Placing emergency department crowding on the decision agenda

Os médicos e a gestão do cuidado em serviços hospitalares de emergência: poder profissional ameaçado?

Resumo: O Kanban é um arranjo tecnológico de organização do cuidado hospitalar orientado para a gestão de leitos e da clínica, que visa à qualidade e integralidade da assistência, maior rotatividade dos leitos, com consequente redução do tempo de internação e custos hospitalares. O constante e atualizado acompanhamento do paciente, compartilhado pela equipe profissional em reuniões sistemáticas é seu elemento mais marcante e inovador. O objetivo foi caracterizar os prováveis impactos da adoção de tal arranjo no poder profissional (autonomia e autoridade) dos médicos. Estudo qualitativo em hospital de urgência-emergência municipal com uso das seguintes técnicas de produção de dados: etnografia do cotidiano do hospital, com observação e registro em diários de campo, e realização de seminários compartilhados entre pesquisadores e equipes. Os médicos valorizam o trabalho multiprofissional como um qualificador de sua prática, em uma linha auxiliar e complementar. Acresce que o Kanban tende a ser controlado por “híbridos” (médicos que acumulam funções gerenciais e clínicas) que traduzem sinergias entre “gestão clínica” e “gestão de leitos”. Assim, interferências no trabalho dos médicos não são exercidas de fora, e as suas decisões clínicas continuam a condicionar o trabalho dos demais grupos profissionais. Os médicos não percebem sua autoridade e autonomia ameaçadas pelo Kanban, dada a articulação entre a autoridade administrativa e a autoridade profissional. Contudo, aspectos relacionados à hibridização e estratificação interna da profissão médica precisam ser mais convocados para o debate do poder profissional em saúde.

Nurses in the Kanban: are there news meanings of professional practice in innovative tools for hospital care management?

Kanban is a care management tool that values multi-professional work and intensive use of data and has been growingly used in Brazil to address overcrowding in hospital emergency services (HES). The researchers monitored the Kanban for ten months in multiple wards of a municipal HES, and their observations were recorded in field diaries and discussed in biweekly research team meetings. The empirical material was organized from two questions: Are there changes in "traditional attributions" of Kanban-operating nursing? Are Medicine-Nursing interprofessional relationships transformed? A strong nurse adherence to this tool was observed, coupled with greater specialization and fragmentation of their work: nurses working as diarists assume more traditional administrative functions, while those on-call develop more direct assistance to patients. Nurses consider that clinical decisions are still in the doctors' hands, although Kanban provides them with a stronger influence on such decisions. Nurses' role in the management of significant mass of clinical and operational data, central to Kanban's operationalization, strengthens their professional authority.

Analysis of the Internal Bed Regulation Committees from hospitals of a Southern Brazilian city

Objective

To evaluate the composition of the Internal Regulation Committees created in hospitals of a capital city.

Methods

A cross-sectional descriptive study assessing the structure, processes and results of each Committee.

Results

The main reasons for implementing the committees were legal issues and overcrowding in the emergency department. The most monitored indicators were the occupancy rate and the mean length of stay, and the most observed results were reductions in the latter. Institutional protocols were developed in 70% of cases, and the degree of support that the Internal Regulation Committee received from the hospital managers was high, despite being only average the support received from the medical teams. Promoting the efficient use of beds seemed to be the main goal. To achieve it, the Internal Regulation Committee had to control hospital capacity at levels that allowed proper and safe bed turnover for patients. The strategies for this were varied and needed to integrate administrative and care issues.

Conclusion

The Internal Regulation Committees were a management tool with great potential and promising results in the experiences evaluated.

Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion

OBJECTIVE

To determine if a lean intervention improved emergency department (ED) throughput and reduced ED boarding by improving patient discharge efficiency from a tertiary care children's hospital.

METHODS

The study was conducted at a tertiary care children's hospital to study the impact lean that changes made to an inpatient pediatric service line had on ED efficiency. Discharge times from the general pediatrics' service were compared to patients discharged from all other pediatric subspecialty services. The intervention was multifaceted. First, team staffing reconfiguration permitted all discharge work to be done at the patient's bedside using a new discharge checklist. The intervention also incorporated an afternoon interdisciplinary huddle to work on the following day's discharges. Retrospectively, we determined the impact this had on median times of discharge order entry, patient discharge, and percent of patients discharged before noon. As a marker of ED throughput, we determined median hour of day that admitted patients left the ED to move to their hospital bed. As marker of ED congestion we determined median boarding times.

RESULTS

For the general pediatrics service line, the median discharge order entry time decreased from 1:43pm to 11:28am (p < 0.0001) and the median time of discharge decreased from 3:25pm to 2:25pm (p < 0.0001). The percent of patients discharged before noon increased from 14.0% to 26.0% (p < 0.0001). The discharge metrics remained unchanged for the pediatric subspecialty services group. Median ED boarding time decreased by 49 minutes (p < 0.0001). As a result, the median time of day admitted patients were discharged from the ED was advanced from 5 PM to 4 PM.

CONCLUSION

Lean principles implemented by one hospital service line improved patient discharge times enhanced patient ED throughput, and reduced ED boarding times.

Validation of the new Vancouver Chest Pain Rule in Asian chest pain patients presenting at the emergency department

Objectives

The new Vancouver Chest Pain (VCP) Rule recommends early discharge for chest pain patients who are at low risk of developing acute coronary syndrome (ACS), and thus can be discharged within 2 hours of arrival at the emergency department (ED). This study aimed to assess the performance of the new VCP Rule for Asian patients presenting with chest pain at the ED.

Methods

This prospective cohort study involved patients attended to at the ED of a large urban centre. Patients of at least 25 years old, presenting with stable chest pain and a non-diagnostic ECG, and with no history of active coronary artery disease were included in the study. The main outcome measures were cardiac events, angioplasty, or coronary artery bypass within 30 days of enrolment.

Results

The study included 1690 patients from 27 August 2000 to 1 May 2002, with 661 patients fulfilling the VCP criteria. Of those for early discharge, 24 had cardiac events and 13 had angioplasty or bypass at 30 days, compared to 91 and 41, respectively, for those unsuitable for discharge. This gave the rule a sensitivity of 78.1% for cardiac events, including angioplasty and bypass. Specificity was 41.0%, and negative predictive value (NPV) was 94.4%.

Conclusion

We found the new VCP Rule to have moderate sensitivity and poor specificity for adverse cardiac events in our population. With an NPV of less than 100%, this means that a small proportion of patients sent home with early discharge would still have adverse cardiac events.

Nutrition Risk Screening in Patients Admitted to an Adult Emergency Department of a Brazilian University Hospital

BACKGROUND

The prevalence of malnutrition in emergency units is high, and data on the nutrition risk of patients admitted in these units are scarce. The aims of this study are to determine the nutrition risk profile of individuals admitted in an emergency unit and to identify clinical, anthropometric, and laboratory attributes according to nutrition risk classification.

MATERIALS AND METHODS

A total of 234 individuals in an emergency unit from 1 university hospital in Brazil were enrolled in this cross-sectional study. The nutrition risk profile was determined using the Nutrition Risk Screening 2002. Sociodemographic, clinical, anthropometric, and laboratory data were collected. Comparisons between individuals "at risk" and "not at risk" and logistic regression analyzes were performed.

RESULTS

The prevalence of nutrition risk at admission was 48.7%. Patients at risk were older ( P = .031), were less educated ( P = .022), had a lower body mass index ( P < .001), had higher concentrations of C-reactive protein (CRP; P = .007), had a higher CRP/serum albumin ratio ( P = .004), had lower concentrations of serum albumin ( P = .002), and had severe weight loss ( P < .001). Altogether, this profile resulted in a longer hospital stay ( P = .004), more complications ( P = .005), and greater use of antibiotics ( P = .024). In regression analyses, low serum albumin (odds ratio [OR], 2.75; 95% confidence interval [CI], 1.23-6.13) and, higher serum CRP (OR, 1.13; 95% CI, 1.00-3.72), use of antibiotics (OR, 13.3; 95% CI, 1.59-111.16) were predictors of long hospital stay.

CONCLUSION

The prevalence of nutrition risk in emergency patients was high and its profile associated with worse clinical, laboratory, and anthropometric outcomes. The use of other laboratory and clinical variables may also be a good strategy for predicting adverse outcomes in emergency units.

Effect of troponin I Point-of-Care testing on emergency department throughput measures and staff satisfaction

Emergency departments (EDs) are challenged to provide rapid triage and evaluation to make appropriate patient disposition and timely treatment decisions. Cardiac troponin is the preferred biomarker for evaluation of patients with chest pain. The objective of this before-and-after study was to determine the impact of Point-of-Care (POC) troponin testing on turnaround times, door-to-troponin result times, ED length of stay (LOS) in patients with chest pain, and staff satisfaction with POC testing. After POC implementation, the average door-to-troponin result time significantly decreased from 105 to 51 min (p < 0.000). The average LOS decreased from 290 to 255 min; however, the change was not significant (p = 0.082). The majority of nurses (81%) felt that POC testing encouraged communication among patient care team members, and satisfaction was high with 82% of all ED staff members rating their satisfaction as excellent.

Emergency department crowding in The Netherlands: managers' experiences

Background

In The Netherlands, the state of emergency department (ED) crowding is unknown. Anecdotal evidence suggests that current ED patients experience a longer length of stay (LOS) compared to some years ago, which is indicative of ED crowding. However, no multicenter studies have been performed to quantify LOS and assess crowding at Dutch EDs. We performed this study to describe the current state of emergency departments in The Netherlands regarding patients’ length of stay and ED nurse managers’ experiences of crowding.

Methods

A survey was sent to all 94 ED nurse managers in The Netherlands with questions regarding the type of facility, annual ED census, and patients’ LOS. Additional questions included whether crowding was ever a problem at the particular ED, how often it occurred, which time periods had the worst episodes of crowding, and what measures the particular ED had undertaken to improve patient flow.

Results

Surveys were collected from 63 EDs (67%). Mean annual ED visits were 24,936 (SD ± 9,840); mean LOS for discharged patients was 119 (SD ± 40) min and mean LOS for admitted patients 146 (SD ± 49) min. Consultation delays, laboratory and radiology delays, and hospital bed shortages for patients needing admission were the most cited reasons for crowding. Admitted patients had a longer LOS because of delays in obtaining inpatient beds. Thirty-nine of 57 respondents (68%) reported that crowding occurred several times a week or even daily, mostly between 12:00 and 20:00. Measures taken by hospitals to manage crowding included placing patients in hallways and using fasttrack with treatment of patients by trained nurse practitioners.

Conclusions

Despite a relatively short LOS, frequent crowding appears to be a nationwide problem according to Dutch ED nurse managers, with 68% of them reporting that crowding occurred several times a week or even daily. Consultations delays, laboratory and radiology delays, and hospital bed shortage for patients needing admission were believed to be the most important factors contributing to ED crowding.

Forecasting peak asthma admissions in London: an application of quantile regression models

Asthma is a chronic condition of great public health concern globally. The associated morbidity, mortality and healthcare utilisation place an enormous burden on healthcare infrastructure and services. This study demonstrates a multistage quantile regression approach to predicting excess demand for health care services in the form of asthma daily admissions in London, using retrospective data from the Hospital Episode Statistics, weather and air quality. Trivariate quantile regression models (QRM) of asthma daily admissions were fitted to a 14-day range of lags of environmental factors, accounting for seasonality in a hold-in sample of the data. Representative lags were pooled to form multivariate predictive models, selected through a systematic backward stepwise reduction approach. Models were cross-validated using a hold-out sample of the data, and their respective root mean square error measures, sensitivity, specificity and predictive values compared. Two of the predictive models were able to detect extreme number of daily asthma admissions at sensitivity levels of 76 % and 62 %, as well as specificities of 66 % and 76 %. Their positive predictive values were slightly higher for the hold-out sample (29 % and 28 %) than for the hold-in model development sample (16 % and 18 %). QRMs can be used in multistage to select suitable variables to forecast extreme asthma events. The associations between asthma and environmental factors, including temperature, ozone and carbon monoxide can be exploited in predicting future events using QRMs.

An overview of health forecasting

Health forecasting is a novel area of forecasting, and a valuable tool for predicting future health events or situations such as demands for health services and healthcare needs. It facilitates preventive medicine and health care intervention strategies, by pre-informing health service providers to take appropriate mitigating actions to minimize risks and manage demand. Health forecasting requires reliable data, information and appropriate analytical tools for the prediction of specific health conditions or situations. There is no single approach to health forecasting, and so various methods have often been adopted to forecast aggregate or specific health conditions. Meanwhile, there are no defined health forecasting horizons (time frames) to match the choices of health forecasting methods/approaches that are often applied. The key principles of health forecasting have not also been adequately described to guide the process. This paper provides a brief introduction and theoretical analysis of health forecasting. It describes the key issues that are important for health forecasting, including: definitions, principles of health forecasting, and the properties of health data, which influence the choices of health forecasting methods. Other matters related to the value of health forecasting, and the general challenges associated with developing and using health forecasting services are discussed. This overview is a stimulus for further discussions on standardizing health forecasting approaches and methods that will facilitate health care and health services delivery.

Intervenções para solucionar a superlotação nos serviços de emergência hospitalar: uma revisão sistemática

Esta revisão discute as intervenções voltadas para solucionar o problema da superlotação dos Serviços de Emergência Hospitalar (SEH), como evidência de baixa efetividade organizacional. Em bases de dados eletrônicas de livre acesso e acesso restrito, os descritores buscados foram "superlotação; emergência; medicina; pronto-socorro". O levantamento identificou 66 citações de intervenções, agrupadas em 47 intervenções afins. A maioria dos trabalhos teve como desenho os estudos observacionais que avaliaram os resultados das intervenções antes e depois. As mais citadas: implantação da unidade de observação dos pacientes graves; implantação do serviço de enfermagem dedicado à admissão, alta e transferência do paciente; instituição de protocolos de saturação operacional e implantação da unidade de pronto-atendimento. Na análise das 21 intervenções para solucionar a superlotação nos SEH, que tiveram resultados favoráveis no evento principal - tempo de permanência no SEH -, 15 tinham relação com a melhoria do fluxo no próprio SEH ou nos setores do hospital, interferindo ativa e positivamente no fluxo interno dos pacientes. As intervenções que aumentaram as barreiras de acesso aos SEH, ou que apenas melhoram a estrutura dos SEH não foram efetivas.

Using demand analysis and system status management for predicting ED attendances and rostering

INTRODUCTION

It has been observed that emergency department (ED) attendances are not random events but rather have definite time patterns and trends that can be observed historically.

OBJECTIVES

To describe the time demand patterns at the ED and apply systems status management to tailor ED manpower demand.

METHODS

Observational study of all patients presenting to the ED at the Singapore General Hospital during a 3-year period was conducted. We also conducted a time series analysis to determine time norms regarding physician activity for various severities of patients.

RESULTS

The yearly ED attendances increased from 113387 (2004) to 120764 (2005) and to 125773 (2006). There was a progressive increase in severity of cases, with priority 1 (most severe) increasing from 6.7% (2004) to 9.1% (2006) and priority 2 from 33.7% (2004) to 35.1% (2006). We noticed a definite time demand pattern, with seasonal peaks in June, weekly peaks on Mondays, and daily peaks at 11 to 12 am. These patterns were consistent during the period of the study. We designed a demand-based rostering tool that matched doctor-unit-hours to patient arrivals and severity. We also noted seasonal peaks corresponding to public holidays.

CONCLUSION

We found definite and consistent patterns of patient demand and designed a rostering tool to match ED manpower demand.

Emergency department utilization patterns among older adults

BACKGROUND

We identified 4-year (2 years before and 2 years after the index [baseline] interview) ED use patterns in older adults and the factors associated with them.

METHODS

A secondary analysis of baseline interview data from the nationally representative Survey on Assets and Health Dynamics Among the Oldest Old linked to Medicare claims data. Participants were 4310 self-respondents 70 years old or older. Current Procedural Terminology (CPT) codes 99281 and 99282 identified low-intensity use, and CPT codes 99283-99285 identified high-intensity use. Exploratory factor analysis and multivariable multinomial logistic regression were used.

RESULTS

The majority (56.6%) of participants had no ED visits during the 4-year period. Just 5.7% had only low-intensity ED use patterns, whereas 28.9% used the ED only for high-intensity visits, and 8.7% had a mixture of low-intensity and high-intensity use. Participants with lower immediate word recall scores and those who did not live in major metropolitan areas were more likely to be low-intensity-only ED users. Older individuals, those who did not live in rural counties, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to be high-intensity-only ED users. Participants who were older, did not live in major cities, had lower education levels, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to have mixed ED use patterns.

CONCLUSIONS

Nearly half of these older adults used the ED at least once over a 4-year period, with a mean annual ED use percentage of 18.4. Few, however, used the ED only for visits that may have been avoidable. This finding suggests that triaging Medicare patients would not decrease ED overcrowding, although continued surveillance is necessary to detect potential changes in ED use patterns among older adults.