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Choi A, Choi SY, Chung K, Chung HS, Song T, Choi B, Kim JH. Development of a machine learning-based clinical decision support system to predict clinical deterioration in patients visiting the emergency department. Sci Rep 2023; 13:8561. [PMID: 37237057 DOI: 10.1038/s41598-023-35617-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/21/2023] [Indexed: 05/28/2023] Open
Abstract
This study aimed to develop a machine learning-based clinical decision support system for emergency departments based on the decision-making framework of physicians. We extracted 27 fixed and 93 observation features using data on vital signs, mental status, laboratory results, and electrocardiograms during emergency department stay. Outcomes included intubation, admission to the intensive care unit, inotrope or vasopressor administration, and in-hospital cardiac arrest. eXtreme gradient boosting algorithm was used to learn and predict each outcome. Specificity, sensitivity, precision, F1 score, area under the receiver operating characteristic curve (AUROC), and area under the precision-recall curve were assessed. We analyzed 303,345 patients with 4,787,121 input data, resampled into 24,148,958 1 h-units. The models displayed a discriminative ability to predict outcomes (AUROC > 0.9), and the model with lagging 6 and leading 0 displayed the highest value. The AUROC curve of in-hospital cardiac arrest had the smallest change, with increased lagging for all outcomes. With inotropic use, intubation, and intensive care unit admission, the range of AUROC curve change with the leading 6 was the highest according to different amounts of previous information (lagging). In this study, a human-centered approach to emulate the clinical decision-making process of emergency physicians has been adopted to enhance the use of the system. Machine learning-based clinical decision support systems customized according to clinical situations can help improve the quality of care.
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Affiliation(s)
- Arom Choi
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Institute for Innovation in Digital Healthcare, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - So Yeon Choi
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kyungsoo Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Institute for Innovation in Digital Healthcare, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Taeyoung Song
- LG Electronics, 128 Yeoui-daero, Yeongdeungpo-gu, Seoul, 07336, Republic of Korea
| | - Byunghun Choi
- LG Electronics, 128 Yeoui-daero, Yeongdeungpo-gu, Seoul, 07336, Republic of Korea
| | - Ji Hoon Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
- Institute for Innovation in Digital Healthcare, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Tuttle E, Wang X, Modrykamien A. Implementation of a medical intensive care team in the emergency department of a tertiary medical center in the USA. Hosp Pract (1995) 2022; 50:387-392. [PMID: 36108339 DOI: 10.1080/21548331.2022.2126255] [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: 05/29/2022] [Accepted: 08/25/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Critically ill patients boarding in the ED have higher mortality rates. Several strategies have been implemented to deliver care to boarding patients. Our institution opted for a strategy consisting on deploying an Intensive Care team in the ED. This article reports outcomes before-and-after implementation of that team. METHODS On November 2020, a Medical Intensive Care Team was deployed in the ED. The team performed consultations for ICU patients boarding in the ED. A retrospective analysis of critically ill patients arriving to the ED before-and-after team implementation was performed. Outcome data were reviewed. Direct hospitalization costs per patient, and direct costs per department were assessed. Wilcoxon rank sum and Chisq-test were utilized to compare differences pre- and post-implementation. Multivariate analyses to model outcomes toward pre- and post-implementation and other variables were performed. RESULTS 1,828 and 3,272 patients were included in the pre- and post-intervention groups. ICU LOS (days) pre- and post-intervention were 3 (1,6) and 3 (1,6), respectively (p = 0.41). ICU readmission rates were 6.7% pre-intervention and 7.4% post-intervention (p = 0.37). Total direct costs were US$ 19,928 (11,006, 37,815) and US$ 15,795 (9016, 28,993), respectively (p < 0.01). Multivariate analysis showed no association between team deployment and ICU LOS or readmission. However, there was association between its implementation and hospitalization cost reduction per patient of US$ 7,171. CONCLUSION The implementation of a Medical Intensive Care team in the ED is not associated with a reduction of ICU LOS or ICU readmission. Nevertheless, its implementation is associated with a reduction of hospitalization costs.
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Affiliation(s)
- Erin Tuttle
- Division of Pulmonary and Critical Care Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | - Xuan Wang
- Biostatistics Department, Baylor Scott & White Research institute, Dallas, Texas, USA
| | - Ariel Modrykamien
- Division of Pulmonary and Critical Care Medicine, Baylor University Medical Center, Dallas, Texas, USA
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Prediction of hospitalization using artificial intelligence for urgent patients in the emergency department. Sci Rep 2021; 11:19472. [PMID: 34593930 PMCID: PMC8484275 DOI: 10.1038/s41598-021-98961-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
Timely assessment to accurately prioritize patients is crucial for emergency department (ED) management. Urgent (i.e., level-3, on a 5-level emergency severity index system) patients have become a challenge since under-triage and over-triage often occur. This study was aimed to develop a computational model by artificial intelligence (AI) methodologies to accurately predict urgent patient outcomes using data that are readily available in most ED triage systems. We retrospectively collected data from the ED of a tertiary teaching hospital between January 1, 2015 and December 31, 2019. Eleven variables were used for data analysis and prediction model building, including 1 response, 2 demographic, and 8 clinical variables. A model to predict hospital admission was developed using neural networks and machine learning methodologies. A total of 282,971 samples of urgent (level-3) visits were included in the analysis. Our model achieved a validation area under the curve (AUC) of 0.8004 (95% CI 0.7963–0.8045). The optimal cutoff value identified by Youden's index for determining hospital admission was 0.5517. Using this cutoff value, the sensitivity was 0.6721 (95% CI 0.6624–0.6818), and the specificity was 0.7814 (95% CI 0.7777–0.7851), with a positive predictive value of 0.3660 (95% CI 0.3586–0.3733) and a negative predictive value of 0.9270 (95% CI 0.9244–0.9295). Subgroup analysis revealed that this model performed better in the nontraumatic adult subgroup and achieved a validation AUC of 0.8166 (95% CI 0.8199–0.8212). Our AI model accurately assessed the need for hospitalization for urgent patients, which constituted nearly 70% of ED visits. This model demonstrates the potential for streamlining ED operations using a very limited number of variables that are readily available in most ED triage systems. Subgroup analysis is an important topic for future investigation.
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Gualandi R, Masella C, Viglione D, Tartaglini D. Challenges and potential improvements in hospital patient flow: the contribution of frontline, top and middle management professionals. J Health Organ Manag 2021; ahead-of-print. [PMID: 32978906 DOI: 10.1108/jhom-11-2019-0316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE This study aims to describe and understand the contributions of frontline, middle and top management healthcare professionals in detecting areas of potential improvement in hospital patient flow and proposing solutions. DESIGN/METHODOLOGY/APPROACH This is a qualitative interview study. Semistructured interviews were conducted with 22 professionals in the orthopedic department of a 250-bed academic teaching hospital. Data were analyzed through a thematic framework analytical approach by using an a priori framework. The Consolidated Criteria for Reporting Qualitative (COREQ) checklist for qualitative studies was followed. FINDINGS When dealing with a hospital-wide process, the involvement of all professionals, including nonhealth professionals, can reveal priority areas for improvement and for services integration. The improvements identified by the professionals largely focus on covering major gaps detected in the technical and administrative quality. RESEARCH LIMITATIONS/IMPLICATIONS This study focused on the professional viewpoint and the connections between services and further studies should explore the role of patient involvement. The study design could limit the generalizability of findings. PRACTICAL IMPLICATIONS Improving high-quality, efficient hospital patient flow cannot be accomplished without learning the perspective of the healthcare professionals on the process of service delivery. ORIGINALITY/VALUE Few qualitative studies explore professionals' perspectives on patient needs in hospital flow management. This study provides insights into what produces value for the patient within a complex process by analyzing the contribution of professionals from their particular role in the organization.
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Yun H, Choi J, Park JH. XGBoost Algorithm Prediction of Critical Care Outcome for Adult Patients Presenting to Emergency Department Using Initial Triage Information. JMIR Med Inform 2021; 9:e30770. [PMID: 34346889 PMCID: PMC8491120 DOI: 10.2196/30770] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/27/2021] [Accepted: 07/27/2021] [Indexed: 12/23/2022] Open
Abstract
Background The emergency department (ED) triage system to classify and prioritize patients from high risk to less urgent continues to be a challenge. Objective This study, comprising 80,433 patients, aims to develop a machine learning algorithm prediction model of critical care outcomes for adult patients using information collected during ED triage and compare the performance with that of the baseline model using the Korean Triage and Acuity Scale (KTAS). Methods To predict the need for critical care, we used 13 predictors from triage information: age, gender, mode of ED arrival, the time interval between onset and ED arrival, reason of ED visit, chief complaints, systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, body temperature, oxygen saturation, and level of consciousness. The baseline model with KTAS was developed using logistic regression, and the machine learning model with 13 variables was generated using extreme gradient boosting (XGB) and deep neural network (DNN) algorithms. The discrimination was measured by the area under the receiver operating characteristic (AUROC) curve. The ability of calibration with Hosmer–Lemeshow test and reclassification with net reclassification index were evaluated. The calibration plot and partial dependence plot were used in the analysis. Results The AUROC of the model with the full set of variables (0.833-0.861) was better than that of the baseline model (0.796). The XGB model of AUROC 0.861 (95% CI 0.848-0.874) showed a higher discriminative performance than the DNN model of 0.833 (95% CI 0.819-0.848). The XGB and DNN models proved better reclassification than the baseline model with a positive net reclassification index. The XGB models were well-calibrated (Hosmer-Lemeshow test; P>.05); however, the DNN showed poor calibration power (Hosmer-Lemeshow test; P<.001). We further interpreted the nonlinear association between variables and critical care prediction. Conclusions Our study demonstrated that the performance of the XGB model using initial information at ED triage for predicting patients in need of critical care outperformed the conventional model with KTAS.
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Affiliation(s)
- Hyoungju Yun
- Interdisciplinary Program of Medical Informatics, College of Medicine, Seoul National University, Seoul, KR
| | - Jinwook Choi
- Interdisciplinary Program of Medical Informatics, College of Medicine, Seoul National University, Seoul, KR.,Department of Biomedical Engineering, College of Medicine, Seoul National University, Seoul, KR.,Institute of Medical and Biological Engineering,, Seoul National University Medical Research Center, 103 Daehak-Ro, Jongno-Gu, Seoul, KR
| | - Jeong Ho Park
- Department of Emergency Medicine, College of Medicine, Seoul National University, Seoul, KR.,Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, KR
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Mohr NM, Wessman BT, Bassin B, Elie‐Turenne M, Ellender T, Emlet LL, Ginsberg Z, Gunnerson K, Jones KM, Kram B, Marcolini E, Rudy S. Boarding of critically Ill patients in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:423-431. [PMID: 33000066 PMCID: PMC7493502 DOI: 10.1002/emp2.12107] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Emergency department boarding is the practice of caring for admitted patients in the emergency department after hospital admission, and boarding has been a growing problem in the United States. Boarding of the critically ill has achieved specific attention because of its association with poor clinical outcomes. Accordingly, the Society of Critical Care Medicine and the American College of Emergency Physicians convened a Task Force to understand the implications of emergency department boarding of the critically ill. The objective of this article is to review the U.S. literature on (1) the frequency of emergency department boarding among the critically ill, (2) the outcomes associated with critical care patient boarding, and (3) local strategies developed to mitigate the impact of emergency department critical care boarding on patient outcomes. DATA SOURCES AND STUDY SELECTION Review article. DATA EXTRACTION AND DATA SYNTHESIS Emergency department-based boarding of the critically ill patient is common, but no nationally representative frequency estimates has been reported. Boarding literature is limited by variation in the definitions used for boarding and variation in the facilities studied (boarding ranges from 2% to 88% of ICU admissions). Prolonged boarding in the emergency department has been associated with longer duration of mechanical ventilation, longer ICU and hospital length of stay, and higher mortality. Health systems have developed multiple mitigation strategies to address emergency department boarding of critically ill patients, including emergency department-based interventions, hospital-based interventions, and emergency department-based resuscitation care units. CONCLUSIONS Emergency department boarding of critically ill patients was common and was associated with worse clinical outcomes. Health systems have generated a number of strategies to mitigate these effects. A definition for emergency department boarding is proposed. Future work should establish formal criteria for analysis and benchmarking of emergency department-based boarding overall, with subsequent efforts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.
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Affiliation(s)
- Nicholas M. Mohr
- Department of Emergency Medicine and Department of AnesthesiaUniversity of Iowa Carver College of MedicineIowa CityIA
| | - Brian T. Wessman
- Department of Anesthesiology and Department of Emergency MedicineWashington University School of MedicineSt. LouisMO
| | - Benjamin Bassin
- Department of Emergency MedicineDivision of Critical CareUniversity of MichiganAnn ArborMI
| | - Marie‐Carmelle Elie‐Turenne
- Department of Emergency Medicine and Department of MedicineCritical Care MedicinePalliative and Hospice MedicineUniversity of FloridaGainesvilleFL
| | - Timothy Ellender
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIN
| | - Lillian L. Emlet
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPA
| | - Zachary Ginsberg
- Kettering Health SystemDepartment of Emergency & Critical Care MedicineDaytonOH
| | - Kyle Gunnerson
- Department of Emergency MedicineDivision of Critical CareUniversity of MichiganAnn ArborMI
| | - Kevin M. Jones
- Program in TraumaR. Adams Cowley Shock Trauma Center, Department of Emergency MedicineUniversity of Maryland School of MedicineBaltimoreMA
| | | | - Evie Marcolini
- Section of Emergency MedicineDepartment of MedicineGeisel School of Medicine at DartmouthHanoverNH
| | - Susanna Rudy
- Department of NursingVanderbilt UniversityNashvilleTN
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Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008-2018. Crit Care Med 2020; 47:1442-1449. [PMID: 31414993 PMCID: PMC6750122 DOI: 10.1097/ccm.0000000000003925] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To provide a concise review of the literature and data pertaining to the use of nurse practitioners and physician assistants, collectively called advanced practice providers, in ICU and acute care settings. DATA SOURCES Detailed search strategy using the databases PubMed, Ovid MEDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018. STUDY SELECTION Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting. DATA EXTRACTION Relevant studies were reviewed, and the following aspects of each study were identified, abstracted, and analyzed: study population, study design, study aims, methods, results, and relevant implications for critical care practice. DATA SYNTHESIS Five systematic reviews, four literature reviews, and 44 individual studies were identified, reviewed, and critiqued. Of the research studies, the majority were retrospective with others being observational, quasi-experimental, or quality improvement, along with two randomized control trials. Overall, the studies assessed a variety of effects of advanced practice provider care, including on length of stay, mortality, and quality-related metrics, with a majority demonstrating similar or improved patient care outcomes. CONCLUSIONS Over the past 10 years, the number of studies assessing the impact of advanced practice providers in acute and critical care settings continue to increase. Collectively, these studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, patient and staff satisfaction, and on new areas of focus including enhanced educational experience of residents and fellows.
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Abraham J, Burton S, Gordon HS. Moving patients from emergency department to medical intensive care unit: Tracing barriers and root contributors. Int J Med Inform 2019; 133:104012. [PMID: 31726385 DOI: 10.1016/j.ijmedinf.2019.104012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/15/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patient transfers involve the physical movement of patients, along with the transfer of their care-related information, responsibility, and control between sending and receiving clinicians. Patient transfers between critical care units are complex and vulnerable to bottlenecks. OBJECTIVE To examine the patient transfer process from emergency department (ED) to medical intensive care unit (MICU). MATERIALS AND METHOD A qualitative study on transfers from ED to MICU was conducted at two academic hospitals. Using a process-based methodological approach supported by shadowing of patient transfers and clinician interviews, we examined the process-based similarities and differences in barriers and strategies used across hospitals. RESULTS Phases underlying ED-MICU transfer process included: pre-transfer phase involving ED care coordination and MICU transfer decision-making; transfer phase involving ED-MICU resident handoff, and post-transfer phase involving MICU care planning and management. DISCUSSION AND CONCLUSION Transfer of information, responsibility and control between sending and receiving clinicians is key to effective management of interdependencies between the pre-transfer, transfer and post-transfer phases underlying the patient transfer process. Evidence-based strategies to address challenges related to transfer of information, responsibility and control include the use of videophones and communication checklists, the allocation of a crash bed, engagement of sending, receiving and consulting teams in the physical movement of patients, and in-hospital transfer protocols.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology & Institute for Informatics, School of Medicine, Washington University in St Louis, St. Louis, MO, United States.
| | - Shirley Burton
- Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, University of Illinois, Chicago, United States
| | - Howard S Gordon
- Jessse Brown VAMC and VA HSR&D Center of Innovation for Complex Chronic Healthcare, Chicago, United States; Department of Medicine, College of Medicine, University of Illinois, Chicago, United States
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Sahadeo A, McDowald K, Direktor S, Hynes EA, Rogers ME. Effectiveness of collaboration between emergency department and intensive care unit teams on mortality rates of patients presenting with critical illness: a quantitative systematic review protocol. ACTA ACUST UNITED AC 2018; 15:66-75. [PMID: 28085728 DOI: 10.11124/jbisrir-2016-003003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW OBJECTIVE The objective of this review is to identify the effectiveness of collaboration between emergency department (ED) and intensive care unit teams on mortality rates of critically ill adult patients in the ED.
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Affiliation(s)
- Anna Sahadeo
- 1College of Health Professions, Pace University, New York, New York, USA 2The Northeast Institute for Evidence Synthesis and Translation (NEST): a Joanna Briggs Institute Center of Excellence
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Machine-Learning-Based Electronic Triage More Accurately Differentiates Patients With Respect to Clinical Outcomes Compared With the Emergency Severity Index. Ann Emerg Med 2018; 71:565-574.e2. [DOI: 10.1016/j.annemergmed.2017.08.005] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 07/07/2017] [Accepted: 08/01/2017] [Indexed: 11/23/2022]
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Emergency Department Length of Stay for Critical Care Admissions. A Population-based Study. Ann Am Thorac Soc 2018; 13:1324-32. [PMID: 27111127 DOI: 10.1513/annalsats.201511-773oc] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Hospital emergency department (ED) strain is common in North America. Excessive strain may result in prolonged ED length of stay and may lead to worse outcomes for patients admitted to intensive care units (ICUs). OBJECTIVES To describe patient, ED, and hospital characteristics associated with prolonged ED length of stay for adult patients admitted from EDs to ICUs. METHODS We conducted a population-based cohort study in the Province of Ontario, Canada, including patients admitted to an adult ICU from an ED and excluding only interhospital transfers and scheduled visits. Using regression modeling, we examined associations between patient- and hospital-level characteristics and two ED performance measures: length of stay in the ED of more than 6 hours and 90-day mortality. MEASUREMENTS AND MAIN RESULTS From April 2007 to March 2012, 261,274 adults presented to 118 EDs in Ontario, generating 314,836 ICU admissions. This activity represented 4.1% of all adult ED visits (incidence, 1,374 ICU admissions/100,000 ED visits). Median (interquartile range) ED length of stay was 7 (4-13) hours. Less than half (41.4%; 95% confidence interval [CI], 41.2-41.5) of these patients had an ED length of stay of 6 hours or less, whereas 10.5% (95% CI, 10.4-10.6) stayed 24 hours or longer. Hospital characteristics associated with ED length of stay more than 6 hours included shift-level ED crowding (mean length of stay of patients of similar acuity registering during same 8 h epoch) (odds ratio [OR], 1.19/h; 95% CI, 1.19-1.19), ED annual visit volume (OR, 1.01/1,000 patients; 95% CI, 1.01-1.01), time of ED presentation (00:00-07:59) (OR, 1.41; 95% CI, 1.38-1.45), and ICU functioning at greater than 20% above the average annual census (OR, 1.10; 95% CI, 1.08-1.12). ED length of stay more than 6 hours was not associated with 90-day mortality after adjustment for selected confounders (OR, 0.99; 95% CI, 0.97-1.02). CONCLUSIONS In this population-based study, less than half of adult ED patients were admitted to an ICU 6 hours or less after arrival to an ED, an internationally recognized performance indicator for ED care quality. ED and ICU strain generated by time-varying demand on capacity was an important determinant of ED length of stay. However, prolonged length of stay in an ED did not measurably reduce 90-day mortality.
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A “Code ICU” expedited review of critically ill patients is associated with reduced emergency department length of stay and duration of mechanical ventilation. J Crit Care 2017; 42:123-128. [DOI: 10.1016/j.jcrc.2017.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 05/30/2017] [Accepted: 07/03/2017] [Indexed: 11/23/2022]
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Kannan N, Quistberg A, Wang J, Groner JI, Mink RB, Wainwright MS, Bell MJ, Giza CC, Zatzick DF, Ellenbogen RG, Boyle LN, Mitchell PH, Vavilala MS. Frequency of and factors associated with emergency department intracranial pressure monitor placement in severe paediatric traumatic brain injury. Brain Inj 2017; 31:1745-1752. [PMID: 28829632 PMCID: PMC6192829 DOI: 10.1080/02699052.2017.1346296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 06/04/2017] [Accepted: 06/19/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To examine the frequency of and factors associated with emergency department (ED) intracranial pressure (ICP) monitor placement in severe paediatric traumatic brain injury (TBI). METHODS Retrospective, multicentre cohort study of children <18 years admitted to the ED with severe TBI and intubated for >48 hours from 2007 to 2011. RESULTS Two hundred and twenty-four children had severe TBI and 75% underwent either ED, operating room (OR) or paediatric intensive care unit (PICU) ICP monitor placement. Four out of five centres placed ICP monitors in the ED, mostly (83%) fibreoptic. Nearly 40% of the patients who received ICP monitors get it placed in the ED (29% overall). Factors associated with ED ICP monitor placement were as follows: age 13 to <18 year olds compared to infants (aRR 2.02; 95% CI 1.37, 2.98), longer ED length of stay (LOS) (aRR 1.15; 95% CI 1.08, 1.21), trauma centre designation paediatric only I/II compared to adult/paediatric I/II (aRR 1.71; 95% CI 1.48, 1.98) and higher mean paediatric TBI patient volume (aRR 1.88;95% CI 1.68, 2.11). Adjusted for centre, higher bedside ED staff was associated with longer ED LOS (aRR 2.10; 95% CI 1.06, 4.14). CONCLUSION ICP monitors are frequently placed in the ED at paediatric trauma centres caring for children with severe TBI. Both patient and organizational level factors are associated with ED ICP monitor placement.
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Affiliation(s)
- Nithya Kannan
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Alex Quistberg
- Departments of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Jin Wang
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Jonathan I. Groner
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Richard B. Mink
- Department of Pediatrics, Harbor-UCLA and Los Angeles BioMedical Research Institute, Torrance, CA
| | - Mark S. Wainwright
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Michael J. Bell
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher C. Giza
- Department of Neurosurgery and Division of Pediatric Neurology, Mattel Children’s Hospital, UCLA, Los Angeles, CA
| | - Douglas F. Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - Richard G. Ellenbogen
- Departments of Neurological Surgery and Global Health Medicine, University of Washington, Seattle, WA
| | - Linda Ng Boyle
- Departments of Industrial and Systems Engineering, University of Washington, Seattle, WA
| | | | - Monica S. Vavilala
- Departments of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
- Departments of Neurological Surgery and Global Health Medicine, University of Washington, Seattle, WA
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