Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study

Emergency department visit frequency and health care costs following implementation of an integrated practice unit for frequent utilizers

OBJECTIVES

The integrated practice unit (IPU) aims to improve care for patients with complex medical and social needs through care coordination, medication reconciliation, and connection to community resources. This study examined the effects of IPU enrollment on emergency department (ED) utilization and health care costs among frequent ED utilizers with complex needs.

METHODS

We extracted electronic health records (EHR) data from patients in a large health care system who had at least four distinct ED visits within any 6-month period between March 1, 2018, and May 30, 2021. Interrupted time series (ITS) analyses were performed to evaluate the impact of IPU enrollment on monthly ED visits and health care costs. A control group was matched to IPU patients using a propensity score at a 3:1 ratio.

RESULTS

We analyzed EHRs of 775 IPU patients with a control group of 2325 patients (mean [±SD] age 43.6 [±17]; 45.8% female; 50.9% White, 42.3% Black). In the single ITS analysis, IPU enrollment was associated with a decrease of 0.24 ED visits (p < 0.001) and a cost reduction of $466.37 (p = 0.040) in the first month, followed by decreases of 0.11 ED visits (p < 0.001) and $417.61 in costs (p < 0.001) each month over the subsequent year. Our main results showed that, compared to the matched control group, IPU patients experienced 0.20 more ED visits (p < 0.001) after their fourth ED visit within 6 months, offset by a reduction of 0.02 visits (p < 0.001) each month over the next year. No significant immediate or sustained increase in costs was observed for IPU-enrolled patients compared to the control group.

CONCLUSIONS

This quasi-experimental study of frequent ED utilizers demonstrated an initial increase in ED visits following IPU enrollment, followed by a reduction in ED utilization over subsequent 12 months without increasing costs, supporting IPU's effectiveness in managing patients with complex needs and limited access to care.

Using Positive Deviance to Enhance HIV Care Retention in South Africa: Development of a Compassion-Focused Programme to Improve the Staff and Patient Experience

Background

HIV burden remains high in South Africa despite intensive efforts to curtail the epidemic. Public primary care facilities, where most people with HIV (PWH) in South Africa receive treatment, face myriad challenges retaining patients on antiretroviral therapy (ART). Nevertheless, some facilities manage to consistently retain PWH in care. We used a participatory Positive Deviance (PD) approach to discover characteristics of primary care facilities with above-average 12-month retention rates to develop an intervention. PD is an asset-based approach to behavior change that consists of discovering how high-performing outliers succeed despite sizable barriers, and then using those data to develop interventions for low-performers.

Methods

We conducted 11 in-depth leadership interviews, 9 staff focus groups with 29 participants, 11 patient focus groups with 45 participants, 23 patient shadowing visits, and 3 clinic observations in each of 3 high- and 3 low-retention public primary care facilities in Cape Town, South Africa, to discover characteristics of high-retention facilities that might be contributing to higher retention rates.

Results

Themes found to a greater degree in high-retention facilities were compassionate, respectful, patient-centered care; higher staff morale, passion for the work and team cohesion; efficient workflow procedures; and a welcoming physical environment. From these themes we developed the Connect intervention, consisting of strategies within three domains: (1) Engage, encourage, and support staff (e.g., a monthly staff support huddle, a compassion training); (2) Expedite and augment workflow procedures (e.g., adjust folder system to lower wait times); (3) Create a welcoming physical environment (e.g., fresh paint and plants in the waiting area).

Conclusions

A PD approach enabled us to identify factors that could be contributing to higher ART retention rates within low-resource public sector primary care facilities in Cape Town, South Africa. If effective, Connect could be a feasible, affordable complement to existing programmes aimed at improving care for PWH.

Challenges in traumatic spinal cord injury care in developing countries - a scoping review

Objective

To evaluate the leading challenges in developing countries' traumatic spinal cord injury (TSCI) care.

Methods

We conducted a systematic search in electronic databases of PubMed, SCOPUS, Web of Science, EMBASE, and Cochrane Library on 16 April 2023. Studies that investigated challenges associated with the management of TSCI in developing countries were eligible for review. We extracted related outcomes and categorized them into four distinct parts: injury prevention, pre-hospital care, in-hospital care, and post-hospital care.

Results

We identified 82 articles that met the eligibility criteria including 13 studies on injury prevention, 25 on pre-hospital care, 32 on in-hospital care, and 61 on post-hospital care. Challenges related to post-hospital problems including the personal, financial, and social consequences of patients' disabilities and the deficiencies in empowering people with TSCI were foremost studied. Lack of trained human resources, insufficient public education and delays in care delivery were barriers in the acute and chronic management of TSCI. A well-defined pre-hospital network and standard guidelines for the management of acute neurotrauma are needed. Critical challenges in injury prevention include deficiencies in infrastructure and supportive legislation.

Conclusion

Studies focusing on injury prevention and pre-hospital care in TSCI management in developing countries warrant further investigation. It is imperative to develop systematic and evidence-based initiatives that are specifically tailored to the unique circumstances of each country to address these challenges effectively. By understanding the primary obstacles, policymakers and healthcare providers can establish goals for improving education, planning, legislation, and resource allocation.

Leadership conceptions of nurses and physicians in emergency care: A scoping review

BACKGROUND

The Emergency Department (ED) is a setting where teamwork and leadership is imperative, however, the literature to date is mostly discipline (nursing or medical) specific. This scoping review aimed to map what is known about nurses' and physicians' conceptions of leadership in the ED to understand similarities, differences, and opportunities for leadership development and research.

METHOD

Guided by the Joanna Briggs Institute approach, and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Guidelines, a systematic search of three electronic databases was performed. The Mixed Methods Assessment Tool was used for quality appraisal of included articles.

RESULTS

In total, 37 articles were included. Four key findings emerged: 1) leadership was rarely explicitly defined; 2) nurse leaders tended to be characterised as agents of continuity whilst physician leaders tended to be characterised as agents of change and continuity; 3) the clarification of expectations from nurse leaders was more evident than expectations from physician leaders; and 4) leadership discourse tended to be traditional rather than contemporary.

CONCLUSION

Despite the proliferation of studies into ED nurse, physician and interprofessional leadership, opportunities exist to integrate learnings from other sectors to strengthen the development of current and next generation of ED leaders.

A Pilot and Feasibility Study to Evaluate the Effectiveness of Tofacitinib Add-On Therapy to Remdesivir in Severely Ill COVID-19 Patients

AIM

This placebo-controlled and randomized pilot study aimed to assess the feasibility and impact of tofacitinib/remdesivir combination therapy compared to remdesivir alone on clinical and laboratory findings of severely ill COVID-19 patients for future large-scale studies.

METHOD

Fifty patients were included in this study. They were randomly allocated into two groups of 25 subjects each. Patients in the treatment group received a five-day course of tofacitinib (10 mg twice daily) in addition to a five-day course of remdesivir, whereas the control group received a 10-day course of remdesivir with a placebo.

RESULTS

There was no significant difference in rates of need for intubation (oxygen saturation level), intensive care unit (ICU) admission, death and length of hospitalization between the two groups (P>0.05). Nevertheless, the PRIEST severity score was significantly reduced in the treatment group compared to the control group (P=0.03, effect size [95% CI]: -0.616 [0.0233-1.1723]). Moreover, the mean level of C-reactive protein after 10 days was significantly decreased in the treatment group but increased in the control group (P=0.006).

CONCLUSION

Tofacitinib adopted in this pilot study modulate the inflammation and reduce the PRIEST score in severe COVID-19 patients. So, it is feasible and could be applied in future larger-scale trials to precisely determine its effects on coronavirus infections.

The use of positive deviance approach to improve health service delivery and quality of care: a scoping review

BACKGROUND

Quality has been a persistent challenge in the healthcare system, particularly in resource-limited settings. As a result, the utilization of innovative approaches is required to help countries in their efforts to enhance the quality of healthcare. The positive deviance (PD) approach is an innovative approach that can be utilized to improve healthcare quality. The approach assumes that solutions to problems are already available within the community and identifying and sharing those solutions can help others to resolve existing issues. Therefore, this scoping review aimed to synthesize the evidence regarding the use of the PD approach in healthcare system service delivery and quality improvement programs.

METHODS

Articles were retrieved from six international databases. The last date for article search was June 02, 2023, and no date restriction was applied. All articles were assessed for inclusion through a title and/or abstract read. Then, articles that passed the title and abstract review were screened by reading their full texts. In case of duplication, only the full-text published articles were retained. A descriptive mapping and evidence synthesis was done to present data with the guide of the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist and the results are presented in text, table, and figure formats.

RESULTS

A total of 125 articles were included in this scoping review. More than half, 66 (52.8%), of the articles were from the United States, 11(8.8%) from multinational studies, 10 (8%) from Canada, 8 (6.4%) from the United Kingdom and the remaining, 30 (24%) are from other nations around the world. The scoping review indicates that several types of study designs can be applied in utilizing the PD approach for healthcare service and quality improvement programs. However, although validated performance measures are utilized to identify positive deviants (PDs) in many of the articles, some of the selection criteria utilized by authors lack clarity and are subject to potential bias. In addition, several limitations have been mentioned in the articles including issues in operationalizing PD, focus on leaders and senior managers and limited staff involvement, bias, lack of comparison, limited setting, and issues in generalizability/transferability of results from prospects perspective. Nevertheless, the limitations identified are potentially manageable and can be contextually resolved depending on the nature of the study. Furthermore, PD has been successfully employed in healthcare service and quality improvement programs including in increasing surgical care quality, hand hygiene practice, and reducing healthcare-associated infections.

CONCLUSION

The scoping review findings have indicated that healthcare systems have been able to enhance quality, reduce errors, and improve patient outcomes by identifying lessons from those who exhibit exceptional practices and implementing successful strategies in their practice. All the outcomes of PD-based research, however, are dependent on the first step of identifying true PDs. Hence, it is critical that PDs are identified using objective and validated measures of performance as failure to identify true PDs can subsequently lead to failure in identifying best practices for learning and dissemination to other contextually similar settings.

Overcrowding in emergency departments: an overview of reviews describing global solutions and their outcomes

Emergency Department (ED) crowding is defined as a situation wherein the demands of emergency services overcome the ability of a department to provide high-quality care within an appropriate time frame. There is a need for solutions, as the harms of crowding impact patients, staff, and healthcare spending. An overview of ED crowding was previously published by our group, which outlines these global issues. The problem of overcrowding in emergency departments has emerged as a global public health concern, and several healthcare agencies have addressed the issue and proposed possible solutions at each level of emergency care. There is no current literature summarizing the extensive research on interventions and solutions, thus there is a need for data synthesis to inform policymakers in this field. The aim of this overview was to summarize the interventions at each level of emergency care: input, throughput, and output. The methodology was supported by the current PRIOR statement for an overview of reviews. The study summarized twenty-seven full-text systematic reviews, which encompassed three hundred and eight primary studies. The results of the summary displayed a requirement for increasing studies in input and output interventions, as these showed the best outcomes with regard to ED crowding metrics. Moreover, the results displayed heterogeneous results at each level of ED care; these reflected that generally solutions have not been matched to specific problems facing regional centres. Thus, individual factors need to be considered when implementing solutions in Emergency Departments.

Strategies to Measure and Improve Emergency Department Performance: A Review

Emergency Departments (EDs) globally face escalating challenges such as overcrowding, resource limitations, and increased patient demand. This study aims to identify and analyze strategies to enhance the structural performance of EDs, with a focus on reducing overcrowding, optimizing resource allocation, and improving patient outcomes. Through a comprehensive review of the literature and observational studies, the research highlights the effectiveness of various approaches, including triage optimization, dynamic staffing, technological integration, and strategic resource management. Key findings indicate that tailored strategies, such as implementing advanced triage protocols and leveraging telemedicine, can significantly reduce wait times and enhance patient throughput. Furthermore, evidence suggests that dynamic staffing models and the integration of cutting-edge diagnostic tools contribute to operational efficiency and improved quality of care. These strategies, when combined, offer a multifaceted solution to the complex challenges faced by EDs, promising better patient care and satisfaction. The study underscores the need for a comprehensive approach, incorporating both organizational and technological innovations, to address the evolving needs of emergency healthcare.

Clinicians' Insights on Emergency Department Boarding: An Explanatory Mixed Methods Study Evaluating Patient Care and Clinician Well-Being

BACKGROUND

The aim of this study was to describe clinicians' insights into the quality and safety of patient care delivered to emergency department (ED) boarding patients, as well as clinician safety and satisfaction related to ED boarding.

METHODS

This was a single-site, mixed methods sequential explanatory study. Quantitative data were obtained from a cross-sectional survey sent to ED attending physicians, resident physicians, advanced practice providers, and nurses. Semistructured focus group interviews with a subsample of participants sought to add depth to the interpretation of survey data and identify areas of improvement in boarding care. Chi-square and Wilcoxon rank sum tests were used to evaluate for response differences between groups. Qualitative data were thematically coded and analyzed.

RESULTS

A total of 94 questionnaires were obtained for a response rate of 34.1%. Clinicians reported that boarding highly contributed to the perception of burnout. All groups reported high rates of perceived verbal and/or physical abuse from boarding patients (86.8% of nurses, 41.1% of providers, p = 0.0002). A total of 39 clinicians participated in focus groups regarding boarding care, and six themes were identified, including patient safety concerns, lack of knowledge/resources/training, and poor communication. Key themes identified as possible solutions to improve care included standardization of care, proactive planning, and culture change.

CONCLUSION

Clinicians identified many concerns regarding patient safety and the quality of care delivered to boarding patients and identified several areas for improvement. Clinicians also felt that boarding negatively affected their satisfaction and safety.

Patient-to-nurse ratios: Balancing quality, nurse turnover, and cost

We consider the problem of setting appropriate patient-to-nurse ratios in a hospital, an issue that is both complex and widely debated. There has been only limited effort to take advantage of the extensive empirical results from the medical literature to help construct analytical decision models for developing upper limits on patient-to-nurse ratios that are more patient- and nurse-oriented. For example, empirical studies have shown that each additional patient assigned per nurse in a hospital is associated with increases in mortality rates, length-of-stay, and nurse burnout. Failure to consider these effects leads to disregarded potential cost savings resulting from providing higher quality of care and fewer nurse turnovers. Thus, we present a nurse staffing model that incorporates patient length-of-stay, nurse turnover, and costs related to patient-to-nurse ratios. We present results based on data collected from three participating hospitals, the American Hospital Association (AHA), and the California Office of Statewide Health Planning and Development (OSHPD). By incorporating patient and nurse outcomes, we show that lower patient-to-nurse ratios can potentially provide hospitals with financial benefits in addition to improving the quality of care. Furthermore, our results show that higher policy patient-to-nurse ratio upper limits may not be as harmful in smaller hospitals, but lower policy patient-to-nurse ratios may be necessary for larger hospitals. These results suggest that a "one ratio fits all" patient-to-nurse ratio is not optimal. A preferable policy would be to allow the ratio to be hospital-dependent.

War and disaster are forcing a major rethink around mass casualty management

Mass casualty events (MASCAL) do not follow the same rules as typical major incidents. In the West at least, the latter often occur in stable, networked trauma systems, whereas MASCAL are characterised by overwhelming numbers of patients, compounded by protracted scene and transport times, decompensated response systems and significant disruption to infrastructure, command and control.This paper describes the 8Ds approach being taken by the UK Defence Medical Services and the North Atlantic Treaty Organization Emergency Medicine Panel framework to approach MASCAL. The eight domains were derived from literature about management of casualties in the World Wars, and also from approaches taken by civilian health systems as they struggle to manage increasing demand. They are: distribute; decompress; delay; delegate; deliver faster and deliver better; dynamic levels of care; and de-escalate These domains will allow a structured approach to research and innovate around MASCAL, informing better guidelines for their management.

Emergency department care of ABSSSI with dalbavancin infusion, direct discharge, and outpatient telemedicine follow up: a study protocol

Novel therapeutic strategies such as the long-acting lipoglycopeptide antibiotics allow for the treatment and discharge of selected emergency department (ED) patients with Acute Bacterial Skin and Skin Structure Infections (ABSSSI), who require intravenous antibiotics and would otherwise be hospitalized. The COVID-19 pandemic highlighted the need to develop strategies that may reduce hospitalization. The telehealth approach has shown success in remote management of cellulitis patients and could aid in the remote follow up of overall ABSSSI patients. This article describes a study protocol for the telemedicine follow up of patients diagnosed with ABSSSI in the ED, requiring intravenous treatment, receiving a single dalbavancin dose, and directly discharged. A telehealth system for remote follow up is evaluated as well as the possible inclusion of point-of-care ultrasound for the appropriate diagnosis of ABSSSI. The study will be conducted in compliance with regulatory requirements; and all collected data will be kept strictly confidential and in accordance with all relevant legislation on the control and protection of personal information. Dissemination of the study protocol may help increasing knowledge and awareness on this topic, with the aim of optimizing patient management, reducing hospitalization and lower the impact on healthcare associated costs.

Impact of sequential capacity building on emergency department organisational flow during COVID-19 pandemic: a quasi-experimental study in a low-resource, tertiary care centre

INTRODUCTION

A quasi-experimental study was conducted to estimate the impact of sequential emergency department (ED) capacity building interventions on key performance indicators such as patients' length of stay (LOS) and wait time (WT) during the COVID-19 pandemic. This was achieved through augmenting personnel education and head count, space restructuring and workflow reorganisation.

SETTING AND PARTICIPANTS

This study included 268 352 patients presenting from January 2019 to December 2020 at Indus Hospital and Health network Karachi, a philanthropic tertiary healthcare facility in a city of 20 million residents. A follow-up study was undertaken from January to December 2021 with 123 938 participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

These included mean and median ED-LOS and WT for participants presenting in different cohorts. The results of the pre-COVID-19 year 2019 (phase 0) were compared with that of the COVID-19 year, 2020 (phases 1-3 corresponding to peaks, and phase 4 corresponding to reduction in caseloads). The follow-up was conducted in 2021 to see the sustainability of the sequential capacity building.

RESULTS

Phases 1, 2 and 3 had a lower mean adjusted LOS (4.42, 3.92 and 4.40 hours) compared with phase 0 (4.78 hours, p<0.05) with the lowest numbers seen in phase 2. The same held true for WT with 45.1, 23.8 and 30.4 min in phases 1-3 compared with 49.9 in phase 0. However, phase 4 had a higher LOS but a lower WT when compared with phase 0 with a p<0.05.

CONCLUSION

Sequential capacity building and improving the operational flow through stage appropriate interventions can be used to off-load ED patients and improve process flow metrics. This shows that models created during COVID-19 can be used to develop sustainable solutions and investment is needed in ideas such as ED-based telehealth to improve patient satisfaction and outcomes.

Integrating Psychiatric Services in the Emergency Room to Improve Patient Care by Using Quality Improvement Methods

ABSTRACT

Prolonged length of stay in emergency departments (EDs) for patients with a psychiatric chief complaint is a widespread problem. Prolonged stays can lead to adverse outcomes and poor quality of care. We sought to improve quality of care for patients in the medical ED who needed psychiatric care. To identify the areas of weakness, we queried the ED staff via an online survey about the perception of the challenges working with our Comprehensive Psychiatric Emergency Program (CPEP), which is located adjacent to and works closely with the medical ED providing psychiatric consultation. We identified several action steps and used the Plan-Do-Study-Act methodology for implementation. We reported a reduction in time to complete consultations and improved communication between CPEP and the medical ED staff.

Nurse Performance Metrics: A Scoping Review

OBJECTIVE

The purposes of this scoping review are: 1) to identify instances in the literature that describe measuring individual nurse performance and 2) characterize those metrics.

BACKGROUND

The impact of nurses on patient outcomes has been demonstrated at the unit or hospital level, with nurses measured in aggregate. There is an opportunity to evaluate individual nurse performance by creating metrics that capture it.

METHODS

A scoping review based on the framework published by the Joanna Briggs Institute was performed.

RESULTS

Researchers identified 12 articles. Three themes were trended: the emerging nature of these metrics in the literature, variability in their applications, and performance implications.

CONCLUSIONS

Individual nurse performance metrics is an emerging body of research with variability in the types of metrics developed. There is an opportunity for future researchers to work with nurse leaders and staff nurses to optimize these metrics and to use them to support nursing practice and patient care.

Association between acute care collaborations and health care utilization as compared to stand-alone facilities in the Netherlands: a quasi-experimental study

Health systems invest in coordination and collaboration between emergency departments (ED) and after-hours primary care providers (AHPCs) to alleviate pressure on the acute care chain. There are substantial gaps in the existing evidence, limited in sample size, follow-up care, and costs. We assess whether acute care collaborations (ACCs) are associated with decreased ED utilization, hospital admission rates, and lower costs per patient journey, compared with stand-alone facilities. The design is a quasi-experimental study using claims data. The study included 610 845 patients in the Netherlands (2017). Patient visits in ACCs were compared to stand-alone EDs and AHPCs. The number of comorbidities was similar in both groups. Multiple logistic and gamma regressions were used to determine whether patient visits to ACCs were negatively associated with ED utilization, hospital admission rates, and costs. Logistic regression analysis did not find an association between patients visiting ACCs and ED utilization compared to patients visiting stand-alone facilities [odds ratio (OR), 1.01; 95% confidence interval (CI), 1.00-1.03]. However, patients in ACCs were associated with an increase in hospital admissions (OR, 1.07; 95% CI, 1.04-1.09). ACCs were associated with higher total costs incurred during the patient journey (OR, 1.02; 95% CI, 1.01-1.03). Collaboration between EDs and AHPCs was not associated with ED utilization, but was associated with increased hospital admission rates, and higher costs. These collaborations do not seem to improve health systems' financial sustainability.

The Association between Emergency Department Overcrowding and Delay in Treatment: A Systematic Review

Emergency department (ED) overcrowding is a global health issue that is associated with poor quality of care and affects the timeliness of treatment initiation. The purpose of this systematic review is to assess the association between overcrowding and delay in treatment. A systematic review was conducted using four databases (CINAHL, PubMed, Scopus, Cochrane Library), following the preferred reporting items for systematic reviews and meta-analysis (PRISMA). A structured search was conducted to identify peer-reviewed articles aimed at assessing the relationship between overcrowding and delay in treatment, published between January 2000 and January 2021. Only studies that were conducted in the ED settings were included, and that includes both triage and observation rooms. The studies were appraised using two quality appraisal tools including the critical appraisal skills programme (CASP) for cohort studies and the Joanna Briggs Institute (JBI) checklist tool for cross-sectional studies. A total of 567 studies screened, and 10 met the inclusion criteria. Of these studies, 8 were cohorts and 2 were cross-sectionals. The majority reported that overcrowding is associated with a delay in the initiation of antibiotics for patients with sepsis and pneumonia. The review identified that overcrowding might impact time-to-treatment and, thus, the quality of care delivered to the patient. However, further research aimed at finding feasible solutions to overcrowding is encouraged.

Prospective External Validation of a Commercial Model Predicting the Likelihood of Inpatient Admission From the Emergency Department

STUDY OBJECTIVE

Early notification of admissions from the emergency department (ED) may allow hospitals to plan for inpatient bed demand. This study aimed to assess Epic's ED Likelihood to Occupy an Inpatient Bed predictive model and its application in improving hospital bed planning workflows.

METHODS

All ED adult (18 years and older) visits from September 2021 to August 2022 at a large regional health care system were included. The primary outcome was inpatient admission. The predictive model is a random forest algorithm that uses demographic and clinical features. The model was implemented prospectively, with scores generated every 15 minutes. The area under the receiver operator curves (AUROC) and precision-recall curves (AUPRC) were calculated using the maximum score prior to the outcome and for each prediction independently. Test characteristics and lead time were calculated over a range of model score thresholds.

RESULTS

Over 11 months, 329,194 encounters were evaluated, with an incidence of inpatient admission of 25.4%. The encounter-level AUROC was 0.849 (95% confidence interval [CI], 0.848 to 0.851), and the AUPRC was 0.643 (95% CI, 0.640 to 0.647). With a prediction horizon of 6 hours, the AUROC was 0.758 (95% CI, 0.758 to 0.759,) and the AUPRC was 0.470 (95% CI, 0.469 to 0.471). At a predictive model threshold of 40, the sensitivity was 0.49, the positive predictive value was 0.65, and the median lead-time warning was 127 minutes before the inpatient bed request.

CONCLUSION

The Epic ED Likelihood to Occupy an Inpatient Bed model may improve hospital bed planning workflows. Further study is needed to determine its operational effect.

Hospital crowdedness evaluation and in-hospital resource allocation based on image recognition technology

How to allocate the existing medical resources reasonably, alleviate hospital congestion and improve the patient experience are problems faced by all hospitals. At present, the combination of artificial intelligence and the medical field is mainly in the field of disease diagnosis, but lacks successful application in medical management. We distinguish each area of the emergency department by the division of medical links. In the spatial dimension, in this study, the waitlist number in real-time is got by processing videos using image recognition via a convolutional neural network. The congestion rate based on psychology and architecture is defined for measuring crowdedness. In the time dimension, diagnosis time and time-consuming after diagnosis are calculated from visit records. Factors related to congestion are analyzed. A total of 4717 visit records from the emergency department and 1130 videos from five areas are collected in the study. Of these, the waiting list of the pediatric waiting area is the largest, including 10,436 (person-time) people, and its average congestion rate is 2.75, which is the highest in all areas. The utilization rate of pharmacy is low, with an average of only 3.8 people using it at the one time. Its average congestion rate is only 0.16, and there is obvious space waste. It has been found that the length of diagnosis time and the length of time after diagnosis are related to age, the number of diagnoses and disease type. The most common disease type comes from respiratory problems, accounting for 54.3%. This emergency department has congestion and waste of medical resources. People can use artificial intelligence to investigate the congestion in hospitals effectively. Using artificial intelligence methods and traditional statistics methods can lead to better research on healthcare resource allocation issues in hospitals.

Creating a Rapid Assessment Zone with Limited Emergency Department Capacity Decreases Patients Leaving Without Being Seen: A Quality Improvement Initiative

INTRODUCTION

Patients leaving the emergency department before treatment (left without being seen) result in increased risks to patients and loss of revenue to the hospital system. Rapid assessment zones, where patients can be quickly evaluated and treated, have the potential to improve ED throughput and decrease the rates of patients leaving without being seen. We sought to evaluate the impact of a rapid assessment zone on the rate of patients leaving without being seen.

METHODS

A pre- and post-quality improvement process was performed to examine the impact of implementing a rapid assessment zone process at an urban community hospital emergency department. Through a structured, multidisciplinary approach using the Plan, Do, Check, Act Deming Cycle of process improvement, the triage area was redesigned to include 8 rapid assessment rooms and shifted additional ED staff, including nurses and providers, into this space. Rates of patients who left without being seen, median arrival to provider times, and discharge length of stay between the pre- and postintervention periods were compared using parametric and nonparametric tests when appropriate.

RESULTS

Implementation of the rapid assessment zone occurred February 1, 2021, with 42,115 ED visits eligible for analysis; 20,731 visits before implementation and 21,384 visits after implementation. All metrics improved from the 6 months before intervention to the 6 month after intervention: rate of patients who left without being seen (5.64% vs 2.55%; c² = 258.13; P < .01), median arrival to provider time in minutes (28 vs 11; P < .01), and median discharge length of stay in minutes (205 vs 163; P < .01).

DISCUSSION

Through collaboration and an interdisciplinary team approach, leaders and staff developed and implemented a rapid assessment zone that reduced multiple throughput metrics.

Predicting Need for Hospital Beds to Reduce Emergency Department Boarding

Introduction Accurately determining the supply and demand of hospital beds for new admissions can help prevent adverse patient outcomes. Quantitative analysis of modern electronic medical record data can help predict supply and demand for unoccupied staffed hospital beds (SEDs) and aid in eliminating human approximations, standardizing daily work through concrete and objective data. The purpose of this study was to reduce variability and human error in predicting the number of SEDs needed. Methods In this study,the authors analyzed bed calculator data from a medium-sized, suburban medical center to evaluate the efficacy of a unique bed calculator prediction tool to determine the need for SEDs. The calculator aggregates multiple key reference factors available through the bed calculator system into a cohesive linear regression model. Results Compared with human estimation, the authors found that the bed calculator is able to predict the number of SEDs needed more effectively. That being said, there was no significant difference in the average boarding times pre- and postintervention, indicating that the bed calculator did not result in decreased boarding times for patients. Discussion These findings establish the efficacy of the bed calculator and its ability to align bed supply and demand. Because patient boarding times depend on the system's patient flow management, future studies should focus on how to improve various streams of communication and coordination.

How Do Health Systems Address Patient Flow When Services Are Misaligned With Population Needs? A Qualitative Study

BACKGROUND

Patient flow through health services is increasingly recognized as a system issue, yet the flow literature has focused overwhelmingly on localized interventions, with limited examination of system-level causes or remedies. Research suggests that intractable flow problems may reflect a basic misalignment between service offerings and population needs, requiring fundamental system redesign. However, little is known about health systems' approaches to population-capacity misalignment, and guidance for system redesign remains underdeveloped.

METHODS

This qualitative study, part of a broader investigation of patient flow in urban Western Canada, explored health-system strategies to address or prevent population-capacity misalignment. We conducted in-depth interviews with a purposive sample of managers in 10 jurisdictions across 4 provinces (N = 300), spanning all healthcare sectors and levels of management. We used the constant comparative method to develop an understanding of relevant strategies and derive principles for system design.

RESULTS

All regions showed evidence of pervasive population-capacity misalignment. The most superficial level of response - mutual accommodation (case-by-case problem solving) - was most prevalent; capacity (re)allocation occurred less frequently; population redefinition most rarely. Participants' insights yielded a general principle: Define populations on the basis of clusters of co-occurring need. However, defining such clusters demands a difficult balance between narrowness/rigidity and breadth/flexibility. Deeper analysis suggested a further principle: Populations that can be divided into homogeneous subgroups experiencing similar needs (eg, surgical patients) are best served by narrow/ rigid models; heterogeneous populations featuring diverse constellations of need (eg, frail older adults) require broad/ flexible models.

CONCLUSION

To remedy population-capacity misalignment, health system planners should determine whether clusters of population need are separable vs. fused, select an appropriate service model for each population, allocate sufficient capacity, and only then promote mutual accommodation to address exceptions. Overreliance on case-by-case solutions to systemic problems ensures the persistence of population-capacity misalignment.

The effect of batched patient-physician assignment on patient length of stay in the emergency department

Objectives

Queuing theory suggests that signing up for multiple patients at once (batching) can negatively affect patients' length of stay (LOS). At academic centers, resident assignment adds a second layer to this effect. In this study, we measured the rate of batched patient assignment by resident physicians, examined the effect on patient in-room LOS, and surveyed residents on underlying drivers and perceptions of batching.

Methods

This was a retrospective study of discharged patients from August 1, 2020 to October 27, 2020, supplemented with survey data conducted at a large, urban, academic hospital with an emergency medicine training program in which residents self-assign to patients. Time stamps were extracted from the electronic health record and a definition of batching was set based on findings of a published time and motion study.

Results

A total of 3794 patients were seen by 28 residents and ultimately discharged during the study period. Overall, residents batched 23.7% of patients, with a greater rate of batching associated with increasing resident seniority and during the first hour of resident shifts. In-room LOS for batched assignment patients was 15.9 minutes longer than single assignment patients (P value < 0.01). Residents' predictions of their rates of batching closely approximated actual rates; however, they underestimated the effect of batching on LOS.

Conclusions

Emergency residents often batch patients during signup with negative consequences to LOS. Moreover, residents significantly underestimate this negative effect.

Level-loading a health system by transferring emergency department patients to a community hospital: Prospective cohort study

BACKGROUND

Emergency department boarding and crowding lead to worse patient outcomes and patient satisfaction.

OBJECTIVE

We describe the implementation of a program to transfer patients requiring medical admission from an academic emergency department to a community hospital's medical floor and analyze its effects on patient outcomes.

METHODS

A prospective cohort study was performed. Data was collected on patient flow through the transfer program. Patient characteristics, boarding time in the emergency department, and hospital-based outcome measures were compared between patients in the transfer program who were successfully transferred to the community hospital and patients who were admitted to the academic medical center.

RESULTS

79 patients were successfully transferred to the community hospital between November 23, 2020 and August 5, 2021, resulting in 279 bed days in the community hospital. Successfully transferred patients experienced a statistically shorter ED boarding time (5.7 vs. 10.9 h, p < 0.0001), ED length of stay (10.5 vs 16.1 h, p < 0.0001), and hospital length of stay (3.5 vs 5.7 days, p < 0.0001) compared to patients initially referred to the transfer program who were admitted to the academic medical center. There were no reported adverse events during transfer, upgrades to the ICU within 24 h of admission, or inpatient deaths for patients who were transferred.

CONCLUSION

We implemented an academic emergency department to partner community hospital transfer program that safely level-loads medical patients in a healthcare system.

The Implementation of Improvement Interventions for "Low Performing" and "High Performing" Organisations in Health, Education and Local Government: A Phased Literature Review

BACKGROUND

There is limited understanding about whether and how improvement interventions are effective in supporting failing healthcare organisations and improving the quality of care in high-performing organisations. The aim of this review was to examine the underlying concepts guiding the design of interventions aimed at low and high performing healthcare organisations, processes of implementation, unintended consequences, and their impact on costs and quality of care. The review includes articles in the healthcare sector and other sectors such as education and local government.

METHODS

We carried out a phased rapid systematic review of the literature. Phase one was used to develop a theoretical framework of organisational failure and turnaround, and the types of interventions implemented to improve quality. The framework was used to inform phase 2, which was targeted and focused on organisational failure and turnaround in healthcare, education and local government settings. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to guide the reporting of the methods and findings and the Mixed Methods Appraisal Tool (MMAT) as a quality assessment tool. The review protocol was registered with PROSPERO (CRD: 42019131024).

RESULTS

Failure is frequently defined as the inability of organisations to meet pre-established performance standards and turnaround as a linear process. Improvement interventions are designed accordingly and are focused on the organisation, with limited system-level thinking. Successful interventions included restructuring senior leadership teams, inspections, and organisational restructuring by external organisations. Limited attention was paid to the potential negative consequences of the interventions and their costs.

CONCLUSION

Dominant definitions of success/failure and turnaround have led to the reduced scope of improvement interventions, the linear perception of turnaround, and lack of consideration of organisations within the wider system in which they operate. Future areas of research include an analysis of the costs of delivering these interventions in relation to their impact on quality of care.

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

Increasing demand and changing case-mix have resulted in bottlenecks and longer waiting times in emergency departments (ED). However, many process improvement efforts addressing the bottlenecks have limitations, as they lack accurate models of the real system as input accounting for operational complexities. To understand the limitation, this research modelled granular procedural information, to analyse processes in a Level-1 ED of a 1200-bed teaching hospital in the UK. Semi-structured interviews with 21 clinicians and direct observations provided the necessary information. Results identified Majors as the most crowded area, hence, a systems modelling technique, role activity diagram, was used to derive highly granular process maps illustrating care in Majors which were further validated by 6 additional clinicians. Bottlenecks observed in Majors included awaiting specialist input, tests outside the ED, awaiting transportation, bed search, and inpatient handover. Process mapping revealed opportunities for using precedence information to reduce repeat tests; informed alerting; and provisioning for operational complexity into ED processes as steps to potentially alleviate bottlenecks. Another result is that this is the first study to map care processes in Majors, the area within the ED that treats complex patients whose care journeys are susceptible to variations. Findings have implications on the development of improvement approaches for managing bottlenecks.

Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions

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.

How to fix the Merit-based Incentive Payment System (MIPS) in emergency medicine

In this issue of Academic Emergency Medicine, Gettel et al. report participation and performance of emergency clinicians in 2018's Merit-based Incentive Payment System (MIPS). MIPS is an enormous government program that assesses U.S. clinicians on several factors and makes payment adjustments for Medicare fee for service patients based on those results. MIPS performance is assessed in variable ways based on clinical specialty.

Conceptual Model of Emergency Department Utilization among Deaf and Hard-of-Hearing Patients: A Critical Review

Deaf and hard-of-hearing (DHH) populations are understudied in health services research and underserved in healthcare systems. Existing data indicate that adult DHH patients are more likely to use the emergency department (ED) for less emergent conditions than non-DHH patients. However, the lack of research focused on this population’s ED utilization impedes the development of health promotion and quality improvement interventions to improve patient health and quality outcomes. The purpose of this study was to develop a conceptual model describing patient and non-patient (e.g., community, health system, provider) factors influencing ED utilization and ED care processes among DHH people. We conducted a critical review and used Andersen’s Behavioral Model of Health Services Use and the PRECEDE-PROCEED Model to classify factors based on their theoretical and/or empirically described role. The resulting Conceptual Model of Emergency Department Utilization Among Deaf and Hard-of-Hearing Patients provides predisposing, enabling, and reinforcing factors influencing DHH patient ED care seeking and ED care processes. The model highlights the abundance of DHH patient and non-DHH patient enabling factors. This model may be used in quality improvement interventions, health services research, or in organizational planning and policymaking to improve health outcomes for DHH patients.

Mixed effect of increasing outflow of medical patients from an emergency department

Background and aim

Since 2014, the annual number of patients entering our emergency department (ED) has increased significantly. These were primarily Internal Medicine (IM) patients, and of these, 25–30% were admitted. The present governmental policy presents a deterrent to adding IM beds for these patients, and Emergency and IM departments cope with ever-increasing number of IM patients. We describe a quality improvement intervention to increase outflow of IM patients from the ED to the IM departments.

Methods

We conducted a quality improvement intervention at the Shaare Zedek Medical Center from 2014 to 2018. The first stage consisted of an effort to increase morning discharges from the IM departments. The second stage consisted of establishing a process to increase the number of admissions to the IM departments from the ED.

Results

Implementation of the first stage led to an increased morning discharge rate from a baseline of 2–4 to 18%. The second stage led to an immediate mean (± SD) morning transfer of 35 ± 7 patients to the medical departments (8–12 per department), providing significant relief for the ED. However, the additional workload for the IM departments’ medical and nursing staff led to a rapid decrease in morning discharges, returning to pre-intervention rates. Throughout the period of the new throughput intervention, morning admissions increased from 30 to > 70%, and were sustained. The number of patients in each department increased from 36 to 38 to a new steady state of 42–44, included constant hallway housing, and often midday peaks of 48–50 patients. Mean length of stay did not change. IM physician and nurse dissatisfaction led to increased number of patients being admitted during the evening and night hours and fewer during the morning.

Conclusion

We describe a quality improvement intervention to improve outflow of medical patients from the ED in the morning hours. The new ED practices had mixed effects. They led to less ED crowding in the morning hours but increased dissatisfaction among the IM department medical and nursing staff due to an increased number of admissions in a limited number of hours. The present governmental reimbursement policy needs to address hospital overcrowding as it relates to limited community healthcare beds and an aging population.

Realist analysis of streaming interventions in emergency departments

Background

Several of the many emergency department (ED) interventions intended to address the complex problem of (over)crowding are based on the principle of streaming: directing different groups of patients to different processes of care. Although the theoretical basis of streaming is robust, evidence on the effectiveness of these interventions remains inconclusive.

Methods

This qualitative research, grounded in the population-capacity-process model, sought to determine how, why and under what conditions streaming interventions may be effective. Data came from a broader study exploring patient flow strategies across Western Canada through in-depth interviews with managers at all levels. We undertook realist analysis of interview data from the 98 participants who discussed relevant interventions (fast-track/minor treatment areas, rapid assessment zones, diverse short-stay units), focusing on their explanations of initiatives’ perceived outcomes.

Results

Essential features of streaming interventions included separation of designated populations (population), provision of dedicated space and resources (capacity) and rapid cycle time (process). These features supported key mechanisms of impact: patients wait only for services they need; patient variability is reduced; lag time between steps is eliminated; and provider attitude change promotes prompt discharge. Conversely, reported failures usually involved neglect of one of these dimensions during intervention design and/or implementation. Participants also identified important contextual barriers to success, notably lack of outflow sites and demand outstripping capacity. Nonetheless, failure was more commonly attributed to intervention flaws than to context factors.

Conclusions

While streaming interventions have the potential to reduce crowding, a theory-based intervention relies on its implementers’ adherence to the theory. Streaming interventions cannot be expected to yield the desired results if operationalised in a manner incongruent with the theory on which they are supposedly based.

Improving hospital flow 'Ensiab Project'

Emergency department (ED) boarding is an indicator of less efficient hospital flow and is associated with longer inpatient length of stay, higher readmission rates and increased risk of mortality and medical errors. In addition to being associated with poor patient and staff satisfaction.This article describes the efforts of six tertiary care governmental hospitals in the Kingdom of Saudi Arabia that have enrolled in a collaborative improvement project to reduce ED boarding time.The hospitals implemented a multifaceted system intervention that included forming multidisciplinary flow improvement teams, implementing the National Health Service (NHS) SAFER patient flow bundle, visual management system and multidisciplinary ED bed huddles.By the end of the project, all hospitals significantly reduced ED boarding time with a pooled mean difference of - 7.1 hours (16.6 before, 9.5 hours after, p<0.001), reaching a pooled average of 2 hours in March 2020.Furthermore, by the end of the third learning session, all hospitals were able to achieve a boarding time below 6 hours. The enrolled hospitals also experienced an improvement in hospital flow process measures without any increase in 30-day readmission rates or bed occupancy rates.Our project demonstrates that implementing multifaceted system-wide interventions improves hospital flow and ED boarding time. Additionally, our project demonstrates a significant correlation between improvements in ED boarding time, daily consultant-led rounds and early discharge from inpatient units and time till discharge.

A scoping review of rebel nurse leadership: Descriptions, competences and stimulating/hindering factors

AIMS

To (1) give an overview of rebel nurse leadership by summarising descriptions of positive deviance, tempered radicals and healthcare rebels; (2) examine the competences of nurse rebel leadership; and (3) describe factors that stimulate or hinder the development of rebel nurse leadership.

BACKGROUND

Research shows nurses have lower intention to leave their jobs when they can control their work practices, show leadership and provide the best care. However, organisational rules and regulations do not always fit the provision of good care, which challenges nurses to show leadership and deviate from the rules and regulations to benefit the patient. Three concepts describe this practice: positive deviance, healthcare rebels and tempered radicals.

DESIGN

Scoping review using the Joanna Briggs Institute methodology and PRISMA-ScR checklist.

METHODS

Papers describing positive deviance, healthcare rebels and tempered radicals in nursing were identified by searching Scopus, CINAHL, PubMed and PsycINFO. After data extraction, these three concepts were analysed to study the content of descriptions and definitions, competences and stimulating and hindering factors.

RESULTS

Of 2705 identified papers, 25 were included. The concept descriptions yielded three aspects: (1) positive deviance approach, (2) unconventional and non-confirmative behaviour and (3) relevance of networks and relationships. The competences were the ability to: (1) collaborate in/outside the organisation, (2) gain and share expert (evidence-based) knowledge, (3) critically reflect on working habits/problems in daily care and dare to challenge the status quo and (4) generate ideas to improve care. The factors that stimulate or hinder the development of rebel nurse leadership are as follows: (1) dialogue and reflection, (2) networking conditions and (3) the managers' role.

CONCLUSIONS

Based on our analysis, we summarise the descriptions given of rebel nurse leadership, the mentioned competences and provide an overview of the factors that stimulate or hinder rebel nurse leadership.

RELEVANCE TO CLINICAL PRACTICE

The descriptions produced in this review of rebel nurse leadership and the stimulating or hindering factors listed should help nurses and managers encourage rebel leadership.

Comparison of Japan nurse practitioner-led care and physician trainee-led care on patients' length of stay in a secondary emergency department: A retrospective study

Aim

We compared Japan nurse practitioner‐led care and physician trainee‐led care in terms of patients' length of stay in a secondary emergency department in Japan.

Methods

This was a retrospective observational study, utilizing medical records. Participants (n = 1419; mean age = 63.9 ± 23.4 years; 52.3% men) were patients transferred to the emergency department by ambulance between April 2016 and March 2018 in western Tokyo. Multiple linear regression analyses were performed, with length of stay as the dependent variable and factors related to the length of stay, including medical care leaders, as the independent variable.

Results

Approximately half of the patients (n = 763; 53.8%) received Japan nurse practitioner‐led care. Patients' length of stay was significantly shorter, by 6 min, in the Japan nurse practitioner‐led care group, compared with the physician trainee‐led care group (unstandardized coefficient: −6.81; 95% confidence interval: −13.35 to −0.26; p < 0.05).

Conclusion

Patients' shorter length of stay in the Japan nurse practitioner group, compared with the physician trainee group, suggests that Japan nurse practitioners are not inferior to physician trainees in terms of the time spent to manage patients.

The Surgical Safety Huddle: Novel Quality Improvement Patient Safety Initiative

Background: Acutely deteriorating patients are entitled to the best possible care which includes early recognition and timely appropriate intervention to reduce adverse events, unnecessary admissions to intensive care and/or cardiac arrest. Aim: To reduce the number of poor outcomes for surgical patients with a National Early Warning Score (NEWS) score ≥7 in our institution by 50%. A poor outcome was defined as: 1. Cardiac arrest 2. NEWS >7 not improving after 72 hours 3. Transfer to ICU >6 hours Methods: Surgical inpatients from a variety of surgical specialties (general, vascular, breast, colorectal, hepatobiliary, and plastic surgery) in a large university teaching hospital were included. Quality improvement tools were used to generate regular dialogue with the clinical teams, resulting in the concept of the surgical safety huddle being proposed. Deteriorating patients were highlighted at the daily huddle and a plan of early intervention was implemented. An incremental approach with continuous PDSA [Plan- Do-Study-Act] cycles and subsequent feedback was adopted on the surgical ward to develop the huddle. Poor patient outcomes were analysed prospectively via chart reviews. Results: Prior to the introduction of the “surgical huddle” 110 patients with NEWS >7 were audited. Twenty-eight of these patients had a poor outcome at 72 hours (25%). Following the introduction of the surgical huddle supported by the deteriorating patient team, 64 patients with NEWS >7 were reviewed. Three of these patients had a poor outcome at 72 hours (4.7%). The introduction of the surgical huddle increased the interval between cardiac arrests more than sixfold on the surgical ward. Discussion: The introduction of the surgical safety huddle supported by the deteriorating patient response team reduced the number of cardiac arrests and poor outcomes in a surgical inpatient cohort.

Despite Interventions, Emergency Flow Stagnates in Urban Western Canada

Purpose

This paper reports the quantitative component of a mixed-methods study of patient flow in the 10 urban health regions/zones of Western Canada. We assessed whether jurisdictions differed meaningfully in their emergency flow performance, defined as mean emergency department length of stay (ED LOS).

Methods

We used hierarchical linear modelling to compare ED LOS across jurisdictions, based on nationally reported data for 2017 to 2018. We also explored 36-month performance trends. Admitted and discharged patients were analyzed separately.

Results

With the exception of one high performer, no region's performance differed significantly from average for both admitted and discharged patients. The regions' levels of performance remained largely static throughout the study period.

Conclusions

Results precluded any mixed-methods comparison of high- and low-performing regions. However, they converged with our qualitative findings, which suggested that most regions were pursuing similar flow-improvement strategies with limited effectiveness. Deeper changes may be required to address persistent misalignment between capacity and demand.

Reducing Pediatric ED Length of Stay by Reducing Diagnostic Testing: A Discrete Event Simulation Model

Supplemental Digital Content is available in the text.

Quality improvement efforts can require significant investment before the system impact of those efforts can be evaluated. We used discrete event simulation (DES) modeling to test the theoretical impact of a proposed initiative to reduce diagnostic testing for low-acuity pediatric emergency department (ED) patients.

NO2 exposure increases eczema outpatient visits in Guangzhou, China: an indication for hospital management

Background

Ambient nitrogen dioxide (NO₂) is a common air pollutant in developing countries and causes skin conditions, but its effect on eczema in subtropical areas is not clear in China.

Object

To measure the effect of short-term exposure of NO₂ on the incidence of eczema and the change of outpatient visits.

Methods

Data of daily temperature, air pollutants, and outpatient visits from 2013 to 2018 were collected in a row. The generalized additive model (GAM) and Poisson distribution were used to assess the association between short-term exposure of NO₂ and the outpatient visits of patients with eczema. The cumulative exposure effect of lag 0–3 days and the displacement effect of NO₂ and other pollutants were considered as well. A single pollutant model was used to examine the independent association, and a two-pollutant model was adopted to control the confounding effect.

Results

The daily outpatient visits of eczema increased from 75.26 to 190.85 from 2013 to 2018 (P < 0.001). The combined influence of NO₂ and the related pollutant exerted a stronger influence on the incidence of eczema. The maximum effect of NO₂ appeared on the exposed day.

(lag 0) and disappeared on day 4 (lag 3). The children and seniors were more vulnerable to NO₂ exposure.

Conclusion

Exposure to NO₂ is tightly associated with eczema incidence and outpatient visits. The hospitals should react to the visit fluctuations and adjust physician duty shifts to improve outpatient service efficiency.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10549-7.

Managing intergroup silos to improve patient flow

BACKGROUND

Health care managers face the critical challenge of overcoming divisions among the many groups involved in patient care, a problem intensified when patients must flow across multiple settings. Surprisingly, however, the patient flow literature rarely engages with its intergroup dimension.

PURPOSE

This study explored how managers with responsibility for patient flow understand and approach intergroup divisions and "silo-ing" in health care.

METHODOLOGY/APPROACH

We conducted in-depth interviews with 300 purposively sampled senior, middle, and frontline managers across 10 Canadian health jurisdictions. We undertook thematic analysis using sensitizing concepts drawn from the social identity approach.

RESULTS

Silos, at multiple levels, were reported in every jurisdiction. The main strategies for ameliorating silos were provision of formal opportunities for staff collaboration, persuasive messages stressing shared values or responsibilities, and structural reorganization to redraw group boundaries. Participants emphasized the benefits of the first two but described structural change as neither necessary nor sufficient for improved collaboration.

CONCLUSION

Silos, though an unavoidable feature of organizational life, can be managed and mitigated. However, a key challenge in redefining groups is that the easiest place to draw boundaries from a social identity perspective may not be the best place from one of system design. Narrowly defined groups forge strong identities more easily, but broader groups facilitate coordination of care by minimizing the number of boundaries patients must traverse.

PRACTICE IMPLICATIONS

A thoughtfully designed combination of strategies may help to improve intergroup relations and their impact on flow. It may be ideal to foster a "mosaic" identity that affirms group allegiances at multiple levels.

The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis

BACKGROUND

Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP.

METHODS

FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost.

RESULTS

During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs.

CONCLUSIONS

In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.

Does Telemedicine Reduce Emergency Room Congestion? Evidence from New York State

Overcrowding in emergency rooms (ERs) is a common yet nagging problem. It not only is costly for hospitals but also compromises care quality and patient experience. Our paper provides solid evidence that telemedicine can significantly improve ER care delivery, especially in the presence of demand and supply fluctuations. We believe such findings are critical for ERs, due to the special setting of unscheduled arrivals leading to high unpredictability of patient traffic. Additional evidence suggests that the efficiency gained from telemedicine does not come at the expense of lower care quality or higher medical expenditure, which points to telemedicine as a feasible solution to the ER overcrowding problem. For healthcare practitioners, our paper highlights the general applicability of telemedicine through the “hub and spoke” architecture. Besides increasing patients’ access to more immediate care from specialists who were not available otherwise, telemedicine enables flexible resource allocation for any hospitals, regardless of where hospitals are located. Our research also provides ground for policymakers to incentivize hospitals to adopt telemedicine in ER, which we believe is critical given the relatively low adoption rate, the lack of direct evidence on its effectiveness, and the current inflexibility of reimbursement policies regarding the application of ER telemedicine.

Organizational Support in Healthcare Redesign Education: A Mixed-Methods Exploratory Study of Expert Coach and Executive Sponsor Experiences

Healthcare organizations must continue to improve services to meet the rising demand and patient expectations. For this to occur, the health workforce needs to have knowledge and skills to design, implement, and evaluate service improvement interventions. Studies have shown that effective training in health service improvement and redesign combines didactic education with experiential project-based learning and on-the-ground coaching. Project-based learning requires organizational support and oversight, generally through executive sponsorship. A mixed-methods approach, comprising online surveys and semi-structured interviews, was used to explore the experiences of expert coaches and executive sponsors as key facilitators of workplace-based projects undertaken during an Australian postgraduate healthcare redesign course. Fifteen (54%) expert coaches and 37 (20%) executive sponsors completed the online survey. Ten expert coaches and six executive sponsors participated in interviews. The survey data revealed overall positive experiences for coaches and mixed experiences for sponsors. Interview participants expressed a sense of fulfillment that came from working with project teams to deliver a successful project and educational outcomes. However, concerns were raised about adequate resourcing, organizational recognition, competing priorities, and the skills required to effectively coach and sponsor. Expert coaches and executive sponsors sometimes felt under-valued and may benefit from cohort-tailored and evidence-based professional development.

Design of the Academic Emergency Department

This article introduces a clinical audience to the process of emergency department (ED) design, particularly relating to academic EDs. It explains some of the major terms, processes, and key decisions that clinical staff will experience as participants in the design process. Topics covered include an overview of the planning and design process, issues related to determining needed patient capacity, the impact of patient flow models on design, and a description of several common ED design types and their advantages and disadvantages.

Emergency Department Operations: An Overview

Emergency department (ED) operations reflect the intersection of factors external and internal to the ED itself, with unique problems posed by community and academic environments. ED crowding is primarily caused by a lack of inpatient beds for patients admitted through the ED. Changes to front-end operations, such as point-of-care testing and putting physicians in triage, can yield benefits in throughput, but require individual cost analyses. Balancing physician workloads can lead to substantial improvements in throughput. Observation pathways can reduce crowding while maintaining safety. Physician and nurse well-being is an underappreciated topic within operations, and demands close attention and further research.

Prevalence of crowding, boarding and staffing levels in Swedish emergency departments - a National Cross Sectional Study

Background

Emergency Department (ED) crowding occurs when demand for care exceeds the available resources. Crowding has been associated with decreased quality of care and increased mortality, but the prevalence on a national level is unknown in most countries.

Method

We performed a national, cross-sectional study on staffing levels, staff workload, occupancy rate and patients waiting for an in-hospital bed (boarding) at five time points during 24 h in Swedish EDs.

Results

Complete data were collected from 37 (51% of all) EDs in Sweden. High occupancy rate indicated crowding at 12 hospitals (37.5%) at 31 out of 170 (18.2%) time points. Mean workload (measured on a scale from 1, no workload to 6, very high workload) was moderate at 2.65 (±1.25). Boarding was more prevalent in academic EDs than rural EDs (median 3 vs 0). There were an average of 2.6, 4.6 and 3.2 patients per registered nurse, enrolled nurse and physician, respectively.

Conclusion

ED crowding based on occupancy rate was prevalent on a national level in Sweden and comparable with international data. Staff workload, boarding and patient to staff ratios were generally lower than previously described.

"Working Against Gravity": The Uphill Task of Overcapacity Management

While most health systems have implemented interventions to manage situations in which patient demand exceeds capacity, little is known about the long-term sustainability or effectiveness of such interventions. A large multi-jurisdictional study on patient flow in Western Canada provided the opportunity to explore experiences with overcapacity management strategies across 10 diverse health regions. Four categories of interventions were employed by all or most regions: overcapacity protocols, alternative locations for emergency patients, locations for discharge-ready inpatients, and meetings to guide redistribution of patients. Two mechanisms undergirded successful interventions: providing a capacity buffer and promoting action by inpatient units by increasing staff accountability and/or solidarity. Participants reported that interventions demanded significant time and resources and the ongoing active involvement of middle and senior management. Furthermore, although most participants characterized overcapacity management practices as effective, this effectiveness was almost universally experienced as temporary. Many regions described a context of chronic overcapacity, which persisted despite continued intervention. Processes designed to manage short-term surges in demand cannot rectify a long-term mismatch between capacity and demand; solutions at the level of system redesign are needed.