Impact of an Express Admit Unit on Emergency Department Length of Stay

Nurses' perception of emergency department overcrowding: A qualitative study

INTRODUCTION

One of the most important wards of the hospital is the emergency department (ED). Due to the increasing number of referrals, overcrowding has become a significant problem. It means an increase in patients' referrals and swarms at the ED, limiting their medical staff access. This study investigates the nurses' experiences and perceptions about the reasons for ED overcrowding.

MATERIALS AND METHODS

Twelve emergency nurses were purposefully selected to take part in this study. Data collection was through face-to-face semi-structured interviews until data saturation was finalized. Data analysis was conducted using Graneheim and Lundman's conventional content analysis.

RESULTS

Nurses' experiences with the reasons for ED overcrowding came into two main categories. The first was "increased referral to the emergency department," which had three subcategories: "increased referral due to health system reform plan," "increased referral due to corona pandemic," and "improper triage." The second was "increased patients' length of stay at the ED" with seven subcategories including "shortage of bed," "shortage of nursing staff," "lack of physical space," "turtle para-clinic," "on-call specialists' delay," "timely medical record documentation requirements," and "delaying in patients' transfer from the ED to the ward."

CONCLUSION

The results showed ED overcrowding is inevitable. Intentional or unintentional changes in the health system, such as implementing the health system reform plan or the corona pandemic, can also increase overcrowding. Findings showed ED overcrowding increased referrals and patients' length of stay. This study suggests the health system authorities pay more attention to this phenomenon and look for solutions.

Risk factors for unplanned ICU admission after emergency department holding orders

STUDY HYPOTHESIS

Emergency department (ED) holding orders are used in an effort to streamline patient flow. Little research exists on the safety of this practice. Here, we report on prevalence and risk factors for upgrade of medical admissions to ICU for whom holding orders were written.

METHODS

Retrospective review of holding order admissions through our ED for years 2013-2018. Pregnancy, prisoner, pediatric, surgical, and ICU admissions were excluded, as were transfers from other hospitals. Risk factors of interest included vital signs, physiologic data, laboratory markers, sequential organ failure assessment (SOFA), Quick SOFA (qSOFA), modified early warning (MEWS) scores, and Charlson Comorbidity Index (CCI). Primary outcome was ICU transfer within 24 hours of admission. Analysis was completed using multivariable logistic regression.

RESULTS

Between 2013 and 2018, the ED had 203,374 visits. Approximately 20% (N = 54,915) were admitted, 23% of whom had holding orders (N = 12,680). A minority of those with a holding order were transferred to the ICU within 24 hours (N = 79; 0.62%). Those transferred to ICU had increased heart and respiratory rate, P/F ratio, and increased oxygen need. They also had higher MEWS, quick SOFA (qSOFA), and SOFA scores. Multivariable logistic regression demonstrated a significant association between ICU admission and FiO2 (odds ratio [OR] 1.47; 95% confidence interval [CI] 1.25-1.74), MEWS (OR 1.31; 95% CI 1.14-1.52), SOFA Score (OR 1.19; 95% CI 1.05-1.35), and gastrointestinal (OR 3.25; 95% CI: 1.50-7.03) or other combined diagnosis (OR 2.19; CI: 1.07-4.48) (P = 0.0017).

CONCLUSION

Holding orders are used for >20% of all admissions and <1% of those admissions required transfer to ICU within 24 hours.

An Edge Computing Based Smart Healthcare Framework for Resource Management

The revolution in information technologies, and the spread of the Internet of Things (IoT) and smart city industrial systems, have fostered widespread use of smart systems. As a complex, 24/7 service, healthcare requires efficient and reliable follow-up on daily operations, service and resources. Cloud and edge computing are essential for smart and efficient healthcare systems in smart cities. Emergency departments (ED) are real-time systems with complex dynamic behavior, and they require tailored techniques to model, simulate and optimize system resources and service flow. ED issues are mainly due to resource shortage and resource assignment efficiency. In this paper, we propose a resource preservation net (RPN) framework using Petri net, integrated with custom cloud and edge computing suitable for ED systems. The proposed framework is designed to model non-consumable resources and is theoretically described and validated. RPN is applicable to a real-life scenario where key performance indicators such as patient length of stay (LoS), resource utilization rate and average patient waiting time are modeled and optimized. As the system must be reliable, efficient and secure, the use of cloud and edge computing is critical. The proposed framework is simulated, which highlights significant improvements in LoS, resource utilization and patient waiting time.

Assessing the Physical Environment of Emergency Departments

Background:

Emergency Department (ED) is considered to be the heart of a hospital. Based on many studies, a well-organized physical environment can enhance efficacy.

Objectives:

In this study, we aimed to investigate the influence of physical environment in EDs on efficacy.

Materials and Methods:

This analytical cross-sectional study was conducted via the faculty members of the ED and residents of Shahid Beheshti University of Medical Sciences in Tehran, Iran. Data were collected using a predefined questionnaire. Descriptive statistics and ANOVA were used to analyze the data.

Results:

Sixty-two participants, including 21 females and 41 males, completed the questionnaires. The mean age of the participants was 37 years (SD: 8.42). The mean work experience was 8 years (SD: 4.52) and all the studied variables varied within a range of 3.3 - 4.2. Time indices had the highest mean among variables followed by capacity, work space, treatment units, critical care units and, triage indices, respectively.

Conclusions:

In general, time indices including length of patient stay in the ED and space capacity, emphasizing the need to address these shortcomings.

Cost-effectiveness of a physician-nurse supplementary triage assessment team at an academic tertiary care emergency department

OBJECTIVE

The purpose of this study was to evaluate the cost-effectiveness of physician-nurse supplementary triage assistance team (MDRNSTAT) from a hospital and patient perspective.

METHODS

This was a cost-effectiveness evaluation of a cluster randomized control trial comparing the MDRNSTAT with nurse-only triage in the emergency department (ED) between the hours of 0800 and 1500. Cost was MDRNSTAT salary. Revenue was from Ontario's Pay-for-Results and patient volume-case mix payment programs. The incremental cost-effectiveness ratio was based on MDRNSTAT cost and three consequence assessments: 1) per additional patient-seen; 2) per physician initial assessment (PIA) hour saved; and 3) per ED length of stay (EDLOS) hour saved. Patient opportunity cost was determined. Patient satisfaction was quantified by a cost-benefit ratio. A sensitivity analysis extrapolating MDRNSTAT to different working hours, salary, and willingness-to-pay data was performed.

RESULTS

The added cost of the MDRNSTAT was $3,597.27 [$1,729.47 to ∞] per additional patient-seen, $75.37 [$67.99 to $105.30] per PIA hour saved, and $112.99 [$74.68 to $251.43] per EDLOS hour saved. From the hospital perspective, the cost-benefit ratio was 38.6 [19.0 to ∞] and net present value of -$447,996 [-$435,646 to -$459,900]. For patients, the cost-benefit ratio for satisfaction was 2.8 [2.3 to 4.6]. If MDRNSTAT performance were consistently implemented from noon to midnight, it would be more cost-effective.

CONCLUSIONS

The MDRNSTAT is not a cost-effective daytime strategy but appears to be more feasible during time periods with higher patient volume, such as late morning to evening.

Review article: Emergency department models of care in the context of care quality and cost: a systematic review

To identify current ED models of care and their impact on care quality, care effectiveness, and cost. A systematic search of key health databases (Medline, CINAHL, Cochrane, EMbase) was conducted to identify literature on ED models of care. Additionally, a focused review of the contents of 11 international and national emergency medicine, nursing and health economic journals (published between 2010 and 2013) was undertaken with snowball identification of references of the most recent and relevant papers. Articles published between 1998 and 2013 in the English language were included for initial review by three of the authors. Studies in underdeveloped countries and not addressing the objectives of the present study were excluded. Relevant details were extracted from the retrieved literature, and analysed for relevance and impact. The literature was synthesised around the study's main themes. Models described within the literature mainly focused on addressing issues at the input, throughput or output stages of ED care delivery. Models often varied to account for site specific characteristics (e.g. onsite inpatient units) or to suit staffing profiles (e.g. extended scope physiotherapist), ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Only a few studies conducted cost-effectiveness analysis of service models. Although various models of delivering emergency healthcare exist, further research is required in order to make accurate and reliable assessments of their safety, clinical effectiveness and cost-effectiveness.

Inter-facility transfer of surgical emergencies in a developing country: effects on management and surgical outcomes

OBJECTIVES

Outcomes of surgical emergencies are associated with promptness of the appropriate surgical intervention. However, delayed presentation of surgical patients is common in most developing countries. Delays commonly occur due to transfer of patients between facilities. The aim of the present study was to assess the effect of delays in treatment caused by inter-facility transfers of patients presenting with surgical emergencies as measured by objective and subjective parameters.

METHODS

We prospectively collected data on all patients presenting with an acute surgical emergency at Aga Khan University Hospital (AKUH). Information regarding demographics, social class, reason and number of transfers, and distance traveled were collected. Patients were categorized into two groups, those transferred to AKUH from another facility (transferred) and direct arrivals (non-transfers). Differences between presenting physiological parameters, vital statistics, and management were tested between the two groups by the chi square and t tests.

RESULTS

Ninety-nine patients were included, 49 (49.5 %) patients having been transferred from another facility. The most common reason for transfer was "lack of satisfactory surgical care." There were significant differences in presenting pulse, oxygen saturation, respiratory rate, fluid for resuscitation, glasgow coma scale, and revised trauma score (all p values <0.001) between transferred and non-transferred patients. In 56 patients there was a further delay in admission, and the most common reason was bed availability, followed by financial constraints. Three patients were shifted out of the hospital due to lack of ventilator, and 14 patients left against medical advice due to financial limitations. One patient died.

CONCLUSIONS

Inter-facility transfer of patients with surgical emergencies is common. These patients arrive with deranged physiology which requires complex and prolonged hospital care. Patients who cannot afford treatment are most vulnerable to transfers and delays.

Solutions to emergency department 'boarding' and crowding are underused and may need to be legislated

The practice of keeping admitted patients on stretchers in hospital emergency department hallways for hours or days, called "boarding," causes emergency department crowding and can be harmful to patients. Boarding increases patients' morbidity, lengths of hospital stay, and mortality. Strategies that optimize bed management reduce boarding by improving the efficiency of hospital patient flow, but these strategies are grossly underused. Convincing hospital leaders of the value of such solutions, and educating patients to advocate for such changes, may promote improvements. If these strategies do not work, legislation may be required to effect meaningful change.

Using Data to Drive Emergency Department Design: A Metasynthesis

Objective:

There has been an uptick in the field of emergency department (ED) operations research and data gathering, both published and unpublished. This new information has implications for ED design. The specialty suffers from an inability to have these innovations reach frontline practitioners, let alone design professionals and architects. This paper is an attempt to synthesize for design professionals the growing data regarding ED operations.

Methods:

The following sources were used to capture and summarize the research and data collections available regarding ED operations: the Emergency Department Benchmarking Alliance database; a literature search using both PubMed and Google Scholar search engines; and data presented at conferences and proceedings.

Results:

Critical information that affects ED design strategies is summarized, organized, and presented. Data suggest an optimal size for ED functional units. The now-recognized arrival and census curves for the ED suggest a department that expands and contracts in response to changing census. Operational improvements have been clearly identified and are grouped into three categories: input, throughput, and outflow. Applications of this information are suggested.

Conclusion:

The sentinel premise of this meta-synthesis is that data derived from improvement work in the area of ED operations has applications for ED design. EDs can optimize their functioning by marrying good processes and operations to good design. This review paper is an attempt to bring this new information to the attention of the multidisciplinary team of architects, designers, and clinicians.

Evaluation of a flexible acute admission unit: effects on transfers to other hospitals and patient throughput times

INTRODUCTION

To prevent overcrowding of the emergency department, a flexible acute admission unit (FAAU) was created, consisting of 15 inpatient regular beds located in different departments. We expected the FAAU to result in fewer transfers to other hospitals and in a lower length of stay (LOS) of patients needing hospital admission.

METHODS

A before-and-after interventional study was performed in a level 1 trauma center in the Netherlands. Number of transfers and LOS of admitted ED patients in a 4-month period in 2008 (control period) and a 4-month period in 2009 (intervention period) were analyzed.

RESULTS

Of 1,619 regular admission patients, 768 were admitted in the control period and 851 in the intervention period. The number of transfers decreased from 80 (10.42%) to 54 (6.35%) (P = .0037). The mean ED LOS of both the non-admitted patients and the admitted patients needing special care significantly increased (105 minutes vs 117 minutes [P = .022] and 176 minutes vs 191 minutes [P < .001], respectively). However, the mean LOS of FAAU-admissible patients was unaltered (226 minutes vs 225 minutes, P = .865).

CONCLUSIONS

The FAAU reduced the number of transfers of admitted patients to other hospitals. The increase in LOS for special care patients and non-admitted patients was not observed for regular, FAAU-admissible patients. Flexible bed management might be useful in preventing overcrowding.