A Pilot Study Examining Undesirable Events Among Emergency Department–Boarded Patients Awaiting Inpatient Beds

Impact of the Implementation of a Low-Complexity Emergency Care Protocol in the Patient Experience at a Level 3 Academic Institution in Colombia

Introduction

Emergency department overcrowding is a universal problem. It is associated not only with poor clinical outcomes but also with a decrease in patient satisfaction, especially in patients with low complexity emergencies or triage 4 and 5, who tend to have a longer waiting time.

Objective

This study aims to determine whether the implementation of a care strategy for patients with low complexity emergencies called "The special Line" in the emergency department of a third level academic institution in Colombia, has a positive impact on the level of satisfaction with the care received by the patient and the number of people who leave without being seen.

Methods

This is a retrospective analytical observational study that looks at the effect on the rate of patients who leave without being seen and the net promoter score (NPS) of the entire emergency department of establishing a protocol for the care of patients with low complexity emergencies.

Results

Of a total of 22,743 patients divided into the two comparison groups, it was found that after the implementation of the care protocol, a non-significant reduction in the median rate of patients without care from 2.35% to 1.85% was documented, as well as a significant improvement in the median value of the NPS from 44 to 53, p: 0.001.

Conclusion

The implementation of a protocol for the care of patients with low-complexity emergencies demonstrated a significant improvement in the experience of care for all users in the emergency service, additionally, indirectly influencing the leave without being seen of the entire emergency service.

Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing

STUDY OBJECTIVE

Boarding admitted patients in emergency departments (EDs) is a national crisis that is worsening despite potential financial disadvantages. The objective of this study was to assess costs associated with boarding.

METHODS

We conducted a prospective, observational investigation of patients admitted through an ED for management of acute stroke at a large, urban, academic, comprehensive stroke center hospital. We employed time-driven activity-based costing methodology to estimate cost for patient care activities during admission and aggregated results to estimate the total cost of boarding versus inpatient care. Primary outcomes were total daily costs per patient for medical-surgical (med/surg) boarding, med/surg inpatient care, ICU boarding, and ICU inpatient care.

RESULTS

The total daily cost per patient with acute stroke was US$1856, for med/surg boarding versus US$993 for med/surg inpatient care and US$2267, for ICU boarding versus US$2165, for ICU inpatient care. These differences were even greater when accounting for costs associated with traveler nurses. ED nurses spent 293 min/d (mean) caring for each med/surg boarder; inpatient nurses spent 313 min/d for each med/surg inpatient. ED nurses spent 419 min/d caring for each ICU boarder; inpatient nurses spent 787 min/d for each ICU inpatient. Neurology attendings and residents spent 25 and 52 min/d caring for each med/surg boarder versus 62 minutes and 90 minutes for each med/surg inpatient, respectively.

CONCLUSION

Using advanced cost-accounting methods, our investigation provides novel evidence that boarding of admitted patients is financially costly, adding greater urgency for elimination of this practice.

Emergency Department Length of Stay for Older Adults With Dementia

STUDY OBJECTIVE

The emergency department (ED) poses unique challenges and risks to persons living with dementia. A longer ED length of stay is associated with the risk of death, delirium, and medication errors. We sought to determine whether ED length of stay differed by dementia status and trends in ED length of stay for persons living with dementia from 2014 to 2018 and whether persons living with dementia were at a higher risk for prolonged ED length of stay (defined as a length of stay > 90th percentile).

METHODS

In this observational study, we used data from the Healthcare Cost and Utilization Project State Emergency Department Database from Massachusetts, Arkansas, Arizona, and Florida. We included ED visits resulting in discharge for adults aged ≥65 years from 2014 to 2018. We used inverse probability weighting to create comparable groups of visits on the basis of dementia status. We used generalized linear models to estimate the mean difference in ED length of stay on the basis of dementia status and logistic regression to determine the odds of prolonged ED length of stay.

RESULTS

We included 1,039,497 ED visits (mean age: 83.5 years; 64% women; 78% White, 12% Hispanic). Compared with visits by persons without dementia, ED length of stay was 3.1 hours longer (95% confidence interval [CI] 3.0 to 3.3 hours) for persons living with dementia. Among the visits resulting in transfer, ED length of stay was on average 4.1 hours longer (95% CI 3.6 to 4.5 hours) for persons living with dementia. Visits by persons living with dementia were more likely to have a prolonged length of stay (risk difference 4.1%, 95% CI 3.9 to 4.4).

CONCLUSION

ED visits were more than 3 hours longer for persons living with versus without dementia. Initiatives focused on optimizing ED care for persons living with dementia are needed.

Association of Hospitalist Care and Outcomes for Patients Electively Admitted for Chemotherapy

Introduction

Patients with hematologic malignancies frequently receive elective anticancer therapy as inpatients. The impact of introducing hospitalists on quality outcomes in this subset of patients is unknown.

Methods

Patients with leukemia or lymphoma electively admitted for anticancer therapy to either a hematologist-led service (TS; n=59) or to a hospitalist-led service (HS; n=102) during two parallel 18-month time periods were included. Mixed linear regression models with first-order random effects for intercept (individual) and slope (time) were used to estimate the association between service and the quality outcomes of length of stay (LOS), time from admission to anticancer therapy initiation, and discharge time of day.

Results

For patients who received a fixed-duration anticancer therapy regimen, after adjustment for clinical and demographic covariates, mean LOS was reduced by >2 days (TS=5.97 days (95% CI: 5.13, 6.81); HS=3.88 days (95% CI, 3.53, 4.23); p<0.001), mean time from admission to first anticancer therapy administration decreased by 4 hours (TS=8.32 hours (95% CI: 5.72, 10.93); HS= 4.36 hours (95% CI: 3.49, 5.23); p=0.001)), and mean discharge time was similarly decreased by 110 minutes (TS=3:12 PM (95% CI: 2:06 PM, 4:19 PM); HS=1:22 PM (95% CI: 12:48 PM, 1:57 PM); p=0.01)). For regimens that required variable monitoring for post-treatment methotrexate clearance, tumor lysis syndrome, or white blood cell count recovery, no significant difference in outcomes was noted.

Conclusion

Hospitalist care of patients with hematologic malignancies admitted for elective anticancer therapy may lead to improved quality and efficiency of care.

Impact of emergency department length of stay on in-hospital mortality: a retrospective cohort study

BACKGROUND AND IMPORTANCE

Emergency Department (ED) workload may lead to ED crowding and increased ED length of stay (LOS). ED crowding has been shown to be associated with adverse events and increasing mortality. We hypothesised that ED-LOS is associated with mortality.

OBJECTIVE

To study the relationship between ED-LOS and in-hospital mortality.

DESIGN

Observational retrospective cohort study.

SETTINGS AND PARTICIPANTS

From 1 January 2015 to 30 September 2018, all visits by patients aged 15 or older to one of the two ED at Toulouse University Hospital were screened. Patients admitted to the hospital after ED visits were included. Visits followed by ED discharge, in-ED death or transfer to ICU or another hospital were not included.

OUTCOME MEASURE AND ANALYSIS

The primary outcome was 30-day in-hospital mortality. ED-LOS was defined as time from ED registration to inpatient admission. ED-LOS was categorised according to quartiles [<303 min (Q1), between 303 and 433 minutes (Q2), between 434 and 612 minutes (Q3) and >612 min (Q4)]. A multivariable logistic regression tested the association between ED-LOS and in-hospital mortality.

MAIN RESULTS

A total of 49 913 patients were admitted to our hospital after ED visits and included in the study. ED-LOS was not independently associated with in-hospital mortality. Compared to ED-LOS < 303 min (Q1, reference), odd-ratios (OR) [95% CI] of in-hospital mortality for Q2, Q3, and Q4 were respectively 0.872 [0.747-1.017], 0.906 [0.777-1.056], and 1.137 [0.985-1.312]. Factors associated to in-hospital mortality were: aged over 75 years (OR [95% CI] = 4.3 [3.8-4.9]), Charlson Comorbidity Index score > 1 (OR [95% CI] = 1.3 [1.1-1.5], and 2.2 [1.9-2.5] for scores 2 and ≥ 3 respectively), high acuity at triage (OR [95% CI] = 3.9 [3.5-4.4]), ED visit at Hospital 1 (OR [95% CI] = 1.6 [1.4-1.7]), and illness diagnosis compared to trauma (OR [95% CI] = 2.1 [1.7-2.6]). Night-time arrival was associated with decreased in-hospital mortality (OR [95% CI] = 0.852 [0.767-0.947]).

CONCLUSION

In this retrospective cohort study, there was no independent association between ED-LOS before admission to general non-ICU wards and in-patient mortality.

Emergency department crowding increases 10-day mortality for non-critical patients: a retrospective observational study

The current evidence suggests that higher levels of crowding in the Emergency Department (ED) have a negative impact on patient outcomes, including mortality. However, only limited data are available about the association between crowding and mortality, especially for patients discharged from the ED. The primary objective of this study was to establish the association between ED crowding and overall 10-day mortality for non-critical patients. The secondary objective was to perform a subgroup analysis of mortality risk separately for both admitted and discharged patients. An observational single-centre retrospective study was conducted in the Tampere University Hospital ED from January 2018 to February 2020. The ED Occupancy Ratio (EDOR) was used to describe the level of crowding and it was calculated both at patient's arrival and at the maximum point during the stay in the ED. Age, gender, Emergency Medical Service transport, triage acuity, and shift were considered as confounding factors in the analyses. A total of 103,196 ED visits were included. The overall 10-day mortality rate was 1.0% (n = 1022). After controlling for confounding factors, the highest quartile of crowding was identified as an independent risk factor for 10-day mortality. The results were essentially similar whether using the EDOR at arrival (OR 1.31, 95% CI 1.07-1.61, p = 0.009) or the maximum EDOR (OR 1.27, 95% CI 1.04-1.56, p = 0.020). A more precise, mortality-associated threshold of crowding was identified at EDOR 0.9. The subgroup analysis did not yield any statistically significant findings. The risk for 10-day mortality increased among non-critical ED patients treated during the highest EDOR quartile.

Methods of the PivotaL triAl of the Atellica VTLi point of care emergencY dePartment high sensitivity troponin evalUationS

BACKGROUND

The Atellica® VTLi point-of-care (POC) High Sensitivity Cardiac Troponin-I (hs-cTnI) assay is intended for use as an aid in the diagnosis of myocardial infarction (MI). Our primary objective is to assess its diagnostic performance in patients presenting with suspected acute coronary syndrome (ACS).

METHODS

This prospective observational study will enrol ∼1500 patients at ∼20 U.S. Emergency Departments. After informed consent, adults (>21 years of age) with suspected ACS, and no prior enrollment in this study, will provide a fingerstick and venous blood sample within 2 h of ED presentation, >2 to ≤4 h, and >4 to ≤9 h (max. blood draw = 60 mL). HEART and EDACS scores will be prospectively documented. Patients without the first blood draw may be enrolled if the second draw was obtained. Capillary and venous whole blood will undergo Atellica VTLi assay testing, with remaining venous sample processed to plasma and run. All results will be blinded to the clinical care team. Site operators will undergo a 3-day familiarization period. Quality control testing will be performed daily. At 30 ± 3 days, patient mortality status, major adverse cardiac events, and rehospitalizations will be determined. A clinical endpoint adjudication committee, blinded to hs-cTnI VTLi result, will define the final diagnosis. Sensitivity, specificity, and predictive values will describe the assay performance.

RESULTS

We expect study completion within 114 weeks of enrollment of the first patient.

CONCLUSIONS

It is anticipated that the Atellica VTLi hs-cTnI assay validation study will define a performance equivalent to lab-based hs-cTnI, with results within ∼8 min at the point of care.

Who, When, Why?-Traumatological Patients in the Emergency Department of a Maximum Care Provider

Nationwide, there is an annual increase in the number of patients in German emergency departments resulting in a growing workload for the entire emergency department staff. Several studies have investigated the situation in emergency departments, most of which were interdisciplinary, but there are no data on a solely traumatological patient population. The present study therefore aims to investigate the situation in a university-based trauma surgery emergency department. A total of 8582 traumatological patients attending a university hospital from 1 January 2019 to 31 December 2019 were studied. Various variables, such as reason for presentation, time of accident, diagnosis, and diagnostic as well as therapeutic measures performed were analyzed from the admission records created. The mean age was 36.2 years, 60.1% were male, 63.3% presented on their own to the emergency department, and 41.2% presented during regular working hours between 8:00 a.m. and 6:00 p.m., Monday through Friday. The most common reason for presentation was outdoor falls at 17.4%, and 63.3% presented to the emergency department within the first 12 h after the sustained trauma. The most common diagnosis was bruise (27.6%), and 14.2% of patients were admitted as inpatients. Many of the emergency room patients suffered no relevant trauma sequelae. In order to reduce the number of patients in emergency rooms in the future, existing institutions in the outpatient emergency sector must be further expanded and effectively advertised to the public. In this way, the emergency medical resources of clinics, including staff, can be relieved to provide the best possible care for actual emergency patients.

Association Between the Emergency Department Length of Stay and in-Hospital Mortality: A Retrospective Cohort Study

Purpose

The number of emergency department (ED) visits and prolonged ED length of stay (LOS) are increasing worldwide. Prolonged ED LOS may be associated with a higher risk of in-hospital mortality. Here, we analysed the association between of ED LOS and the risk of in-hospital mortality in a hospital in Jakarta, Indonesia.

Patients and methods

This was a single-centre retrospective cohort study performed in a referral academic hospital in Jakarta, Indonesia. Data on ED visits in 2019 were obtained from the electronic medical records. ED patient was used as the unit of the analysis. The dependent variable was all-cause in-hospital mortality during one's visit. The main independent variable was ED LOS with respect to approval (<8 h) and prolonged (≥8 h). Potential confounders were sex, age, triage categories, trauma-related case, malignancy-related case, labour-related case, and referral patients from other healthcare facilities. Multivariate logistic regression analysis was performed to evaluate the association of ED LOS and in-hospital mortality after adjusting for other confounders.

Results

There were 18,553 participants included in the analysis. The in-hospital mortality was 13.5% among all participants, and 63.5% participants had an ED LOS ≥8 h. Multivariate analysis showed that a prolonged ED LOS was associated with an increased risk of in-hospital mortality (adjusted relative risk, 2.69; 95% confidence interval, 2.40-3.03; P<0.001).

Conclusion

Prolonged ED LOS was associated with risk an increased of in-hospital mortality after adjusting for several confounders. In future, hospital service plans should aim to reduce ED LOS and increase patient flow from the ED to in-patient wards.

Near-Miss Events Detected Using the Emergency Department Trigger Tool

OBJECTIVES

Near misses include conditions with potential for harm, intercepted medical errors, and events requiring monitoring or intervention to prevent harm. Little is reported on near misses or their importance for quality and safety in the emergency department (ED).

METHODS

This is a secondary evaluation of data from a retrospective study of the ED Trigger Tool (EDTT) at an urban, academic ED (data from October 1, 2014, to October 31, 2015; 92,859 eligible visits). All patients 18 years and older completing a visit were eligible. We ran the EDTT, a computerized query for triggers on 13 months of ED visit data, reviewing 5582 selected records using a 2-tiered approach. Events were categorized by occurrence (ED vs present on arrival [POA]), severity, omission/commission, and type, using a taxonomy with categories, subcategories, and cross-cutting modifiers.

RESULTS

We identified 1458 ED near misses in 1269 of 5582 records (22.7%) and 80 near misses that were POA. Patient care events represented most ED near misses, including delays in diagnosis, treatment, and failure to monitor, primarily driven by ED boarding and crowding. Medication events were second most common (17%), including 80 medication administration errors. Of 80 POA events, 42% were related to overanticoagulation. We estimate that 19.3% of all ED visits include a near miss.

CONCLUSIONS

Near-miss events are relatively common (22.7% of our sample, 19.3% in the population) and are associated with an increased risk for an adverse event. Most events were patient care related (77%) involving delays due to crowding and ED boarding followed by medication administration errors. The EDTT is a high-yield approach for detecting important near misses and latent system deficiencies that impact patient safety.

Effects of Emergency Transfer Coordination Center on Length of Stay of Critically Ill Patients in the Emergency Department

Introduction: Critically ill patients are frequently transferred from other hospitals to the emergency departments (ED) of tertiary hospitals. Due to the unforeseen transfer, the ED length of stay (LOS) of the patient is likely to be prolonged in addition to other potentially adverse effects. In this study we sought to confirm whether the establishment of an organized unit — the Emergency Transfer Coordination Center (ETCC) — to systematically coordinate emergency transfers would be effective in reducing the ED LOS of transferred, critically ill patients. Methods: The present study is a retrospective observational study focusing on patients who were transferred from other hospitals and admitted to the intensive care unit (ICU) of the ED in a tertiary hospital located in northwestern Seoul, the capital city of South Korea, from January 2019 – December 2020. The exposure variable of the study was ETCC approval before transfer, and ED LOS was the primary outcome. We used propensity score matching for comparison between the group with ETCC approval and the control group. Results: Included in the study were 1,097 patients admitted to the ICU after being transferred from other hospitals, of whom 306 (27.9%) were transferred with ETCC approval. The median ED LOS in the ETCC-approved group was significantly reduced to 277 minutes compared to 385 minutes in the group without ETCC approval. The ETCC had a greater effect on reducing evaluation time than boarding time, which was the same for populations with different clinical features. Conclusion: An ETCC can be effective in systematically reducing the ED LOS of critically ill patients who are transferred from other hospitals to tertiary hospitals that are experiencing severe crowding.

Clinical incidents in the emergency department: is there an association with emergency nursing shift patterns? A retrospective observational study

Introduction

Clinical incident (CI) management within healthcare settings is a crucial component of patient safety and quality improvement. The complex environment in the emergency department (ED) and nursing work schedules are important aspects of human factor ergonomic (HFE) systems that requires closer examination. Nursing shifts are closely related to fatigue, including the late/early shift pattern and night shift. All nursing shifts were examined over a 1-year period when a CI occurred to a patient in the ED to identify if there was an association.

Methods

This was a retrospective observational study, conducted and reported using the Strengthening of the Reporting of Observational Studies in Epidemiology statement. All CIs reported in the ED over a 1-year period were reviewed by accessing the CI database, emergency department information system and patient health records. The nursing roster database was accessed to record nursing shifts and were de-identified.

Results

A total of n=244 CIs were eligible for inclusion into the study. ED nursing shift analysis included n=1095 nursing shifts. An analysis of early, late and night shifts, including days not worked by the ED nurse was conducted over a 48-hour and 96-hour period. There was no significant relationship identified between the CI and nursing shift patterns. ED length of stay (LOS) was significantly higher for a patient presentation when a CI occurred.

Conclusion

This study focused on the HFE system of nursing work schedules and CI events that occurred in the ED. This study found there was no relationship between emergency nursing shift patterns and an increased risk for the occurrence of a CI in the ED. Although a strong link was found between patients experiencing a CI in the ED and an extended LOS. This demonstrates the need for studies to investigate the interrelationships of multiple HFE systems in the ED, including the environment, patient, clinical team and organisational factors.

Increased Length of Stay of Critically Ill Patients in the Emergency Department Associated with Higher In-hospital Mortality

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.

Multicenter Test of an Emergency Department Trigger Tool for Detecting Adverse Events

OBJECTIVES

Traditional approaches to safety and quality screening in the emergency department (ED) are porous and low yield for identifying adverse events (AEs). A better approach may be in the use of trigger tool methodology. We recently developed a novel ED trigger tool using a multidisciplinary, multicenter approach. We conducted a multicenter test of this tool and assess its performance.

METHODS

In design and participants, we studied the ED trigger tool for a 13-month period at four EDs. All patients 18 years and older with Emergency Severity Index acuity levels of 1 to 3 seen by a provider were eligible. Reviewers completed standardized training modules. Each site reviewed 50 randomly selected visits per month. A first-level reviewer screened for presence of predefined triggers (findings that increase the probability of an AE). If no trigger is present, the review is deemed complete. When present, a trigger prompts an in-depth review for an AE. Any event identified is assigned a level of harm using the Medication Event Reporting and Prevention (MERP) Index, ranging from a near miss (A) to patient death (I). Events are noted as present on arrival or in the ED, an act of commission or omission, and are assigned one of four event categories. A second-level physician performs a confirmatory review of all AEs and independently reviews 10% of cases to estimate the false-negative rate. All AEs or potential AEs were reviewed in monthly group calls for consensus on findings. The primary outcome is the proportion of visits in which an AE is identified, overall and by site. Secondary outcomes include categories of events, distribution of harm ratings, and association of AEs with sociodemographic and clinical factors and triggers. We present sociodemographic data and details about AEs and results of logistic regression for associations of AEs with of triggers, sociodemographics, and clinical variables.

RESULTS

We captured 2594 visits that are representative, within site, of their patient population. Overall, the sample is 64% white, 54% female, and with a mean age of 51. Variability is observed between sites for age, race, and insurance, but not sex. A total of 240 events were identified in 228 visits (8.8%) of which 53.3% were present on arrival, 19.7% were acts of omission, and 44.6% were medication-related, with some variability across sites. A MERP F score (contributing to need for admission, higher level of care, or prolonged hospitalization) was the most common severity level (35.4% of events). Overall, 185 (77.1%) of 240 events involved patient harm (MERP level ≥ E), affecting 175 visits (6.7%). Triggers were present in 951 visits (36.6%). Presence of any trigger was strongly associated with an AE (adjusted odds ratio = 4.6, 95% confidence interval = 3.2-6.6). Ten triggers were individually associated with AEs (adjusted odds ratio = 2.1-7.7). Variability was observed across sites in individual trigger associations, event rates, and categories, but not in severity ratings of events. The overall false-negative rate was 6.1%.

CONCLUSIONS

The trigger tool approach was successful in identifying meaningful events. The ED trigger tool seems to be a promising approach for identifying all-cause harm in the ED.

Exploring the experience of boarded psychiatric patients in adult emergency departments

BACKGROUND

This study quantifies the frequency of adverse events (AEs) experienced by psychiatric patients while boarded in the emergency department (ED) and describes those events over a broad range of categories.

METHODS

A retrospective chart review (RCR) of adult psychiatric patients aged 18-55 presenting to one of four Calgary EDs (Foothills Medical Centre (FMC), the Peter Lougheed Centre (PLC), the Rockyview General Hospital (RGH), and South Health Campus (SHC)) who were subsequently admitted to an inpatient psychiatric unit between January 1, 2019 and May 15, 2019 were eligible for review. A test of association was used to determine the odds of an independent variable being associated with an adverse event.

RESULTS

During the study time period, 1862 adult patients were admitted from EDs (city wide) to the psychiatry service. Of the 200 charts reviewed, the average boarding time was 23.5 h with an average total ED length of stay of 31 h for all presentations within the sample. Those who experienced an AE while boarded in the ED had a significantly prolonged average boarding time (35 h) compared to those who did not experience one (6.5 h) (p = 0.005).

CONCLUSIONS

The length of time a patient is in the emergency department and the length of time a patient is boarded after admission significantly increases the odds that the patient will experience an AE while in the ED. Other significant factors associated with AEs include the type of admission and the hospital the patient was admitted from.

The impact of urgent care centers on nonemergent emergency department visits

OBJECTIVE

To estimate the impact of urgent care centers on emergency department (ED) use.

DATA SOURCES

Secondary data from a novel urgent care center database, linked to the Healthcare Cost and Utilization Project State Emergency Department Databases (SEDD) from six states.

STUDY DESIGN

We used a difference-in-differences design to examine ZIP code-level changes in the acuity mix of emergency department visits when local urgent care centers were open versus closed. ZIP codes with no urgent care centers served as a control group. We tested for differential impacts of urgent care centers according to ED wait time and patient insurance status.

DATA COLLECTION/EXTRACTION METHODS

Urgent care center daily operating times were determined via the urgent care center database. Emergency department visit acuity was assessed by applying the NYU ED algorithm to the SEDD data. Urgent care locations and nearby emergency department encounters were linked via zip code.

PRINCIPAL FINDINGS

We found that having an open urgent care center in a ZIP code reduced the total number of ED visits by residents in that ZIP code by 17.2% (P < 0.05), due largely to decreases in visits for less emergent conditions. This effect was concentrated among visits to EDs with the longest wait times. We found that urgent care centers reduced the total number of uninsured and Medicaid visits to the ED by 21% (P < 0.05) and 29.1% (P < 0.05), respectively.

CONCLUSIONS

During the hours they are open, urgent care centers appear to be treating patients who otherwise would have visited the ED. This suggests that urgent care centers have the potential to reduce health care expenditures, though questions remain about their net cost impact. Future work should assess whether urgent care centers can improve health care access among populations that often experience barriers to receiving timely care.

Adverse Events in Emergency Department Boarding: A Systematic Review

BACKGROUND

Overcrowding in emergency departments (EDs) is a worldwide challenge. As a result of the increased demand for EDs, slow internal patient flow, and unavailability of hospital beds, patients are kept in the corridors, causing a boarding effect. Studies have associated boarding in EDs with unfavorable clinical outcomes and adverse events. Thus, the purpose of this systematic review was to describe the effects of ED boarding on the occurrence of adverse events.

DESIGN

We followed the Meta-Analysis of Observational Studies in Epidemiology checklist and registered this systematic review with PROSPERO (CRD42020117915).

METHODS

Literature searches were performed using the databases PubMed, Scopus, Latin American and Caribbean Center on Health Sciences Information (LILACS), Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane, as well as Google Scholar, OpenThesis, and the Brazilian Digital Library of Theses and Dissertations from September to November 2019. Cohort or case control studies that evaluated the occurrence of adverse events in patients who remained in an ED, waiting for a hospital bed, were included in the review.

RESULTS

Seven studies met our eligibility criteria. Boarding in EDs may be related to a reduction in the quality of care, resulting in unfavorable clinical outcomes and adverse events.

CONCLUSIONS

Boarding in EDs may be related to increases in adverse incidents and events.

CLINICAL RELEVANCE

The evidence in this review suggests that ED boarding increases the occurrence of unfavorable outcomes and identifies important considerations for future research.

Increasing consultant-level staffing as a proportion of overall physician coverage improves emergency department length of stay targets

Objectives

One goal of Emergency Department (ED) operations is achieving an overall length of stay (LOS) that is less than four hours. The goal of the current study was to assess for association between increasing number of on-duty EM Consultants and LOS, while adjusting for overall (all-grade) on-duty emergency doctors’ numbers and other operational factors.

Methods

This was a retrospective analysis of three years (2016–2019) of data, employing a unit of analysis of 3276 eight-hour ED shifts. The study was conducted using a prospectively populated ED database in a busy (annual census 420,000) Middle Eastern ED with staffing by Consultants and multiple non-Consultant grades (Specialists, fellows, and residents). Using logistic regression, the main predictor variable of “on-duty Consultant n” was assessed for association with the study’s primary (dichotomous) endpoint: whether a shift’s median LOS met the target of < 240 min. Linear regression was used to assess for association between on-duty Consultant n and the study’s secondary (continuous) endpoint: median LOS for the ED shift.

Results

Multivariate logistic regression adjusting for a number of operations factors (including total EP on-duty complement) identified an association between increasing n of on-duty Consultants and the likelihood of a shift’s meeting the 4-h ED LOS target (OR 1.27, 95% CI 1.20 to 1.34, p < .0001). Multiple linear regression, which also adjusted for total on-duty EP n and other operational factors, also indicated LOS benefit from more on-duty Consultants: each additional on-duty Consultant was associated with a shift’s median LOS improving by 5.4 min (95% CI 4.3 to 6.5, p < .0001).

Conclusions

At the study site, in models that adjusted for overall on-duty EP numbers as well as myriad other operational factors, increasing numbers of on-duty Consultants was associated with a statistically and operationally significant reduction in ED LOS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-020-00399-8.

The Meaning of Boarding in a Swedish Accident & Emergency Department: A Qualitative Study on Patients' Experiences of Awaiting Admission

The number of in-hospital beds in Sweden has decreased during recent decades, resulting in the smallest number (2.2 available beds/1000 inhabitants) within the European Union. At the same time, the number of patients attending Accident and Emergency (A&E) departments has increased, resulting in overcrowding and boarding. The aim of this study was to explore the meaning of being subjected to boarding at an A&E department, as experienced by patients. A phenomenological-hermeneutic approach was chosen to interpret and understand the meaning of boarding at A&E. The study was carried out at a hospital in the south of Sweden. Seventeen participants with a mean age of 64 years (range: 35-86 years) were interviewed. The thematic structural analysis covers seven themes: Being in a state of uncertainty, Feeling abandoned, Fearing death, Enduring, Adjusting to the circumstances, Being a visitor in an unsafe place, and Acknowledging the staff, all illustrating that the participants were in a state of constant uncertainty and felt abandoned with no guidance or support from the clinicians. The conclusion is that the situation where patients are forced to wait in A&E, i.e., boarding, violates all conditions for professional ethics, presumably causing profound ethical stress in the healthcare professionals involved. Thus, boarding should be avoided.

Short- and intermediate-term effects of a hospital-integrated walk-in clinic on emergency department-visits and case mix

BACKGROUND AND IMPORTANCE

Emergency department (ED) admissions have been rising over the last decades, especially in countries without any effective gate-keeping functions. Integration of walk-in clinics into the hospital might reduce ED-visits. Over a longer period, however, the additional service of a walk-in clinic might attract even more patients, nullifying an initial decrease in patients for the ED.

OBJECTIVES, DESIGN, SETTINGS AND PARTICIPANTS

This study aimed to determine short- and intermediate-term changes after the implementation of a hospital-integrated walk-in clinic. This is an observational study using routinely-collected health data. Study setting was the ED of a large tertiary care hospital in Austria, a country with universal health care and no regulations regarding level of care.

OUTCOMES MEASURE AND ANALYSIS

ED-visits were compared between before (2015) and after (2017 and 2018) establishment of a hospital-integrated walk-in clinic.

MAIN RESULTS

Total ED-visits decreased from 87,624 in 2015 to 67,479 in 2017, and 67,871 in 2018 (p < 0.001), mainly due to a decrease in non-urgent (ESI 4 & 5) cases (45,715 (54.1%) in 2015; 33,142 (51.3%) in 2017; 30,846 (47.5%) in 2018; short term OR non-urgent vs. urgent: 0.89 (95% CI 0.88-0.91); intermediate term OR urgent vs. non-urgent: 0.76 (95% CI 0.78-0.75)). A total of 2611 (13%) (2017) and 1714 (8.5%) (2018) patients were referred back to the ED.

CONCLUSIONS

After the introduction of the walk-in clinic, ED-visits declined significantly. This remained stable over a two-year period. Reduction in ED-visits was mainly due to low-acuity patients not requiring admission to the hospital.

Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care

Background: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients’ characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient’s clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients’ management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusions: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.

Impact of Around-the-Clock Mental Health Staffing on Emergency Department Management of Patients Who Deliberately Self-Harm

OBJECTIVE

Emergency departments (EDs) offer opportunities to deliver critical frontline suicide prevention services via assessment, safety planning, and linkages with community-based mental health care after discharge. Because mental health crises can occur at any time, this study sought to evaluate whether around-the-clock mental health staffing in the ED influences the likelihood of providing these evidence-based mental health services.

METHODS

ED nursing leadership from a national sample of 406 hospitals completed a survey on the ED management of patients who deliberately self-harm, including availability of mental health staff (psychiatrists, psychiatric nurses, psychologists, social workers, other mental health professionals). Analyses examined whether around-the-clock mental health staffing was associated with provision of key assessments, safety planning, and discharge practices, controlling for hospital characteristics.

RESULTS

There were no significant differences in the extent to which EDs with and without around-the-clock mental health staff routinely completed recommended assessment practices (71% and 70%, respectively). EDs with around-the-clock mental health staff were more likely than their counterparts to routinely provide two recommended safety planning practices (59% vs. 27%, p<0.001; adjusted odds ratio [AOR]=3.76) and were more likely to routinely schedule follow-up outpatient care (44% vs. 21%, p=0.002; AOR=3.26).

CONCLUSIONS

Around-the-clock mental health coverage in the ED is associated with routine provision of key safety planning and discharge practices. EDs should have consistent access to staff either in person or remotely to facilitate the delivery of evidence-based mental health practices.

Influence of physicians’ seniority on head computed tomography use for patients with isolated vertigo/dizziness

Objective

Vertigo/dizziness is a common reason for emergency department (ED) visits. Emergency physicians (EPs) must distinguish patients with dizziness/vertigo owing to serious central nervous system (CNS) disorders. We aimed to evaluate the association between physician seniority and use of head computed tomography (CT) and ED length of stay (LOS) in patients presenting to the ED with isolated dizziness/vertigo.

Methods

This retrospective cohort study included adult patients with non-traumatic dizziness/vertigo in the ED. EPs were categorized according to seniority: junior (less than 6 years’ clinical experience), intermediate (7–12 years), and senior (≥12 years).

Results

Among 2589 patients with isolated dizziness/vertigo, 460 (17.8%) received brain CT; 46 (1.78%) had CNS disorder as a final diagnosis. Junior and intermediate EPs ordered more CT examinations than senior EPs: (odds ratio [OR] = 1.329, 95% confidence interval [CI]: 1.002–1.769 and OR = 1.531, 95% CI: 1.178–2.001, respectively). Patients treated by junior and intermediate EPs had lower patient ED LOS (OR = −0.432, 95% CI: −0.887 to 0.024 and OR = −0.436, 95% CI: −0.862 to −0.011).

Conclusions

We revealed different judgment strategies among senior, intermediate, and junior EPs. Senior EPs ordered fewer CT examinations for patients with isolated vertigo/dizziness but had longer patient LOS.

When Safety Event Reporting Is Seen as Punitive: "I've Been PSN-ed!"

STUDY OBJECTIVE

Reporting systems are designed to identify patient care issues so changes can be made to improve safety. However, a culture of blame discourages event reporting, and reporting seen as punitive can inhibit individual and system performance in patient safety. This study aimed to determine the frequency and factors related to punitive patient safety event report submissions, referred to as Patient Safety Net reports, or PSNs.

METHODS

Three subject matter experts reviewed 513 PSNs submitted between January and June 2019. If the PSN was perceived as blaming an individual, it was coded as punitive. The experts had high agreement (κ=0.84 to 0.92), and identified relationships between PSN characteristics and punitive reporting were described.

RESULTS

A total of 25% of PSNs were punitive, 7% were unclear, and 68% were designated nonpunitive. Punitive (vs nonpunitive) PSNs more likely focused on communication (41% vs 13%), employee behavior (38% vs 2%), and patient assessment issues (17% vs 4%). Nonpunitive (vs punitive) PSNs were more likely for equipment (19% vs 4%) and patient or family behavior issues (8% vs 2%). Punitive (vs nonpunitive) PSNs were more common with adverse reactions or complications (21% vs 10%), communication failures (25% vs 16%), and noncategorized events (19% vs 8%), and nonpunitive (vs punitive) PSNs were more frequent in falls (5% vs 0%) and radiology or laboratory events (17% vs 7%).

CONCLUSION

Punitive reports have important implications for reporting systems because they may reflect a culture of blame and a failure to recognize system influences on behaviors. Nonpunitive wording better identifies factors contributing to safety concerns. Reporting systems should focus on patient outcomes and learning from systems issues, not blaming individuals.

Prolonged Length of Stay in the Emergency Department and Increased Risk of In-Hospital Cardiac Arrest: A nationwide Population-Based Study in South Korea, 2016-2017

This study was to determine whether prolonged emergency department (ED) length of stay (LOS) is associated with increased risk of in-hospital cardiac arrest (IHCA). A retrospective cohort with a nationwide database of all adult patients who visited the EDs in South Korea between January 2016 and December 2017 was performed. A total of 18,217,034 patients visited an ED during the study period. The median ED LOS was 2.5 h. IHCA occurred in 9,180 patients (0.2%). IHCA was associated with longer ED LOS (4.2 vs. 2.5 h), and higher rates of intensive care unit (ICU) admission (58.6% vs. 4.7%) and in-hospital mortality (35.7% vs. 1.5%). The ED LOS correlated positively with the development of IHCA (Spearman ρ = 0.91; p < 0.01) and was an independent risk factor for IHCA (odds ratio (OR) 1.10; 95% confidence interval (CI), 1.10-1.10). The development of IHCA increased in a stepwise fashion across increasing quartiles of ED LOS, with ORs for the second, third, and fourth relative to the first being 3.35 (95% CI, 3.26-3.44), 3.974 (95% CI, 3.89-4.06), and 4.97 (95% CI, 4.89-5.05), respectively. ED LOS should be reduced to prevent adverse events in patients visiting the ED.

Liu S, A. Camargo C, Aburawi E, Moeckel M, Slagman A, Christ M, Singer A, Tazarourte K, Rathlev NK, A. Grossman S, Bellou A. Association between boarding in the emergency department and in-hospital mortality: A systematic review

IMPORTANCE

Boarding in the emergency department (ED) is a critical indicator of quality of care for hospitals. It is defined as the time between the admission decision and departure from the ED. As a result of boarding, patients stay in the ED until inpatient beds are available; moreover, boarding is associated with various adverse events.

STUDY OBJECTIVE

The objective of our systematic review was to determine whether ED boarding (EDB) time is associated with in-hospital mortality (IHM).

METHODS

A systematic search was conducted in academic databases to identify relevant studies. Medline, PubMed, Scopus, Embase, Cochrane, Web of Science, Cochrane, CINAHL and PsychInfo were searched. We included all peer-reviewed published studies from all previous years until November 2018. Studies performed in the ED and focused on the association between EDB and IHM as the primary objective were included. Extracted data included study characteristics, prognostic factors, outcomes, and IHM. A search update in PubMed was performed in May 2019 to ensure the inclusion of recent studies before publishing.

RESULTS

From the initial 4,321 references found through the systematic search, the manual screening of reference lists and the updated search in PubMed, a total of 12 studies were identified as eligible for a descriptive analysis. Overall, six studies found an association between EDB and IHM, while five studies showed no association. The last remaining study included both ICU and non-ICU subgroups and showed conflicting results, with a positive association for non-ICU patients but no association for ICU patients. Overall, a tendency toward an association between EDB and IHM using the pool random effect was observed.

CONCLUSION

Our systematic review did not find a strong evidence for the association between ED boarding and IHM but there is a tendency toward this association. Further well-controlled, international multicenter studies are needed to demonstrate whether this association exists and whether there is a specific EDB time cut-off that results in increased IHM.

Association between long boarding time in the emergency department and hospital mortality: a single-center propensity score-based analysis

Once diagnostic work-up and first therapy are completed in patients visiting the emergency department (ED), boarding them within the ED until an in-hospital bed became available is a common practice in busy hospitals. Whether this practice may harm the patients remains a debate. We sought to determine whether an ED boarding time longer than 4 h places the patients at increased risk of in-hospital death. This retrospective, propensity score-matched analysis and propensity score-based inverse probability weighting analysis was conducted in an adult ED in a single, academic, 1136-bed hospital in France. All patients hospitalized via the adult ED from January 1, 2013 to March 31, 2018 were included. Hospital mortality (primary outcome) and hospital length of stay (LOS) were assessed in (1) a matched cohort (1:1 matching of ED visits with or without ED boarding time longer than 4 h but similar propensity score to experience an ED boarding time longer than 4 h); and (2) the whole study cohort. Sensitivity analysis to unmeasured confounding and analyses in pre-specified cohorts of patients were conducted. Among 68,632 included ED visits, 17,271 (25.2%) had an ED boarding time longer than 4 h. Conditional logistic regression performed on a 10,581 pair-matched cohort, and generalized estimating equations with adjustment on confounders and stabilized propensity score-based inverse probability weighting applied on the whole cohort showed a significantly increased risk of hospital death in patients experiencing an ED boarding time longer than 4 h: odds ratio (OR) of 1.13 (95% confidence interval [95% CI] 1.05-1.22), P = 0.001; and OR of 1.12 (95% CI 1.03-1.22), P = 0.007, respectively. Sensitivity analyses showed that these findings might be robust to unmeasured confounding. Hospital LOS was significantly longer in patients exposed to ED boarding time longer than 4 h: median difference 2 days (95% CI 1-2) (P < 0.001) in matched analysis and mean difference 1.15 days (95% CI 1.02-1.28) (P < 0.001) in multivariable unmatched analysis. In this single-center propensity score-based cohort analysis, patients experiencing an ED boarding time longer than 4 h before being transferred to an in-patient bed were at increased risk of hospital death.

Lean management in a liaison psychiatry department: implementation, benefits and pitfalls

AIMS AND METHOD

To apply process mapping, a component of lean management, to a liaison psychiatry service of an emergency department. Lean management is a strategy that has been adapted to healthcare from business and production industries and aims to improve efficiency of a process. The process consisted of four stages: individual interviews with stakeholders, generation of process maps, allocation of goals and assessment of outcomes.

RESULTS

There was a significant reduction in length of stay of psychiatric patients in the emergency department (median difference: 1 h; P = 0.015). Five of the six goals were met successfully.

CLINICAL IMPLICATIONS

This article demonstrates a management intervention that successfully reduced length of stay in an emergency department. Further to the improvements in tangible (quantitative) outcomes, process mapping improved interpersonal relations between different disciplines. This paper may be used to guide similar quality improvement exercises in other areas of healthcare.

Emergency short-stay wards and boarding time in emergency departments: A propensity-score matching study

OBJECTIVES

This study aimed to validate the effectiveness of an emergency short-stay ward (ESSW) and its impact on clinical outcomes.

METHODS

This retrospective observational study was performed at an urban tertiary hospital. An ESSW has been operating in this hospital since September 2017 to reduce emergency department (ED) boarding time and only targets patients indicated for admission to the general ward from the ED. Propensity-score matching was performed for comparison with the control group. The primary outcome was ED boarding time, and the secondary outcomes were subsequent intensive care unit (ICU) admission and 30-day in-hospital mortality.

RESULTS

A total of 7461 patients were enrolled in the study; of them, 1523 patients (20.4%) were admitted to the ESSW. After propensity-score matching, there was no significant difference in the ED boarding time between the ESSW group and the control group (P = 0.237). Subsequent ICU admission was significantly less common in the ESSW group than in the control group (P < 0.001). However, the 30-day in-hospital mortality rate did not differ significantly between the two groups (P = 0.292). When the overall hospital bed occupancy ranged from 90% to 95%, the proportion of hospitalization was the highest in the ESSW group (29%). An interaction effect test using a general linear model confirmed that the ESSW served as an effect modifier with respect to bed occupancy and boarding time (P < 0.001).

CONCLUSION

An ESSW can alleviate prolonged boarding time observed with hospital bed saturation. Moreover, the ESSW is associated with a low rate of subsequent ICU admission.

The Emergency Department Trigger Tool: A Novel Approach to Screening for Quality and Safety Events

STUDY OBJECTIVE

Trigger tools improve surveillance for harm by focusing reviews on records with "triggers" whose presence increases the likelihood of an adverse event. We refine and automate a previously developed emergency department (ED) trigger tool and present record selection strategies to further optimize yield.

METHODS

We specified 97 triggers for extraction from our electronic medical record, identifying 76,894 ED visits with greater than or equal to 1 trigger. We reviewed 1,726 records with greater than or equal to 1 trigger, following a standard trigger tool review process. We validated query performance against manual review and evaluated individual triggers, retaining only those associated with adverse events in the ED. We explored 2 approaches to enhance record selection: on number of triggers present and using trigger weights derived with least absolute shrinkage and selection operator logistic regression.

RESULTS

The automated query performed well compared with manual review (sensitivity >70% for 80 triggers; specificity >92% for all). Review yielded 374 adverse events (21.6 adverse events per 100 records). Thirty triggers were associated with risk of harm in the ED. An estimated 10.3% of records with greater than 1 of these triggers would include an adverse event in the ED. Selecting only records with greater than or equal to 4 or greater than or equal to 9 triggers improves yield to 17% and 34.8%, respectively, whereas use of least absolute shrinkage and selection operator trigger weighting enhances the yield to as high as 52%.

CONCLUSION

The ED trigger tool is a promising approach to improve yield, scope, and efficiency of review for all-cause harm in emergency medicine. Beginning with a broad set of candidate triggers, we validated a computerized query that eliminates the need for manual screening for triggers and identified a refined set of triggers associated with adverse events in the ED. Review efficiency can be further enhanced with enhanced record selection.

Emergency department crowding and length of stay before and after an increased catchment area

Background

Emergency department (ED) crowding and prolonged length of stay (LOS) are associated with delays in treatment, adverse outcomes and decreased patient satisfaction. Hospital restructuring and mergers are often associated with increased ED crowding. The aim of this study was to explore ED crowding and LOS in Norway’s largest ED before and after an increased catchment area.

Methods

The catchment area of Akershus University Hospital increased by approximately 150,000 inhabitants in 2011, from 340,000 to 490,000. In this retrospective study, admissions to the ED during a six-year period, from Jan 1st 2010 to Dec 31st 2015 were included and analyzed.

Results

A total of 179,989 admissions were included (51.0% men). The highest occupancy rate was in the age group 70–79 years. Following the increase in the catchment area, the annual ED admissions increased by 8343 (40.9%) from 2010 to 2011, and peaked in 2013 (34,002). Mean LOS increased from 3:59 h in 2010 to 4:17 in 2012 (highest), and decreased to 3:45 h in 2015 after staff, capacity and organizational measures. In 2010, 37.9% of the ED patients experienced crowding, and this proportion increased to between 52.9–77.6% in 2011–2015. Crowding peaked between 4 and 5 PM.

Conclusions

LOS increased and crowding was more frequent after a major increase in the hospital’s catchment area in Norway’s largest emergency department. Even after 5 years, the LOS was higher than before the expansion, mainly because of the throughput and output components, which were not properly adapted to the changes in input.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4342-4) contains supplementary material, which is available to authorized users.

Emergency department and hospital crowding: causes, consequences, and cures

Overcrowding with associated delays in patient care is a problem faced by emergency departments (EDs) worldwide. ED overcrowding can be the result of poor ED department design and prolonged throughput due to staffing, ancillary service performance, and flow processes. As such, the problem may be addressed by process improvements within the ED. A broad body of literature demonstrates that ED overcrowding can be a function of hospital capacity rather than an ED specific issue. Lack of institutional capacity leads to boarding in the ED with resultant ED crowding. This is a problem not solvable by the ED and must be addressed as an institution-wide problem. This paper discusses the causes of ED overcrowding, provides a brief overview of the drastic consequences, and discusses possible cures that have been successfully implemented.

Multistate model of the patient flow process in the pediatric emergency department

Objectives

The main purpose of this paper was to model the process by which patients enter the ED, are seen by physicians, and discharged from the Emergency Department at Nationwide Children’s Hospital, as well as identify modifiable factors that are associated with ED lengths of stay through use of multistate modeling.

Methods

In this study, 75,591 patients admitted to the ED from March 1^st, 2016 to February 28^th, 2017 were analyzed using a multistate model of the ED process. Cox proportional hazards models with transition-specific covariates were used to model each transition in the multistate model and the Aalen-Johansen estimator was used to obtain transition probabilities and state occupation probabilities in the ED process.

Results

Acuity level, season, time of day and number of ED physicians had significant and varying associations with the six transitions in the multistate model. Race and ethnicity were significantly associated with transition to left without being seen, but not with the other transitions. Conversely, age and gender were significantly associated with registration to room and subsequent transitions in the model, though the magnitude of association was not strong.

Conclusions

The multistate model presented in this paper decomposes the overall ED length of stay into constituent transitions for modeling covariate-specific effects on each transition. This allows physicians to understand the ED process and identify which potentially modifiable covariates would have the greatest impact on reducing the waiting times in each state in the model.

Critical Review, Development, and Testing of a Taxonomy for Adverse Events and Near Misses in the Emergency Department

OBJECTIVES

An adverse event (AE) is a physical harm experienced by a patient due to health care, requiring intervention. Describing and categorizing AEs is important for quality and safety assessment and identifying areas for improvement. Safety science suggests that improvement efforts should focus on preventing and mitigating harm rather than on error, which is commonplace but infrequently leads to AEs. Most taxonomies fail to describe harm experienced by patients (e.g., hypoxia, hemorrhage, anaphylaxis), focusing instead on errors, and use categorizations that are too broad to be useful (e.g., "communication error"). We set out to create a patient-centered, emergency department (ED)-specific framework for describing AEs and near misses to advance quality and safety in the acute care setting.

METHODS

We performed a critical review of existing taxonomies of harm, evaluating their applicability to the ED. We identified and adopted a classification framework and developed a taxonomy using an iterative process categorizing approximately 600 previously identified AEs and near misses. We reviewed this taxonomy with collaborators at four medical centers, receiving feedback and providing clarification. We then disseminated a set of representative scenarios for these safety experts to categorize independently using the taxonomy. We calculated interrater reliability and performance compared to our criterion standard.

RESULTS

Our search identified candidate taxonomies for detailed review. We selected the Adventist Health Systems AE taxonomy and modified this for use in the ED, adopting a framework of categories, subcategories, and up to three modifiers to further describe events. On testing, overall reviewer agreement with the criterion standard was 92% at the category level and 88% at the subcategory level. Three of the four raters concurred in 55 of 59 scenarios (93%) and all four concurred in 46 of 59 scenarios (78%). At the subcategory level, there was complete agreement in 40 of 59 (68%) scenarios and majority agreement in 55 of 59 instances (93%). Performance of individual raters ranged from very good (88%, 52/59) to near perfect (98%, 58/59) at the main category level.

CONCLUSIONS

We developed a taxonomy of AEs and near misses for the ED, modified from an existing framework. Testing of the tool with minimal training yielded high performance and good inter-rater reliability. This taxonomy can be adapted and modified by EDs seeking to enhance their quality and safety reviews and characterize harm occurring in their EDs for quality improvement purposes.

Use of Systems Engineering to Design a Hospital Command Center

BACKGROUND

In hospitals and health systems across the country, patient flow bottlenecks delay care delivery-emergency department boarding and operating room exit holds are familiar examples. In other industries, such as oil, gas, and air traffic control, command centers proactively manage flow through complex systems.

METHODS

A systems engineering approach was used to analyze and maximize existing capacity in one health system, which led to the creation of the Judy Reitz Capacity Command Center. This article describes the key elements of this novel health system command center, which include strategic colocation of teams, automated visual displays of real-time data providing a global view, predictive analytics, standard work and rules-based protocols, and a clear chain of command and guiding tenets. Preliminary data are also shared.

RESULTS

With proactive capacity management, subcycle times decreased and allowed the health system's flagship hospital to increase occupancy from 85% to 92% while decreasing patient delays.

CONCLUSION

The command center was built with three primary goals-reducing emergency department boarding, eliminating operating room holds, and facilitating transfers in from outside facilities-but the command center infrastructure has the potential to improve hospital operations in many other areas.

Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge

BACKGROUND

Discharge delays adversely affect hospital bed availability and thus patient flow.

OBJECTIVE

We aimed to increase the percentage of early discharges (EDCs; before 11 am). We hypothesized that obtaining at least 25% EDCs would decrease emergency department (ED) and postanesthesia care unit (PACU) hospital bed wait times.

DESIGN

This study used a pre/postintervention retrospective analysis.

SETTING

All acute care units in a quaternary care academic children's hospital were included in this study.

PATIENTS

The patient sample included all discharges from the acute care units and all hospital admissions from the ED and PACU from January 1, 2014, to December 31, 2016.

INTERVENTION

A multidisciplinary team identified EDC barriers, including poor identification of EDC candidates, accountability issues, and lack of team incentives. A total of three successive interventions were implemented using Plan-Do-Check-Act (PDCA) cycles over 10 months between 2015 and 2016 addressing these barriers. Interventions included EDC identification and communication, early rounding on EDCs, and modest incentives.

MEASUREMENTS

Calendar month EDC percentage, ED (from time bed requested to the time patient left ED) and PACU (from time patient ready to leave to time patient left PACU) wait times were measured.

RESULTS

EDCs increased from an average 8.8% before the start of interventions (May 2015) to 15.8% after interventions (February 2016). Using an interrupted time series, both the jump and the slope increase were significant (3.9%, P = .02 and 0.48%, P < .01, respectively). Wait times decreased from a median of 221 to 133 minutes (P < .001) for ED and from 56 to 36 minutes per patient (P = .002) for PACU.

CONCLUSION

A multimodal intervention was associated with more EDCs and decreased PACU and ED bed wait times.

Investigating Immediate and Intermediate Patient Outcomes Following Transfer From the Acute Medicine Unit at the Western General Hospital, Edinburgh: A Prospective Cohort Study

BACKGROUND

An ageing population is placing increasing pressure on acute medical units (AMUs), necessitating frequent, and often inappropriate transfer of patients. We identified a gap in the literature, with similar studies relating to either cardiac or intensive care settings, with another, reporting frequency of movement and adverse outcomes in the elderly. The aim of this study was to ascertain whether patients admitted to the AMU and who are moved "out of hours" (22:00-06:59) experience adverse outcomes opposed to patients moved "within hours."

METHODS

Data was extracted from TrakCare-a unified, web-based healthcare information system- which facilitates real-time bed management processes. This prospective cohort study was carried out at the Western General Hospital (WGH), Edinburgh. The final cohort (n = 219) was split into two groups (out of hours vs. within hours) for statistical analysis. Specific sub-group analysis was used to supplement findings, with eight sub-groups, each defined by a 3-hr time frame around the 24-hr clock.

RESULTS

The final cohort after application of exclusion criteria was n = 219 (female: n = 114, median age = 76; male: n = 105, median age = 75). There was a significant difference in length of stay (LoS) between boarded and non-boarded patients who were: (1) moved out of hours (2) moved within hours (p = 0.003). Remainder of patient outcome results (readmission at 7 and 30 days respectively; mortality during admission, and at 7 and 30 days) were not statistically significant.

CONCLUSION

We revealed a significant difference in LoS between patients moved within and out with hours; the "out of hours" patient group-was significantly less than that of the "within" hours group.

Association between emergency department length of stay and patient outcomes: a systematic review protocol

REVIEW QUESTION

The question of this review is: what is the association between emergency department length of stay and patient outcomes?More specifically, what is the association between the length of time a patient spends in the emergency department and outcomes, including, but not limited to: mortality, omitted episodes of care (e.g. non-administration of prescribed medication), adverse events, time to treatment (e.g. time to analgesia or time to operating theater), inpatient length of stay, leave without being seen rate and patient satisfaction?

Emergency department overcrowding: Quality improvement in a Taiwan Medical Center

BACKGROUND/PURPOSE

Overcrowding of hospital emergency departments (ED) is a worldwide health problem. The Taiwan Joint Commission on Hospital Accreditation has stressed the importance of finding solutions to overcrowding, including, reducing the number of patients with >48 h stay in the ED. Moreover, the Ministry of Health and Welfare aims at transferring non-critical patients to district or regional hospitals. We report the results of our Quality Improvement Project (QIP) on ED overcrowding, especially focusing on reducing length of stay (LOS) in ED.

METHODS

For QIP, the following 3 action plans were initiated: 1) Changing the choice architecture of patients' willingness to transfer from opt-in to opt-out; 2) increasing the turnover rate of beds and daily monitoring of the number of free beds for boarding ED patients; 3) reevaluation of patients with a LOS of >32 h after the morning shift.

RESULTS

Transfer rates increased minimally after implementation of this project, but the sample size was too small to achieve statistical significance. No significant increase was observed in the number of free medical beds, but discharge rates after 12 pm decreased significantly (p < 0.001). The proportion of over 48 h LOSs decreased from 4.9% to 3.7% before and after QIP implementation, respectively (p < 0.001).

CONCLUSION

Patients with LOS of >32 h were reevaluated first. After QIP, the proportion of LOSs of >48 h dropped significantly. Changing the choice architecture may require further systemic effort and a longer observation duration. Higher-level administrators will need to formulate a more comprehensive bed management plan to speed up the turnover rate of free inpatient beds.

Using Lean Management to Reduce Emergency Department Length of Stay for Medicine Admissions

BACKGROUND

The practice of boarding admitted patients in the emergency department (ED) carries negative operational, clinical, and patient satisfaction consequences. Lean tools have been used to improve ED workflow. Interventions focused on reducing ED length of stay (LOS) for admitted patients are less explored.

OBJECTIVE

To evaluate a Lean-based initiative to reduce ED LOS for medicine admissions.

DESIGN, SETTING, PATIENTS

Prospective quality improvement initiative performed at a single university-affiliated Department of Veterans Affairs (VA) medical center from February 2013 to February 2016.

INTERVENTION

We performed a Lean-based multidisciplinary initiative beginning with a rapid process improvement workshop to evaluate current processes, identify root causes of delays, and develop countermeasures. Frontline staff developed standard work for each phase of the ED stay. Units developed a daily management system to reinforce, evaluate, and refine standard work.

MEASUREMENTS

The primary outcome was the change in ED LOS for medicine admissions pre- and postintervention. ED LOS at the intervention site was compared with other similar VA facilities as controls over the same time period using a difference-in-differences approach.

RESULTS

ED LOS for medicine admissions reduced 26.4%, from 8.7 to 6.4 hours. Difference-in-differences analysis showed that ED LOS for combined medicine and surgical admissions decreased from 6.7 to 6.0 hours (-0.7 hours, P = .003) at the intervention site compared with no change (5.6 hours, P = .2) at the control sites.

CONCLUSIONS

We utilized Lean management to significantly reduce ED LOS for medicine admissions. Specifically, the development and management of standard work were key to sustaining these results.

Ambulatory High-dose Methotrexate Administration in Pediatric Osteosarcoma Patients at a Single Institution in Argentina

BACKGROUND

The purpose of this study was to evaluate the feasibility and safety of ambulatory high-dose methotrexate (HDMTX) administration with oral hydration, alkalinization, and leucovorin rescue. HDMTX (12 g/m) was given intravenously over 4 hours after urine alkalinization. Families and patients were instructed to continue ambulatory oral hydration and alkalinization to monitor urine pH and to adjust bicarbonate according to our institution's treatment algorithm. Clinical status and MTX levels were controlled every 24 hours, and oral leucovorin dose was adjusted accordingly.

RESULTS

From April 2007 to December 2010, 150 of 447 courses of HDMTX (31.4%) were given on an outpatient basis, and 91.2% were successfully completed. The main causes of failure were poor oral tolerance (n=6) and fever (n=4). Most patients (81%) had MTX levels of <10 μmol/L 24 hours post-HDMTX; only in 1 course the levels were >50 μmol/L (50.96 μmol/L). Neutropenia grade III/IV was observed in 18.3% of the courses, grade III/IV leukopenia in 2.7%, and grade III/IV thrombocytopenia and anemia in 4.7%. Around 39% were associated with grade III/IV hepatic toxicity (asymptomatic hypertransaminasemia), grade III-IV gastrointestinal toxicity (vomiting and diarrhea) (5%), grade III-IV mucositis (4%), and none of the patients developed renal toxicity.

CONCLUSIONS

Ambulatory HDMTX administration is feasible and safe in a population with poor resources in a developing country.

The n-by-T Target Discharge Strategy for Inpatient Units

BACKGROUND

Ineffective inpatient discharge planning often causes discharge delays and upstream boarding. While an optimal discharge strategy that works across all units at a hospital is likely difficult to identify and implement, a strategy that provides a reasonable target to the discharge team appears feasible.

METHODS

We used observational and retrospective data from an inpatient trauma unit at a Level 2 trauma center in the Midwest US. Our proposed novel n-by-T strategy-discharge n patients by the Tth hour-was evaluated using a validated simulation model. Outcome measures included 2 measures: time-based (mean discharge completion and upstream boarding times) and capacity-based (increase in annual inpatient and upstream bed hours). Data from the pilot implementation of a 2-by-12 strategy at the unit was obtained and analyzed.

RESULTS

The model suggested that the 1-by-T and 2-by-T strategies could advance the mean completion times by over 1.38 and 2.72 h, respectively (for 10 AM ≤ T ≤ noon, occupancy rate = 85%); the corresponding mean boarding time reductions were nearly 11% and 15%. These strategies could increase the availability of annual inpatient and upstream bed hours by at least 2,469 and 500, respectively. At 100% occupancy rate, the hospital-favored 2-by-12 strategy reduced the mean boarding time by 26.1%. A pilot implementation of the 2-by-12 strategy at the unit corroborated with the model findings: a 1.98-h advancement in completion times (P<0.0001) and a 14.5% reduction in boarding times (P = 0.027).

CONCLUSION

Target discharge strategies, such as the n-by-T, can help substantially reduce discharge lateness and upstream boarding, especially during high unit occupancy. To sustain implementation, necessary commitment from the unit staff and physicians is vital, and may require some training.