8%) had no coronary artery stenosis, and 67 (21.3%), 28 (8.9%), and 6 (1.9%) had maximal coronary artery stenosis of 1%-49%, 50%-69%, and 70% or greater, respectively. All MACEs occurred during index hospitalization and include one myocardial infarction and four revascularizations. Sixty-two percent (189/307) of subjects had zero CACS, and 24% (76/314) of subjects had undetected hsTnI. No subjects with undetectable hsTnI or zero CACS had an MACE. A strategy of avoiding further testing in subjects with undetectable initial hsTnI, performing CACS on subjects with detectable initial hsTnI but nonincreased hsTnI (less than 99th percentile), and obtaining CTA in subjects with Agatston greater than 0 will have a negative predictive value of 100.0% (95% confidence interval, 98.2%-100.0%). This strategy will avoid CTA in 63% (198/314) of subjects. CONCLUSIONS In this pilot study, the addition of CACS to hsTnI improves the identification of low-risk subjects in whom CTA might be avoided.
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Maroules CD, Cury RC, Ghoshhajra BB, Hoffmann U, Litt HI, Blankstein R, Abbara S. Strategy for Building a Successful Coronary CT Angiography Program in the Emergency Department. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-015-9337-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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47
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Discharge before noon: an urban legend. Am J Med 2015; 128:445-6. [PMID: 25554378 DOI: 10.1016/j.amjmed.2014.12.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 12/15/2014] [Accepted: 12/15/2014] [Indexed: 11/20/2022]
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Durtschi A, Jülicher P. Assessing the value of cardiac biomarkers: going beyond diagnostic accuracy? Future Cardiol 2015; 10:367-80. [PMID: 24976474 DOI: 10.2217/fca.14.26] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In this era of scrutinized resource utilization, providers and payers are focused on the value of healthcare interventions more than ever. Cost-effectiveness evaluations are required by some health authorities and requested by others in order to guide budget allocation decisions. In the past, these evaluations did not methodologically consider laboratory diagnostics. We set out to explore the current requirements of health technology agencies that include laboratory diagnostics and describe, through a review of the literature, alternative methods for establishing the value of a biomarker or labroatory diagnostic beyond assay specifications and performance. The aim of this study was to evaluate the current use of a linked evidence approach in cost-effectiveness studies for cardiac laboratory tests in the last 5 years.
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Affiliation(s)
- Amy Durtschi
- Abbott, 100 Abbott Park Road, CP1-3NW, Abbott Park, IL 60064-6094, USA
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49
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Abstract
Emergency departments (ED) worldwide have experienced dramatic increases in crowding over the past 20 years that now have reached critical levels. One consequence of ED crowding has been the routine use of ED hallways for patient care. This includes ED patients who are awaiting care but are considered unstable to remain in the waiting room, patients who are undergoing active medical and trauma treatment, and patients who have been stabilized but await transfer to an inpatient bed (boarding) or another institution. Compared with licensed hospital or standard ED beds, care in ED hallways results in increased patient morbidity and mortality, as well as patient and staff dissatisfaction. Complications experienced by hallway patients include unrecognized sudden respiratory arrest or unstable cardiac arrhythmias, delay in time-sensitive procedures and laboratory testing, delay in receiving important medications, excessive or unrelieved pain, overall increased length of stay, increased disability, and exposure to traumatic psychological events. While much has been published on the general problems of ED crowding, only recently have studies focused exclusively on the issues of providing care in ED hallways. This review summarizes the current issues, challenges, and solutions for hallway care.
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Mason S, Mountain G, Turner J, Arain M, Revue E, Weber EJ. Innovations to reduce demand and crowding in emergency care; a review study. Scand J Trauma Resusc Emerg Med 2014; 22:55. [PMID: 25212060 PMCID: PMC4173055 DOI: 10.1186/s13049-014-0055-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 09/03/2014] [Indexed: 11/10/2022] Open
Abstract
Emergency Department demand continues to rise in almost all high-income countries, including those with universal coverage and a strong primary care network. Many of these countries have been experimenting with innovative methods to stem demand for acute care, while at the same time providing much needed services that can prevent Emergency Department attendance and later hospital admissions. A large proportion of patients comprise of those with minor illnesses that could potentially be seen by a health care provider in a primary care setting. The increasing number of visits to Emergency Departments not only causes delay in urgent care provision but also increases the overall cost. In the UK, the National Health Service (NHS) has made a number of efforts to strengthen primary healthcare services to increase accessibility to healthcare as well as address patients' needs by introducing new urgent care services.
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Affiliation(s)
- Suzanne Mason
- />School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Gail Mountain
- />School of Health and Related Research, Sheffield, UK
| | | | - Mubashir Arain
- />Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1 N4 Canada
| | - Eric Revue
- />Emergency Department, Louis Pasteur Hospital and Prehospital EMS, Chartres, France
| | - Ellen J Weber
- />Emergency Medicine, University of California, San Francisco, USA
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