Emergency department crowding affects triage processes

Evaluating LLM-based generative AI tools in emergency triage: A comparative study of ChatGPT Plus, Copilot Pro, and triage nurses

BACKGROUND

The number of emergency department (ED) visits has been on steady increase globally. Artificial Intelligence (AI) technologies, including Large Language Model (LLMs)-based generative AI models, have shown promise in improving triage accuracy. This study evaluates the performance of ChatGPT and Copilot in triage at a high-volume urban hospital, hypothesizing that these tools can match trained physicians' accuracy and reduce human bias amidst ED crowding challenges.

METHODS

This single-center, prospective observational study was conducted in an urban ED over one week. Adult patients were enrolled through random 24-h intervals. Exclusions included minors, trauma cases, and incomplete data. Triage nurses assessed patients while an emergency medicine (EM) physician documented clinical vignettes and assigned emergency severity index (ESI) levels. These vignettes were then introduced to ChatGPT and Copilot for comparison with the triage nurse's decision.

RESULTS

The overall triage accuracy was 65.2 % for nurses, 66.5 % for ChatGPT, and 61.8 % for Copilot, with no significant difference (p = 0.000). Moderate agreement was observed between the EM physician and ChatGPT, triage nurses, and Copilot (Cohen's Kappa = 0.537, 0.477, and 0.472, respectively). In recognizing high-acuity patients, ChatGPT and Copilot outperformed triage nurses (87.8 % and 85.7 % versus 32.7 %, respectively). Compared to ChatGPT and Copilot, nurses significantly under-triaged patients (p < 0.05). The analysis of predictive performance for ChatGPT, Copilot, and triage nurses demonstrated varying discrimination abilities across ESI levels, all of which were statistically significant (p < 0.05). ChatGPT and Copilot exhibited consistent accuracy across age, gender, and admission time, whereas triage nurses were more likely to mistriage patients under 45 years old.

CONCLUSION

ChatGPT and Copilot outperform traditional nurse triage in identifying high-acuity patients, but real-time ED capacity data is crucial to prevent overcrowding and ensure high-quality of emergency care.

Factors affecting early antibiotic delivery in open tibial shaft fractures

INTRODUCTION

The incidence of infection in open tibial shaft injuries varies with the severity of the injury with rates ranging from roughly 2% for Gustilo-Anderson type I to nearly 43% for type IIIB fractures. As with all fractures, timely antibiotics administration in the emergency department (ED) is an essential component of fracture management and infection prevention. This study identifies factors associated with the expedient administration of antibiotics for open tibial shaft fractures.

METHODS

This retrospective study identified patients treated for open tibial shaft fractures at an academic level 1 trauma center between 2015 and 2021. Open fractures were identified by reviewing patient charts. We used chart reviews to gather demographics, fracture characteristics, postoperative outcomes, trauma activation, and time to antibiotic order, delivery, and operating room. Univariate analysis was used to compare patients who received antibiotics within 1 h of ED presentation to those who did not. Multivariate analysis was performed to investigate factors associated with faster delivery of antibiotics.

RESULTS

Among 70 ED patients with open tibial shaft fractures, 39 (56%) received early administration of antibiotics. Arrival at the ED via emergency medical service (EMS) as opposed to walking in (98% vs. 74%, p = 0.01) and trauma activation (90% vs. 52%, p < 0.001) were significantly more common in the early administration group than the late group. The early group had shorter intervals between antibiotic order and delivery (0.02 h vs. 0.35 h, p = 0.007). Multivariate analysis suggested that trauma activation, EMS arrival, and arrival during non-overnight shifts were independent predictors of a shorter time to antibiotic administration (odds ratios 11.9, 30.7, and 5.4, p = 0.001, 0.016, and 0.013, respectively).

DISCUSSION

Earlier antibiotic delivery is associated with non-overnight arrival at the ED, arrival via EMS, and a coordinated trauma activation. Our findings indicate that in cases where administering antibiotics is critical to achieving positive outcomes, it is advisable to initiate a coordinated trauma response. Furthermore, hospital personnel should be attentive to the need for rapid administration of antibiotics to patients with open fractures who arrive via walk-in or during late-night hours.

Estimation of racial and language disparities in pediatric emergency department triage using statistical modeling and natural language processing

OBJECTIVES

The study aims to assess racial and language disparities in pediatric emergency department (ED) triage using analytical techniques and provide insights into the extent and nature of the disparities in the ED setting.

MATERIALS AND METHODS

The study analyzed a cross-sectional dataset encompassing ED visits from January 2019 to April 2021. The study utilized analytical techniques, including K-mean clustering (KNN), multivariate adaptive regression splines (MARS), and natural language processing (NLP) embedding. NLP embedding and KNN were employed to handle the chief complaints and categorize them into clusters, while the MARS was used to identify significant interactions among the clinical features. The study also explored important variables, including age-adjusted vital signs. Multiple logistic regression models with varying specifications were developed to assess the robustness of analysis results.

RESULTS

The study consistently found that non-White children, especially African American (AA) and Hispanic, were often under-triaged, with AA children having >2 times higher odds of receiving lower acuity scores compared to White children. While the results are generally consistent, incorporating relevant variables modified the results for specific patient groups (eg, Asians).

DISCUSSION

By employing a comprehensive analysis methodology, the study checked the robustness of the analysis results on racial and language disparities in pediatric ED triage. The study also recognized the significance of analytical techniques in assessing pediatric health conditions and analyzing disparities.

CONCLUSION

The study's findings highlight the significant need for equal and fair assessment and treatment in the pediatric ED, regardless of their patients' race and language.

Merging of two level-1 trauma centers in Amsterdam: premerger demand in integrated acute trauma care

PURPOSE

Availability of adequate and appropriate trauma care is essential. A merger of two Dutch academic level-1 trauma centers is upcoming. However, in the literature, volume effects after a merger are inconclusive. This study aimed to examine the premerger demand for level-1 trauma care on integrated acute trauma care and evaluate the expected demand on the system.

METHODS

A retrospective observational study was conducted between 1-1-2018 and 1-1-2019 in two level-1 trauma centers in the Amsterdam region using data derived from the local trauma registries and electronic patient records. All trauma patients presented at both centers' Emergency Departments (ED) were included. Patient- and injury characteristics and data concerning all prehospital and in-hospital-delivered trauma care were collected and compared. Pragmatically, the demand for trauma care in the post-merger setting was considered a sum of care demand for both centers.

RESULTS

In total, 8277 trauma patients were presented at both EDs, 4996 (60.4%) at location A and 3281 (39.6%) at location B. Overall, 462 patients were considered severely injured patients (Injury Severity Score ≥ 16). In total, 702 emergency surgeries (< 24 h) were performed, and 442 patients were admitted to the ICU. The sum care demand of both centers resulted in a 167.4% increase in trauma patients and a 151.1% increase in severely injured patients. Moreover, on 96 occasions annually, two or more patients within the same hour would require advanced trauma resuscitation by a specialized team or emergency surgery.

CONCLUSION

A merger of two Dutch level-1 trauma centers would, in this scenario, result in a more than 150% increase in the post-merger setting's demand for integrated acute trauma care.

Comparing Emergency Nursing Measures Before and During COVID-19: A Retrospective Study of Assessment, Triage, and Workflow

Background

The COVID-19 pandemic significantly impacted emergency department (ED) operations and patient care. Understanding its effects on nursing processes, triage accuracy, and wait times is pivotal for optimizing outcomes.

Objectives

This study aimed to analyze the differences in nursing processes, triage accuracy, and wait times before and during the COVID-19 pandemic.

Design

A retrospective cohort study.

Methods

The study analyzed 224 electronic medical records from a single ED, with 120 records from the pre-pandemic period (January 2019-February 2020) and 104 records from the pandemic period (March 2020-March 2021). Dependent variables included missed nursing care per validated scales, triage accuracy per Emergency Severity Index, and wait times for nursing triage and physician examination. Independent factors encompassed sociodemographic, clinical characteristics, and organization dynamics.

Results

Sociodemographic and clinical profiles were comparable between periods. Triage accuracy remained high except for older patients. Nursing triage wait times differed little, yet physician examination and urgent case waits decreased amidst the pandemic. Nursing documentation completeness, such as recording patient status and mental state, augmented during this crisis period.

Conclusion

This evaluation identified differences in triage accuracy, wait times, and documentation completeness before and during the COVID-19 pandemic period at a single institution. Patient age and clinical status influenced some metrics. Lessons from comparing precrisis benchmarks to intra-pandemic nursing performance may guide pandemic preparedness strategies. Further research is warranted to optimize emergency processes and outcomes during public health emergencies, as well as examine strategies through multicenter investigations comparing prepandemic to intra-pandemic performance to provide broader insights into challenges and inform efforts to bolster emergency care through future crises.

Clinical correlations of extraocular motility limitation pattern in orbital fracture cases: a retrospective cohort study in a level 1 trauma centre

PURPOSE

Ocular pathology (OP) following orbital fracture can vary vastly in complexity and severity. Extra-ocular motility (EOM) limitations are frequently present in orbital trauma cases, with patterns of duction limitations being symmetrical or asymmetrical. The aim of this study was to identify if there was any association between increased OP following orbital fracture cases based on the pattern of EOM deficits.

METHODS

This is a retrospective cohort study of patients with fractured orbits presenting with or without EOM limitations to a level 1 trauma center between August 2015 to January 2018. All pertinent elements of the ophthalmic examination were recorded. Outcome measures: Chi-square analyses assessed for association between symmetrical or asymmetrical EOM limitation and OP. Odds ratios were calculated with 95% confidence interval.

RESULTS

278 orbits with wall fractures were included in this study. A significant correlation between EOM limitation and increased OP following orbital trauma was found (p = 0.000081). Cases with symmetrical and asymmetrical EOM limitation were 7.9 (95%CI: 2.3-27.2) and 5.22 (95%CI: 1.9-13.9) times more likely to have OP than cases with no EOM limitation, respectively. With extraocular muscle entrapment excluded, cases with symmetrical limitations had a significantly higher incidence of OP than cases with asymmetrical limitations (p = 0.0161).

CONCLUSIONS

OP is frequently observed in cases of orbital fracture. While any EOM limitations should prompt the clinicians to anticipate OP, intra-ocular injury may be more likely in cases of symmetrical EOM limitation. Future prospective studies are needed to further elucidate the relationship between EOM symmetricity and OP following orbital trauma.

A comparison between the impacts of lecturing and flipped classrooms in virtual learning on triage nurses' knowledge and professional capability: an experimental study

BACKGROUND

The quality of triage in emergency department depends on regular evaluation of triage nurses' professional capabilities and development of programs to improve them. Flipped classrooms are a new approach to learning which can be employed to improve professional capabilities. The present study aims to compare the impact of lecturing to flipped classrooms in virtual learning on the knowledge and professional capabilities of triage nurses in the emergency departments of the state hospitals of Yazd province in south-western Iran in 2022.

METHODS

The present study is an experimental work of research. Seventy-four triage nurses participated in the study. Seventy-four triage nurses were randomly allocated to the two groups, including flipped classrooms (group B) and lecturing (group A). The data collection instruments were an emergency department triage nurses' professional capability questionnaire and a triage knowledge questionnaire. The collected data were analyzed in SPSS v.22 using independent t-test, chi-squared test, and repeated measures analysis of variance. Level of significance was set at p ≥ 0.05.

RESULTS

The participants' mean age was 33.1 ± 4.3 years. As measured one month after the education, the triage knowledge mean score of the nurses who were educated using the flipped classroom method (9.29 ± 1.73) was higher than that of the nurses who were educated via lecturing (8.45 ± 1.788), and the difference was statistically significant (p = 0.001). Also, measured one month after the education, the professional capability mean score of the nurses who were educated using the flipped classroom method (140.27 ± 11.744) was higher than that of the nurses who were educated via lecturing (132.84 ± 10.817), and the difference was statistically significant (p = 0.006).

CONCLUSION

There was a significant difference between the pretest and posttest knowledge and professional capability mean scores of both groups immediately after the education. However, measured one month after the education, the mean and standard deviation of the knowledge and professional capability scores of the triage nurses who had been educated via flipped classrooms were higher than those of the nurses in the lecturing group. Thus, virtual learning using flipped classrooms is more effective than lecturing in improving triage nurses' knowledge and professional capability in the long run.

Strategies to improve the quality of nurse triage in emergency departments: A realist review protocol

AIM

The purpose of this realist review was to assess what works, for whom and in what context, regarding strategies that influence nurses' behaviour to improve triage quality in emergency departments (ED).

DESIGN

Realist review protocol.

METHODS

This protocol follows the PRISMA-P statement and will include any type of study on strategies to improve the triage process in the ED (using recognized and validated triage scales). The included studies were examined for scientific quality using the Mixed Methods Appraisal Tool. The framework for this realist review is based on the Behaviour Change Wheel (BCW) and the context-mechanism-outcome (CMO) models.

DISCUSSION

Nurses and ED decision makers will be informed on the evidence regarding strategies to improve the quality of triage and the factors required to maximize their effectiveness. Research gaps may also be identified to guide future research projects on the adoption of best practices in ED nursing triage.

Investigating the professional capability of triage nurses in the emergency department and its determinants: a multicenter cross-sectional study in Iran

BACKGROUND

Planning to improve the professional capabilities of triage nurses requires determining the level of professional capabilities and its determinants. In this regard, the present study was conducted to determine the professional capability of triage nurses and its determinants for the first time in Iran.

METHODS

A descriptive cross-sectional multicenter study was conducted in 2022. The research population included all nurses working in triage units of emergency departments of seven selected hospitals in Fars Province, south of Iran. The samples were selected using convenience sampling. The data collection tools were the "Triage nurses' professional capability questionnaire in the emergency department" and a questionnaire to investigate determinants of triage nurses' professional capability. Descriptive and analytical (Pearson's correlation test and multiple linear regression analysis) were used for data analysis in the SPSS software version 27. P values ≤ 0.05 were considered significant.

RESULTS

Out of 580 participants, 342 (59%) were female. The professional capability of triage nurses was at a moderate level with a mean score of 124.11 ± 14.72. The mean score of clinical competence, psychological empowerment, and professional commitment was 71.56 ± 9.67, 19.86 ± 3.95, and 32.69 ± 3.54, respectively. The results of multiple linear regression analysis showed that 5 factors, including participation in educational courses (p < 0.001), having clinical experience and specialized knowledge in emergency department (p < 0.001), error registry and assessment system (p < 0.001), managers' support (p < 0.001), and recruiting experienced staff (p = 0.018) affected the nurses' professional capability.

CONCLUSION

In the present study, the triage nurses had moderate levels of professional capability. It is necessary that nursing managers develop effective plans to improve the professional capability of triage nurses in emergency departments to enhance the quality and effectiveness of emergency services.

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.

Impact of the 24/7 nurse practitioner model on emergency department stay at a level 1 trauma center: A retrospective study

AIMS

The aim of the study was to assess the impact of 24/7 trauma nurse practitioner service model on the emergency department patient flow.

BACKGROUND

Seamless transition of trauma patients through the emergency department to inpatient hospital care is crucial for coordination of care, clinical safety and positive health outcomes. A level 1 trauma centre located in Southern West Virginia, USA expanded their trauma nurse practitioner service covering the emergency department 24/7.

DESIGN

Retrospective cohort study conducted in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines.

METHODS

Patients admitted to the trauma centre between March 2019 and February 2020 were divided into two groups: trauma patients managed by trauma nurse practitioners versus the hospitalist service. The hospital service group was chosen as the comparator group because any admission prior to night coverage by the trauma nurse practitioners were managed by the hospitalist service.

RESULTS

The emergency department length of stay was significantly lower in trauma nurse practitioners' patients by an average of 300 min (772.25 ± 831.91 vs. 471.44 ± 336.65, p = <.001). Similarly, time to place emergency department discharge order was shorter by 49 min (277.76 ± 159.69 vs. 228.27 ± 116.04, p = .001) for this group. Moreover, trauma nurse practitioners on an average placed one less consultation (1.06 ± 0.23 vs. 1.46 ± 0.74, p < .001).

CONCLUSION

The patient care provided by trauma nurse practitioners aided in the reduction of strain felt by their emergency department. They were able to help facilitate patient flow thus lessening the pressure of boarding in an overcrowded emergency department. The study institution hopes to sustain the current service model and continue to review outcomes and processes managed by trauma nurse practitioners to ensure consistency and quality.

RELEVANCE TO CLINICAL PRACTICE

Similar trauma centres should evaluate the structure of their trauma service that includes the role of trauma nurse practitioner service and work towards allowing them to manage patient care from the emergency department 24/7.

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.

Development and validation of a prediction rule for patients suspected of acute coronary syndrome in primary care: a cross-sectional study

OBJECTIVE

To develop and validate a symptom-based prediction rule for early recognition of acute coronary syndrome (ACS) in patients with acute chest discomfort who call out-of-hours services for primary care (OHS-PC).

DESIGN

Cross-sectional study. A diagnostic prediction rule was developed with multivariable regression analyses. All models were validated with internal-external cross validation within seven OHS-PC locations. Both age and sex were analysed as statistical interaction terms, applying for age non-linear effects.

SETTING

Seven OHS-PC in the Netherlands.

PARTICIPANTS

2192 patients who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2017. Backed up recordings of telephone triage conversations were analysed.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Diagnosis of ACS retrieved from the patient's medical records in general practice, including hospital specialists discharge letters. Performance of the prediction rules was calculated with the c-statistic and the final model was chosen based on net benefit analyses.

RESULTS

Among the 2192 patients who called the OHS-PC with acute chest discomfort, 8.3% females and 15.3% males had an ACS. The final diagnostic model included seven predictors (sex, age, acute onset of chest pain lasting less than 12 hours, a pressing/heavy character of the pain, radiation of the pain, sweating and calling at night). It had an adjusted c-statistic of 0.77 (95% CI 0.74 to 0.79) with good calibration.

CONCLUSION

The final prediction model for ACS has good discrimination and calibration and shows promise for replacing the existing telephone triage rules for patients with acute chest discomfort in general practice and OHS-PC.

TRIAL REGISTRATION NUMBER

NTR7331.

Bed-to-Bed Transfer Program Among Patients Who Need Hospitalization in a Crowded Emergency Department in Taiwan

BACKGROUND

Emergency department (ED) crowding is a universal issue. In Taiwan, patients with common medical problems prefer to visit ED of medical centers, resulting in overcrowding. Thus, a bed-to-bed transfer program has been implemented since 2014. However, there was few studies that compared clinical outcomes among patients who choose to stay in medical centers to those being transferred to regional hospitals. The aim of this study was to explore the transfer rate, delineate the factors related to patient transfer, and clarify the influence upon the program outcomes.

METHODS

A retrospective cohort study was conducted using demographic and clinical disease factors from the patient electronic referral system, electronic medical records (EMRs) of a medical center in Taipei, and response to referrals from regional hospitals. The study included adult patients who were assessed as appropriate for transfer in 2016. We analyzed the outcomes (length of stay and mortality rate) between the referrals were accepted and refused using propensity score matching.

RESULTS

Of the 1759 patients eligible for transfer to regional hospitals, 420 patients (24%) accepted the referral. Medical records were obtained from the regional hospitals for 283 patients (67%). After propensity score matching, the results showed that interhospital transfer resulted in similar median total length of stay (8.7 days in the medical center vs 7.9 days in regional hospitals; P=.245). In-hospital mortality was low for both groups (3.1% in the medical center vs 1.3% in regional hospitals; P=.344).

CONCLUSION

Transfer from an overcrowded ED in a medical center to regional hospitals in eligible patients results in non-significant outcome of total length of stay. With the caveat of an underpowered sample, we did not find statistically significant differences in in-hospital mortality. This healthcare delivery model may be used in other cities facing similar problems of ED overcrowding.

The Feasibility of Ultra-Sensitive Phonocardiography in Acute Chest Pain Patients of a Tertiary Care Emergency Department (ScorED Feasibility Study)

BACKGROUND

Thoracic pain is one of the most frequent chief complaints at emergency departments (EDs). However, a respective workup in cases without clear electrocardiographic signs is complex. In addition, after having ruled out acute coronary syndrome (ACS), patients are often left with an unclear etiology of their symptoms. Ultra-sensitive phonocardiography is already used to rule out stable coronary artery disease (CAD); however, its feasibility in an ED-setting remains unknown.

METHODS

We prospectively used ultra-sensitive phonocardiography via the CADScor®System to measure hemodynamically stable patients with the chief complaint of chest pain during routine waiting times at a high-volume tertiary ED.

RESULTS

A total of 101 patients (49% male; 94% Caucasian; 61 (51-71) years; BMI 28.3 (24.2-31.6)) were enrolled. Patient workflow was not hindered, and no adverse events were recorded. In 80% of cases, a score was successfully calculated, with 74% at the first, 5% at the second, and 1% at the third attempt. Feasibility was judged as 9.0 (±1.8) by the patients, and 8.9 (±2.6) by the investigators on a 10-point Likert scale.

CONCLUSIONS

Ultra-sensitive phonocardiography was found to be feasible in acute chest pain patients presenting to a tertiary ED. Thus, the CAD score measured during routine waiting times could potentially serve as an additional tool in a diagnostic pathway for thoracic pain.

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.

Machine learning methods applied to triage in emergency services: A systematic review

BACKGROUND

In emergency services is important to accurately assess and classify symptoms, which may be improved with the help of technology. One mechanism that could help and improve predictions from health records or patient flow is machine learning (ML).

AIM

To analyse the effectiveness of ML systems in triage for making predictions at the emergency department in comparison with other triage scales/scores.

METHODS

Following the PRISMA recommendations, a systematic review was conducted using CINAHL, Cochrane, Cuiden, Medline and Scopus databases with the search equation "Machine learning AND triage AND emergency".

RESULTS

Eleven studies were identified. The studies show that the use of ML methods consistently predict important outcomes like mortality, critical care outcomes and admission, and the need for hospitalization in comparison with scales like Emergency Severity Index or others. Among the ML models considered, XGBoost and Deep Neural Networks obtained the highest levels of prediction accuracy, while Logistic Regression performed obtained the worst values.

CONCLUSIONS

Machine learning methods can be a good instrument for helping triage process with the prediction of important emergency variables like mortality or the need for critical care or hospitalization.

A NICE combination for predicting hospitalisation at the Emergency Department: a European multicentre observational study of febrile children

Background

Prolonged Emergency Department (ED) stay causes crowding and negatively impacts quality of care. We developed and validated a prediction model for early identification of febrile children with a high risk of hospitalisation in order to improve ED flow.

Methods

The MOFICHE study prospectively collected data on febrile children (0-18 years) presenting to 12 European EDs. A prediction models was constructed using multivariable logistic regression and included patient characteristics available at triage. We determined the discriminative values of the model by calculating the area under the receiver operating curve (AUC).

Findings

Of 38,424 paediatric encounters, 9,735 children were admitted to the ward and 157 to the PICU. The prediction model, combining patient characteristics and NICE alarming, yielded an AUC of 0.84 (95%CI 0.83-0.84).The model performed well for a rule-in threshold of 75% (specificity 99.0% (95%CI 98.9-99.1%, positive likelihood ratio 15.1 (95%CI 13.4-17.1), positive predictive value 0.84 (95%CI 0.82-0.86)) and a rule-out threshold of 7.5% (sensitivity 95.4% (95%CI 95.0-95.8), negative likelihood ratio 0.15 (95%CI 0.14-0.16), negative predictive value 0..95 (95%CI 0.95-9.96)). Validation in a separate dataset showed an excellent AUC of 0.91 (95%CI 0.90- 0.93). The model performed well for identifying children needing PICU admission (AUC 0.95, 95%CI 0.93-0.97). A digital calculator was developed to facilitate clinical use.

Interpretation

Patient characteristics and NICE alarming signs available at triage can be used to identify febrile children at high risk for hospitalisation and can be used to improve ED flow.

Funding

European Union, NIHR, NHS.

Advances in point-of-care testing for cardiovascular diseases

Point-of-care testing (POCT) is a specific format of diagnostic testing that is conducted without accompanying infrastructure or sophisticated instrumentation. Traditionally, such rapid sample-to-answer assays provide inferior analytical performances to their laboratory counterparts when measuring cardiac biomarkers. Hence, their potentially broad applicability is somewhat bound by their inability to detect clinically relevant concentrations of cardiac troponin (cTn) in the early stages of myocardial injury. However, the continuous refinement of biorecognition elements, the optimization of detection techniques, and the fabrication of tailored fluid handling systems to manage the sensing process has stimulated the production of commercial assays that can support accelerated diagnostic pathways. This review will present the latest commercial POC assays and examine their impact on clinical decision-making. The individual elements that constitute POC assays will be explored, with an emphasis on aspects that contribute to economically feasible and highly sensitive assays. Furthermore, the prospect of POCT imparting a greater influence on early interventions for medium to high-risk individuals and the potential to re-shape the paradigm of cardiovascular risk assessments will be discussed.

Areas of delay related to prolonged length of stay in an emergency department of an academic hospital in South Africa

Introduction

Globally, length of stay of patients in emergency departments remains a challenge. Remaining in the emergency department for >12 h increases health care costs, morbidity and mortality rates and leads to crowding and lower patient satisfaction.The aim of this research was to describe the areas of delay related to prolonged length of stay in the emergency department of an academic hospital.

Methods

A quantitative retrospective study was done. The Input-Throughput-Output model was used to identify the areas of patients' journey through the emergency department. The possible areas of delay where then described. Using systematic sampling, a total of 100 patient files managed in an emergency department of an academic hospital in South Africa were audited over a period of 3 months. Descriptive statistics and regression analysis was used to analyse data.

Results

The mean length of stay of patients in the emergency department was 73 h 49 min. The length of stay per phase was: input (3 h 17 min), throughput (16 h 25 min) and output (54 h 7 min). A strong significant relationship found between the length of stay and the time taken between disposition decision (throughput phase) disposition decision to admission or discharge of patients from the ED (output phase) (p < 0.05).

Conclusion

The output phase was identified as the longest area of delay in this study, with the time taken between disposition decision to admission or discharge of patients from the ED (patients waiting for inpatient beds) as the main significant area of delay.

Delayed flow is a risk to patient safety: A mixed method analysis of emergency department patient flow

INTRODUCTION

Increasing emergency department (ED) demand and crowding has heightened focus on the need for better understanding of patient flow.

AIM

This study aimed to identify input, throughput and output factors contributing to ED patient flow bottlenecks and extended ED length of stay (EDLOS).

METHOD

Concurrent nested mixed method study based on retrospective analysis of attendance data, patient flow observational data and a focus group in an Australian regional ED.

RESULTS

Analysis of 89 013 ED presentations identified increased EDLOS, particularly for patients requiring admission. Mapping of 382 patient journeys identified delays in time to triage assessment (0-39 mins) and extended waiting room stays (0-348 mins). High proportions of patients received care outside ED cubicles. Four qualitative themes emerged: coping under pressure, compromising care and safety, makeshift spaces, and makeshift roles.

CONCLUSION

Three key findings emerged: i) hidden waits such as extended triage-queuing occur during the input phase; ii) makeshift spaces are frequently used to assess and treat patients during times of crowding; and iii) access block has an adverse effect on output flow. Data suggests arrival numbers may not be a key predictor of EDLOS. This research contributes to our understanding of ED crowding and patient flow, informing service delivery and planning.

Physical violence and verbal abuse against nurses working with risk stratification: characteristics, related factors, and consequences

OBJECTIVE

to analyze the characteristics, related factors, and consequences of physical violence and verbal abuse against nurses working with risk stratification.

METHODS

a cross-sectional, descriptive and quantitative study carried out with 80 nurses who work with risk stratification in emergency services. Data were collected using an adapted instrument and analyzed using (uni)bivariate inferential statistics.

RESULTS

companions were the main perpetrators of verbal abuse (86.1%); and patients inflicted physical violence (100%). Professionals with up to five years of experience are 74% less likely to suffer physical violence (p=0.029). Women suffer 5.83 times more verbal abuse than men (p=0.026). Sadness (15.8%) and fear of the aggressor (15.3%) were the main consequences of verbal abuse; and fear of the aggressor (22.2%) and stress (22.2%) were results of physical violence.

CONCLUSION

violence is influenced by institutional, professional and client aspects. Therefore, coping with it requires multidimensional strategies.

Factors related to fear of movement after acute cardiac hospitalization

Background

Fear of movement (kinesiophobia) after an acute cardiac hospitalization (ACH) is associated with reduced physical activity (PA) and non-adherence to cardiac rehabilitation (CR).

Purpose

To investigate which factors are related to kinesiophobia after an ACH, and to investigate the support needs of patients in relation to PA and the uptake of CR.

Methods

Patients were included 2–3 weeks after hospital discharge for ACH. The level of kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK-NL Heart). A score of > 28 points is defined as ‘high levels of kinesiophobia’ (HighKin) and ≤ 28 as ‘low levels of kinesiophobia’ (LowKin). Patients were invited to participate in a semi-structured interview with the fear avoidance model (FAM) as theoretical framework. Interviews continued until data-saturation was reached. All interviews were analyzed with an inductive content analysis.

Results

Data-saturation was reached after 16 participants (median age 65) were included in this study after an ACH. HighKin were diagnosed in seven patients. HighKin were related to: (1) disrupted healthcare process, (2) negative beliefs and attitudes concerning PA. LowKin were related to: (1) understanding the necessity of PA, (2) experiencing social support. Patients formulated ‘tailored information and support from a health care provider’ as most important need after hospital discharge.

Conclusion

This study adds to the knowledge of factors related to kinesiophobia and its influence on PA and the uptake of CR. These findings should be further validated in future studies and can be used to develop early interventions to prevent or treat kinesiophobia and stimulate the uptake of CR.

Pediatric emergency care: Associations between process factors and outcomes - Children's and parents' views combined with register data

BACKGROUND

Care quality in hospital units can be assessed based on three elements: structure, process, and outcomes. Relationships between elements are particularly important but have largely been unexplored.

PURPOSE

The purpose of the study was to investigate the relationships between factors of the emergency care process, length of stay, and care outcomes (i.e. care quality and patient satisfaction).

METHODS

Medical and administrative registry data from children's visits were combined with cross-sectional survey data and analyzed using descriptive methods, median test, and linear regression. Eighty-nine child-parent pairs from four emergency departments participated.

RESULTS

The shortest length of stay had children at the lowest triage level (p < 0.001) Children with more diagnostic tests (p < 0.001) and more procedures (p < 0.001) performed had the longest length of stay. In linear regression analysis (f = 6.626, df = 6, p = 0.001, R² = 0.214), the satisfaction of child-parent pairs was associated with performance of more tests and procedures, higher triage levels, and child streaming onto the pediatrician care track.

CONCLUSIONS

Care process factors affect length of children's stay in emergency departments and could predict children's and parents' satisfaction with, and evaluations of, care quality.

Effects of environmental distractors on nurse emergency triage accuracy: a pilot study protocol

Background

The clinical decisions of emergency department triage nurses need to be of the highest accuracy. However, studies have found repeatedly that these nurses over- or underestimate the severity of patient health conditions. This has major consequences for patient safety and patient flow management. Workplace distractors such as noise and task interruptions have been pointed to as factors that might explain this inaccuracy. The use of a serious game reproducing the work environment during triage affords the opportunity to explore the impact of these distractors on nurse emergency triage accuracy, in a safe setting.

Methods/design

A pilot study with a factorial design will be carried out to test the acceptability and feasibility of a serious game developed specifically to simulate the triage process in emergency departments and to explore the primary effects of distractors on nurse emergency triage accuracy. Eighty emergency nurses will be randomized into four groups: three groups exposed to different distractors (A, noise; B, task interruptions; C, noise and task interruptions) and one control group. All nurses will have to complete 20 clinical vignettes within 2 h. For each vignette, a gold standard assessment will be determined by experts. Pre-tests will be conducted with clinicians and certified emergency nurses to evaluate the appeal of the serious game.

Discussion

Study results will inform the design of large-scale investigations and will help identify teaching, training, and research areas that require further development.

Perceptions of the Essential Components of Triage: A Qualitative Analysis

INTRODUCTION

Triage is an important process to determine severity of illness and prioritize patient emergencies while also ensuring patient safety. The emergency nurse must use critical thinking and decision-making to identify life-threatening emergencies and improve patient outcomes. However, the addition of risk screenings and quality improvement initiatives has extended the triage process time, which may increase interruptions and opportunities for errors. The purpose of this descriptive qualitative study was to determine emergency nurse perceptions of current triage processes and categorize essential and nonessential triage components.

METHODS

Focus groups of frontline emergency nurses who regularly conduct triage in the emergency department were conducted to discuss perceptions of triage assessments and questions. The 3 focus group discussions were digitally recorded and transcribed. Data analysis consisted of descriptive statistics of the sample and the conventional content analysis of the transcripts.

RESULTS

A total of 12 emergency nurses participated in the study. The overall theme that emerged surrounding essential triage components was a perceived conflict between individualized care and maintaining systems and processes. This theme consisted of 4: (a) must ask, (b) actions of triage, (c) relevant but not urgent for triage, and (d) not perceived as relevant.

CONCLUSION

This study identified the perceptions of emergency nurses surrounding the urgency of triage components in the emergency department. Emergency nurses perceived some assessments as essential to determining "sick versus not sick," and other triage components were able to be delayed, streamlining the triage process.

Primary care assessment of orbital trauma at a level 1 trauma centre

OBJECTIVE

With increasing constraints on our publicly funded health care system, appropriate triage of trauma patients is becoming pivotal, making the primary care assessment (PCA) invaluable. Our study aims to compare the initial assessment of patients with orbital fractures with that conducted by the ophthalmology service.

DESIGN

Retrospective chart review.

PARTICIPANTS

243 patients with 277 fractured orbits presenting to a level 1 trauma centre seen between August 2015 and January 2018.

METHODS

Key elements of the PCA, including subjective vision loss, visual acuity, intraocular pressure, pupil examination, and extraocular movements, were documented and compared with the assessment by the ophthalmology service as the control. The primary outcome was inter-rater reliability as estimated by Cohen's kappa (κ) coefficient. Secondary outcomes included the sensitivity and specificity, as well as the rate of completion of examination components.

RESULTS

PCA examination findings agreed with the ophthalmology service on most components of the examination with the highest agreement with relative afferent pupillary defects and detection of hyphemas (κ = 1). Primary care physicians less often performed most aspects of the assessment. Among performed components of the examination, the average sensitivity was 60.6%, and the average specificity was 84.2%.

CONCLUSIONS

Our results show good inter-rater reliability of the PCA compared with the ophthalmology examination but low rate of completion of examination components, suggesting a potential overdependence on the ophthalmology assessment. Given the limited resources of the public health care system, our study may highlight the PCA as a potential focus to improve effective and safe patient management.

Implementation of a Standardized Initial Assessment for Demand Management in Outpatient Emergency Care in Germany: Early Qualitative Process Evaluation

BACKGROUND

Inadequate assessment of the severity and urgency of medical problems is one of the factors contributing to unnecessary emergency department (ED) visits. The implementation of a software-based instrument for standardized initial assessment-Standardisierte medizinische Ersteinschätzung in Deutschland (SmED) (Standardized medical Initial Assessment in Germany in English)-aims to support health care professionals and steer patients toward the right health care provider. This study aimed to explore the implementation process of SmED from a user perspective.

OBJECTIVE

This study aims to evaluate the overall perception of SmED by health care professionals using the software, to examine to what extent SmED influences the workload and work routines of health care professionals, and to determine which factors are associated with the use of SmED.

METHODS

An early qualitative process evaluation on the basis of interviews was carried out alongside the implementation of SmED in 26 outpatient emergency care services within 11 federal states in Germany. Participants were 30 health care professionals who work with SmED either at the joint central contact points of the outpatient emergency care service and the EDs of hospitals (ie, the Joint Counter; Gemeinsamer Tresen in German) or at the initial telephone contact points of the outpatient emergency care service (phone number 116117). Matrix-based framework analysis was applied to analyze the interview data.

RESULTS

Health care professionals perceived that workload increased initially, due to additional time needed per patient. When using SmED more frequently and over a longer time period, its use became more routine and the time needed per call, per patient, decreased. SmED was perceived to support decision making regarding urgency for medical treatment, but not all types of patients were eligible. Technical problems, lack of integration with other software, and lack of practicability during peak times affected the implementation of SmED.

CONCLUSIONS

Initial experiences with SmED were positive, in general, but also highlighted organizational issues that need to be addressed to enhance sustainability.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00017014; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017014.

Development and psychometric assessment of the triage nurses' professional capability questionnaire in the emergency department

BACKGROUND

Evaluation of triage nurses' professional capability is integral to identifying potentials for professional development and nurses' educational needs, thus, there is a need for valid instruments to assess their professional capability. The present study was conducted to develop and measure the reliability and validity of a triage nurses' professional capability questionnaire.

METHODS

This exploratory research was conducted in two stages: in the first stage (the qualitative phase), the concept of professional capability in triage nurses was defined and the items of the questionnaire were developed through conventional content analysis. In the second stage (the quantitative phase), the psychometric properties of the questionnaire were assessed based on analyses of its face validity, content validity, construct validity, internal homogeneity, and consistency.

RESULTS

The initial item pool consisted of 90 items, while the final scale was comprised of 35 items. The S-CVI/Ave of the questionnaire was found to be 0.96.The exploratory factor analysis showed that the factor loading of the items was between 0.46-0.89, all of which were significant, and the three dimensions introduced in the main instrument were verified with acceptable values. The overall intraclass correlation coefficient of the instrument was calculated to be 0.90. The reliability of the instrument was assessed in terms of its internal homogeneity where the Cronbach's alpha of the whole instrument was found to be 0.89.

CONCLUSIONS

The results showed that the questionnaire developed for assessment of triage nurses' professional capability is sufficiently reliable and valid and can be employed by nurse administrators to evaluate triage nurses' professional capability.

Referral rates for children with acute gastroenteritis: a retrospective cohort study

Background

Hospital admission rates are increasing for children with acute gastroenteritis. However, it is unknown whether this increase is accompanied by an increase in referral rates from GPs due to increased workloads in primary care out-of-hours (OOH) services.

Aim

To assess trends in referral rates from primary care OOH services to specialist emergency care for children presenting with acute gastroenteritis.

Design & setting

This retrospective cohort study covered a period from September 2007–September 2014. Children aged 6 months to 6 years presenting with acute gastroenteritis to a primary care OOH service were included.

Method

Pseudonymised data were obtained, and children were analysed overall and by age category. Χ² trend tests were used to assess rates of acute gastroenteritis, referrals, face-to-face contacts, and oral rehydration therapy (ORT) prescriptions.

Results

The data included 12 455 children (6517 boys), with a median age of 20.2 months (interquartile range [IQR] 11.6 to 36.0 months). Over 7 years, incidence rates of acute gastroenteritis decreased significantly, and face-to-face contact rates increased significantly (both, P<0.01). However, there was no significant trend for referral rates (P = 0.87) or prescription rates for ORT (P = 0.82). Subgroup analyses produced comparable results, although there was an increase in face-to-face contact rates for the older children.

Conclusion

Incidence rates for childhood acute gastroenteritis presenting in OOH services decreased and referral rates did not increase significantly. These findings may be useful as a reference for the impact of new interventions for childhood acute gastroenteritis.

Impact of Advanced Practice Prehospital Programs on Health Care Costs and ED Overcrowding: A Literature Review

Health care costs in the United States continue to increase, requiring solutions that permit safe, quality care with a lower financial investment. Utilization of the emergency department for nonemergent care is considered to be one of the costliest, and most preventable methods of health care delivery. This review seeks to demonstrate how advanced practice prehospital programs can potentially decrease the cost of health care without sacrificing quality or safety. Utilization of the emergency department for nonemergent care contributes to the escalating cost of health care as well as to emergency department overcrowding. Advanced practice prehospital programs are a novel approach to potentially decreasing health care costs and emergency department overcrowding. This review introduces the current state of health care costs, emergency department overcrowding, and advanced practice prehospital programs. Further research is needed to determine the actual fiscal impact of these programs.

Blood sampling during nurse triage reduces patient length of stay in the emergency department: A propensity score-weighted, population-based study

BACKGROUND

Increases in patients' length of stay (LOS) in the emergency department (ED) have led to overcrowding.

OBJECTIVES

In this study, the implementation of blood sampling during triage in lower priority level patients was assessed as a possible means to reduce LOS.

METHODS

A retrospective study was performed from January 2018 to January 2019. Lower priority level patients who required blood sampling for further diagnosis were considered. Patients who underwent blood sampling during triage evaluation were compared with those who underwent blood sampling after a physician's initial evaluation.

RESULTS

During the study period, 15,596 patients were enrolled. LOS was shorter in patients who underwent triage blood sampling, presenting a median value of 154 min in comparison with the 172 min recorded in the control group (p < 0.001). Using a propensity score-matching to control the two groups' differences, LOS remained lower in the triage-sampling group (151 vs. 175 min; p < 0.001). In the adjusted multivariate model, triage blood sampling was found to be an independent factor for a decrease in the LOS, with standardized coefficient β = 0.857 (0.822-0.894; p < 0.001).

CONCLUSIONS

Performing blood sampling during nurse triage can decrease LOS in ED and also reduce ED permanence after a physician's initial evaluation.

Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study

Background

Emergency Department (ED) overcrowding adversely affects patients’ health, accessibility, and quality of healthcare systems for communities. Several studies have addressed this issue. This study aimed to conduct a systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals.

Methods

Original research articles on crowding of emergencies at hospitals published from 1st January 2007, and 1st August 2018 were utilized. Relevant studies from the PubMed and EMBASE databases were assessed using suitable keywords. Two reviewers independently screened the titles, abstracts and the methodological validity of the records using data extraction format before their inclusion in the final review. Discussions with the senior faculty member were used to resolve any disagreements among the reviewers during the assessment phase.

Results

Out of the total 117 articles in the final record, we excluded 11 of them because of poor quality. Thus, this systematic review synthesized the reports of 106 original articles. Overall 14, 55 and 29 of the reviewed refer to causes, effects, and solutions of ED crowding, respectively. The review also included four articles on both causes and effects and another four on causes and solutions. Multiple individual patients and healthcare system related challenges, experiences and responses to crowding and its consequences are comprehensively synthesized.

Conclusion

ED overcrowding is a multi-facet issue which affects by patient-related factors and emergency service delivery. Crowding of the EDs adversely affected individual patients, healthcare delivery systems and communities. The identified issues concern organizational managers, leadership, and operational level actions to reduce crowding and improve emergency healthcare outcomes efficiently.

Triage accuracy and causes of mistriage using the Korean Triage and Acuity Scale

Purpose

To identify emergency department triage accuracy using the Korean Triage and Acuity Scale (KTAS) and evaluate the causes of mistriage.

Methods

This cross-sectional retrospective study was based on 1267 systematically selected records of adult patients admitted to two emergency departments between October 2016 and September 2017. Twenty-four variables were assessed, including chief complaints, vital signs according to the initial nursing records, and clinical outcomes. Three triage experts, a certified emergency nurse, a KTAS provider and instructor, and a nurse recommended based on excellent emergency department experience and competence determined the true KTAS. Triage accuracy was evaluated by inter-rater agreement between the expert and emergency nurse KTAS scores. The comments of the experts were analyzed to evaluate the cause of triage error. An independent sample t-test was conducted to compare the number of patient visits per hour in terms of the accuracy and inaccuracy of triage.

Results

Inter-rater reliability between the emergency nurse and the true KTAS score was weighted kappa = .83 and Pearson’s r = .88 (p < .001). Of 1267 records, 186 (14.7%) showed some disagreement (under triage = 131, over triage = 55). Causes of mistriage included: error applying the numerical rating scale (n = 64) and misjudgment of the physical symptoms associated with the chief complaint (n = 47). There was no statistically significant difference in the number of patient visits per hour for accurate and inaccurate triage (t = -0.77, p = .442).

Conclusion

There was highly agreement between the KTAS scores determined by emergency nurses and those determined by experts. The main cause of mistriage was misapplication of the pain scale to the KTAS algorithm.

Improving STEMI management in the emergency department: Examining the role of minority groups and sociodemographic characteristics

OBJECTIVE

To evaluate whether a fast-track intervention program will reduce time-lags of patients with STEMI considering minority groups, various socioeconomic status (SES) and clinical risk factors.

METHODS

A retrospective-archive study was conducted according to clinical guidelines, comparing all STEMI patients (n = 140) admitted to the emergency department (ED) before (n = 60) and during (n = 80) implementation of the fast track intervention program. The program comprised four steps: (1) immediate bed rest, (2) marking patient chart, (3) assessing time-lags according to defined clinical guidelines, and (4) physician signing a dedicated sticker on the ECG.

RESULTS

The major ethnic group compared to other minority patients with STEMI were less delayed for physician examination (r = -0.398, p < 0.01), spent less time at ED (r = -0.541, p < 0.01) and reached percutaneous coronary intervention earlier (r = -0.672, p < 0.01). Patients with higher SES spent less time for physician (r = -338, p < 0.05) and in the ED (r = -0.415, p < 0.01). Before intervention patients with diabetes mellitus (DM) spent more time at ED compared to non DM patients, however during intervention this difference was blurred (β = -0.803, p < 0.001). Gaps regarding sociodemographic bias remained present throughout the intervention despite monthly staff evaluations considering patient cases.

CONCLUSIONS

The fast track intervention was associated with less time at ED and to cardiac reperfusion. Yet, sociodemographic bias was present. Our findings highlight the need for the healthcare profession to address the role of biases in disparities in healthcare.

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Emergency department crowding: A systematic review of causes, consequences and solutions

BACKGROUND

Emergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions.

AIM

The aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A structured search of four databases (Medline, CINAHL, EMBASE and Web of Science) was undertaken to identify peer-reviewed research publications aimed at investigating the causes or consequences of, or solutions to, emergency department crowding, published between January 2000 and June 2018. Two reviewers used validated critical appraisal tools to independently assess the quality of the studies. The study protocol was registered with the International prospective register of systematic reviews (PROSPERO 2017: CRD42017073439).

RESULTS

From 4,131 identified studies and 162 full text reviews, 102 studies met the inclusion criteria. The majority were retrospective cohort studies, with the greatest proportion (51%) trialling or modelling potential solutions to emergency department crowding. Fourteen studies examined causes and 40 investigated consequences. Two studies looked at both causes and consequences, and two investigated causes and solutions.

CONCLUSIONS

The negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. This review identified a mismatch between causes and solutions. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Solutions aimed at the introduction of whole-of-system initiatives to meet timed patient disposition targets, as well as extended hours of primary care, demonstrated promising outcomes. While the review identified increased presentations by the elderly with complex and chronic conditions as an emerging and widespread driver of crowding, more research is required to isolate the precise local factors leading to ED crowding, with system-wide solutions tailored to address identified causes.

Assessing bottlenecks in Emergency Department flow of patients with abdominal pain

INTRODUCTION

Abdominal pain has a wide range of possible causes, which may lead to difficulties in diagnosing and lengthy Emergency Department (ED) stays. In this study, bottlenecks in ED processes of patients with abdominal pain were identified.

METHODS

Time-points of patients who presented to a Dutch ED with abdominal pain were observed and documented. The institutional review board approved the study.

RESULTS

In total, 3015 min of patient time were observed in 54 patients. Median length of stay (LOS) was 218 min for admitted patients, and 168 min for discharged patients. For 65 patients (27.4%), LOS exceeded 4 h. Delays were found during the diagnostic process, when multiple physicians were needed in order to make a decision, and during departure.

CONCLUSIONS

Our study concerning individual patients' time-points provides important insight into delays in the patient journey of patients with abdominal pain. Flow improvement can be achieved by focusing on these bottlenecks, for example by minimizing diagnostic delays and by simultaneous specialists' consultations for patients who need more than one physician. The optimization of ED flow for patients with abdominal pain depends on coordinated efforts between ED staff, medical specialists, radiology and laboratory staff, staff from inpatient units, and hospital supporting services.

Systematically assessed symptoms as outcome predictors in emergency patients

INTRODUCTION

It is known that symptoms are predictive of mortality in "nonsurgical" emergency patients. It is unknown whether a prospective, systematic, and "unscreened" assessment of all symptoms is of any prognostic value. Therefore, we aimed to examine the association between symptoms and outcomes in an all-comer population.

METHODS

Data were acquired during 6weeks at the ED of the University Hospital Basel, a tertiary hospital. Consecutive patients presenting to the ED were included. Symptoms at presentation were systematically assessed using a comprehensive questionnaire.

RESULTS

A consecutive sample of 3960 emergency patients with a median age of 51years (51.7% male) was studied. The median number of symptoms was two. In the group of patients with the most prevalent symptoms, the median number of symptoms ranged between two and five. Overall, hospitalisation rate was 31.2%, referral to intensive care was 5.5%, in-hospital-mortality was 1.4%, and one-year mortality was 5.8%. In-hospital mortality ranged from 0% to 4.3%, and one-year mortality from 0% to 14.4% depending on the presenting symptoms. Dyspnoea and weakness were significant predictors of one-year mortality (14.4% and 9.2%, respectively).

DISCUSSION

Most emergency patients indicated two or more symptoms. Systematically assessed symptoms at presentation can be used for prediction of outcomes. While dyspnoea is a known predictor, weakness has not been identified as predictor of mortality before. This knowledge could be used to improve risk stratification- thereby reducing the risk of adverse outcomes.

Two emergency departments, 6000km apart: Differences in patient flow and staff perceptions about crowding

INTRODUCTION

Emergency department (ED) crowding is a worldwide public health issue. In this study, patient flow and staff perceptions of crowding were assessed in Pakistan (Aga Khan University Hospital (AKUH)) and in the Netherlands (Haaglanden Medical Centre Westeinde (HMCW)). Bottlenecks affecting ED patient flow were identified.

METHODS

First, a one-year review of patient visits was performed. Second, staff perceptions about ED crowding were collected using face-to-face interviews. Non-participant observation and document review were used to interpret the findings.

RESULTS

At AKUH 58,839 (160visits/day) and at HMCW 50,802 visits (140visits/day) were registered. Length of stay (LOS) at AKUH was significantly longer than at HMCW (279min (IQR 357) vs. 100min (IQR 152)). There were major differences in patient acuities, admission and mortality rates, indicating a sicker population at AKUH. Respondents from both departments experienced hampered patient flow on a daily basis, and perceived similar causes for crowding: increased patients' complexity, long treatment times, and poor availability of inpatient beds.

CONCLUSION

Despite differences in environment, demographics, and ED patient flow, respondents perceived similar bottlenecks in patient flow. Interventions should be tailored to specific ED and hospital needs. For both EDs, improving the outflow of boarded patients is essential.