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Sato N, Takaku R, Chiba T, Higashi H, Shiga T. Impact of increased reimbursement for ambulance transportation on hospital acceptance in Japan: a difference-in-difference study. BMJ Open 2023; 13:e071523. [PMID: 37491094 PMCID: PMC10373704 DOI: 10.1136/bmjopen-2022-071523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
OBJECTIVE Emergency medical services (EMS) often face difficulties in finding accepting hospitals in Japan. The universal medical insurance system in Japan increased the reimbursement for ambulance transportation acceptance at night, and on Sundays and holidays from 1 April 2016. This study investigated the effect of the reimbursement increase on the number of EMS calls, and transportation time from arrival at the scene to arrival at the hospital. DESIGN A difference-in-difference study. The treatment group consisted of people who called an ambulance at night while the control group consisted of people who called an ambulance during the daytime. SETTING The national ambulance records of the Fire and Disaster Management Agency in Japan from 1 April 2015 to 31 December 2016. PARTICIPANTS 7 625 463 ambulance dispatches were eligible for inclusion. PRIMARY AND SECONDARY OUTCOME MEASURES The changes in EMS calls, transportation time and the number of ambulance transports per 1000 population in one month in a comparison of daytime and night-time transport. RESULTS The treatment effect (night-time vs daytime) on the number of EMS calls was -0.013 (95% CI, -0.023 to -0.004), which was significant. The transportation time decreased slightly by 0.080 min (95% CI, -0.157 to -0.004). No impact was observed on the number of ambulance transports per 1000 population per month (0.00; 95% CI, -0.008 to 0.002). CONCLUSION An increase in reimbursement for ambulance transportation acceptance was associated with a decrease in the number of EMS calls. Further strategies for decreasing the number of EMS calls are needed to avoid delays in the treatment of emergency patients with critical illness.
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Affiliation(s)
- Nobuhiro Sato
- Department of Emergency and Critical Care Medicine, Niigata City General Hospital, Niigata, Niigata, Japan
| | - Reo Takaku
- Graduate School of Economics, Hitotsubashi University, Kunitachi, Tokyo, Japan
| | - Takuyo Chiba
- Department of Emergency Medicine, International University of Health and Welfare, Narita, Chiba, Japan
| | - Hidenori Higashi
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Wakayama Medical Center, Wakayama, Wakayama, Japan
| | - Takashi Shiga
- Department of Emergency Medicine, International University of Health and Welfare, Narita, Chiba, Japan
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Savioli G, Ceresa IF, Gri N, Bavestrello Piccini G, Longhitano Y, Zanza C, Piccioni A, Esposito C, Ricevuti G, Bressan MA. Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions. J Pers Med 2022; 12:279. [PMID: 35207769 PMCID: PMC8877301 DOI: 10.3390/jpm12020279] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 12/14/2022] Open
Abstract
It is certain and established that overcrowding represents one of the main problems that has been affecting global health and the functioning of the healthcare system in the last decades, and this is especially true for the emergency department (ED). Since 1980, overcrowding has been identified as one of the main factors limiting correct, timely, and efficient hospital care. The more recent COVID-19 pandemic contributed to the accentuation of this phenomenon, which was already well known and of international interest. Considering what would appear to be a trivial definition of overcrowding, it may seem simple for the reader to hypothesize solutions for what seems to be one of the most avoidable problems affecting the hospital system. However, proposing solutions to overcrowding, as well as their implementation, cannot be separated from a correct and precise definition of the issue, which must consider the main causes and aggravating factors. In light of the need of finding solutions that can put an end to hospital overcrowding, this review aims, through a review of the literature, to summarize the triggering factors, as well as the possible solutions that can be proposed.
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Affiliation(s)
- Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy; (G.S.); (M.A.B.)
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | | | - Nicole Gri
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy; (N.G.); (G.B.P.)
| | - Gaia Bavestrello Piccini
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy; (N.G.); (G.B.P.)
- School of Master in Emergency Medicine, Université Libre de Bruxelles, 1050 Brussels, Belgium
| | - Yaroslava Longhitano
- Foundation “Ospedale Alba-Bra Onlus”, Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital, 12060 Verduno, Italy;
- Research Training Innovation Infrastructure, Research and Innovation Department, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Christian Zanza
- Foundation “Ospedale Alba-Bra Onlus”, Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital, 12060 Verduno, Italy;
- Research Training Innovation Infrastructure, Research and Innovation Department, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy;
| | - Andrea Piccioni
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy;
| | - Ciro Esposito
- Unit of Nephrology and Dialysis, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Giovanni Ricevuti
- School of Pharmacy, Department of Drug Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Maria Antonietta Bressan
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy; (G.S.); (M.A.B.)
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Noel G, Maghoo A, Piarroux J, Viudes G, Minodier P, Gentile S. Impact of Viral Seasonal Outbreaks on Crowding and Health Care Quality in Pediatric Emergency Departments. Pediatr Emerg Care 2021; 37:e1239-e1243. [PMID: 32058424 DOI: 10.1097/pec.0000000000001985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT In pediatric emergency departments (PEDs), seasonal viral outbreaks are believed to be associated with an increase of workload, but no quantification of this impact has been published. A retrospective cross-sectional study aimed to measure this impact on crowding and health care quality in PED. The study was performed in 1 PED for 3 years. Visits related to bronchiolitis, influenza, and gastroenteritis were defined using discharge diagnoses. The daily epidemic load (DEL) was the proportion of visits related to one of these diagnoses. The daily mean of 8 crowding indicators (selected in a published Delphi study) was used. A total of 93,976 children were admitted (bronchiolitis, 2253; influenza, 1277; gastroenteritis, 7678). The mean DEL was 10.4% (maximum, 33.6%). The correlation between the DEL and each indicator was significant. The correlation was stronger for bronchiolitis (Pearson R from 0.171 for number of hospitalization to 0.358 for length of stay). Between the first and fourth quartiles of the DEL, a significant increase, between 50% (patients left without being seen) and 8% (patient physician ratio), of all the indicators was observed. In conclusion, seasonal viral outbreaks have a strong impact on crowding and quality of care. The evolution of "patients left without being seen" between the first and fourth quartiles of DEL could be used as an indicator reflecting the capacity of adaptation of an emergency department to outbreaks.
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Affiliation(s)
| | | | | | - Gilles Viudes
- From the Observatoire Régional des Urgences PACA, Hyères
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4
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Fundamentals of care in the emergency room - An ethnographic observational study. Int Emerg Nurs 2021; 58:101050. [PMID: 34520964 DOI: 10.1016/j.ienj.2021.101050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 04/11/2021] [Accepted: 07/02/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is a strong biomedical focus within emergency care. However, while failure to meet patients' fundamental care needs has severe consequences for the patient, there is limited knowledge on how nursing care is provided in emergency rooms and the related implications for patients. AIM This study aims to explore how fundamental care needs of critically ill patients are met in emergency rooms. METHODS Non-participant observations at an emergency department in Sweden included 108 observations and field notes (150 h). Data were analysed using descriptive statistics. RESULTS Observations showed that registered nurses (RN) identified patients' fundamental care needs and provided nursing care. However, the RNs' focus on the patient decreased over time. When the RN communicated with the patient, the patients' physical needs were met to a greater extent. The organisational structure and physical environment of emergency rooms limit RNs' ability to meet patients' fundamental care needs. CONCLUSION Not all patients had their fundamental care needs optimally met. This study highlights the importance of RNs working in an integrated manner; an RN working bedside is crucial for establishing a patient-nurse relationship to meet the patient's physical, psychosocial, and relational needs.
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Woolridge D, Homme J(J, Amato CS, Pauze D, Rose E, Valente J, Ishimine P, Friesen P, Baldwin S, Joseph M, Saidinejad M, Perina D, Goodloe JM. Optimizing the workforce: a proposal to improve regionalization of care and emergency preparedness by broader integration of pediatric emergency physicians certified by the American Board of Pediatrics. J Am Coll Emerg Physicians Open 2020; 1:1520-1526. [PMID: 33392559 PMCID: PMC7771807 DOI: 10.1002/emp2.12114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/09/2020] [Accepted: 05/05/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Emergency care in the United States faces notable challenges with regard to children. In some jurisdictions, available resources are not sufficient to meet local needs. Physicians with specialty training in pediatric emergency care are largely concentrated in children's medical centers within larger urban areas. Rural emergency facilities, which are more likely to face ongoing staffing shortages in all specialties, are particularly deficient in pediatric emergency medicine (PEM) physicians. This paper addresses challenges in distribution of pediatric emergency care specialists into suburban and rural health care facilities, and proposes potential local and regional solutions to improve pediatric emergency care capabilities as well as to enhance disaster response in children. OBJECTIVES The American College of Emergency Physicians (ACEP) committee on PEM generated the objective to study and explore methods and strategies to address current challenges and shortcomings in the distribution of pediatric emergency physicians and to develop recommendations to improve access to emergency pediatric expertise in all care settings. A sub-committee was formed to generate a written report followed by full committee input. The content was reviewed by the ACEP Board of Directors. DISCUSSION Pediatric emergency physicians are certified either by the American Board of Emergency Medicine or the American Board of Pediatrics (ABP) depending on whether their training occurred through the emergency medicine or a pediatric residency program. ABP-certified PEM that account for the majority of PEM physicians, remain largely concentrated in urban tertiary pediatric care centers, primarily children's hospitals. By contrast to the resources, the majority of pediatric patients receive emergency care in emergency departments (EDs) outside this setting. The goal of our recommendations is to help regionalize PEM expertise, allowing sharing of such resources with facilities that have traditionally not had access to PEM expertise. Financial or low number of pediatric cases likely contributed to lack of PEM resources in suburban and rural EDs, although a significant factor for lack of access to ABP-certified PEM physicians may be local privilege and practice restrictions. Expanding the scope of practice for ABP-certified PEM physicians beyond traditionally assigned arbitrary age limits to include selective adult patients has the potential to alleviate credentialing barriers and offset the financial and volume concerns while enhancing preparedness efforts, resource utilization, and access to specialized pediatric emergency care. CONCLUSION Recognition that the training of ABP-certified PEM physicians allows for these individuals to safely care for selective adult patients with common disease patterns that extend beyond traditionally assigned arbitrary pediatric age limits has the potential to improve resource dissemination and utilization, allowing for greater access to pediatric emergency physicians in currently underserved settings.
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Affiliation(s)
- Dale Woolridge
- Department of Emergency MedicineUniversity of ArizonaTucsonArizonaUSA
| | - James (Jim) Homme
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | | | - Denis Pauze
- Department of Emergency MedicineAlbany Medical CenterAlbanyNew YorkUSA
| | - Emily Rose
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
- Department of Emergency MedicineLos Angeles County and USC Medical CenterLos AngelesCaliforniaUSA
| | - Jon Valente
- Departments of Emergency Medicine and PediatricsAlpert Medical School of Brown UniversityRhode Island Hospital and Hasbro Children's HospitalProvidenceRhode IslandUSA
| | - Paul Ishimine
- Departments of Emergency Medicine and PediatricsUniversity of CaliforniaSan Diego School of MedicineSan DiegoCaliforniaUSA
| | - Phillip Friesen
- Department of PediatricsThe University of Texas at Austin Dell Medical SchoolAustinTexasUSA
| | - Steve Baldwin
- Pediatric Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Madeline Joseph
- Pediatric Emergency MedicineDepartment of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFloridaUSA
| | - Mohsen Saidinejad
- Pediatrics and Emergency MedicineDavid Geffen School of Medicine at UCLATorranceCaliforniaUSA
- Health Services and Outcomes ResearchThe Los Angeles Biomedical Research InstituteTorranceCaliforniaUSA
- Department of Emergency MedicineHarbor UCLA Medical CenterTorranceCaliforniaUSA
| | - Debra Perina
- Emergency MedicineUniversity of VirginiaCharlottesvilleVirginiaUSA
| | - Jeffrey M. Goodloe
- Department of Emergency MedicineUniversity of Oklahoma School of Community MedicineTulsaOklahomaUSA
- OU Schusterman CenterTulsaOklahomaUSA
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6
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Behr M, Le Borgne P, Baicry F, Lavoignet CE, Berard L, Tuzin N, Oberlin M, Bilbault P. Crise nationale des urgences : le résultat d'un déséquilibre croissant entre offre et demande de soins ? Rev Med Interne 2020; 41:684-692. [DOI: 10.1016/j.revmed.2020.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/14/2020] [Accepted: 05/21/2020] [Indexed: 11/28/2022]
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7
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Oberlin M, Andrès E, Behr M, Kepka S, Le Borgne P, Bilbault P. [Emergency overcrowding and hospital organization: Causes and solutions]. Rev Med Interne 2020; 41:693-699. [PMID: 32861534 DOI: 10.1016/j.revmed.2020.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 04/14/2020] [Accepted: 05/05/2020] [Indexed: 10/23/2022]
Abstract
Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.
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Affiliation(s)
- M Oberlin
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France.
| | - E Andrès
- Service de Médecine Interne, Diabète et Maladies métaboliques, Hôpitaux Universitaires de Strasbourg, Clinique Médicale B - HUS, 1 porte de l'Hôpital, 67000 Strasbourg, France; Unité INSERM EA 3072 « Mitochondrie, Stress oxydant et Protection musculaire », Faculté de Médecine - Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg, France
| | - M Behr
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France
| | - S Kepka
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France
| | - P Le Borgne
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France; Unité INSERM UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), Faculté de Médeine - Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg, France
| | - P Bilbault
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France; Unité INSERM UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), Faculté de Médeine - Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg, France
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8
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Abstract
Emergency department crowding is a multifactorial issue with causes intrinsic to the emergency department and to the health care system. Understanding that the causes of emergency department crowding span this continuum allows for a more accurate analysis of its effects and a more global consideration of potential solutions. Within the emergency department, boarding of inpatients is the most appreciable effect of hospital-wide crowding, and leads to further emergency department crowding. We explore the concept of emergency department crowding, and its causes, effects, and potential strategies to overcome this problem.
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Affiliation(s)
- James F Kenny
- Milstein Adult Emergency Department, NewYork-Presbyterian Hospital, Department of Emergency Medicine, Columbia University Irving Medical Center, 622 West 168th Street, Suite VC2-260, New York, NY 10032, USA.
| | - Betty C Chang
- Milstein Adult Emergency Department, NewYork-Presbyterian Hospital, Department of Emergency Medicine, Columbia University Irving Medical Center, 622 West 168th Street, Suite VC2-260, New York, NY 10032, USA
| | - Keith C Hemmert
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Ground Floor Ravdin, Philadelphia PA 19104, USA
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9
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Okafor NG, Doshi PB, Miller SK, McCarthy JJ, Hoot NR, Darger BF, Benitez RC, Chathampally YG. Voluntary Medical Incident Reporting Tool to Improve Physician Reporting of Medical Errors in an Emergency Department. West J Emerg Med 2015; 16:1073-8. [PMID: 26759657 PMCID: PMC4703179 DOI: 10.5811/westjem.2015.8.27390] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/30/2015] [Accepted: 08/06/2015] [Indexed: 11/23/2022] Open
Abstract
Introduction Medical errors are frequently under-reported, yet their appropriate analysis, coupled with remediation, is essential for continuous quality improvement. The emergency department (ED) is recognized as a complex and chaotic environment prone to errors. In this paper, we describe the design and implementation of a web-based ED-specific incident reporting system using an iterative process. Methods A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety. Results The utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012. This is an increase in rate of reported events from 0.07% of all ED visits to 0.44% of all ED visits. In 2012, faculty reported 60% of all incidents, while residents and midlevel providers reported 24% and 16% respectively. The most commonly reported incidents were delays in care and management concerns. Conclusion Error reporting frequency can be dramatically improved by using a web-based, user-friendly, voluntary, and non-punitive reporting system.
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Affiliation(s)
- Nnaemeka G Okafor
- University of Texas Health Science Center, Department of Emergency Medicine, Houston, Texas
| | - Pratik B Doshi
- University of Texas Health Science Center, Department of Emergency Medicine, Houston, Texas
| | - Sara K Miller
- University of Texas Health Science Center, Department of Emergency Medicine, Houston, Texas
| | - James J McCarthy
- University of Texas Health Science Center, Department of Emergency Medicine, Houston, Texas
| | - Nathan R Hoot
- University of Texas Health Science Center, Department of Emergency Medicine, Houston, Texas
| | - Bryan F Darger
- University of Texas Health Science Center, Department of Emergency Medicine, Houston, Texas
| | - Roberto C Benitez
- University of Texas Health Science Center, Department of Emergency Medicine, Houston, Texas
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Gabayan GZ, Derose SF, Chiu VY, Yiu SC, Sarkisian CA, Jones JP, Sun BC. Emergency Department Crowding and Outcomes After Emergency Department Discharge. Ann Emerg Med 2015; 66:483-492.e5. [PMID: 26003004 PMCID: PMC5270644 DOI: 10.1016/j.annemergmed.2015.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 03/31/2015] [Accepted: 04/02/2015] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE We assess whether a panel of emergency department (ED) crowding measures, including 2 reported by the Centers for Medicare & Medicaid Services (CMS), is associated with inpatient admission and death within 7 days of ED discharge. METHODS We conducted a retrospective cohort study of ED discharges, using data from an integrated health system for 2008 to 2010. We assessed patient transit-level (n=3) and ED system-level (n=6) measures of crowding, using multivariable logistic regression models. The outcome measures were inpatient admission or death within 7 days of ED discharge. We defined a clinically important association by assessing the relative risk ratio and 95% confidence interval (CI) difference and also compared risks at the 99th percentile and median value of each measure. RESULTS The study cohort contained a total of 625,096 visits to 12 EDs. There were 16,957 (2.7%) admissions and 328 (0.05%) deaths within 7 days. Only 2 measures, both of which were patient transit measures, were associated with the outcome. Compared with a median evaluation time of 2.2 hours, the evaluation time of 10.8 hours (99th percentile) was associated with a relative risk of 3.9 (95% CI 3.7 to 4.1) of an admission. Compared with a median ED length of stay (a CMS measure) of 2.8 hours, the 99th percentile ED length of stay of 11.6 hours was associated with a relative risk of 3.5 (95% CI 3.3 to 3.7) of admission. No system measure of ED crowding was associated with outcomes. CONCLUSION Our findings suggest that ED length of stay is a proxy for unmeasured differences in case mix and challenge the validity of the CMS metric as a safety measure for discharged patients.
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Affiliation(s)
- Gelareh Z Gabayan
- Department of Medicine, University of California, and the Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA.
| | - Stephen F Derose
- Kasier Permanente Southern California, Department of Research and Evaluation, Pasadena, CA
| | - Vicki Y Chiu
- Kasier Permanente Southern California, Department of Research and Evaluation, Pasadena, CA
| | - Sau C Yiu
- Kasier Permanente Southern California, Department of Research and Evaluation, Pasadena, CA
| | - Catherine A Sarkisian
- Department of Medicine, University of California, and the Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
| | - Jason P Jones
- Kasier Permanente Southern California, Department of Research and Evaluation, Pasadena, CA
| | - Benjamin C Sun
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
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11
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McCoy JV, Gale AR, Sunderram J, Ohman-Strickland PA, Eisenstein RM. Reduced Hospital Duration of Stay Associated with Revised Emergency Department-Intensive Care Unit Admission Policy: A before and after Study. J Emerg Med 2015; 49:893-900. [PMID: 26409680 DOI: 10.1016/j.jemermed.2015.06.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 04/22/2015] [Accepted: 06/25/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency department (ED) and hospital crowding adversely impacts patient care. Although reduction methods for duration of stay in the ED have been explored, few focus on medical intensive care unit (MICU) patients. OBJECTIVE To quantify duration of stay or mortality changes associated with a policy intervention that changed the role of an MICU resident to "screen" and write MICU admission orders in the ED to instead meet the patient and write orders in the MICU if there was an available bed. The intervention moved "screening" bed management-appropriateness discussions to the MICU attending or fellow level. METHODS We performed a retrospective before and after study at an urban, level 1 trauma center of adults admitted to the MICU from the ED during the first 6 months in 2009 before, and the corresponding 6 months in 2010, after the intervention. We collected demographics, ED, MICU, and hospital duration of stay, duration of mechanical ventilation, Acute Physiology and Chronic Health Evaluation (APACHE) scores, and mortality from electronic medical records. Linear models compared duration of stay differences; logistic regression compared in-hospital mortality. T-tests assessed APACHE score changes before and after the policy change. Analyses were adjusted for age and sex. RESULTS We included 498 patients, average age 66 years (±18), 52% male. Hospital duration of stay decreased 18% from 6.8 to 5.6 days (unadjusted p = 0.029). MICU duration of stay decreased from 3.5 to 3.3 days (unadjusted p = 0.34) and ED duration of stay from arrival to physical transfer decreased 40 min (375 to 324 min; unadjusted p = 0.006). Mortality and APACHE scores were unchanged. CONCLUSIONS A streamlined admission intervention from the ED to the MICU was associated with decreased ED and hospital duration of stay without altering mortality.
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Affiliation(s)
- Jonathan V McCoy
- Department of Emergency Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Alexa R Gale
- Department of Emergency Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jag Sunderram
- Division of Pulmonary and Critical Care Medicine, Director Medical Intensive Care Unit, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Robert M Eisenstein
- Department of Emergency Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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12
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The rise in K2 use with varying clinical symptoms and the potential for ED crowding. Am J Emerg Med 2015; 33:582. [DOI: 10.1016/j.ajem.2014.12.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 12/12/2014] [Accepted: 12/12/2014] [Indexed: 11/24/2022] Open
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13
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Kulla M, Baacke M, Schöpke T, Walcher F, Ballaschk A, Röhrig R, Ahlbrandt J, Helm M, Lampl L, Bernhard M, Brammen D. Kerndatensatz „Notaufnahme“ der DIVI. Notf Rett Med 2014. [DOI: 10.1007/s10049-014-1860-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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14
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Millard WB. Medical Supermarkets, Preferably Without Whole Foods' Prices. Ann Emerg Med 2014; 63:13A-20A. [DOI: 10.1016/j.annemergmed.2014.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Blom MC, Jonsson F, Landin-Olsson M, Ivarsson K. The probability of patients being admitted from the emergency department is negatively correlated to in-hospital bed occupancy - a registry study. Int J Emerg Med 2014; 7:8. [PMID: 24499660 PMCID: PMC3917619 DOI: 10.1186/1865-1380-7-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 01/10/2014] [Indexed: 11/18/2022] Open
Abstract
Background The association between emergency department (ED) overcrowding and poor patient outcomes is well described, with recent work suggesting that the phenomenon causes delays in time-sensitive interventions, such as resuscitation. Even though most researchers agree on the fact that admitted patients boarding in the ED is a major contributing factor to ED overcrowding, little work explicitly addresses whether in-hospital occupancy is associated to the probability of patients being admitted from the ED. The objective of the present study is to investigate whether such an association exists. Methods Retrospective analysis of data on all ED visits to Helsingborg General Hospital in southern Sweden between January 1, 2011, and December 31, 2012, was undertaken. The fraction of admitted patients was calculated separately for strata of in-hospital occupancy <95%, 95–100%, 100–105%, and >105%. Multivariate models were constructed in an attempt to take confounding factors, e.g., presenting complaints, age, referral status, triage priority, and sex into account. Subgroup analysis was performed for each specialty unit within the ED. Results Overall, 118,668 visits were included. The total admitted fraction was 30.9%. For levels of in-hospital occupancy <95%, 95–100%, 100–105%, and >105% the admitted fractions were 31.5%, 30.9%, 29.9%, and 28.7%, respectively. After taking confounding factors into account, the odds ratio for admission were 0.88 (CI 0.84–0.93, P >0.001) for occupancy level 95–100%, 0.82 (CI 0.78–0.87, P >0.001) for occupancy level 100–105%, and 0.74 (CI 0.67–0.81, P >0.001) for occupancy level >105%, relative to the odds ratio for admission at occupancy level <95%. A similar pattern was observed upon subgroup analysis. Conclusions In-hospital occupancy was significantly associated with a decreased odds ratio for admission in the study population. One interpretation is that patients who would benefit from inpatient care instead received suboptimal care in outpatient settings at times of high in-hospital occupancy. A second interpretation is that physicians admit patients who could be managed safely in the outpatient setting, in times of good in-hospital bed availability. Physicians thereby expose patients to healthcare-associated infections and other hazards, in addition to consuming resources better needed by others.
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Affiliation(s)
- Mathias C Blom
- IKVL, Lund University, IKVL/Sektion I-II, Akutmedicin, Hs 32, EA-blocket, plan 2, Universitetssjukhuset, 221 85 Lund, Sweden.
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Arya R, Wei G, McCoy JV, Crane J, Ohman-Strickland P, Eisenstein RM. Decreasing length of stay in the emergency department with a split emergency severity index 3 patient flow model. Acad Emerg Med 2013; 20:1171-9. [PMID: 24238321 DOI: 10.1111/acem.12249] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 06/12/2013] [Accepted: 06/20/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES There has been a steady increase in emergency department (ED) patient volume and wait times. The desire to maintain or decrease costs while improving throughput requires novel approaches to patient flow. The break-out session "Interventions to Improve the Timeliness of Emergency Care" at the June 2011 Academic Emergency Medicine consensus conference "Interventions to Assure Quality in the Crowded Emergency Department" posed the challenge for more research of the split Emergency Severity Index (ESI) 3 patient flow model. A split ESI 3 patient flow model divides high-variability ESI 3 patients from low-variability ESI 3 patients. The study objective was to determine the effect of implementing a split ESI 3 flow model has on patient length of stay (LOS) for discharged patients. METHODS This was a retrospective chart review at an urban academic ED seeing over 70,000 adult patients a year. Cases consisted of adults who presented from 9 a.m. to 11 p.m. from June 1, 2011, to December 31, 2011, and were discharged. Controls were patients who presented on the same times and days, but in 2010. Visit descriptors included age, race, sex, ESI score, and first diagnosis. The first diagnosis was coded based on methods used by the Agency for Healthcare Research and Quality to codify International Classification of Diseases, ninth version, into disease groups. Linear models compared log-transformed LOS for cases and controls. A front-end ED redesign involved creating guidelines to split ESI 3 patients into low and high variability, a hybrid sort/triage registered nurse, an intake area consisting of an internal results waiting room, and a treatment area for patients after initial assessment. The previous low-acuity area (ESI 4s and 5s) began to see low-variability ESI 3 patients as well. This was done without additional beds. The intake area was staffed with an attending emergency physician (EP), a physician assistant (PA), three nurses, two medical technicians, and a scribe. RESULTS There was a 5.9% decrease, from 2.58 to 2.43 hours, in the geometric mean of LOS for discharged patients from 2010 to 2011 (95% confidence interval CI = 4.5% to 7.2%; 2010, n = 20,215; 2011, n = 20,653). Abdominal pain was the most common diagnostic grouping (2010, n = 2,484; 2011, n = 2,464) with a reduction in LOS of 12.9%, from 4.37 to 3.8 hours (95% CI = 10.3% to 15.3%). CONCLUSIONS A split ESI 3 patient flow model improves door-to-discharge LOS in the ED.
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Affiliation(s)
- Rajiv Arya
- Department of Emergency Medicine; UMDNJ/ Robert Wood Johnson Medical School; New Brunswick NJ
| | - Grant Wei
- Department of Emergency Medicine; UMDNJ/ Robert Wood Johnson Medical School; New Brunswick NJ
| | - Jonathan V. McCoy
- Department of Emergency Medicine; UMDNJ/ Robert Wood Johnson Medical School; New Brunswick NJ
| | - Jody Crane
- Mid-Atlantic Permanente Medical Group; Rockville MD
| | | | - Robert M. Eisenstein
- Department of Emergency Medicine; UMDNJ/ Robert Wood Johnson Medical School; New Brunswick NJ
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