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Farimani RM, Karim H, Atashi A, Tohidinezhad F, Bahaadini K, Abu-Hanna A, Eslami S. Models to predict length of stay in the emergency department: a systematic literature review and appraisal. BMC Emerg Med 2024; 24:54. [PMID: 38575857 PMCID: PMC10996208 DOI: 10.1186/s12873-024-00965-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/11/2024] [Indexed: 04/06/2024] Open
Abstract
INTRODUCTION Prolonged Length of Stay (LOS) in ED (Emergency Department) has been associated with poor clinical outcomes. Prediction of ED LOS may help optimize resource utilization, clinical management, and benchmarking. This study aims to systematically review models for predicting ED LOS and to assess the reporting and methodological quality about these models. METHODS The online database PubMed, Scopus, and Web of Science (10 Sep 2023) was searched for English language articles that reported prediction models of LOS in ED. Identified titles and abstracts were independently screened by two reviewers. All original papers describing either development (with or without internal validation) or external validation of a prediction model for LOS in ED were included. RESULTS Of 12,193 uniquely identified articles, 34 studies were included (29 describe the development of new models and five describe the validation of existing models). Different statistical and machine learning methods were applied to the papers. On the 39-point reporting score and 11-point methodological quality score, the highest reporting scores for development and validation studies were 39 and 8, respectively. CONCLUSION Various studies on prediction models for ED LOS were published but they are fairly heterogeneous and suffer from methodological and reporting issues. Model development studies were associated with a poor to a fair level of methodological quality in terms of the predictor selection approach, the sample size, reproducibility of the results, missing imputation technique, and avoiding dichotomizing continuous variables. Moreover, it is recommended that future investigators use the confirmed checklist to improve the quality of reporting.
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Affiliation(s)
| | - Hesam Karim
- Department of Health Information Management, Faculty of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Atashi
- E-Health Department, Virtual School, Tehran University of Medical Sciences, Tehran, Iran
| | - Fariba Tohidinezhad
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kambiz Bahaadini
- Department of Medical Informatics, Kerman University of Medical Sciences, Kerman, Iran
| | - Ameen Abu-Hanna
- Medical Informatics, UMC Location University of Amsterdam, Meibergdreef, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Saeid Eslami
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
- Medical Informatics, UMC Location University of Amsterdam, Meibergdreef, Amsterdam, The Netherlands.
- Pharmaceutical Research Center, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
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Saidinejad M, Duffy S, Wallin D, Hoffmann JA, Joseph MM, Schieferle Uhlenbrock J, Brown K, Waseem M, Snow S, Andrew M, Kuo AA, Sulton C, Chun T, Lee LK. The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies. Pediatrics 2023; 152:e2023063256. [PMID: 37584106 DOI: 10.1542/peds.2023-063256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 08/17/2023] Open
Abstract
Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed.
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Affiliation(s)
- Mohsen Saidinejad
- Department of Clinical Emergency Medicine & Pediatrics, David Geffen School of Medicine at UCLA, Institute for Health Services and Outcomes Research, The Lundquist Institute for Biomedical Innovation at Harbor UCLA, and Department of Emergency Medicine, Harbor UCLA Medical Center, Los Angeles, California
| | - Susan Duffy
- Department of Emergency Medicine, Brown University School of Medicine, Providence, Rhode Island
| | - Dina Wallin
- Department of Emergency Medicine, University of California San Francisco, UCSF Benioff Children's Hospital, San Francisco, California
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Evanston, Illinois
| | - Madeline M Joseph
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, University of Florida Health Sciences Center, Jacksonville, Jacksonville, Florida
| | | | - Kathleen Brown
- Emergency Medicine and Trauma Center, Children's National Hospital, Washington, District of Columbia
| | - Muhammad Waseem
- Department of Emergency Medicine, Lincoln Medical Center, Bronx, New York
| | - Sally Snow
- Independent Consultant, Pediatric Emergency and Trauma Nursing
| | | | - Alice A Kuo
- Departments of Medicine and Pediatrics, University of California, Los Angeles, Los Angeles, California
| | - Carmen Sulton
- Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, CPG Sedation Services, Children's Healthcare of Atlanta, Egleston, Atlanta, Georgia
| | - Thomas Chun
- Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, Hasbro Children's Hospital, Warren Alpert Medical School of Medicine at Brown University, Providence, Rhode Island
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Department of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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Savioli G, Ceresa IF, Bressan MA, Piccini GB, Varesi A, Novelli V, Muzzi A, Cutti S, Ricevuti G, Esposito C, Voza A, Desai A, Longhitano Y, Saviano A, Piccioni A, Piccolella F, Bellou A, Zanza C, Oddone E. Five Level Triage vs. Four Level Triage in a Quaternary Emergency Department: National Analysis on Waiting Time, Validity, and Crowding-The CREONTE (Crowding and RE-Organization National TriagE) Study Group. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040781. [PMID: 37109739 PMCID: PMC10143416 DOI: 10.3390/medicina59040781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Triage systems help provide the right care at the right time for patients presenting to emergency departments (EDs). Triage systems are generally used to subdivide patients into three to five categories according to the system used, and their performance must be carefully monitored to ensure the best care for patients. Materials and Methods: We examined ED accesses in the context of 4-level (4LT) and 5-level triage systems (5LT), implemented from 1 January 2014 to 31 December 2020. This study assessed the effects of a 5LT on wait times and under-triage (UT) and over-triage (OT). We also examined how 5LT and 4LT systems reflected actual patient acuity by correlating triage codes with severity codes at discharge. Other outcomes included the impact of crowding indices and 5LT system function during the COVID-19 pandemic in the study populations. Results: We evaluated 423,257 ED presentations. Visits to the ED by more fragile and seriously ill individuals increased, with a progressive increase in crowding. The length of stay (LOS), exit block, boarding, and processing times increased, reflecting a net raise in throughput and output factors, with a consequent lengthening of wait times. The decreased UT trend was observed after implementing the 5LT system. Conversely, a slight rise in OT was reported, although this did not affect the medium-high-intensity care area. Conclusions: Introducing a 5LT improved ED performance and patient care.
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Affiliation(s)
- Gabriele Savioli
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Maria Antonietta Bressan
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Angelica Varesi
- Faculty of Medicine, University of Pavia, 27100 Pavia, Italy
| | - Viola Novelli
- Health Department, University of Pavia, 27100 Pavia, Italy
| | - Alba Muzzi
- Health Department, University of Pavia, 27100 Pavia, Italy
| | - Sara Cutti
- Health Department, University of Pavia, 27100 Pavia, Italy
| | | | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy
| | - Antonio Voza
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Desai
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Department of Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Angela Saviano
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Fabio Piccolella
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Abdel Bellou
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Christian Zanza
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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Nordt SP, Ryan JM, Kelly D, Kutubi A, Saleh R, Quinn C, Al Kharusi T, Tiernan EJ. Palliative care patient emergency department visits at tertiary university-based emergency department in Ireland. Am J Emerg Med 2023; 66:76-80. [PMID: 36736062 DOI: 10.1016/j.ajem.2023.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/15/2023] [Accepted: 01/18/2023] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Palliative care patients often present to the emergency department (ED) for various reasons e.g., acute illness, pain, altered mental status, and complications of therapy. Many visits involve less severe etiologies e.g., dyspnea, constipation, fear as patients approach the end of life, which may be more effectively and efficiently managed outside of the ED. The objective of this study is to identify and assess the frequency of presenting complaints, primary diagnosis, triage acuity, need for admission, in an Irish setting. METHODS A single-center retrospective, observational study of palliative care patients presenting to a tertiary-care university hospital emergency department in Dublin, Ireland. Study subjects were identified using the palliative care database and cross-referencing with the ED electronic patient record system database. The primary objective to identify potential areas to minimize ED visits and improve patient care and quality of life by elucidating reasons for visits. Outcome measures include presenting complaint, primary diagnosis, triage severity score, admission, discharge, death in hospital. Statistical analysis presented as descriptive statistics. RESULTS Four-hundred-ninety-nine ED visits, 245 (49%) were male, and 254 (51%) were female with a mean age of 69.3 years-of-age. Most patients, 285 (57.1%) self-referred to the emergency department, with general practitioners and skilled nursing facility referrals 72 (14.4%) and 39 (7.8%), respectively. Primary diagnoses were various cancers, chronic obstructive pulmonary disease, congestive heart failure, and dementia. Major reasons for visits were dyspnea, pain, falls, trauma, fever, and altered mental status. Two-hundred-eighty-nine patients (58%) had an emergency severity index (ESI) score of 1 or 2 demonstrating a higher level of acuity. Three-hundred-fifty-eight (71.7%) were admitted, 141 (28.3%) discharged to home, 64 (12.8%) admitted patients died during their hospital admission. CONCLUSIONS Palliative care patients utilize ED services not uncommonly. Though many of these patients presented with higher acuity triage scores, 42% had lower ESI scores and may be effectively managed outside of the ED. These data suggest developing mechanisms for these patients to be urgently evaluated in their homes or facilities obviating the need for an ED evaluation.
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Affiliation(s)
- Sean Patrick Nordt
- Department of Emergency Medicine, Loma Linda University, School of Medicine, Loma Linda, CA, United States of America.
| | - John M Ryan
- Department of Emergency Medicine, St. Vincent's University Hospital, Dublin, Ireland
| | | | | | | | | | | | - Eoin J Tiernan
- Department of Palliative Medicine, St. Vincent's University Hospital, Dublin, Ireland
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Decreased readmission rates following use of modified trauma-specific frailty index in older trauma patients: A follow-up study. Injury 2023; 54:1302-1305. [PMID: 36740474 DOI: 10.1016/j.injury.2023.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 01/02/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Post-discharge readmission rates using modified Trauma-Specific Frailty Index (mTSFI) compared to the Emergency Severity Index (ESI) are unknown. In our pilot study, we demonstrated that mTSFI usage more accurately triages older trauma patients. In the current study, we hypothesized that adult trauma patients triaged using mTSFI would have lower readmission rates at the 30-day interval post discharge. METHODS Retrospective review of readmission rates for 96 trauma patients ≥ 50 years old was performed. The two study groups were categorized as mTSFI-concordant and ESI-concordant. Fisher's exact test was performed. RESULTS Mean ages for ESI and mTSFI groups were 63.8 (SD 10.6) and 65.2 (SD 10.8) years. The 30-day readmission rate was 0% (0/32) in the mTSFI group vs 11% (7/64) in the ESI group (p = 0.104). CONCLUSIONS Utilization of mTSFI for adult trauma patients may lead to lower 30-day readmission rates compared to using ESI, despite our sample sizes being too small to demonstrate a statistically significant difference.
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Vali M, Salimifard K, Gandomi AH, Chaussalet TJ. Application of job shop scheduling approach in green patient flow optimization using a hybrid swarm intelligence. COMPUTERS & INDUSTRIAL ENGINEERING 2022; 172:108603. [PMID: 36061977 PMCID: PMC9420315 DOI: 10.1016/j.cie.2022.108603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 07/21/2022] [Accepted: 08/22/2022] [Indexed: 06/15/2023]
Abstract
With the increasing demand for hospital services amidst the COVID-19 pandemic, allocation of limited public resources and management of healthcare services are of paramount importance. In the field of patient flow scheduling, previous research primarily focused on classical-based objective functions, while ignoring environmental-based objective functions. This study presents a flexible job shop scheduling problem to optimize patient flow and, thereby, minimize the total carbon footprint, as the sustainability-based objective function. Since flexible job shop scheduling is an NP-hard problem, a metaheuristic optimization algorithm, called Chaotic Salp Swarm Algorithm Enhanced with Opposition-Based Learning and Sine Cosine (CSSAOS), was developed. The proposed algorithm integrates the Salp Swarm Algorithm (SSA) with chaotic maps to update the position of followers, the sine cosine algorithm to update the leader position, and opposition-based learning for a better exploration of the search space. generating more accurate solutions. The proposed method was successfully applied in a real-world case study and demonstrated better performance than other well-known metaheuristic algorithms, including differential evolution, genetic algorithm, grasshopper optimization algorithm, SSA based on opposition-based learning, quantum evolutionary SSA, and whale optimization algorithm. In addition, it was found that the proposed method is scalable to different sizes and complexities.
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Affiliation(s)
- Masoumeh Vali
- Computational Intelligence & Intelligent Research Group, Business & Economics School, Persian Gulf University, Bushehr 75168, Iran
| | - Khodakaram Salimifard
- Computational Intelligence & Intelligent Research Group, Business & Economics School, Persian Gulf University, Bushehr 75168, Iran
| | - Amir H Gandomi
- Faculty of Engineering & Information Technology, University of Technology Sydney, Ultimo, NSW, 2007, Australia
| | - Thierry J Chaussalet
- Health and Social Care Modelling Group, School of Computer Science and Engineering, University of Westminster, London W1W 6UW, UK
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Völk S, Koedel U, Horster S, Bayer A, D'Haese JG, Pfister HW, Klein M. Patient disposition using the Emergency Severity Index: a retrospective observational study at an interdisciplinary emergency department. BMJ Open 2022; 12:e057684. [PMID: 35551090 PMCID: PMC9109098 DOI: 10.1136/bmjopen-2021-057684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Early patient disposition is crucial to prevent crowding in emergency departments (EDs). Our study aimed to characterise the need of in-house resources for patients treated in the ED according to the Emergency Severity Index (ESI) and the presenting complaint at the timepoint of triage. DESIGN A retrospective single-centre study was conducted. SETTING Data of all patients who presented to the interdisciplinary ED of a tertiary care hospital in Munich, Germany, from 2014 to 2017 were analysed. PARTICIPANTS n=113 694 patients were included. MEASURES ESI Score, medical speciality according to the chief complaint, mode of arrival, admission rates and discharge destination from the ED were evaluated. RESULTS Patient disposition varied according to ESI scores in combination with the chief complaint. Patients with low ESI scores were more likely to be admitted after treatment in the ED than patients with high ESI scores. Highly prioritised patients (ESI 1) mainly required admission to an intensive care unit (ICU, 27%), intermediate care unit (IMC, 37%) or immediate intervention (11%). In this critical patient group, 30% of patients with neurological or medical symptoms required immediate intensive care, whereas only 17% of patients with surgical problems were admitted to an ICU. A significant number of patients (particularly with neurological or medical problems) required hospital (and in some cases even ICU or IMC) admission despite high ESI scores. CONCLUSIONS Overall, ESI seems to be a useful tool to anticipate the need for specialised in-hospital resources on arrival. Patients with symptoms pointing at neurological or medical problems need particular attention as ESI may fail to sufficiently predict the care facility level for this patient group.
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Affiliation(s)
- Stefanie Völk
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Sophia Horster
- Emergency Department, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Andreas Bayer
- Department of Anaesthesiology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Jan G D'Haese
- Department of General, Visceral and Transplantation Surgery, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Matthias Klein
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
- Emergency Department, University Hospital, Ludwig Maximilians University, Munich, Germany
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Saberian SM, Chester DJ, Udobi KF, Childs EW, Danner OK, Sola R. A Comparative Analysis of Hospital Triage Systems in the Geriatric Adult Trauma Patients: A Quality Improvement Pilot Study. Am Surg 2022:31348221087907. [PMID: 35451871 DOI: 10.1177/00031348221087907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The objective of our study is to compare the predicted hospital admission disposition based on the level of risk as determined by the modified Trauma-Specific Frailty Index (mTSFI) score with those determined by arbitrary decisions made based on the Emergency Severity Index (ESI) severity level. METHODS We surveyed 100 trauma patients ages 50 and older, admitted to a level 1 trauma center between April 2019 and July 2019. We retrospectively reviewed the hospital admission disposition of each patient under the ESI, which was then compared to the mTSFI-predicted hospital admission disposition. The mTSFI scores were calculated by surveying each patient. Statistical analysis was performed to identify any statistical significance of concordance and discordance when comparing the mTSFI and ESI. RESULTS The average age was 57.6 ± 4.2 years old in the non-geriatric group vs 76.3 ± 7.3 years old in the geriatric group. There was a male predominance in both groups (61% vs 69.5%). The mTSFI identified a higher percentage of triage discordance in the non-geriatric group (73%) compared to the geriatric cohort (53%) (95% difference CI, [39.6-40], P = .05). DISCUSSION Non-geriatric patients have higher recorded rate of frailty than previously recognized and screening should begin at age 50, not 65. The mTSFI may be an effective tool to appropriately triage adult trauma patients at increased risk due to frailty and may reduce in-hospital complications.
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Affiliation(s)
- Sepehr M Saberian
- Department of Surgery, 1374Morehouse School of Medicine, Atlanta, GA, USA
| | - Daniel J Chester
- Department of Surgery, 1374Morehouse School of Medicine, Atlanta, GA, USA
| | - Kahdi F Udobi
- Department of Surgery, 1374Morehouse School of Medicine, Atlanta, GA, USA
| | - Ed W Childs
- Department of Surgery, 1374Morehouse School of Medicine, Atlanta, GA, USA
| | - Omar K Danner
- Department of Surgery, 1374Morehouse School of Medicine, Atlanta, GA, USA
| | - Richard Sola
- Department of Surgery, 1374Morehouse School of Medicine, Atlanta, GA, USA
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Minichsdorfer C, Jeryczynski G, Krall C, Achhorner AM, Caraan A, Pasalic S, Reininger K, Wagner C, Bartsch R, Preusser M, Laggner A, Raderer M, Fuereder T. Impact of COVID-19 lockdown on routine oncology versus emergency care at a high volume cancer centre. Eur J Clin Invest 2021; 51:e13623. [PMID: 34085717 PMCID: PMC8209914 DOI: 10.1111/eci.13623] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/22/2021] [Accepted: 05/22/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND We investigated the influence of population-wide COVID-19 lockdown measures implemented on 16, March 2020 on routine and emergency care of cancer outpatients at a tertiary care cancer centre in Vienna, Austria. METHODS We compared the number/visits of cancer outpatients receiving oncological therapies at the oncologic day clinic (DC) and admissions at the emergency department (ED) of our institution in time periods before (pre-lockdown period: 1 January - 15 March 2020) and after (post-lockdown period: 16 March- 31 May 2020) lockdown implementation with the respective reference periods of 2018 and 2019. Additionally, we analysed Emergency Severity Index (ESI) score of unplanned cancer patient presentations to the ED in the same post-lockdown time periods. Patient outcome was described as 3-month mortality rate (3-MM). RESULTS In total, 16 703 visits at the DC and 2664 patient visits for the respective time periods were recorded at the ED. No decrease in patient visits was observed at the DC after lockdown implementation (P = .351), whereas a substantial decrease in patient visits at the ED was seen (P < .001). This translates into a 26%-31% reduction of cancer-related patient visits per half month after the lockdown at the ED (P < .001 vs. 2018 + 2019). There was no difference in the distribution of ESI scores at ED presentation (P = .805), admission rates or 3-MM in association with lockdown implementation (P = .086). CONCLUSION We demonstrate the feasibility of maintaining antineoplastic therapy administration during the COVID-19 pandemic. However, our data underline the need for adapted management strategies for emergency presentations of cancer patients.
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Affiliation(s)
- Christoph Minichsdorfer
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Georg Jeryczynski
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Christoph Krall
- Centre for Medical Statistics, Informatics, and Intelligent Systems, Institute of Clinical Biometrics, Medical University of Vienna, Vienna, Austria
| | | | - Ariane Caraan
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sabina Pasalic
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Katharina Reininger
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Christina Wagner
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Rupert Bartsch
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anton Laggner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Raderer
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Thorsten Fuereder
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Lu FQ, Hanchate AD, Paasche-Orlow MK. Racial/ethnic disparities in emergency department wait times in the United States, 2013-2017. Am J Emerg Med 2021; 47:138-144. [PMID: 33812329 DOI: 10.1016/j.ajem.2021.03.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Previous research shows that Black and Hispanic patients have longer ED wait times than White patients, but these data do not reflect recent changes such as the Affordable Care Act. In addition, previous research does not account for the non-normal distribution of wait times, wherein a sizable subgroup of patients seen promptly and those not seen promptly experience long wait times. METHODS We utilized National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets (2013-2017) to examine mean ED wait time comparing visits by Black, Hispanic, and Asian patients to White patients. Using a two-part regression model, we adjusted for patient, hospital, and health system factors, and estimated differences, for each of five triage levels, in (a) likelihood of waiting at least 5 min and (b) difference in wait time among those not seen promptly. RESULTS Our cohort included 38,800 White, 14,838 Black, 10,619 Hispanic, and 1257 Asian patient visits. Black (triage level 3) and Hispanic (triage levels 3 and 4) patients had longer mean wait times than White patients. Adjusted likelihood of not being seen promptly was lower among Blacks (triage levels 3, 4 and 5), Hispanics (triage level 5) and Asians (triage level 5) compared to Whites. Among those waiting at least 5 min, adjusted wait time was longer among Blacks in triage level 3 (5.2 min, 95% CI, 1.3 to 9.0) and level 4 (2.5 min, 95% CI, 0.2 to 4.9), Hispanics in triage level 4 (4.7 min, 95% CI, 1.7 to 7.7) and Asians in triage level 5 (16.3 min, 95% CI, 0.6 to 31.9) compared to Whites. CONCLUSIONS Minority patients were less likely to wait to be seen, but waited longer if not seen promptly. These data exhibit that ED wait time disparities persist for African American and Hispanic patients and extend this observation to Asian patients.
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Affiliation(s)
| | - Amresh D Hanchate
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA; Department of Medicine, Boston Medical Center, Boston, MA, USA
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Müller M, Schechter CB, Hautz WE, Sauter TC, Exadaktylos AK, Stock S, Birrenbach T. The development and validation of a resource consumption score of an emergency department consultation. PLoS One 2021; 16:e0247244. [PMID: 33606767 PMCID: PMC7894944 DOI: 10.1371/journal.pone.0247244] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/03/2021] [Indexed: 11/18/2022] Open
Abstract
Background Emergency Department (ED) visits and health care costs are increasing globally, but little is known about contributing factors of ED resource consumption. This study aims to analyse and to predict the total ED resource consumption out of the patient and consultation characteristics in order to execute performance analysis and evaluate quality improvements. Methods Characteristics of ED visits of a large Swiss university hospital were summarized according to acute patient condition factors (e.g. chief complaint, resuscitation bay use, vital parameter deviations), chronic patient conditions (e.g. age, comorbidities, drug intake), and contextual factors (e.g. night-time admission). Univariable and multivariable linear regression analyses were conducted with the total ED resource consumption as the dependent variable. Results In total, 164,729 visits were included in the analysis. Physician resources accounted for the largest proportion (54.8%), followed by radiology (19.2%), and laboratory work-up (16.2%). In the multivariable final model, chief complaint had the highest impact on the total ED resource consumption, followed by resuscitation bay use and admission by ambulance. The impact of age group was small. The multivariable final model was validated (R2 of 0.54) and a scoring system was derived out of the predictors. Conclusions More than half of the variation in total ED resource consumption can be predicted by our suggested model in the internal validation, but further studies are needed for external validation. The score developed can be used to calculate benchmarks of an ED and provides leaders in emergency care with a tool that allows them to evaluate resource decisions and to estimate effects of organizational changes.
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Affiliation(s)
- Martin Müller
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
- Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
- * E-mail: (MM); (TB)
| | - Clyde B. Schechter
- Department of Family & Social Medicine & Department of Epidemiology Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Wolf E. Hautz
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
- Center for Educational Measurement, University of Oslo, Oslo, Norway
| | - Thomas C. Sauter
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Aristomenis K. Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Stephanie Stock
- Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Tanja Birrenbach
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
- * E-mail: (MM); (TB)
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Heppner S, Mohr NM, Carter KD, Ullrich F, Merchant KAS, Ward MM. HRSA's evidence-based tele-emergency network grant program: Multi-site prospective cohort analysis across six rural emergency department telemedicine networks. PLoS One 2021; 16:e0243211. [PMID: 33434197 PMCID: PMC7802919 DOI: 10.1371/journal.pone.0243211] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 11/17/2020] [Indexed: 11/18/2022] Open
Abstract
Background The Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP) funded the Evidence-Based Tele-Emergency Network Grant Program (EB TNGP) to serve the dual purpose of providing telehealth services in rural emergency departments (teleED) and systematically collecting data to inform the telehealth evidence base. This provided a unique opportunity to examine trends across multiple teleED networks and examine heterogeneity in processes and outcomes. Method and findings Six health systems received funding from HRSA under the EB TNGP to implement teleED services and they did so to 65 hospitals (91% rural) in 11 states. Three of the grantees provided teleED services to a general patient population while the remaining three grantees provided teleED services to specialized patient populations (i.e., stroke, behavioral health, critically ill children). Over a 26-month period (November 1, 2015 –December 31, 2017), each grantee submitted patient-level data for all their teleED encounters on a uniform set of measures to the data coordinating center. The six grantees reported a total of 4,324 teleED visits and 99.86% were technically successful. The teleED patients were predominantly adult, White, not Latinx, and covered by Medicare or private insurance. Across grantees, 7% of teleED patients needed resuscitation services, 58% were rated as emergent, and 30% were rated as urgent. Across grantees, 44.2% of teleED patients were transferred to another inpatient facility, 26.0% had a routine discharge, and 24.5% were admitted to the local inpatient facility. For the three grantees who served a general patient population, the most frequent presenting complaints for which teleED was activated were chest pain (25.7%), injury or trauma (17.1%), stroke symptoms (9.9%), mental/behavioral health (9.8%), and cardiac arrest (9.5%). The teleED consultation began before the local clinician exam in 37.8% of patients for the grantees who served a general patient population, but in only 1.9% of patients for the grantees who provided specialized services. Conclusions Grantees used teleED services for a representative rural population with urgent or emergent symptoms largely resulting in transfer to a distant hospital or inpatient admission locally. TeleED was often available as the first point of contact before a local provider examination. This finding points to the important role of teleED in improving access for rural ED patients.
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Affiliation(s)
- Sarah Heppner
- Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland, United States of America
- * E-mail:
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
- Department of Anesthesia Critical Care, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, United States of America
| | - Knute D. Carter
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, United States of America
| | - Fred Ullrich
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, United States of America
| | - Kimberly A. S. Merchant
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, United States of America
| | - Marcia M. Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, United States of America
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Sterling NW, Brann F, Patzer RE, Di M, Koebbe M, Burke M, Schrager JD. Prediction of emergency department resource requirements during triage: An application of current natural language processing techniques. J Am Coll Emerg Physicians Open 2020; 1:1676-1683. [PMID: 33392576 PMCID: PMC7771761 DOI: 10.1002/emp2.12253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/04/2020] [Accepted: 08/26/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Accurate triage in the emergency department (ED) is critical for medical safety and operational efficiency. We aimed to predict the number of future required ED resources, as defined by the Emergency Severity Index (ESI) triage protocol, using natural language processing of nursing triage notes. METHODS We constructed a retrospective cohort of all 265,572 consecutive ED encounters from 2015 to 2016 from 3 separate clinically heterogeneous academically affiliated EDs. We excluded encounters missing relevant information, leaving 226,317 encounters. We calculated the number of resources used by patients in the ED retrospectively and based outcome categories on criteria defined in the ESI algorithm: 0 (30,604 encounters), 1 (49,315 encounters), and 2 or more (146,398 encounters). A neural network model was trained on a training subset to predict the number of resources using triage notes and clinical variables at triage. Model performance was evaluated using the test subset and was compared with human ratings. RESULTS Overall model accuracy and macro F1 score for number of resources were 66.5% and 0.601, respectively. The model had similar macro F1 (0.589 vs 0.592) and overall accuracy (65.9% vs 69.0%) compared to human raters. Model predictions had slightly higher F1 scores and accuracy for 0 resources and were less accurate for 2 or more resources. CONCLUSIONS Machine learning of nursing triage notes, combined with clinical data available at ED presentation, can be used to predict the number of required future ED resources. These findings suggest that machine learning may be a valuable adjunct tool in the initial triage of ED patients.
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Affiliation(s)
- Nicholas W. Sterling
- Department of Emergency MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | | | - Rachel E. Patzer
- Department of SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
- Department of EpidemiologyRollins School of Public Health, Emory UniversityAtlantaGeorgiaUSA
| | - Mengyu Di
- Department of Biostatistics and BioinformaticsEmory UniversityAtlantaGeorgiaUSA
| | - Megan Koebbe
- Department of Emergency MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | - Madalyn Burke
- Department of Emergency MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | - Justin D. Schrager
- Department of Emergency MedicineEmory University School of MedicineAtlantaGeorgiaUSA
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Theiling BJ, Kennedy KV, Limkakeng AT, Manandhar P, Erkanli A, Pitts SR. A Method for Grouping Emergency Department Visits by Severity and Complexity. West J Emerg Med 2020; 21:1147-1155. [PMID: 32970568 PMCID: PMC7514412 DOI: 10.5811/westjem.2020.6.44086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 04/30/2020] [Accepted: 06/19/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Triage functions to quickly prioritize care and sort patients by anticipated resource needs. Despite widespread use of the Emergency Severity Index (ESI), there is still no universal standard for emergency department (ED) triage. Thus, it can be difficult to objectively assess national trends in ED acuity and resource requirements. We sought to derive an ESI from National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items (NHAMCS-ESI) and to assess the performance of this index with respect to stratifying outcomes, including hospital admission, waiting times, and ED length of stay (LOS). METHODS We used data from the 2010-2015 NHAMCS, to create a measure of ED visit complexity based on variables within NHAMCS. We used NHAMCS data on chief complaint, vitals, resources used, interventions, and pain level to group ED visits into five levels of acuity using a stepwise algorithm that mirrored ESI. In addition, we examined associations of NHAMCS-ESI with typical indicators of acuity such as waiting time, LOS, and disposition. The NHAMCS-ESI categorization was also compared against the "immediacy" variable across all of these outcomes. Visit counts used weighted scores to estimate national levels of ED visits. RESULTS The NHAMCS ED visits represent an estimated 805,726,000 ED visits over this time period. NHAMCS-ESI categorized visits somewhat evenly, with most visits (42.5%) categorized as a level 3. The categorization pattern is distinct from that of the "immediacy" variable within NHAMCS. Of admitted patients, 89% were categorized as NHAMCS-ESI level 2-3. Median ED waiting times increased as NHAMCS-ESI levels decreased in acuity (from approximately 14 minutes to 25 minutes). Median LOS decreased as NHAMCS-ESI decreased from almost 200 minutes for level 1 patients to nearly 80 minutes for level 5 patients. CONCLUSION We derived an objective tool to measure an ED visit's complexity and resource use. This tool can be validated and used to compare complexity of ED visits across hospitals and regions, and over time.
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Affiliation(s)
- B. Jason Theiling
- Duke University School of Medicine, Department of Emergency Medicine, Durham, North Carolina
| | - Kendrick V. Kennedy
- Duke University School of Medicine, Department of Emergency Medicine, Durham, North Carolina
| | - Alexander T. Limkakeng
- Duke University School of Medicine, Department of Emergency Medicine, Durham, North Carolina
| | - Pratik Manandhar
- Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Alaatin Erkanli
- Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Stephen R. Pitts
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
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Lim BJV, Wahab SFA, Kueh YC. Validity and Reliability of Emergency Severity Index and Conventional Three-Tier Triage System in the Emergency Department, Hospital Universiti Sains Malaysia. Malays J Med Sci 2020; 27:90-100. [PMID: 32788845 PMCID: PMC7409571 DOI: 10.21315/mjms2020.27.2.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 03/07/2020] [Indexed: 11/07/2022] Open
Abstract
Background The study aimed to examine the reliability and validity of the existing three-tier triaging system and a new five-level emergency triaging system, emergency severity index (ESI), in the Emergency Department (ED) of Hospital Universiti Sains Malaysia (HUSM). Methods This study was conducted in HUSM’s ED over two study periods. In the first three months, 300 patients were triaged under the three-tier triaging system, and, in the subsequent three months, 280 patients were triaged under the ESI. The patients were triaged by junior paramedics and the triage records were retained and later re-triaged by senior paramedics. The inter-rater reliability was evaluated using Cohen's Kappa statistics. The acuity ratings of the junior paramedics were compared with those of the expert panel to determine the sensitivity and specificity of each acuity level for both the ESI and the three-tier triaging system. The over-triage rate, under-triage rate, amount of resources used, admission rate and discharge rate were also determined. Results The inter-rater agreement for the three-tier triaging system was 0.81 while that of the ESI was 0.75. The ESI had a higher average sensitivity of 74.3% and a specificity of 94.4% while the three-tier system’s average sensitivity was 68.5% and its specificity 87.0%. The average under-triage and over-triage rates for the ESI were 10.7% and 6.2%, respectively, which were lower than the three-tier system’s average under-triage rate of 13.1% and over-triage rate of 17.1%. The urgency levels of both the ESI and the three-tier system were associated with increased admission rates and resources used in the ED. Conclusion The ESI’s inter-rater reliability was comparable to the three-tier triaging system and it demonstrated better validity than the existing three-tier system.
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Affiliation(s)
- Ban Jin Victor Lim
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Shaik Farid Ab Wahab
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Yee Cheng Kueh
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
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Kwon H, Kim YJ, Jo YH, Lee JH, Lee JH, Kim J, Hwang JE, Jeong J, Choi YJ. The Korean Triage and Acuity Scale: associations with admission, disposition, mortality and length of stay in the emergency department. Int J Qual Health Care 2020; 31:449-455. [PMID: 30165654 DOI: 10.1093/intqhc/mzy184] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/20/2018] [Accepted: 08/12/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The Korean Triage and Acuity Scale (KTAS) was implemented in our emergency department (ED) in May 2016 and is fully integrated into the electronic medical record (EMR) system. Our objective was to determine whether the KTAS is associated with changes in admissions to the hospital, admission disposition, inpatient mortality and length of stay (LOS). DESIGN Quasi-experimental, uncontrolled before-and-after study. SETTING The urban tertiary teaching hospital with 1100 beds and receives approximately annual 90 000 ED visits. PARTICIPANTS 122 370 patients who visited the ED during the before-and-the after period. INTERVENTIONS ED staff were educated on the KTAS for 1 month, after which the KTAS evaluation period began. Admission, disposition, mortality and LOS were compared between the 'before' period (1 June 2015 to 30 April 2016) and the 'after' period (1 June 2016 to 30 April 2017). MAIN OUTCOME MEASURES Admissions to the hospital, admission disposition, inpatient mortality and LOS. RESULTS A total of 59 220 and 63 150 patients were included in the before-and-after periods of KTAS implementation, respectively. The pattern of admission and disposition changed significantly after implementation of the KTAS. The mean LOS was 343 min (standard deviation [SD] = 432 min) during the before period, which significantly decreased to 289 min (SD = 333 min) after implementation (P < 0.001). The total mortality rate was significantly reduced after implementation of the KTAS (213 (0.36%) vs. 179 (0.28%), P = 0.020). CONCLUSION Implementation of the KTAS changed admission and disposition patterns and reduced the LOS and mortality in the ED.
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Affiliation(s)
- Hyuksool Kwon
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Yu Jin Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Jin Hee Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Ji Eun Hwang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Joo Jeong
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Yoo Jin Choi
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
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d'Etienne JP, Zhou Y, Kan C, Shaikh S, Ho AF, Suley E, Blustein EC, Schrader CD, Zenarosa NR, Wang H. Two-step predictive model for early detection of emergency department patients with prolonged stay and its management implications. Am J Emerg Med 2020; 40:148-158. [PMID: 32063427 DOI: 10.1016/j.ajem.2020.01.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To develop a novel model for predicting Emergency Department (ED) prolonged length of stay (LOS) patients upon triage completion, and further investigate the benefit of a targeted intervention for patients with prolonged ED LOS. MATERIALS AND METHODS A two-step model to predict patients with prolonged ED LOS (>16 h) was constructed. This model was initially used to predict ED resource usage and was subsequently adapted to predict patient ED LOS based on the number of ED resources using binary logistic regressions and was validated internally with accuracy. Finally, a discrete event simulation was used to move patients with predicted prolonged ED LOS directly to a virtual Clinical Decision Unit (CDU). The changes of ED crowding status (Overcrowding, Crowding, and Not-Crowding) and savings of ED bed-hour equivalents were estimated as the measures of the efficacy of this intervention. RESULTS We screened a total of 123,975 patient visits with final enrollment of 110,471 patient visits. The overall accuracy of the final model predicting prolonged patient LOS was 67.8%. The C-index of this model ranges from 0.72 to 0.82. By implementing the proposed intervention, the simulation showed a 12% (1044/8760) reduction of ED overcrowded status - an equivalent savings of 129.3 ED bed-hours per day. CONCLUSIONS Early prediction of prolonged ED LOS patients and subsequent (simulated) early CDU transfer could lead to more efficiently utilization of ED resources and improved efficacy of ED operations. This study provides evidence to support the implementation of this novel intervention into real healthcare practice.
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Affiliation(s)
- James P d'Etienne
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Yuan Zhou
- Department of Industrial, Manufacturing, and Systems Engineering, The University of Texas at Arlington, 701 S. Nedderman Dr., Arlington, TX 760199, USA.
| | - Chen Kan
- Department of Industrial, Manufacturing, and Systems Engineering, The University of Texas at Arlington, 701 S. Nedderman Dr., Arlington, TX 760199, USA.
| | - Sajid Shaikh
- Department of Information Technology, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Amy F Ho
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Eniola Suley
- Department of Industrial, Manufacturing, and Systems Engineering, The University of Texas at Arlington, 701 S. Nedderman Dr., Arlington, TX 760199, USA.
| | - Erica C Blustein
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Chet D Schrader
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA; Integrative Emergency Services, 4835 LBJ Fwy Suite 900, Dallas, TX 75244, USA.
| | - Nestor R Zenarosa
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA; Integrative Emergency Services, 4835 LBJ Fwy Suite 900, Dallas, TX 75244, USA.
| | - Hao Wang
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA; Integrative Emergency Services, 4835 LBJ Fwy Suite 900, Dallas, TX 75244, USA.
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Indirect impact of violent events on emergency department utilization and disease patterns. BMC Emerg Med 2020; 20:10. [PMID: 32054436 PMCID: PMC7020587 DOI: 10.1186/s12873-020-0307-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 02/04/2020] [Indexed: 12/02/2022] Open
Abstract
Background The health effects of war and armed conflict on casualties and mental health of those directly exposed has been well described, but few studies have explored the indirect health effects of violent events. This paper assesses the indirect health impact of several violent events that took place in Beirut in 2013–2014 on ED visit utilization and disease patterns. Methods As tracked by media reports, there were 9 violent events in Beirut during 2013–2014. We compared visits to the Emergency Department of a major medical center during weeks when violent events happened and weeks without such events (the preceding week and the same week in preceding years). After re-coding de-identified data from the medical records of 23,067 patients, we assessed differences in the volume of visits, severity index, and discharge diagnoses. Individual control charts were used to analyze ED visit trends post-event. Results Comparisons of weeks with violent events and weeks without such events indicate that the socio-demographic characteristics of patients who visited the Emergency Department were similar. Patients seen during violent weeks were significantly more likely to be admitted to the hospital, and less likely to present with low acuity complaints, indicating greater complexity of their conditions. The discharge diagnoses that were significantly higher during violent event weeks included anxiety disorders, sprains, and gastritis. Daily ED visits dropped post events by 14.111%, p < 0.0001. Conclusions The results indicate that violent events such as bombs, explosions, and terrorist attacks reverberate through the population, impact patterns of ED utilization immediately post-event and are associated with adverse health outcomes, even among those who are not directly affected by the events.
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Zhang X, Bellolio MF, Medrano-Gracia P, Werys K, Yang S, Mahajan P. Use of natural language processing to improve predictive models for imaging utilization in children presenting to the emergency department. BMC Med Inform Decis Mak 2019; 19:287. [PMID: 31888609 PMCID: PMC6937987 DOI: 10.1186/s12911-019-1006-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 12/12/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To examine the association between the medical imaging utilization and information related to patients' socioeconomic, demographic and clinical factors during the patients' ED visits; and to develop predictive models using these associated factors including natural language elements to predict the medical imaging utilization at pediatric ED. METHODS Pediatric patients' data from the 2012-2016 United States National Hospital Ambulatory Medical Care Survey was included to build the models to predict the use of imaging in children presenting to the ED. Multivariable logistic regression models were built with structured variables such as temperature, heart rate, age, and unstructured variables such as reason for visit, free text nursing notes and combined data available at triage. NLP techniques were used to extract information from the unstructured data. RESULTS Of the 27,665 pediatric ED visits included in the study, 8394 (30.3%) received medical imaging in the ED, including 6922 (25.0%) who had an X-ray and 1367 (4.9%) who had a computed tomography (CT) scan. In the predictive model including only structured variables, the c-statistic was 0.71 (95% CI: 0.70-0.71) for any imaging use, 0.69 (95% CI: 0.68-0.70) for X-ray, and 0.77 (95% CI: 0.76-0.78) for CT. Models including only unstructured information had c-statistics of 0.81 (95% CI: 0.81-0.82) for any imaging use, 0.82 (95% CI: 0.82-0.83) for X-ray, and 0.85 (95% CI: 0.83-0.86) for CT scans. When both structured variables and free text variables were included, the c-statistics reached 0.82 (95% CI: 0.82-0.83) for any imaging use, 0.83 (95% CI: 0.83-0.84) for X-ray, and 0.87 (95% CI: 0.86-0.88) for CT. CONCLUSIONS Both CT and X-rays are commonly used in the pediatric ED with one third of the visits receiving at least one. Patients' socioeconomic, demographic and clinical factors presented at ED triage period were associated with the medical imaging utilization. Predictive models combining structured and unstructured variables available at triage performed better than models using structured or unstructured variables alone, suggesting the potential for use of NLP in determining resource utilization.
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Affiliation(s)
- Xingyu Zhang
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, USA.
| | | | - Pau Medrano-Gracia
- Department of Anatomy and Medical Imaging, University of Auckland, Auckland, New Zealand
| | - Konrad Werys
- Oxford Centre for Clinical Magnetic Resonance Research, University of Oxford, Oxford, UK
| | - Sheng Yang
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China. .,Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA.
| | - Prashant Mahajan
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, USA
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Are Emergency Departments in the United States Following Recommendations by the Emergency Severity Index to Promote Quality Triage and Reliability? J Emerg Nurs 2019; 45:677-684. [DOI: 10.1016/j.jen.2019.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/05/2019] [Accepted: 05/10/2019] [Indexed: 11/23/2022]
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Zaerpour F, Bischak DP, Menezes MBC, McRae A, Lang ES. Patient classification based on volume and case-mix in the emergency department and their association with performance. Health Care Manag Sci 2019; 23:387-400. [PMID: 31446556 DOI: 10.1007/s10729-019-09495-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 07/25/2019] [Indexed: 11/27/2022]
Abstract
Predicting daily patient volume is necessary for emergency department (ED) strategic and operational decisions, such as resource planning and workforce scheduling. For these purposes, forecast accuracy requires understanding the heterogeneity among patients with respect to their characteristics and reasons for visits. To capture the heterogeneity among ED patients (case-mix), we present a patient coding and classification scheme (PCCS) based on patient demographics and diagnostic information. The proposed PCCS allows us to mathematically formalize the arrival patterns of the patient population as well as each class of patients. We can then examine the volume and case-mix of patients presenting to an ED and investigate their relationship to the ED's quality and time-based performance metrics. We use data from five hospitals in February, July and November for the years of 2007, 2012, and 2017 in the city of Calgary, Alberta, Canada. We find meaningful arrival time patterns of the patient population as well as classes of patients in EDs. The regression results suggest that patient volume is the main predictor of time-based ED performance measures. Case-mix is, however, the key predictor of quality of care in EDs. We conclude that considering both patient volume and the mix of patients are necessary for more accurate strategic and operational planning in EDs.
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Affiliation(s)
- Farzad Zaerpour
- Faculty of Business and Economics, The University of Winnipeg, Winnipeg, MB, R3B 2E9, Canada.
| | - Diane P Bischak
- Haskayne School of Business, University of Calgary, 2500 University DR NW, Calgary, AB, Canada
| | - Mozart B C Menezes
- Faculty of Supply Chain and Operations Management, NEOMA Business School, 1 Rue du Maréchal Juin, 76130, Mont-Saint-Aignan, France
| | - Andrew McRae
- Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, Alberta, Canada
| | - Eddy S Lang
- Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, Alberta, Canada
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Gong C, Byczkowski T, McAneney C, Goyal MK, Florin TA. Emergency Department Management of Bronchiolitis in the United States. Pediatr Emerg Care 2019; 35:323-329. [PMID: 28441240 PMCID: PMC5654708 DOI: 10.1097/pec.0000000000001145] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to examine differences between general and pediatric emergency departments (PEDs) in adherence to the American Academy of Pediatrics bronchiolitis management guidelines. METHODS We conducted a nationally representative study of ED visits by infants younger than 24 months with bronchiolitis from 2002 to 2011 using the National Hospital Ambulatory Medical Care Survey. Diagnostic testing (complete blood counts, radiographs) and medication use (albuterol, corticosteroids, antibiotics and intravenous fluids) in general emergency departments (GEDs) were compared with those in PEDs before and after 2006 American Academy of Pediatrics guideline publication. Weighted percentages were compared, and logistic regression evaluated the association between ED type and resource use. RESULTS Of more than 2.5 million ED visits for bronchiolitis from 2002 to 2011, 77.3% occurred in GEDs. General emergency departments were more likely to use radiography (62.7% vs 42.1%; adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.1), antibiotics (41.3% vs 18.8%; aOR, 2.8; 95% CI, 1.5-5.2), and corticosteroids (24.3% vs 12.5%; aOR, 2.1; 95% CI, 1.0-4.5) compared with PEDs. Compared with preguideline, after guideline publication PEDs had a greater decrease in radiography use (-19.7%; 95% CI, -39.3% to -0.03%) compared with GEDs (-12.2%; 95% CI, -22.3% to -2.1%), and PEDs showed a significant decline in corticosteroid use (-12.4%; 95% CI, -22.1% to -2.8%), whereas GEDs showed no significant decline (-4.6%; 95% CI, -13.5% to 4.3%). CONCLUSIONS The majority of ED visits for bronchiolitis in the United States occurred in GEDs, yet GEDs had increased use of radiography, corticosteroids, and antibiotics and did not show substantial declines with national guideline publication. Given that national guidelines discourage the use of such tests and treatments in the management of bronchiolitis, efforts are required to decrease ED use of these resources in infants with bronchiolitis, particularly in GEDs.
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Affiliation(s)
- Constance Gong
- Division of Emergency Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta
| | - Terri Byczkowski
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Constance McAneney
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Monika K. Goyal
- Division of Emergency Medicine, Children's National Health System, The George Washington University
| | - Todd A. Florin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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French S, Gordon-Strachan G, Kerr K, Bisasor-McKenzie J, Innis L, Tanabe P. Implementing the Emergency Severity Index Triage System in Jamaican Accident and Emergency Departments. J Emerg Nurs 2019; 45:124-131. [DOI: 10.1016/j.jen.2018.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 11/09/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
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Zook HG, Payne NR, Puumala SE, Burgess K, Kharbanda AB. Racial/Ethnic Variation in Emergency Department Care for Children With Asthma. Pediatr Emerg Care 2019; 35:209-215. [PMID: 28926508 PMCID: PMC5857394 DOI: 10.1097/pec.0000000000001282] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess the variation between racial/ethnic groups in emergency department (ED) treatment of asthma for pediatric patients. METHODS This study was a cross-sectional analysis of pediatric (2-18 years) asthma visits among 6 EDs in the Upper Midwest between June 2011 and May 2012. We used mixed-effects logistic regression to assess the odds of receiving steroids, radiology tests, and returning to the ED within 30 days. We conducted a subanalysis of asthma visits where patients received at least 1 albuterol treatment in the ED. RESULTS The sample included 2909 asthma visits by 1755 patients who were discharged home from the ED. After adjusting for demographics, insurance type, and triage score, African American (adjusted odds ratio [aOR], 1.78; 95% confidence interval [CI], 1.40-2.26) and Hispanic (aOR, 1.64; 95% CI, 1.22-2.22) patients had higher odds of receiving steroids compared with whites. African Americans (aOR, 0.58; 95% CI, 0.46-0.74) also had lower odds of radiological testing compared with whites. Asians had the lowest odds of 30-day ED revisits (aOR, 0.26; 95% CI, 0.08-0.84), with no other significant differences detected between racial/ethnic groups. Subgroup analyses of asthma patients who received albuterol revealed similar results, with American Indians showing lower odds of radiological testing as well (aOR, 0.47; 95% CI, 0.22-1.01). CONCLUSIONS In this study, children from racial/ethnic minority groups had higher odds of steroid administration and lower odds of radiological testing compared with white children. The underlying reasons for these differences are likely multifactorial, including varying levels of disease severity, health literacy, and access to care.
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Affiliation(s)
- Heather G. Zook
- Department of Research and Sponsored Programs, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
- Department of Evaluation, Professional Data Analysts, Inc., 219 Main Street SE, Suite 302, Minneapolis, MN 55414
| | - Nathaniel R. Payne
- Department of Research and Sponsored Programs, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
- Department of Quality and Safety, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
| | - Susan E. Puumala
- Center for Health Outcomes and Prevention Research, Sanford Research, 2301 E 60th Street North, Sioux Falls, SD 57104
- Department of Pediatrics, Sanford School of Medicine at the University of South Dakota, 1400 W 22nd Street, Sioux Falls, SD 57105
| | - Katherine Burgess
- Center for Health Outcomes and Prevention Research, Sanford Research, 2301 E 60th Street North, Sioux Falls, SD 57104
- Department of Epidemiology, Colorado School of Public Health at the University of Colorado at Denver, 13001 East 17 Place, Aurora, CO 80045
| | - Anupam B. Kharbanda
- Department of Emergency Medicine, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
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Benda NC, Blumenthal HJ, Hettinger AZ, Hoffman DJ, LaVergne DT, Franklin ES, Roth EM, Perry SJ, Bisantz AM. Human Factors Design in the Clinical Environment: Development and Assessment of an Interface for Visualizing Emergency Medicine Clinician Workload. IISE Trans Occup Ergon Hum Factors 2018. [DOI: 10.1080/24725838.2018.1522392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Natalie C. Benda
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health, 3007 Tilden Street, NW, Suite 7M, Washington, DC 20008, USA
- Department of Industrial and Systems Engineering, State University of New York at Buffalo, Buffalo, New York, USA
| | - H. Joseph Blumenthal
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health, 3007 Tilden Street, NW, Suite 7M, Washington, DC 20008, USA
| | - A. Zachary Hettinger
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health, 3007 Tilden Street, NW, Suite 7M, Washington, DC 20008, USA
- Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Daniel J. Hoffman
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health, 3007 Tilden Street, NW, Suite 7M, Washington, DC 20008, USA
| | - David T. LaVergne
- Department of Industrial and Systems Engineering, State University of New York at Buffalo, Buffalo, New York, USA
| | - Ella S. Franklin
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health, 3007 Tilden Street, NW, Suite 7M, Washington, DC 20008, USA
- School of Nursing, The George Washington University, Washington, DC, USA
| | | | - Shawna J. Perry
- Department of Emergency Medicine, University of Florida, Jacksonville, Florida, USA
| | - Ann M. Bisantz
- Department of Industrial and Systems Engineering, State University of New York at Buffalo, Buffalo, New York, USA
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Lo AX, Donnelly JP, Durant RW, Collins SP, Levitan EB, Storrow AB, Bittner V. A National Study of U.S. Emergency Departments: Racial Disparities in Hospitalizations for Heart Failure. Am J Prev Med 2018; 55:S31-S39. [PMID: 30670199 DOI: 10.1016/j.amepre.2018.05.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/11/2018] [Accepted: 05/16/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Racial disparities in heart failure hospitalizations are well documented. The majority of heart failure hospitalizations originate from emergency departments, but emergency department hospitalization patterns for heart failure and the factors that influence hospitalization are poorly understood. This gap in knowledge was examined using a nationally representative sample of emergency department visits for heart failure. METHODS National Hospital Ambulatory Medicare Care Survey data on 2001-2010 emergency department visits were analyzed in 2015-2017 to examine age-related racial differences in hospitalization patterns for heart failure, using multivariable modified Poisson regression models. RESULTS More than 12million adult visits for heart failure to U.S. emergency departments occurred from 2001 to 2010, with 23% of visits by blacks. Overall, 71% of visits resulted in hospitalization (57% to floor beds and 14% to intensive care units). Among floor admissions for higher clinical acuity visits, whites were more likely than blacks to be hospitalized. Whites with higher clinical acuity were more likely to be hospitalized than those with lower clinical acuity (71% vs 63%, p=0.005). This expected pattern was not observed in blacks, particularly those aged ≥65years, who were hospitalized in 71% of lower clinical acuity visits, but only 61% of higher acuity visits. Among adults aged ≥65years, there was a significant interaction between clinical acuity Xrace with regard to hospitalization (p=0.037). CONCLUSIONS These results suggest age and racial disparities in hospitalization rates for emergency department patients with heart failure. The reasons for these disparities in hospitalization are unclear. Further studies on emergency department hospitalization decisions, and the impact of emergency department clinical factors, may help clarify this finding. SUPPLEMENT INFORMATION This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.
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Affiliation(s)
- Alexander X Lo
- Department of Emergency Medicine and Center for Healthcare Studies, Northwestern University, Chicago, Illinois.
| | - John P Donnelly
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Raegan W Durant
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vera Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Maximizing Patient Coverage Through Optimal Allocation of Residents and Scribes to Shifts in an Emergency Department. J Med Syst 2018; 42:212. [DOI: 10.1007/s10916-018-1080-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 09/19/2018] [Indexed: 10/28/2022]
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Hocker MB, Gerardo CJ, Theiling BJ, Villani J, Donohoe R, Sandesara H, Limkakeng AT. NHAMCS Validation of Emergency Severity Index as an Indicator of Emergency Department Resource Utilization. West J Emerg Med 2018; 19:855-862. [PMID: 30202499 PMCID: PMC6123086 DOI: 10.5811/westjem.2018.7.37556] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 07/18/2018] [Accepted: 07/18/2018] [Indexed: 11/16/2022] Open
Abstract
Introduction Triage systems play a vital role in emergency department (ED) operations and can determine how well a given ED serves its local population. We sought to describe ED utilization patterns for different triage levels using the National Hospital Ambulatory Medical Care Survey (NHAMCS) database. Methods We conducted a multi-year secondary analysis of the NHAMCS database from 2009-2011. National visit estimates were made using standard methods in Analytics Software and Solutions (SAS, Cary, NC). We compared patients in the mid-urgency range in regard to ED lengths of stay, hospital admission rates, and numbers of tests and procedures in comparison to lower or higher acuity levels. Results We analyzed 100,962 emergency visits (representing 402,211,907 emergency visits nationwide). In 2011, patients classified as triage levels 1–3 had a higher number of diagnoses (5.5, 5.6 and 4.2, respectively) when compared to those classified as levels 4 and 5 (1.61 and 1.25). This group also underwent a higher number of procedures (1.0, 0.8 and 0.7, versus 0.4 and 0.4), had a higher ED length of stay (220, 280 and 237, vs. 157 and 135), and admission rates (32.2%, 32.3% and 15.5%, vs. 3.1% and 3.6%). Conclusion Patients classified as mid-level (3) triage urgency require more resources and have higher indicators of acuity as those in triage levels 4 and 5. These patients’ indicators are more similar to those classified as triage levels 1 and 2.
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Affiliation(s)
- Michael B Hocker
- Medical College of Georgia, Augusta University, Department of Emergency Medicine and Hospitalist Services, Augusta, Georgia.,Duke University School of Medicine, Department of Emergency Medicine, Durham, North Carolina
| | - Charles J Gerardo
- Duke University School of Medicine, Department of Emergency Medicine, Durham, North Carolina
| | - B Jason Theiling
- Duke University School of Medicine, Department of Emergency Medicine, Durham, North Carolina
| | - John Villani
- Duke University School of Medicine, Department of Emergency Medicine, Durham, North Carolina.,Duke University, Durham Veterans Affairs Medical Center, Department of Emergency Medicine, Durham, North Carolina
| | - Rebecca Donohoe
- Duke University School of Medicine, Department of Emergency Medicine, Durham, North Carolina
| | - Hirsh Sandesara
- Duke University School of Medicine, Department of Emergency Medicine, Durham, North Carolina
| | - Alexander T Limkakeng
- Duke University School of Medicine, Department of Emergency Medicine, Durham, North Carolina
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Graves PS, Graves SR, Minhas T, Lewinson RE, Vallerand IA, Lewinson RT. Effects of medical scribes on physician productivity in a Canadian emergency department: a pilot study. CMAJ Open 2018; 6:E360-E364. [PMID: 30181347 PMCID: PMC6182119 DOI: 10.9778/cmajo.20180031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Emergency department efficiency is a priority across Canada. In the United States, scribes may increase the number of patients seen per hour per physician; however, Canadian data are lacking. We sought to implement scribes in a Canadian emergency department with the hypothesis that scribes would increase the number of patients seen per hour per physician. METHODS We conducted a 4-month quality improvement pilot study in a community emergency department in Ottawa, Ontario. Data collection began January 2015 after scribe training. Physicians received shifts with and without a scribe for a period of 4 months. Across the study, the mean number of patients seen per hour was determined for each physician during shifts with and without a scribe. We compared mean (± standard deviation [SD]) number of patients seen per hour based on presence or absence of a scribe by 2-tailed paired-samples t test. RESULTS Eleven scribes participated and ranged in age from 18 to 23 years. Twenty-two full- or part-time emergency physicians were followed. We documented 463 physician-hours without use of a scribe and 693.75 physician-hours with use of a scribe. Across all 22 physicians, 18 (81.8%) saw more patients per hour with use of a scribe. Overall, the number of patients seen per hour per physician was significantly greater (+12.9%) during shifts with a scribe (mean [± SD] 2.81 [± 0.78]) than during shifts without a scribe (mean [± SD] 2.49 [± 0.60]; p = 0.006). INTERPRETATION In this pilot study, the use of scribes resulted in an increased number of patients seen per hour per physician. Because this was a small study at a single centre, further research on the effects of scribes in Canada is warranted.
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Affiliation(s)
- Peter S Graves
- Department of Emergency Medicine (P. Graves), Queensway- Carleton Hospital; Faculty of Medicine (P. Graves, Minhas), University of Ottawa; Medical Scribes of Canada (P. Graves, S. Graves, Minhas, R.E. Lewinson), Ottawa, Ont.; Faculty of Health (R.E. Lewinson), York University, Toronto, Ont.; Cumming School of Medicine (Vallerand, R.T. Lewinson), University of Calgary, Calgary, Alta.
| | - Stephen R Graves
- Department of Emergency Medicine (P. Graves), Queensway- Carleton Hospital; Faculty of Medicine (P. Graves, Minhas), University of Ottawa; Medical Scribes of Canada (P. Graves, S. Graves, Minhas, R.E. Lewinson), Ottawa, Ont.; Faculty of Health (R.E. Lewinson), York University, Toronto, Ont.; Cumming School of Medicine (Vallerand, R.T. Lewinson), University of Calgary, Calgary, Alta
| | - Tanvir Minhas
- Department of Emergency Medicine (P. Graves), Queensway- Carleton Hospital; Faculty of Medicine (P. Graves, Minhas), University of Ottawa; Medical Scribes of Canada (P. Graves, S. Graves, Minhas, R.E. Lewinson), Ottawa, Ont.; Faculty of Health (R.E. Lewinson), York University, Toronto, Ont.; Cumming School of Medicine (Vallerand, R.T. Lewinson), University of Calgary, Calgary, Alta
| | - Rebecca E Lewinson
- Department of Emergency Medicine (P. Graves), Queensway- Carleton Hospital; Faculty of Medicine (P. Graves, Minhas), University of Ottawa; Medical Scribes of Canada (P. Graves, S. Graves, Minhas, R.E. Lewinson), Ottawa, Ont.; Faculty of Health (R.E. Lewinson), York University, Toronto, Ont.; Cumming School of Medicine (Vallerand, R.T. Lewinson), University of Calgary, Calgary, Alta
| | - Isabelle A Vallerand
- Department of Emergency Medicine (P. Graves), Queensway- Carleton Hospital; Faculty of Medicine (P. Graves, Minhas), University of Ottawa; Medical Scribes of Canada (P. Graves, S. Graves, Minhas, R.E. Lewinson), Ottawa, Ont.; Faculty of Health (R.E. Lewinson), York University, Toronto, Ont.; Cumming School of Medicine (Vallerand, R.T. Lewinson), University of Calgary, Calgary, Alta
| | - Ryan T Lewinson
- Department of Emergency Medicine (P. Graves), Queensway- Carleton Hospital; Faculty of Medicine (P. Graves, Minhas), University of Ottawa; Medical Scribes of Canada (P. Graves, S. Graves, Minhas, R.E. Lewinson), Ottawa, Ont.; Faculty of Health (R.E. Lewinson), York University, Toronto, Ont.; Cumming School of Medicine (Vallerand, R.T. Lewinson), University of Calgary, Calgary, Alta
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Simulation-Based Design of ED Operations with Care Streams to Optimize Care Delivery and Reduce Length of Stay in the Emergency Department. J Med Syst 2017; 41:162. [PMID: 28879622 DOI: 10.1007/s10916-017-0804-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/22/2017] [Indexed: 10/18/2022]
Abstract
Faced with the opportunity to significantly deviate from classic operations, a new emergency department (ED) and novel strategy for patient care delivery were simultaneously initiated with the aid of model-based simulation. To answer the design and implementation questions, a traditional strategy for construction of discrete-eventmodel simulation was employed to define ED operations for a newly constructed facility in terms of workflow, variables, resources, structure, process logic and associated assumptions. Benefits were achieved before, during and after implementation of an unprecedented operations strategy-i.e., the organization of the ED care delivery around four care streams: Critical, Diagnostic, Therapeutic and Fast Track. Prior to opening, it shed light on the range of context variables where benefits might be anticipated, and it facilitated staff understanding and judgements of performance. Two years after opening, the operations data is compared to the simulation with encouraging results that shed light on where to continue pursuit of improvement.
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Zhang X, Kim J, Patzer RE, Pitts SR, Patzer A, Schrager JD. Prediction of Emergency Department Hospital Admission Based on Natural Language Processing and Neural Networks. Methods Inf Med 2017; 56:377-389. [PMID: 28816338 DOI: 10.3414/me17-01-0024] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 07/26/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe and compare logistic regression and neural network modeling strategies to predict hospital admission or transfer following initial presentation to Emergency Department (ED) triage with and without the addition of natural language processing elements. METHODS Using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a cross-sectional probability sample of United States EDs from 2012 and 2013 survey years, we developed several predictive models with the outcome being admission to the hospital or transfer vs. discharge home. We included patient characteristics immediately available after the patient has presented to the ED and undergone a triage process. We used this information to construct logistic regression (LR) and multilayer neural network models (MLNN) which included natural language processing (NLP) and principal component analysis from the patient's reason for visit. Ten-fold cross validation was used to test the predictive capacity of each model and receiver operating curves (AUC) were then calculated for each model. RESULTS Of the 47,200 ED visits from 642 hospitals, 6,335 (13.42%) resulted in hospital admission (or transfer). A total of 48 principal components were extracted by NLP from the reason for visit fields, which explained 75% of the overall variance for hospitalization. In the model including only structured variables, the AUC was 0.824 (95% CI 0.818-0.830) for logistic regression and 0.823 (95% CI 0.817-0.829) for MLNN. Models including only free-text information generated AUC of 0.742 (95% CI 0.731- 0.753) for logistic regression and 0.753 (95% CI 0.742-0.764) for MLNN. When both structured variables and free text variables were included, the AUC reached 0.846 (95% CI 0.839-0.853) for logistic regression and 0.844 (95% CI 0.836-0.852) for MLNN. CONCLUSIONS The predictive accuracy of hospital admission or transfer for patients who presented to ED triage overall was good, and was improved with the inclusion of free text data from a patient's reason for visit regardless of modeling approach. Natural language processing and neural networks that incorporate patient-reported outcome free text may increase predictive accuracy for hospital admission.
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Affiliation(s)
- Xingyu Zhang
- Justin D. Schrager, MD, MPH, Emory University School of Medicine, Department of Emergency Medicine, 531 Asbury Circle, Annex Building N340, Atlanta, GA 30322, USA, E-mail:
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Kuriyama A, Urushidani S, Nakayama T. Five-level emergency triage systems: variation in assessment of validity. Emerg Med J 2017; 34:703-710. [PMID: 28751363 DOI: 10.1136/emermed-2016-206295] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 04/19/2017] [Accepted: 05/05/2017] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Triage systems are scales developed to rate the degree of urgency among patients who arrive at EDs. A number of different scales are in use; however, the way in which they have been validated is inconsistent. Also, it is difficult to define a surrogate that accurately predicts urgency. This systematic review described reference standards and measures used in previous validation studies of five-level triage systems. METHODS We searched PubMed, EMBASE and CINAHL to identify studies that had assessed the validity of five-level triage systems and described the reference standards and measures applied in these studies. Studies were divided into those using criterion validity (reference standards developed by expert panels or triage systems already in use) and those using construct validity (prognosis, costs and resource use). RESULTS A total of 57 studies examined criterion and construct validity of 14 five-level triage systems. Criterion validity was examined by evaluating (1) agreement between the assigned degree of urgency with objective standard criteria (12 studies), (2) overtriage and undertriage (9 studies) and (3) sensitivity and specificity of triage systems (7 studies). Construct validity was examined by looking at (4) the associations between the assigned degree of urgency and measures gauged in EDs (48 studies) and (5) the associations between the assigned degree of urgency and measures gauged after hospitalisation (13 studies). Particularly, among 46 validation studies of the most commonly used triages (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System), 13 and 39 studies examined criterion and construct validity, respectively. CONCLUSION Previous studies applied various reference standards and measures to validate five-level triage systems. They either created their own reference standard or used a combination of severity/resource measures.
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Affiliation(s)
- Akira Kuriyama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan.,Department of General Medicine, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Seigo Urushidani
- Department of Emergency Medicine, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
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Lubanski E, Rozario N, Moore CG, Mulder HP, Dulin M, Ludden T, Rossman W, Ashby A, McWilliams A. Traditional Risk Indices as Predictors of Future Utilization and Charges in the Context of Population Health for an Uninsured Cohort. EGEMS (WASHINGTON, DC) 2017; 5:11. [PMID: 29930959 PMCID: PMC5994958 DOI: 10.5334/egems.220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The uninsured population presents unique challenges to the application of an integrated approach to population health. Our objective is to compare and test population risk indices for identifying a cohort of uninsured patients at high-risk for avoidable healthcare utilization and costs. METHODS Patients who had a least one visit at a safety-net clinic, had a primary address in Mecklenburg County, were aged 18-74, and had the most recent healthcare visit coded as 'uninsured' were identified in the baseline period. The five risk indices used were: the HHS Hierarchical Conditions Category (HCC), the Charlson Comorbidity Index (CCI), Total Cost Index, Total Inpatient Visits Index, and Total Emergency Department Visits Index. First, agreement across the five indices was analyzed. Then, the accuracy of the five risk indices was tested in predicting future utilization and costs for the subsequent 12-month follow-up period. RESULTS Kappa statistics and percent overlap values showed below average to poor agreement between indices when comparing scorers.The strongest predictors of being in the 90th percentile of total cost during the 12 months follow-up period were the Total Cost Index at baseline (C statistic=0.75) and the HCC (C-statistic=0.73). The CCI and Total Inpatient Visit Index's demonstrated the lowest accuracy for predicting an unnecessary ED visit (C-statistic=0.51, for both). DISCUSSION/CONCLUSION Prior cost and ED utilization were key in predicting their corresponding 12-month metrics. In contrast, the Total Inpatient Visit Index had the worst predictive performance for future hospitalization rates. Some indices were similarly predictive as compared to insured cohorts but others showed contrasting results.
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Geramian A, Shahin A, Bandarrigian S, Shojaie Y. Proposing a two-criterion quality loss function using critical process capability indices. BENCHMARKING-AN INTERNATIONAL JOURNAL 2017. [DOI: 10.1108/bij-11-2015-0106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeAverage quadratic quality loss function (QQLF) measures quality of a given process using mean shift from its target value and variance. While it has a target parameter for the mean, it lacks a target for the variance revisable for counting any progress of the process across different quality levels, above/below the standard level; thus, it appears too general. Hence, in this research, it was initially supposed that all processes are located at two possible quality spaces, above/below the standard level. The purpose of this paper is to propose a two-criterion QQLF, in which each criterion is specifically proper to one of the quality spaces.Design/methodology/approachSince 1.33 is a literarily standard or satisfactory value for two most important process capability indicesCpandCpk, its upper/lower spaces are assumed as high-/low-quality spaces. Then the indices are integrated into traditional QQLF, of type nominal the best (NTB), to develop a two-criterion QQLF, in which each criterion is more suitable for each quality space. These two criteria have also been innovatively embedded in the plan-do-check-act (PDCA) cycle to help continuous improvement. Finally, the proposed function has been examined in comparison with the traditional one in Feiz Hospital in the province of Isfahan, Iran.FindingsResults indicate that the internal process of the studied case is placed on the lower quality space. So the first criterion of revised QQLF gives a more relevant evaluation for that process, compared with the traditional function. Moreover, this study has embedded both proposed criteria in the PDCA cycle as well.Research limitations/implicationsFormulating the two-criterion QQLF only for observations of normal and symmetric distributions, and offering it solely for NTB characteristics are limitations of this study.Practical implicationsTwo more relevant quality loss criteria have been formulated for each process (service or manufacturing). However, in order to show the comprehensiveness of the proposed method even in service institutes, emergency function of Feiz Hospital has been examined.Originality/valueThe traditional loss function of type NTB merely and implicitly targets zero defect for variance. In fact, it calculates quality loss of all processes placed on different quality spaces using a same measure. This study, however, provides a practitioner with opportunity of targeting excellent or satisfactory targets.
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Bryan MA, Desai AD, Wilson L, Wright DR, Mangione-Smith R. Association of Bronchiolitis Clinical Pathway Adherence With Length of Stay and Costs. Pediatrics 2017; 139:peds.2016-3432. [PMID: 28183732 DOI: 10.1542/peds.2016-3432] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To examine the associations between the level of adherence to bronchiolitis clinical pathway recommendations, health care use, and costs. METHODS We conducted a retrospective cohort study of 267 patients ≤24 months old diagnosed with bronchiolitis from 12/2009 to 7/2012. Clinical pathway adherence was assessed by using a standardized scoring system (0-100) for 18 quality measures obtained by medical record review. Level of adherence was categorized into low, middle, and high tertiles. Generalized linear models were used to examine relationships between adherence tertile and (1) length of stay (LOS) and (2) costs. Logistic regression was used to examine the associations between adherence tertile and probability of inpatient admission and 7-day readmissions. RESULTS Mean adherence scores were: ED, 78.8 (SD, 18.1; n = 264), inpatient, 95.0 (SD, 6.3; n = 216), and combined ED/inpatient, 89.1 (SD, 8.1; n = 213). LOS was significantly shorter for cases in the highest versus the lowest adherence tertile (ED, 90 vs 140 minutes, adjusted difference, -51 [95% confidence interval (CI), -73 to -29; P <.05]; inpatient, 3.1 vs 3.8 days, adjusted difference, -0.7 [95% CI, -1.4 to 0.0; P <.05]). Costs were less for cases in the highest adherence tertile (ED, -$84, [95% CI, -$7 to -$161; P <.05], total, -$1296 [95% CI, -126.43 to -2466.03; P <.05]). ED cases in the highest tertile had a lower odds of admission (odds ratio, 0.38 [95% CI, 0.15-0.97; P < .05]). Readmissions did not differ by tertile. CONCLUSIONS High adherence to bronchiolitis clinical pathway recommendations across care settings was associated with shorter LOS and lower cost.
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Affiliation(s)
- Mersine A Bryan
- Department of Pediatrics, University of Washington, Seattle, Washington; and .,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington; and.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Lauren Wilson
- Department of Pediatrics, University of Washington, Seattle, Washington; and
| | - Davene R Wright
- Department of Pediatrics, University of Washington, Seattle, Washington; and.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington; and.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
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Valentian M, Mewasing BI, Burggraff E, Mintandjian A, Lefranc V, Verbbrugghe R, Debost P, Ray P. Intérêt d’une demande anticipée de radiographies par l’infirmière organisatrice de l’accueil, dans les traumatismes de cheville. ANNALES FRANCAISES DE MEDECINE D URGENCE 2017. [DOI: 10.1007/s13341-017-0719-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Hasselbalch RB, Plesner LL, Pries-Heje M, Ravn L, Lind M, Greibe R, Jensen BN, Rasmussen LS, Iversen K. The Copenhagen Triage Algorithm: a randomized controlled trial. Scand J Trauma Resusc Emerg Med 2016; 24:123. [PMID: 27724978 PMCID: PMC5057417 DOI: 10.1186/s13049-016-0312-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/30/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Crowding in the emergency department (ED) is a well-known problem resulting in an increased risk of adverse outcomes. Effective triage might counteract this problem by identifying the sickest patients and ensuring early treatment. In the last two decades, systematic triage has become the standard in ED's worldwide. However, triage models are also time consuming, supported by limited evidence and could potentially be of more harm than benefit. The aim of this study is to develop a quicker triage model using data from a large cohort of unselected ED patients and evaluate if this new model is non-inferior to an existing triage model in a prospective randomized trial. METHODS The Copenhagen Triage Algorithm (CTA) study is a prospective two-center, cluster-randomized, cross-over, non-inferiority trial comparing CTA to the Danish Emergency Process Triage (DEPT). We include patients ≥16 years (n = 50.000) admitted to the ED in two large acute hospitals. Centers are randomly assigned to perform either CTA or DEPT triage first and then use the other triage model in the last time period. The CTA stratifies patients into 5 acuity levels in two steps. First, a scoring chart based on vital values is used to classify patients in an immediate category. Second, a clinical assessment by the ED nurse can alter the result suggested by the score up to two categories up or one down. The primary end-point is 30-day mortality and secondary end-points are length of stay, time to treatment, admission to intensive care unit, and readmission within 30 days. DISCUSSION If proven non-inferior to standard DEPT triage, CTA will be a faster and simpler triage model that is still able to detect the critically ill. Simplifying triage will lessen the burden for the ED staff and possibly allow faster treatment. TRIAL REGISTRATION Clinicaltrials.gov: NCT02698319 , registered 24. of February 2016, retrospectively registered.
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Affiliation(s)
| | | | - Mia Pries-Heje
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Lisbet Ravn
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Morten Lind
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Rasmus Greibe
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Lars S. Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
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Khan A, Mahadevan SV, Dreyfuss A, Quinn J, Woods J, Somontha K, Strehlow M. One-two-triage: validation and reliability of a novel triage system for low-resource settings. Emerg Med J 2016; 33:709-15. [PMID: 27466347 PMCID: PMC5050286 DOI: 10.1136/emermed-2015-205430] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 06/27/2016] [Indexed: 11/17/2022]
Abstract
Objectives To validate and assess reliability of a novel triage system, one-two-triage (OTT), that can be applied by inexperienced providers in low-resource settings. Methods This study was a two-phase prospective, comparative study conducted at three hospitals. Phase I assessed criterion validity of OTT on all patients arriving at an American university hospital by comparing agreement among three methods of triage: OTT, Emergency Severity Index (ESI) and physician-defined acuity (the gold standard). Agreement was reported in normalised and raw-weighted Cohen κ using two different scales for weighting, Expert-weighted and triage-weighted κ. Phase II tested reliability, reported in Fleiss κ, of OTT using standardised cases among three groups of providers at an urban and rural Cambodian hospital and the American university hospital. Results Normalised for prevalence of patients in each category, OTT and ESI performed similarly well for expert-weighted κ (OTT κ=0.58, 95% CI 0.52 to 0.65; ESI κ=0.47, 95% CI 0.40 to 0.53) and triage-weighted κ (κ=0.54, 95% CI 0.48 to 0.61; ESI κ=0.57, 95% CI 0.51 to 0.64). Without normalising, agreement with gold standard was less for both systems but performance of OTT and ESI remained similar, expert-weighted (OTT κ=0.57, 95% CI 0.52 to 0.62; ESI κ=0.6, 95% CI 0.58 to 0.66) and triage-weighted (OTT κ=0.31, 95% CI 0.25 to 0.38; ESI κ=0.41, 95% CI 0.35 to 0.4). In the reliability phase, all triagers showed fair inter-rater agreement, Fleiss κ (κ=0.308). Conclusions OTT can be reliably applied and performs as well as ESI compared with gold standard, but requires fewer resources and less experience.
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Affiliation(s)
- Ayesha Khan
- Division of Emergency Medicine, Stanford University, Stanford, California, USA
| | - S V Mahadevan
- Division of Emergency Medicine, Stanford University, Stanford, California, USA
| | - Andrea Dreyfuss
- Department of Emergency Medicine, Highland General Hospital, Oakland, California, USA
| | - James Quinn
- Division of Emergency Medicine, Stanford University, Stanford, California, USA
| | - Joan Woods
- University Research Co. Centre for Human Services, Phnom Penh, Cambodia
| | - Koy Somontha
- University Research Co. Centre for Human Services, Phnom Penh, Cambodia
| | - Matthew Strehlow
- Division of Emergency Medicine, Stanford University, Stanford, California, USA
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Dugas AF, Kirsch TD, Toerper M, Korley F, Yenokyan G, France D, Hager D, Levin S. An Electronic Emergency Triage System to Improve Patient Distribution by Critical Outcomes. J Emerg Med 2016; 50:910-8. [DOI: 10.1016/j.jemermed.2016.02.026] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 11/02/2015] [Accepted: 02/17/2016] [Indexed: 10/21/2022]
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Saleh S, Mourad Y, Dimassi H, Hitti E. Distribution and predictors of emergency department charges: the case of a tertiary hospital in Lebanon. BMC Health Serv Res 2016; 16:97. [PMID: 26993108 PMCID: PMC4797130 DOI: 10.1186/s12913-016-1337-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 03/07/2016] [Indexed: 12/05/2022] Open
Abstract
Background As health care costs continue to increase worldwide, health care systems, and more specifically hospitals are facing continuous pressure to operate more efficiently. One service within the hospital sector whose cost structure has been modestly investigated is the Emergency Department (ED). The study aims to report on the distribution of ED resource use, as expressed in charges, and to determine predictors of/contributors to total ED charges at a major tertiary hospital in Lebanon. Methods The study used data extracted from the ED discharge database for visits between July 31, 2012 and July 31, 2014. Patient visit bills were reported under six major categories: solutions, pharmacy, laboratory, physicians, facility, and radiology. Characteristics of ED visits were summarized according to patient gender, age, acuity score, and disposition. Univariate and multivariate analyses were conducted with total charges as the dependent variable. Results Findings revealed that the professional fee (40.9 %) followed by facility fee (26.1 %) accounted for the majority of the ED charges. While greater than 80 % of visit charges went to physician and facility fee for low acuity cases, these contributed to only 52 and 54 % of the high acuity presentations where ancillary services and solutions’ contribution to the total charges increased. The total charges for males were $14 higher than females; age was a predictor of higher charges with total charges of patients greater than 60 years of age being around $113 higher than ages 0–18 after controlling for all other variables. Conclusion Understanding the components and determinants of ED charges is essential to developing cost-containment interventions. Institutional modeling of charging patterns can be used to offer price estimates to ED patients who request this information and ultimately help create market competition to drive down costs.
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Affiliation(s)
- Shadi Saleh
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Yara Mourad
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Hani Dimassi
- School of Pharmacy, Lebanese American University, Beirut, Lebanon
| | - Eveline Hitti
- Department of Emergency Medicine, Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Ethnic Disparities in Emergency Severity Index Scores among U.S. Veteran's Affairs Emergency Department Patients. PLoS One 2015; 10:e0126792. [PMID: 26024515 PMCID: PMC4449190 DOI: 10.1371/journal.pone.0126792] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 03/29/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The goal of these analyses was to determine whether there were systematic differences in Emergency Severity Index (ESI) scores, which are intended to determine priority of treatment and anticipate resource needs, across categories of race and ethnicity, after accounting for patient-presenting vital signs and examiner characteristics, and whether these differences varied among male and female Veterans Affairs (VA) ED patients. METHODS AND FINDINGS We used a large national database of electronic medical records of ED patients from twenty-two U.S. Department of Veterans Affairs ED stations to determine whether ESI assignments differ systematically by race or ethnicity. Multi-level, random effects linear modeling was used to control for demographic characteristics and patient's vital signs (heart rate, respiratory rate, and pain level), as well as age, gender, and experience of triage nurses. The dataset included 129,991 VA patients presenting for emergency care between 2008 and 2012 (91% males; 61% non-Hispanic White, 28% Black, 7% Hispanic, 2% Asian, <1% American Indian/Alaska Native, 1% mixed ethnicity) and 774 nurses for a total of 359,642 patient/examiner encounters. Approximately 13% of the variance in ESI scores was due to patient characteristics and 21% was due to the nurse characteristics. After controlling for characteristics of nurses and patients, Black patients were assigned less urgent ESI scores than White patients, and this effect was more prominent for Black males compared with Black females. A similar interaction was found for Hispanic males. It remains unclear how these results may generalize to EDs and patient populations outside of the U.S. VA Health Care system. CONCLUSIONS The findings suggest the possibility that subgroups of VA patients receive different ESI ratings in triage, which may have cascading, downstream consequences for patient treatment quality, satisfaction with care, and trust in the health equity of emergency care.
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Mirhaghi A, Kooshiar H, Esmaeili H, Ebrahimi M. Outcomes for emergency severity index triage implementation in the emergency department. J Clin Diagn Res 2015; 9:OC04-7. [PMID: 26023578 PMCID: PMC4437092 DOI: 10.7860/jcdr/2015/11791.5737] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 02/10/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Hospital triage scale in emergency departments needs to be valid and reliable. Lack of sufficient data exists on triage scale rigor in emergency departments of Iran. This study aimed to determine the impact of the emergency severity index (ESI) triage scale in the emergency department. MATERIALS AND METHODS A single-center study was conducted. Proportion of triage categories allocated to high-risk patients admitted to high-acuity departments was examined in observational period in June 2012 and May 2013. True triage score was reported based on patients` paper- based scenario questionnaire. Interrater reliability was assessed using unweighted kappa. Concordance among experts, nurses and physicians was examined. The Chi-square test and Kappa statistics was used for statistical analysis. RESULTS Triage decisions regarding high-risk patients before and after implementation period are independent from each other (χ2= 22.254; df=1; p<0.05) and more high-risk patients were recognized after implementation of the ESI. Overall agreement and concordance were (79%) and (κ=0.54) among nurses; (71%) and (κ=0.45) among physicians, (85%) and (κ=0.81) among experts, respectively. Correct triage decisions among clinicians were increased after implementation of the ESI. CONCLUSION The ESI as valid and reliable tool improving desirable outcomes` in the emergency department has been recommended but it may not reveal optimal outcomes in developing countries comparing to what have been achieved in the developed countries. In addition, patient influx in ESI level II could create considerable controversy with clinicians.
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Affiliation(s)
- Amir Mirhaghi
- PhD Candidate, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hadi Kooshiar
- Assistant Professor, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Habibollah Esmaeili
- Associate Professor, Department of Biostatistics, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohsen Ebrahimi
- Assistant Professor, Department of Emergency Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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Does active dissemination of evidence result in faster knowledge transfer than passive diffusion?: An analysis of trends of the management of pediatric asthma and croup in US emergency departments from 1995 to 2009. Pediatr Emerg Care 2015; 31:190-6. [PMID: 24694945 DOI: 10.1097/pec.0000000000000099] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE This study aimed to compare knowledge transfer (KT) in the emergency department (ED) management of pediatric asthma and croup by measuring trends in corticosteroid use for both conditions in EDs. METHODS A retrospective, cross-sectional study of the National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 of corticosteroid use at ED visits for asthma or croup was conducted. Odds ratios (OR) were calculated using logistic regression. Trends over time were compared using an interaction term between disease and year and were adjusted for all other covariates in the model. We included children aged 2 to 18 years with asthma who received albuterol and were triaged emergent/urgent. Children aged between 3 months to 6 years with croup were included. The main outcome measure was the administration of corticosteroids in the ED or as a prescription at the ED visit. RESULTS The corticosteroid use in asthma visits increased from 44% to 67% and from 32% to 56% for croup. After adjusting for patient and hospital factors, this trend was significant both for asthma (OR, 1.07; 95% confidence interval [CI], 1.04-1.10) and croup (OR, 1.07; 95% CI, 1.03-1.12). There was no statistical difference between the 2 trends (P = 0.69). Hospital location in a metropolitan statistical area was associated with increased corticosteroid use in asthma (OR, 1.76; 95% CI, 1.10-2.82). Factors including sex, ethnicity, insurance, or region of the country were not significantly associated with corticosteroid use. CONCLUSIONS During a 15-year period, knowledge transfer by passive diffusion or active guideline dissemination resulted in similar trends of corticosteroid use for the management of pediatric asthma and croup.
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Ashour OM, Okudan Kremer GE. Dynamic patient grouping and prioritization: a new approach to emergency department flow improvement. Health Care Manag Sci 2014; 19:192-205. [PMID: 25487711 DOI: 10.1007/s10729-014-9311-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 11/25/2014] [Indexed: 11/25/2022]
Abstract
The demand on emergency departments (ED) is variable and ever increasing, often leaving them overcrowded. Many hospitals are utilizing triage algorithms to rapidly sort and classify patients based on the severity of their injury or illness, however, most current triage methods are prone to over- or under-triage. In this paper, the group technology (GT) concept is applied to the triage process to develop a dynamic grouping and prioritization (DGP) algorithm. This algorithm identifies most appropriate patient groups and prioritizes them according to patient- and system-related information. Discrete event simulation (DES) has been implemented to investigate the impact of the DGP algorithm on the performance measures of the ED system. The impact was studied in comparison with the currently used triage algorithm, i.e., emergency severity index (ESI). The DGP algorithm outperforms the ESI algorithm by shortening patients' average length of stay (LOS), average time to bed (TTB), time in emergency room, and lowering the percentage of tardy patients and their associated risk in the system.
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Affiliation(s)
- Omar M Ashour
- Industrial Engineering Department, Pennsylvania State University, The Behrend College, Erie, PA, 16506, USA.
| | - Gül E Okudan Kremer
- Industrial and Manufacturing Engineering, and School of Engineering Design, Pennsylvania State University, University Park, PA, 16802, USA
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Murphy SO, Barth BE, Carlton EF, Gleason M, Cannon CM. Does an ED Flow Coordinator Improve Patient Throughput? J Emerg Nurs 2014; 40:605-12. [DOI: 10.1016/j.jen.2014.03.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 02/28/2014] [Accepted: 03/16/2014] [Indexed: 11/30/2022]
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Pereira GF, Bulik CM, Weaver MA, Holland WC, Platts-Mills TF. Malnutrition among cognitively intact, noncritically ill older adults in the emergency department. Ann Emerg Med 2014; 65:85-91. [PMID: 25129819 DOI: 10.1016/j.annemergmed.2014.07.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/20/2014] [Accepted: 07/14/2014] [Indexed: 12/22/2022]
Abstract
STUDY OBJECTIVE We estimate the prevalence of malnutrition among older patients presenting to an emergency department (ED) in the southeastern United States and identify subgroups at increased risk. METHODS We conducted a cross-sectional study with random time block sampling of cognitively intact patients aged 65 years and older. Nutrition was assessed with the Mini Nutritional Assessment Short-Form (0 to 14 scale), with malnutrition defined as a score of 7 or less and at risk for malnutrition defined as a score of 8 to 11. The presence of depressive symptoms was defined as a Center for Epidemiological Studies Depression-10 score of 4 or more (0 to 10 scale). RESULTS Among 138 older adults, 16% (95% confidence interval [CI] 11% to 23%) were malnourished and 60% (95% CI 52% to 68%) were either malnourished or at risk for malnutrition. Seventeen of the 22 malnourished patients (77%) denied previously receiving a diagnosis of malnutrition. The prevalence of malnutrition was not appreciably different between men and women, across levels of patient education, or between those living in urban and rural areas. However, the prevalence of malnutrition was higher among patients with depressive symptoms (52%), those residing in assisted living (44%), those with difficulty eating (38%), and those reporting difficulty buying groceries (33%). CONCLUSION Among a random sample of cognitively intact older ED patients, more than half were malnourished or at risk for malnutrition, and the majority of malnourished patients had not previously received a diagnosis. Higher rates of malnutrition among individuals with depression, difficulty eating, and difficulty buying groceries suggest the need to explore multifaceted interventions.
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Affiliation(s)
- Greg F Pereira
- Department of Nutrition, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Cynthia M Bulik
- Department of Nutrition, UNC Gillings School of Global Public Health, Chapel Hill, NC; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Mark A Weaver
- Departments of Medicine and Biostatistics, University of North Carolina, Chapel Hill, NC
| | - Wesley C Holland
- Department of Biology, University of North Carolina, Chapel Hill, NC
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Hurwitz JE, Lee JA, Lopiano KK, McKinley SA, Keesling J, Tyndall JA. A flexible simulation platform to quantify and manage emergency department crowding. BMC Med Inform Decis Mak 2014; 14:50. [PMID: 24912662 PMCID: PMC4059027 DOI: 10.1186/1472-6947-14-50] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 06/02/2014] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Hospital-based Emergency Departments are struggling to provide timely care to a steadily increasing number of unscheduled ED visits. Dwindling compensation and rising ED closures dictate that meeting this challenge demands greater operational efficiency. METHODS Using techniques from operations research theory, as well as a novel event-driven algorithm for processing priority queues, we developed a flexible simulation platform for hospital-based EDs. We tuned the parameters of the system to mimic U.S. nationally average and average academic hospital-based ED performance metrics and are able to assess a variety of patient flow outcomes including patient door-to-event times, propensity to leave without being seen, ED occupancy level, and dynamic staffing and resource use. RESULTS The causes of ED crowding are variable and require site-specific solutions. For example, in a nationally average ED environment, provider availability is a surprising, but persistent bottleneck in patient flow. As a result, resources expended in reducing boarding times may not have the expected impact on patient throughput. On the other hand, reallocating resources into alternate care pathways can dramatically expedite care for lower acuity patients without delaying care for higher acuity patients. In an average academic ED environment, bed availability is the primary bottleneck in patient flow. Consequently, adjustments to provider scheduling have a limited effect on the timeliness of care delivery, while shorter boarding times significantly reduce crowding. An online version of the simulation platform is available at http://spark.rstudio.com/klopiano/EDsimulation/. CONCLUSION In building this robust simulation framework, we have created a novel decision-support tool that ED and hospital managers can use to quantify the impact of proposed changes to patient flow prior to implementation.
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Affiliation(s)
- Joshua E Hurwitz
- Department of Mathematics, University of Florida, Gainesville FL, USA
| | - Jo Ann Lee
- Department of Mathematics, University of Florida, Gainesville FL, USA
| | - Kenneth K Lopiano
- Statistical and Applied Mathematical Sciences Institute, Research Triangle Park NC, USA
| | - Scott A McKinley
- Department of Mathematics, University of Florida, Gainesville FL, USA
| | - James Keesling
- Department of Mathematics, University of Florida, Gainesville FL, USA
| | - Joseph A Tyndall
- Department of Emergency Medicine, University of Florida, Gainesville FL, USA
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Bergs J, Verelst S, Gillet JB, Vandijck D. Evaluating implementation of the emergency severity index in a Belgian hospital. J Emerg Nurs 2014; 40:592-7. [PMID: 24629665 DOI: 10.1016/j.jen.2014.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 12/06/2013] [Accepted: 01/10/2014] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Triage aims to categorize patients based on their clinical need and the available departmental resources. To accomplish this goal, one needs to ensure that the implemented triage system is reliable and that staff use it correctly. Therefore this study assessed the ability of Belgium nurses to apply the Emergency Severity Index (ESI), version 4, to hypothetical case scenarios after an educational intervention. METHODS An ESI educational intervention was implemented in accordance with the ESI manual. Using paper case scenarios, nurses' interrater agreement was assessed by comparing triage nurse ESI levels with the reference answers noted in the implementation manual. Interrater agreement was measured by the percentage of agreement and Cohen's κ coefficient using different weighting schemes. RESULTS Overall, 77.5% of the scenario cases were coded according the ESI guidelines, resulting in a good interrater agreement (κ = 0.72, linear weighted κ = 0.84, quadratic weighted κ = 0.92, and triage-weighted scheme = 0.79). Interrater agreement varied when evaluating each ESI level separately. Undertriage was more common than overtriage. The highest misclassification range (37.8%) occurred in ESI level 2 scenarios, with 99.2% of the misclassifications being undertriaged. DISCUSSION Implementation of the ESI into a novel setting guided by a locally developed training program resulted in suboptimal interrater agreement. Existing weighted κ schemes overestimated the interrater agreement between the triage nurse-assigned ESI level and the reference standard. By providing an aggregated measure of agreement, which allows partial agreement, clinically significant misclassification was masked by a misleading "good" interrater agreement.
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Craig JB, Culley JM, Tavakoli AS, Svendsen ER. Gleaning data from disaster: a hospital-based data mining method to study all-hazard triage after a chemical disaster. Am J Disaster Med 2014; 8:97-111. [PMID: 24352925 DOI: 10.5055/ajdm.2013.0116] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To describe the methods of evaluating currently available triage models for their efficacy in appropriately triaging the surge of patients after an all-hazards disaster. DESIGN A method was developed for evaluating currently available triage models using extracted data from medical records of the victims from the Graniteville chlorine disaster. SETTING On January 6, 2005, a freight train carrying three tanker cars of liquid chlorine was inadvertently switched onto an industrial spur in central Graniteville, SC. The train then crashed into a parked locomotive and derailed. This caused one of the chlorine tankers to rupture and immediately release ~60 tons of chlorine. Chlorine gas infiltrated the town with a population of 7,000. PARTICIPANTS This research focuses on the victims who received emergency care in South Carolina. RESULTS With our data mapping and decision tree logic, the authors were successful in using the available extracted clinical data to estimate triage categories for use in our study. CONCLUSIONS The methodology outlined in this article shows the potential use of well-designed secondary analysis methods to improve mass casualty research. The steps are reliable and repeatable and can easily be extended or applied to other disaster datasets.
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Affiliation(s)
- Jean B Craig
- Office of Biomedical Informatics Services, Medical University of South Carolina, Charleston, South Carolina
| | - Joan M Culley
- Assistant Professor, College of Nursing, University of South Carolina, Charleston, South Carolina
| | - Abbas S Tavakoli
- Director of Statistical Lab, College of Nursing, University of South Carolina, Charleston, South Carolina
| | - Erik R Svendsen
- Department of Global Environmental Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
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