Implications of England's Four-Hour Target for Quality of Care and Resource Use in the Emergency Department

Emergency department overcrowding and its associated factors at HARME medical emergency center in Eastern Ethiopia

Introduction

Emergency department (ED) overcrowding has become a significant concern as it can lead to compromised patient care in emergency settings. Various tools have been used to evaluate overcrowding in ED. However, there is a lack of data regarding this issue in resource-limited countries, including Ethiopia. This study aimed to validate NEDOCS, assess level of ED overcrowding and identify associated factors at HARME Medical Emergency Center, located in Hiwot Fana Comprehensive Specialized Hospital, Harar, Ethiopia.

Methods

A cross-sectional study was conducted at the HARME Medical Emergency Center, Hiwot Fana Comprehensive Specialized Hospital, involving a total of 899 patients during 120 sampling intervals. The area under the receiver operating characteristic curves (AUC) was calculated to evaluate the agreement between objective and subjective assessments of ED overcrowding. A multivariable logistic regression analysis was employed to identify factors associated with ED overcrowding and statistically significant association was declared using 95 % confidence level and a p-value < 0.05.

Results

The interrater agreement showed a strong correlation with a Cohen's kappa (κ) of 0.80. The National Emergency Department Overcrowding Study Score demonstrated a strong association with subjective assessments from residents and case team nurses, with an AUC of 0.81 and 0.79, respectively. According to residents' perceptions, ED were considered overcrowded 65.8 % of the time. Factors significantly associated with ED overcrowding included waiting time for triage (AOR: 2.24; 95 % CI: 1.54-3.27), working time (AOR: 2.23; 95 % CI: 1.52-3.26), length of stay (AOR: 2.40; 95 % CI: 1.27-4.54), saturation level (AOR: 2.35; 95 % CI: 1.31-4.20), chronic illness (AOR: 2.19; 95 % CI: 1.37-3.53), and abnormal pulse rate (AOR: 1.52; 95 % CI: 1.06-2.16).

Conclusion

The study revealed that ED were overcrowded approximately two-thirds of the time.

Effect of removing the 4-hour access standard in the ED: a retrospective observational study

BACKGROUND

Time-based targets are used to improve patient flow and quality of care within EDs. While previous research often highlighted the benefits of these targets, some studies found negative consequences of their implementation. We study the consequences of removing the 4-hour access standard.

METHODS

We conducted a before and after, retrospective, observational study using anonymised, routinely collected, patient-level data from a single English NHS ED between April 2018 and December 2019. The primary outcomes of interest were the proportion of admitted patients, that is, the admission rate, the length of stay in the ED and ambulance handover times. We used interrupted time series models to study and estimate the impact of removing the 4-hour access standard.

RESULTS

A total of 169 916 attendances were included in the analysis. The interrupted time series models for the average daily admission rate indicate a drop from an estimated 35% to an estimated 31% (95% CI -4.1 to -3.9). This drop is only statistically significant for Majors (Ambulant) patients (from an estimated 38.3% to an estimated 31.4%) and, particularly, for short-stay admissions (from an estimated 18.1% to an estimated 12.8%). The models also show an increase in the average daily length of stay for admitted patients from an estimated 316 min to an estimated 387 min (95% CI 33.5 to 108.9), and an increase in the average daily length of stay for discharged patients from an estimated 222 min to an estimated 262 min (95% CI 6.9 to 40.4).

CONCLUSION

Lifting the 4-hour access standard reporting was associated with a drop in short-stay admissions to the hospital. However, it was also associated with an increase in the average length of stay in the ED. Our study also suggests that the removal of the 4-hour standard does not impact all patients equally. While certain patient groups such as those Majors (Ambulant) patients with less severe issues might have benefited from the removal of the 4-hour access standard by avoiding short-stay hospital admissions, the average length of stay in the ED seemed to have increased across all groups, particularly for older and admitted patients.

Acute assessment services for patient flow assistance in hospital emergency departments

BACKGROUND

Emergency departments (EDs) are facing serious and significant issues in the delivery of effective and efficient care to patients. Acute assessment services have been implemented at many hospitals internationally to assist in maintaining patient flow for identified groups of patients attending the ED. Identifying the risks and benefits, and optimal configurations of these services may be beneficial to those wishing to utilise an acute assessment service to improve patient flow.

OBJECTIVES

To assess the effects of acute assessment services on patient flow following attendance at a hospital ED.

SEARCH METHODS

We searched MEDLINE, CENTRAL, Embase and two trials registers on 24 September 2022 to identify studies. No restrictions were imposed on publication year, publication type, or publication language.

SELECTION CRITERIA

Studies eligible for inclusion were randomised trials and cluster-randomised trials with at least two intervention and two control sites. Participants were adults (as defined by study authors) receiving care either in the ED or the acute assessment service, where both were based in the hospital setting. The comparison was hospital-based acute assessment services with usual, ED-only care. The outcomes of this review were mortality at time point closest to 30 days, length of stay in the service (in minutes), and waiting time to see a doctor (in minutes).

DATA COLLECTION AND ANALYSIS

We followed the standard procedures of Cochrane Effective Practice and Organisation of Care for this review (https://epoc.cochrane.org/resources).

MAIN RESULTS

We identified a total of 5754 records in the search. Following assessment of 3609 de-duplicated records, none were found to be eligible for inclusion in this review.

AUTHORS' CONCLUSIONS

At present there are no randomised controlled trials exploring the effects of acute assessment services on patient flow in hospital-based emergency departments compared to usual, ED-only care.

Factors Affecting the Length of Stay in the Emergency Department in Psychiatric Emergency Patients in the COVID-19 Pandemic Context

To reduce overcrowding in emergency departments (ED), which is a serious international problem, it is important to reduce the length of ED stay (ED LOS) of emergency patients. In particular, due to the COVID 19 pandemic, psychiatric emergency patients spent much longer in ED. This study was conducted to identify the characteristics of psychiatric emergency patients who visited the ED during the COVID-19 pandemic and to identify factors affecting ED LOS. This retrospective study was conducted on adult patients aged 19 years or older who visited a psychiatric emergency center operated by an ED from 1 May 2020 to 31 April 2021 because of the COVID-19 pandemic. In this study, the average ED LOS of psychiatric emergency patients was 7.8 h. Factors affecting ED LOS for over 12 h were isolation (OR = 2.39, CI = 1.409-4.052), unaccompanied police officers (OR = 2.106, CI = 1.338-3.316), night-time visits (OR = 2.127, CI = 1.357-3.332), use of sedatives (OR = 1.671, CI = 1.030-2.713), and restraints (OR = 1.968, CI = 1.172-4.895). The ED LOS of psychiatric emergency patients is longer than that of general emergency patients, and a long ED LOS causes ED overcrowding. To reduce the ED LOS of psychiatric emergency patients, they must be accompanied by a police officer when visiting the ED, and the treatment process should be reorganized so that a psychiatrist can promptly intervene. Furthermore, it is necessary to reorganize the isolation guidelines and admission criteria for mental emergency patients.

Effect of a Boarding Restriction Protocol on Emergency Department Crowding

PURPOSE

Access block due to the lack of hospital beds causes crowding of emergency departments (ED). We initiated the "boarding restriction protocol" that limits the time of stay in the ED for patients awaiting hospitalization to 24 hours from arrival. The purpose of this study was to determine the effect of the boarding restriction protocol on ED crowding.

MATERIALS AND METHODS

The primary outcome was ED occupancy rate, which was calculated as the ratio of the number of occupying patients to the total number of ED beds. Time factors, such as length of stay (LOS), treatment time, and boarding time, were investigated.

RESULTS

The mean of the ED occupancy rate decreased from 1.532±0.432 prior to implementation of the protocol to 1.273±0.353 after (p<0.001). According to time series analysis, the absolute effect caused by the protocol was -0.189 (-0.277 to -0.110) (p=0.001). The proportion of patients with LOS exceeding 24 hours decreased from 7.6% to 4.0% (p<0.001). Among admitted patients, ED LOS decreased from 770.7 (421.4-1587.1) minutes to 630.2 (398.0-1156.8) minutes (p<0.001); treatment time increased from 319.6 (198.5-482.8) minutes to 344.7 (213.4-519.5) minutes (p<0.001); and boarding time decreased from 298.9 (109.5-1149.0) minutes to 204.1 (98.7-545.7) minutes (p<0.001). In pre-protocol period, boarding patients accumulated in the ED during the weekdays and resolved on Friday, but this pattern was alleviated in post-period.

CONCLUSION

The boarding restriction protocol was effective in alleviating ED crowding by reducing the accumulation of boarding patients in the ED during the weekdays.

Understanding Emergency Department Healthcare Professionals' Perspectives of Caring for Individuals in Suicidal Crisis: A Qualitative Study

Help seekers regularly present to Emergency Departments (EDs) when in suicidal crisis for intervention to ensure their immediate safety, which may assist in reducing future attempts. The emergency health workforce have unique insights that can inform suicide prevention efforts during this critical junction in an individual's experience with suicide. This paper explores the treatment and care delivery experiences of 54 health professionals working in EDs within one of the LifeSpan suicide prevention trial sites in Australia. Data was collected via six focus groups and six interviews. Thematic analysis resulted in three themes: (1) physicality of the emergency department, (2) juggling it all-the bureaucracy, practicalities, and human approach to care, and (3) impact of care delivery on ED staff. Findings highlight the need for workplace training that incorporates responding to the uncertainty of suicidal crisis, to compliment the solution-focused medical model of care. Broader policy changes to the ED system are also considered to ensure better outcomes for health professionals and help-seekers alike.

Effects of staff grade, overcrowding and presentations on emergency department performance: A regression model

OBJECTIVE

To examine the effect of staffing levels by experience of medical officers and overcrowding on ED key performance indicators (KPIs).

METHODS

Presentations to Nepean ED from 6 May to 3 November 2019 were examined. Staff were designated either Fellows of the Australasian College for Emergency Medicine (FACEMs), non-FACEM senior decision-makers (SDMs), non-senior decision-makers greater than 2 years postgraduate (non-SDMs) and junior medical officers up to 2 years postgraduate (JMOs). The number of admitted patients boarded in the ED waiting for a ward bed at 8 am was used as a marker for overcrowding. Multivariable regression analysis was performed using staffing levels, number of admissions at 8 am and total presentations as the independent variables and various ED KPIs as the dependent variables.

RESULTS

FACEM and SDM had a significant effect on most ED KPIs, with the effect of FACEM consistently larger than the effect of SDM. There was minimal effect on performance by non-SDM and JMO staffing. There was significant effect of overcrowding as measured by the number of admitted patients in ED at 8 am on most ED KPIs. Almost no variables had an effect on Emergency Treatment Performance (4-h target) for admitted patients, suggesting poor performance was caused by factors outside of the ED.

CONCLUSION

Increasing numbers of FACEM and non-FACEM SDM, but not junior staff, and a reduction in overcrowding as measured by the number of admitted patients boarded in the ED at 8 am, were associated with improvements in the ED performance.

Review article: Has the implementation of time-based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature

Time-based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000-2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty-three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short-stay admissions were excluded, and when pre-target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re-presented to EDs. Short-stay admissions and re-admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians.

The 4-hour target in the emergency department, in-hospital mortality, and length of hospitalization: A single center-retrospective study

BACKGROUND

The four-hour (4 h') rule in the emergency department (ED) is a performance-based measure introduced with the objective to improve the quality of care. We evaluated the association between time in the ED with in-hospital mortality and hospital length of stay (LOS).

METHODS

This was a retrospective study performed in one public hospital with over 100,000 ED referrals per year. Hospitalizations from the ED during 2017 were analyzed. We defined time in the ED as either: until a decision was made (DED); or total time in the ED (TED). In-hospital mortality and LOS were evaluated for patients with DED or TED within and beyond 4 h'.

RESULTS

Compared to patients with TED or DED within 4 h', in-hospital mortality did not increase in patients with TED beyond 4 h' (2.8% vs. 3.1%, non-significant), or DED beyond 4 h' (2.1% vs. 3.2%, p < 0.001). LOS did increase in patients with either DED or TED beyond 4 h' (p < 0.001). In-hospital mortality increased with increasing DED-TED intervals for patients hospitalized in the internal medicine departments: 3.7% (0-1 h'), 5.1% (1-2 h'), 5.7% (2-3 h'), and 7.1% (>3 h') (p < 0.001).

CONCLUSIONS

In-hospital mortality was not associated with time in the ED beyond 4 h'. LOS, however, was increased in this group of patients. Decreased LOS observed in patients with time in the ED within 4 h', does not support patients' risk as a contributing factor leading to higher trends in mortality observed in this patient group. In-hospital mortality was associated with an increase in DED-TED intervals in patients hospitalized in the internal medicine departments.

Staff perceptions of how changes occur in an emergency department: a qualitative study

Introduction

Changes in healthcare organisations often incur significant financial costs and disrupt of normal operations. The objective of this research was to explore staff perceptions of changes at a university teaching hospital in the UK.

Methods

Grounded theory methodology was used to perform a secondary analysis of 41 interview transcripts from participants consisting of 20 physicians, 13 nurses, 2 support workers and 6 managers involved in paediatric emergency care at the hospital.

Results

Four major themes identified from the analysis were types of changes, change readiness, change triggers and challenges to implementing changes. Both planned and emergent changes can occur simultaneously, and emergency department staff are ready to manage them although external pressures seem to be the main trigger for changes, emergent changes appear to occur as initiatives to improve performance or improve services. Emergent changes at a systemic level have an inclusive planning, implementation and evaluation process. They have to be implemented at minimal cost and show the value of changes.

Discussion and conclusion

These results suggest that emergent changes that were to be implemented at a system level had higher scrutiny of their value and to occur with zero or minimum financial cost. Planned changes implemented by senior management as top–down process should have similar procedures and scrutiny to emergent changes arising from staff, to ensure value for cost. Policy makers and senior managers should encourage and evaluate group or system level changes that arise as a bottom–up process and assess associated financial cost.

Long emergency department length of stay: A concept analysis

INTRODUCTION

Emergency Department (ED) Length of stay (LOS) has been associated with poor patient outcomes, which has led to the implementation of time targets designed to keep EDLOS below a specific limit. The cut-offs defining long EDLOS varies across settings and seem to be arbitrarily chosen. This study aimed to clarify the meaning of long EDLOS.

METHODS

A concept analysis using the Walker and Avant approach was conducted. It included a literature search aiming to identify all uses of the concept, resulting in a set of defining attributes and a way of measuring the concept empirically.

RESULTS

Long EDLOS was primarily used as proxy for other phenomena, e.g. boarding or crowding. The definitions had cut-offs ranging between 4 and 48 h. The attributes defining long EDLOS was waiting, a crowded ED environment and an inefficient organization.

DISCUSSION

Time targets are probably more suitable when directed towards and tailored for specific sub-groups of the ED population.

Do health care professionals' perceptions help to measure the degree of overcrowding in the emergency department? A pilot study in an Italian University hospital

BACKGROUND

Overcrowding in emergency departments (EDs) is internationally recognized as one of the greatest challenges to healthcare provision. Numerous studies have highlighted the ill-effects of overcrowding, including increased length of stay, mortality and cost per admission. This study measures overcrowding in EDs through health care professionals' perceptions of it, comparing the results with the NEDOCS score, an objectively validated measurement tool and describing meaningful tools and strategies used to manage ED overcrowding.

METHODS

This single-centre prospective, observational, pilot study was conducted from February 19th to March 7th, 2018 at the ED in the University Hospital of Ferrara, Italy to measure the agreement of the NEDOCS, comparing objective scores with healthcare professionals' perception of overcrowding, using the kappa statistic assessing linear weights according to Cohen's method. The tools and strategies used to manage ED overcrowding are described.

RESULTS

Seventy-two healthcare professionals (66.1% of 109 eligible subjects) were included in the analyses. The study obtained a total of 262 surveys from 23 ED physicians (31.9%), 31 nurses (43.1%) and 18 nursing assistants (25.0%) and a total of 262 NEDOCS scores. The agreement between the NEDOCS and the subjective scales was poor (k = 0.381, 95% CI 0.313-0.450).

CONCLUSIONS

The subjective health care professionals' perceptions did not provide an adequate real-time measure of the current demands and capacity of the ED. A more objective measure is needed to make quality decisions about health care professional needs and the ability to manage patients to ensure the provision of proper care.

Decreasing triage time: effects of implementing a step-wise ESI algorithm in an EHR

Objectives

To determine if adapting a widely-used triage scale into a computerized algorithm in an electronic health record (EHR) shortens emergency department (ED) triage time.

Design

Before-and-after quasi-experimental study.

Setting

Urban, tertiary care hospital ED.

Participants

Consecutive adult patient visits between July 2011 and June 2013.

Intervention

A step-wise algorithm, based on the Emergency Severity Index (ESI-5) was programmed into the triage module of a commercial EHR.

Main Outcome Measures

Duration of triage (triage interval) for all patients and change in percentage of high acuity patients (ESI 1 and 2) completing triage within 15 min, 12 months before-and-after implementation of the algorithm. Multivariable analysis adjusted for confounders; interrupted time series demonstrated effects over time. Secondary outcomes examined quality metrics and patient flow.

Results

About 32 546 patient visits before and 33 032 after the intervention were included. Post-intervention patients were slightly older, census was higher and admission rate slightly increased. Median triage interval was 5.92 min (interquartile ranges, IQR 4.2-8.73) before and 2.8 min (IQR 1.88-4.23) after the intervention (P < 0.001). Adjusted mean triage interval decreased 3.4 min (95% CI: -3.6, -3.2). The proportion of high acuity patients completing triage within 15 min increased from 63.9% (95% CI 62.5, 65.2%) to 75.0% (95% CI 73.8, 76.1). Monthly time series demonstrated immediate and sustained improvement following the intervention. Return visits within 72 h and door-to-balloon time were unchanged. Total length of stay was similar.

Conclusion

The computerized triage scale improved speed of triage, allowing more high acuity patients to be seen within recommended timeframes, without notable impact on quality.

Emergency general surgery and trauma: Outcomes from the first consultant-led service in Singapore

INTRODUCTION

There is a significant burden on public health systems from emergency surgical and trauma (ESAT) patients. In Western countries, the response has been to separate acute and elective surgery with the creation of a new sub-specialty: acute care surgery. Dedicated acute units have shown improvements in efficiency and clinical outcomes for patients. The aim of this study was to assess the results of the first such unit in Singapore.

MATERIALS AND METHODS

A retrospective analysis was performed of a 12-month period of acute admissions between May 2014 and April 2015, with comparison of 6-months before and after the creation of the ESAT service. The ESAT service was a consultant led dedicated team managing all daily acute and trauma patients. Demographic, efficiency and clinical outcome key performance indicators were compared.

RESULTS

There were 2527 acute admissions split between the two time periods. The ESAT service (N=1279) managed soft tissue infections (257, 20%), appendicitis (199, 16%) and biliary disease (175, 14%) most commonly. The most common of the 573 procedures performed were incision and drainage (242, 42%), appendicectomy (188, 33%) and laparotomy (84, 16%). Clinical outcome during the ESAT service included reduction in overall mean length of stay (4.5d to 3.5d, P<0.01) and mortality (24/1248 (1.9%) to 11/1279 (0.9%), P=0.03). Efficiency gains in theatre booking time, ED surgical review and overall costs were also noted.

CONCLUSION

The creation of an ESAT service has led to improved efficiency of care with no worsening of clinical outcomes for acute general surgical and trauma patients.

Who breaches the four-hour emergency department wait time target? A retrospective analysis of 374,000 emergency department attendances between 2008 and 2013 at a type 1 emergency department in England

Background

The four-hour target is a key hospital emergency department performance indicator in England and one that drives the physical and organisational design of the ED. Some studies have identified time of presentation as a key factor affecting waiting times. Few studies have investigated other determinants of breaching the four-hour target. Therefore, our objective was to describe patterns of emergency department breaches of the four-hour wait time target and identify patients at highest risk of breaching.

Methods

This was a retrospective cohort study of a large type 1 Emergency department at an NHS teaching hospital in Oxford, England. We analysed anonymised individual level patient data for 378,873 emergency department attendances, representing all attendances between April 2008 and April 2013. We examined patient characteristics and emergency department presentation circumstances associated with the highest likelihood of breaching the four-hour wait time target.

Results

We used 374,459 complete cases for analysis. In total, 8.3% of all patients breached the four-hour wait time target. The main determinants of patients breaching the four-hour wait time target were hour of arrival to the ED, day of the week, patient age, ED referral source, and the types of investigations patients receive (p < 0.01 for all associations). Patients most likely to breach the four-hour target were older, presented at night, presented on Monday, received multiple types of investigation in the emergency department, and were not self-referred (p < 0.01 for all associations). Patients attending from October to February had a higher odds of breaching compared to those attending from March to September (OR 1.63, 95% CI 1.59 to 1.66).

Conclusions

There are a number of independent patient and circumstantial factors associated with the probability of breaching the four-hour ED wait time target including patient age, ED referral source, the types of investigations patients receive, as well as the hour, day, and month of arrival to the ED. Efforts to reduce the number of breaches could explore late-evening/overnight staffing, access to diagnostic tests, rapid discharge facilities, and early assessment and input on diagnostic and management strategies from a senior practitioner.

Deconstructing the 4-h rule for access to emergency care and putting patients first

Evidence suggests improved outcomes for patients requiring emergency admission to hospital are associated with improved emergency department (ED) efficiency and lower transit times. Factors preventing timely transfers of emergency patients to in-patient beds across the ED-in-patient interface are major causes for ED crowding, for which several remedial strategies are possible, including parallel processing of probable admissions, direct-to-ward admissions and single-point medical registrars for receiving and processing all referrals directed at specific speciality units. Dynamic measures of ED overcrowding that focus on boarding time are more indicative of EDs with exit block involving the ED-in-patient interface than static proxy measures such as hospital bed occupancy and numbers of ED presentations. The ideal 4-h compliance rate for all ED presentations is around 80%, based on a large retrospective study of more than 18million presentations to EDs of 59 Australian hospitals over 4 years, which demonstrated a highly significant linear reduction in risk-adjusted in-patient mortality for admitted patients as the compliance rate for all patients rose to 83%, but was not confirmed beyond this rate. Closely monitoring patient outcomes for emergency admissions in addition to compliance with time-based access targets is strongly recommended in ensuring reforms aimed at decongesting EDs do not compromise the quality and safety of patient care.

Validation of the RETRIEVE (REverse TRIage EVEnts) Criteria for Same Day Return of Non-ST Elevation Acute Coronary Syndrome Patients to Referring Non-PCI Centres

BACKGROUND

There are continuing bed constraints in percutaneous coronary intervention centres (PCI) so efficient patient triage from referral hospitals is pivotal. To evaluate a strategy of PCI centre (PCIC) bed-sparing we examined return of patients to referral hospitals screened by the RETRIEVE (REverse TRIage EVEnts) criteria and validated its use as a tool for screening suitability for same day transfer of non-ST-elevation acute coronary syndrome (NSTEACS) patients post PCI to their referring non-PCI centre (NPCIC).

METHODS

From May 2008 to May 2011, 433 NSTEACS patients were prospectively screened for suitability for same day transfer back to the referring hospital at the completion of PCI. Of these patients, 212 were excluded from same day transfer using the RETRIEVE criteria and 221 patients met the RETRIEVE criteria and were transferred back to their NPCIC.

RESULTS

Over the study period, 218 patients (98.6%) had no major adverse events. The primary endpoint (death, arrhythmia, myocardial infarction, major bleeding event, cerebrovascular accident, major vascular site complication, or requirement for return to the PCIC) was seen in only three transferred patients (1.4%).

CONCLUSIONS

The RETRIEVE criteria can be used successfully to identify NSTEACS patients suitable for transfer back to NPCIC following PCI. Same day transfer to a NPCIC using the RETRIEVE criteria was associated with very low rates of major complications or repeat transfer and appears to be as safe as routine overnight observation in a PCIC.

Do Reduced Hospital Mortality Rates Lead to Increased Utilization of Inpatient Emergency Care? A Population-Based Cohort Study

OBJECTIVES

To measure the impact of the improvement in hospital survival rates on patients' subsequent utilization of unplanned (emergency) admissions.

DATA SOURCES/STUDY SETTING

Unplanned admissions occurring in all acute hospitals of the National Health Service in England between 2000 and 2009, including 286,027 hip fractures, 375,880 AMI, 387,761 strokes, and 9,966,246 any cause admissions.

STUDY DESIGN

Population-based retrospective cohort study. Unplanned admissions experienced by patients within 28 days, 1 year, and 2 years of discharge from the index admission are modeled as a function of hospital risk-adjusted survival rates using patient-level probit and negative binomial models. Identification is also supported by an instrumental variable approach and placebo test.

PRINCIPAL FINDINGS

The improvement in hospital survival rates that occurred between 2000 and 2009 explains 37.3 percent of the total increment in unplanned admissions observed over the same period. One extra patient surviving increases the expected number of subsequent admissions occurring within 1 year from discharge by 1.9 admissions for every 100 index admissions (0.019 per admission, 95% CI, 0.016-0.022). Similar results in hip fracture (0.006[0.004-0.007]), AMI (0.006[0.04-0.007]), and stroke (0.004(0.003-0.005)).

CONCLUSIONS

The success of hospitals in improving survival from unplanned admissions can be an important contributory factor to the increase in subsequent admissions.

A qualitative study exploring the factors influencing admission to hospital from the emergency department

OBJECTIVE

The number of emergency admissions to hospital in England and Wales has risen sharply in recent years and is a matter of concern to clinicians, policy makers and patients alike. However, the factors that influence this decision are poorly understood. We aimed to ascertain how non-clinical factors can affect hospital admission rates.

METHOD

We conducted semistructured interviews with 21 participants from three acute hospital trusts. Participants included 11 emergency department (ED) doctors, 3 ED nurses, 3 managers and 4 inpatient doctors. A range of seniority was represented among these roles. Interview questions were developed from key themes identified in a theoretical framework developed by the authors to explain admission decision-making. Interviews were recorded, transcribed and analysed by two independent researchers using framework analysis.

FINDINGS

Departmental factors such as busyness, time of day and levels of senior support were identified as non-clinical influences on a decision to admit rather than discharge patients. The 4-hour waiting time target, while overall seen as positive, was described as influencing decisions around patient admission, independent of clinical need. Factors external to the hospital such as a patient's social support and community follow-up were universally considered powerful influences on admission. Lastly, the culture within the ED was described as having a strong influence (either negatively or positively) on the decision to admit patients.

CONCLUSION

Multiple factors were identified which go some way to explaining marked variation in admission rates observed between different EDs. Many of these factors require further inquiry through quantitative research in order to understand their influence further.

A Systematic Review of the Impact of Healthcare Reforms on Access to Emergency Department and Elective Surgery Services: 1994-2014

This systematic review sought to identify whether health care reforms led to improvement in the emergency department (ED) length of stay (LOS) and elective surgery (ES) access in Australia, Canada, New Zealand, and the United Kingdom. The review was registered in the PROSPERO database (CRD42015016343), and nine databases were searched for peer-reviewed, English-language reports published between 1994 and 2014. We also searched relevant "grey" literature and websites. Included studies were checked for cited and citing papers. Primary studies corresponding to national and provincial ED and ES reforms in the four countries were considered. Only studies from Australia and the United Kingdom were eventually included, as no studies from the other two countries met the inclusion criteria. The reviewers involved in the study extracted the data independently using standardized forms. Studies were assessed for quality, and a narrative synthesis approach was taken to analyze the extracted data. The introduction of health care reforms in the form of time-based ED and ES targets led to improvement in ED LOS and ES access. However, the introduction of targets resulted in unintended consequences, such as increased pressure on clinicians and, in certain instances, manipulation of performance data.

Can hospital dashboards provide visibility of information from bedside to board? A case study approach

Purpose

The purpose of this paper is to analyse hospital dashboards’ visibility of information at different management levels to improve quality and performance in an acute general hospital.

Design/methodology/approach

Data were generated via 21 semi-structured interviews across different management levels.

Findings

All management levels had greater visibility of information, could make informed decisions, and registered performance improvement. Specifically, waiting time improved, however since introduction of hospital dashboards was work-in-progress at time of study, managers could not record improvement in terms of cost reductions, clinical effectiveness, patient safety and patient satisfaction. Different managerial levels had different visibility with top management having the greatest.

Research limitations/implications

In single case studies, where only one context is used, the findings cannot be reproduced in different contexts; even though most of the results could be matched with the current literature.

Practical implications

The need to have balanced key performance indicators that take into account other facets of improvements, apart from time, has been emphasised. Furthermore, if middle and departmental managers have greater visibility, this would allow them to work towards a strategic fit between the departments that they manage with the rest of the hospital.

Originality/value

There is scant literature regarding performance dashboards’ enhancement of visibility of information at different management levels. Furthermore, according to the authors’ knowledge, no other paper has tried to identify and discuss the different levels of information, which should be visible from bedside to board namely to management, clinicians and public.

Effects of a hospital-wide intervention on emergency department crowding and quality: A prospective study

OBJECTIVE

The objective of this study was to determine the impact of a management-supported, multimodal, hospital-wide intervention on ED crowding and quality measures.

METHODS

This is a prospective descriptive study of the first 20 weeks of the intervention, with 3 years of historical controls. The study was conducted in a 600 bed adult/paediatric tertiary hospital with 80 000 ED presentations annually. ED information system data were collected on all presentations in matched 20 week periods. Multiple interventions included ED Navigator role, ED Medical Staff teaming, corporate focus with key performance indicators and dashboards, appointment of a Director of Operations, Long Length of Stay Committee and reorganisation of the flow (bed management) unit. Process outcomes were 4 h performance as a proportion of all patients and mean daily length of crowding with more than 10 inpatients awaiting beds expressed as a time. Quality outcomes were proportions of patients who did not wait and who re-presented within 72 h.

RESULTS

There was a 9.1% increase in presentations and a 22.6% decrease in mean ED occupancy over the previous year. The 4 h performance improved from 56.1% (95% confidence interval [CI] 55.5-56.7) to 68.8% (95% CI 68.3-69.3) and daily crowding with more than 10 inpatients improved from 6:34 (95% CI 5:32-7:37) to 0:29 (95% CI 0:15-0:42). Did not wait improved significantly from 5.1 to 3.0% and rate of representation did not change.

CONCLUSION

This prospective study shows significant improvement in ED flow without compromise in quality measures from a hospital-wide intervention requiring minimal additional resources. Further research is required on sustainability and patient outcomes beyond the ED.

Occupational stress in the ED: a systematic literature review

INTRODUCTION

Occupational stress is a major modern health and safety challenges. While the ED is known to be a high-pressure environment, the specific organisational stressors which affect ED staff have not been established.

METHODS

We conducted a systematic review of literature examining the sources of organisational stress in the ED, their link to adverse health outcomes and interventions designed to address them. A narrative review of contextual factors that may contribute to occupational stress was also performed. All articles written in English, French or Spanish were eligible for conclusion. Study quality was graded using a modified version of the Newcastle-Ottawa Scale.

RESULTS

Twenty-five full-text articles were eligible for inclusion in our systematic review. Most were of moderate quality, with two low-quality and two high-quality studies, respectively. While high demand and low job control were commonly featured, other studies demonstrated the role of insufficient support at work, effort-reward imbalance and organisational injustice in the development of adverse health and occupational outcomes. We found only one intervention in a peer-reviewed journal evaluating a stress reduction programme in ED staff.

CONCLUSIONS

Our review provides a guide to developing interventions that target the origins of stress in the ED. It suggests that those which reduce demand and increase workers' control over their job, improve managerial support, establish better working relationships and make workers' feel more valued for their efforts could be beneficial. We have detailed examples of successful interventions from other fields which may be applicable to this setting.

Do delays in radiology lead to breaches in the 4-hour rule?

AIM

To assess trends in medical imaging requests before and after the 4-hour rule commenced and to assess the imaging time component of emergency department (ED) length of stay (LOS).

MATERIALS AND METHODS

Retrospective analysis of ED patients and imaging requests 1 year prior to and 3 years after implementation of the 4-hour rule (April to December for 2011-2014) was performed at a single adult tertiary referral Level 1 trauma hospital with Level 6 ED. Logistic regression was used to evaluate trends in the number of ED patient presentations, patient triage categories, and imaging requests for these patients. The imaging component of the total ED LOS was compared for patients who met the 4-hour target and patients who did not.

RESULTS

Compared to 2011 (before the 4-hour rule), ED presentations increased 4.74% in 2012, 12.7% in 2013, 21.28% in 2014 (p<0.01). Total imaging requests increased 23.05% in 2012, 48.04% in 2013, 60.77% in 2014 (p<0.01). For patients breaching the 4-hour rule, the mean time before radiology request was 2.4-2.8 hours; mean time from imaging request to completion was 1.2-1.3 hours; mean time from imaging completion to discharge from ED was the longest component of ED LOS (4.9-5.9 hours).

CONCLUSIONS

There has been a significant increase in imaging requests, with a trend towards more CT and less radiography requests. Imaging requests for patients who breached the 4-hour target were made on average 2.4-2.8 hours after triage and average time after imaging in itself, exceeded 4 hours. Imaging is not likely a causative factor for patients breaching the 4-hour target.

A review of inpatient ward location and the relationship to Medical Emergency Team calls

OBJECTIVE

To identify the relationship between in-hospital location and patient outcomes as measured by Medical Emergency Team calls.

STUDY DESIGN

A narrative systematic review of the literature.

DATA SOURCES

A systematic search of the literature was conducted in October 2014 using the electronic databases: Embase, Cochrane, Medline, CINAHL, Science Direct and Google Scholar for the most recent literature from 1997 to 2014.

INCLUSION CRITERIA

Non-randomised study designs such as case control or cohort studies were eligible. Articles were selected independently by two researchers using a predetermined selection criterion.

DATA SYNTHESIS

The screening process removed manuscripts that did not meet the inclusion criteria resulting in an empty review with one manuscript meeting most of the criteria for inclusion. The protocol was revised to a narrative synthesis including a broader scope of studies. The search strategy was expanded and modified to include manuscripts of any study design that comprise both inlier and outlier patients. Two manuscripts were selected for the narrative synthesis.

CONCLUSION

Two recently published studies investigated the incidence of MET calls for outlier patients, and whilst MET calls were increased in outlier hospital patients, definitive conclusions associated with patient outcomes cannot be made at this time due to paucity of studies.

Is a national time target for emergency department stay associated with changes in the quality of care for acute asthma? A multicentre pre-intervention post-intervention study

OBJECTIVE

There is debate whether targets for ED length of stay introduced to reduce ED overcrowding are helpful or harmful, as focus on a process target may divert attention from clinical care. Our objective was to investigate the effect of a national ED target in Aotearoa New Zealand on the recommended care for acute asthma as this is known to suffer in overcrowded departments.

METHODS

We conducted a retrospective chart review study across four sites from 2006 to 2012 (target introduced mid 2009). The primary outcome was time to steroids in the ED. The secondary outcomes were other aspects of asthma care in ED. We used general linear models or logistic regression as appropriate to assess care before and after the target.

RESULTS

Among the 570 (of 1270 randomly selected cases) eligible for analysis, no difference was demonstrated in time to steroids: least square mean (95% CI) = 58.1 (49-67.5) min before and 50.4 (42.9-55.8) min after the target (P = 0.15). More patients received steroids in ED after the target, OR (95% CI) = 2.1 (1.2-4.3). No differences were demonstrated in those receiving steroid prescriptions or re-presentations: OR (95% CI) = 1.3 (0.9-1.96) and 1.1 (0.5-2.3), respectively. Changes in pre-target and post-target ED and hospital length of stay varied between hospitals.

CONCLUSION

Introduction of the target was not associated with a change in times to steroids in ED, although more patients received steroids in ED indicating closer adherence to recommended practice.

The safety of emergency medicine

The patient safety movement has been active for over a decade, but the issue of patient safety in emergency care and the emergency department (ED) has only recently been brought into the forefront. The ED environment has traditionally been considered unsafe, but there is little data to support this assertion. This paper reviews the literature on patient safety and highlights the challenges associated with using the current evidence base to inform practice due to the variability in methods of measuring safety. Studies looking at safety in the ED report low rates for adverse events ranging from 3.6 to 32.6 events per 1000 attendances. The wide variation in reported rates on adverse events reflects the significant differences in methods of reporting and classifying safety incidents and harm between departments; standardisation in the ED context is urgently required to allow comparisons to be made between departments and to quantify the impact of specific interventions. We outline the key factors in emergency care which may hinder the provision of safer care and consider solutions which have evolved or been proposed to identify and mitigate against harm. Interventions such as team training, telephone follow-up, ED pharmacist interventions and rounding, all show some evidence of improving safety in the ED. We further highlight the need for a collaborative whole system approach as almost half of safety incidents in the ED are attributable to external factors, particularly those related to information flow, crowding, demand and boarding.

Solving the worldwide emergency department crowding problem - what can we learn from an Israeli ED?

ED crowding is a prevalent and important issue facing hospitals in Israel and around the world, including North and South America, Europe, Australia, Asia and Africa. ED crowding is associated with poorer quality of care and poorer health outcomes, along with extended waits for care. Crowding is caused by a periodic mismatch between the supply of ED and hospital resources and the demand for patient care. In a recent article in the Israel Journal of Health Policy Research, Bashkin et al. present an Ishikawa diagram describing several factors related to longer length of stay (LOS), and higher levels of ED crowding, including management, process, environmental, human factors, and resource issues. Several solutions exist to reduce ED crowding, which involve addressing several of the issues identified by Bashkin et al. This includes reducing the demand for and variation in care, and better matching the supply of resources to demands in care in real time. However, what is needed to reduce crowding is an institutional imperative from senior leadership, implemented by engaged ED and hospital leadership with multi-disciplinary cross-unit collaboration, sufficient resources to implement effective interventions, access to data, and a sustained commitment over time. This may move the culture of a hospital to facilitate improved flow within and across units and ultimately improve quality and safety over the long-term.

The Association Between Emergency Department Crowding and the Disposition of Patients With Transient Ischemic Attack or Minor Stroke

BACKGROUND

Emergency department (ED) crowding has been associated with adverse events, including short-term death and hospitalization among discharged patients. The mechanisms are poorly understood, but may include altered physician decision-making about ED discharge of higher-risk patients. One example is patients with transient ischemic attack (TIA) and minor stroke, who are at high risk of subsequent stroke. While hospitalization is frequently recommended, little consensus exists on which patients require admission.

OBJECTIVES

The authors sought to determine the association of ED crowding with the disposition of patients with minor stroke or TIA.

METHODS

This was a retrospective cohort study of prospectively collected data from the Registry of the Canadian Stroke Network at 12 EDs in Ontario, Canada, between 2003 and 2008, linked to administrative health databases. A hierarchical logistic regression model was used to determine the association between crowding at the time the patient was seen in the ED (defined as mean ED length of stay) and patient disposition (admission/discharge), after adjusting for patient and hospital-level variables.

RESULTS

The study cohort included 9,759 patients (4,607 with TIA and 5,152 with minor stroke); 49.5% were discharged from the ED. The mean (±SD) age of study patients was 70.78 (±13.40) years, with 52.9% being male, 37.3% arriving by emergency medical services, and 92.3% triaged as emergent or urgent. Greater severity of ED crowding was associated with a lower likelihood of discharge, regardless of ED size.

CONCLUSIONS

These results suggest that crowding may influence clinical decision-making in the disposition of patients with TIA or minor stroke and that, as crowding worsens, the likelihood of hospitalization increases.

Organisational Factors Induce Prolonged Emergency Department Length of Stay in Elderly Patients--A Retrospective Cohort Study

Study objective

To assess the association of patient and organisational factors with emergency department length of stay (ED-LOS) in elderly ED patients (226565 years old) and in younger patients (<65 years old).

Methods

A retrospective cohort study of internal medicine patients visiting the emergency department between September 1^st 2010 and August 31^st 2011 was performed. All emergency department visits by internal medicine patients 226565 years old and a random sample of internal medicine patients <65 years old were included. Organisational factors were defined as non-medical factors. ED-LOS is defined as the time between ED arrival and ED discharge or admission. Prolonged ED-LOS is defined as ≥75^th percentile of ED-LOS in the study population, which was 208 minutes.

Results

Data on 1782 emergency department visits by elderly patients and 597 emergency department visits by younger patients were analysed. Prolonged ED-LOS in elderly patients was associated with three organisational factors: >1 consultation during the emergency department visit (odds ratio (OR) 3.2, 95% confidence interval (CI) 2.3–4.3), a higher number of diagnostic tests (OR 1.2, 95% CI 1.16–1.33) and evaluation by a medical student or non-trainee resident compared with a medical specialist (OR 4.2, 95% CI 2.0–8.8 and OR 2.3, 95% CI 1.4–3.9). In younger patients, prolonged ED-LOS was associated with >1 consultation (OR 2.6, 95% CI 1.4–4.6). Factors associated with shorter ED-LOS were arrival during nights or weekends as well as a high urgency level in elderly patients and self-referral in younger patients.

Conclusion

Organisational factors, such as a higher number of consultations and tests in the emergency department and a lower seniority of the physician, were the main aspects associated with prolonged ED-LOS in elderly patients. Optimisation of the organisation and coordination of emergency care is important to accommodate the needs of the continuously growing number of elderly patients in a better way.

What has the 4-hour access standard achieved?

Few performance management measures create as much heat and debate as the 4-hour target for emergency departments. This article critically reviews the history, evidence and effectiveness of the 4-hour standard for patients attending emergency departments.

Innovations to reduce demand and crowding in emergency care; a review study

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.

Evaluation of an emergency department lean process improvement program to reduce length of stay

STUDY OBJECTIVE

In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care.

METHODS

We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted.

RESULTS

In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (-14 minutes [95% confidence interval {CI} -47 to 20]) but decreased after wave 2 (-87 [95% CI -108 to -66]) and wave 3 (-33 [95% CI -50 to -17]); median ED length of stay decreased after wave 1 (-18 [95% CI -24 to -12]), wave 2 (-23 [95% CI -27 to -19]), and wave 3 (-15 [95% CI -18 to -12]). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 [95% CI -0.2 to 33]) and increases in wave 1 (23 [95% CI 0.9 to 45]) and wave 3 (31 [95% CI 10 to 51]), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone.

CONCLUSION

Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation.

National targets, process transformation and local consequences in an NHS emergency department (ED): a qualitative study

BACKGROUND

In the attempt to reduce waiting times in emergency departments, various national health services have used benchmarking and the optimisation of patient flows. The aim of this study was to examine staff attitudes and experience of providing emergency care following the introduction of a 4 hour wait target, focusing on clinical, organisational and spatial issues.

METHODS

A qualitative research design was used and semi-structured interviews were conducted with 28 clinical, managerial and administrative staff members working in an inner-city emergency department. A thematic analysis method was employed and NVivo 8 qualitative data analysis software was used to code and manage the emerging themes.

RESULTS

The wait target came to regulate the individual and collective timescales of healthcare work. It has compartmentalised the previous unitary network of emergency department clinicians and their workspace. It has also speeded up clinical performance and patient throughput. It has disturbed professional hierarchies and facilitated the development of new professional roles. A new clinical information system complemented these reconfigurations by supporting advanced patient tracking, better awareness of time, and continuous, real-time management of emergency department staff. The interviewees had concerns that this target-oriented way of working forces them to have a less personal relationship with their patients.

CONCLUSIONS

The imposition of a wait-target in response to a perceived "crisis" of patients' dissatisfaction led to the development of a new and sophisticated way of working in the emergency department, but with deep and unintended consequences. We show that there is a dynamic interrelation of the social and the technical in the complex environment of the ED. While the 4 hour wait target raised the profile of the emergency department in the hospital, the added pressure on clinicians has caused some concerns over the future of their relationships with their patients and colleagues. To improve the sustainability of such sudden changes in policy direction, it is important to address clinicians' experience and satisfaction.

Consultant experience as a determinant of outcomes in emergency medical admissions

BACKGROUND

There are little data on the experiential learning of certified consultant specialists and outcomes in acute medicine. We have examined the 30-day in-hospital mortality and hospital length of stay (LOS) in relation to practice duration, using a database of emergency admissions.

METHODS

All emergency admissions (60,864 episodes in 35,168 patients) over eleven years (January 2002 to December 2012) were evaluated. Consultant staff were categorised by duration of clinical practice as <15 years, 15-20 years, >20≤25 years and >25 years. We used a stepwise logistic regression model to predict 30-day in-hospital death, adjusting risk estimates for major predictor variables. Marginal analysis used adjusted predictions to test for interactions of key predictors, while controlling for other variables.

RESULTS

Thirty-day in-hospital mortality correlated with time in clinical practice; decreasing from 8.9% and 9.1% with <15 and 15-20 years to 7.7% for each of the categories of >20≤25 years and >25 years. There was a progressive shortening of LOS with extent of clinical practice - from a median 5.0 days (IQR 1.8, 10.3) for consultants within 15 years of registration to 4.6 (IQR 1.7-8.9; p<0.05) at >20≤25 years and 4.4 (IQR 1.7-9.0; p<0.01) with >25 years. Duration of clinical practice predicted mortality in the univariable analysis - odds ratio (OR) 0.85 (95% CI: 0.78, 0.91; p<0.001); when adjusted in a multivariable model, it remained independently predictive--OR 0.87 (95% CI: 0.79, 0.96; p<0.001) for 30-day in-hospital mortality.

CONCLUSION

Certified specialists appear to continue with experiential learning with evidence of improved outcome after 20 years in clinical practice.

Real time shift reporting by emergency physicians predicts overall ED performance

OBJECTIVE

To investigate factors associated with emergency physician perception of the shift and to determine whether these perceptions were predictors of overall daily emergency department (ED) performance indicators.

METHODS

This was an observational study conducted at an inner city ED in New South Wales. Shift reports completed by the emergency physician in charge at clinical handover times between February and July 2012 were included. Variables collected by the shift report included (1) total number of patients in ED, (2) number of patients in the ED with length of stay (LOS) greater than 4 h, (3) number of admitted patients, (4) number of patients waiting to be seen by a doctor and (5) medical staffing levels. Outcomes of interest for this study were shift perception scores (1=very poor to 5=very good) and daily ED performance measures. Performance measures were the proportion of patients admitted or discharged from ED within 4 h (National Emergency Access Target, NEAT) and the percentage of inpatient admissions leaving ED within 8 h of ED arrival time.

RESULTS

The number of patients in ED with LOS >4 h (OR 0.83, 95% CI 0.79 to 0.87, p value <0.001) and number of patients waiting to be seen (OR 0.92, 95% CI 0.88 to 0.95, p value <0.001) were the factors most strongly associated with shift perception score. After adjustment, the mean NEAT performance improved 6% for each incremental increase in average shift perception score (β=0.06 95% CI 0.04 to 0.07, p<0.001).

CONCLUSIONS

Shift reports and shift perceptions by emergency physicians may be used to predict overall ED performance.