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Imhoff B, Marshall K, Nazir N, Pal A, Parkhurst M. Reducing time to admission in emergency department patients: a cross-functional quality improvement project. BMJ Open Qual 2022; 11:bmjoq-2022-001987. [PMID: 36122996 PMCID: PMC9486293 DOI: 10.1136/bmjoq-2022-001987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/25/2022] [Indexed: 11/15/2022] Open
Abstract
Crowding and boarding are common issues facing emergency departments (EDs) in the USA. These issues have negative effects on efficiency, patient care, satisfaction and healthcare team well-being. Data from an audit of the admissions process at a large, urban, academic US ED demonstrated a lengthy process, exceeding national benchmarks in both length of stay and boarding of admitted patients. We performed a pre–post study between July 2019 and July 2021 focused on the first step of the admission process at our institution, the time to bed request. All patients admitted to an internal medicine (IM) floor team from the ED were included in the study. The primary outcome was the time from decision to admit by the emergency medicine physician to placement of the bed request order by the IM physician. Quality improvement (QI) occurred in three phases: an initial preintervention process and electronic health record change to better capture admission times, a primary intervention focused on process change and provider education and a second intervention focused on improvements to provider communication. During the study period, 25 183 patients were admitted to IM floor teams and met inclusion criteria. Prior to the primary intervention, the mean time from ED decision to admit to IM placement of the bed request order was 75.1 min. Postintervention, the mean time decreased to 39.7 min, a statistically significant improvement of 35.4 min (p value <0.0001). This QI project demonstrates the ability of interventions to reduce the time to admission bed request order, a key step in the overall admission process and a contributor to boarding at our institution. In making process changes, the team also reduced provider handoffs and improved provider communication.
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Affiliation(s)
- Bryan Imhoff
- Department of Emergency Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Kenneth Marshall
- Department of Emergency Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Niaman Nazir
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - Aroop Pal
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Melissa Parkhurst
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
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Pek PP, Lau CY, Sim X, Tan KB, Mao DRH, Liu Z, Ho AF, Liu N, Ong MEH. Nationwide study of the characteristics of frequent attenders with multiple emergency department attendance patterns. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:483-492. [PMID: 36047523 DOI: 10.47102/annals-acadmedsg.2021483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION The burden of frequent attenders (FAs) of emergency departments (EDs) on healthcare resources is underestimated when single-centre analyses do not account for utilisation of multiple EDs by FAs. We aimed to quantify the extent of multiple ED use by FAs and to characterise FAs. METHODS We reviewed nationwide ED attendance in Singapore data from 1 January 2006 to 31 December 2018 (13 years). FAs were defined as patients with ≥4 ED visits in any calendar year. Single ED FAs and multiple ED FAs were patients who attended a single ED exclusively and ≥2 distinct EDs within the year, respectively. Mixed ED FAs were patients who attended a mix of a single ED and multiple EDs in different calendar years. We compared the characteristics of FAs using multivariable logistic regression. RESULTS We identified 200,130 (6.3%) FAs who contributed to1,865,704 visits (19.6%) and 2,959,935 (93.7%) non-FAs who contributed to 7,671,097 visits (80.4%). After missing data were excluded, the study population consisted of 199,283 unique FAs. Nationwide-linked data identified an additional 15.5% FAs and 29.7% FA visits, in addition to data from single centres. Multiple ED FAs and mixed ED FAs were associated with male sex, younger age, Malay or Indian ethnicity, multiple comorbidities, median triage class of higher severity, and a higher frequency of ED use. CONCLUSION A nationwide approach is needed to quantify the national FA burden. The multiple comorbidities and higher frequency of ED use associated with FAs who visited multiple EDs and mixed EDs, compared to those who visited a single ED, suggested a higher level of ED burden in these subgroups of patients. The distinct characteristics and needs of each FA subgroup should be considered in future healthcare interventions to reduce FA burden.
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Affiliation(s)
- Pin Pin Pek
- Pre-hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Yang CF, Chang KL, Phan CS, Lin FY, Wang YD, Ho SW. Pre- and Post-Implementation of One-Hour Rule for the Boarding of Referral of Critically Ill Patients in the Emergency Department. J Acute Med 2021; 11:141-145. [PMID: 35155090 PMCID: PMC8743190 DOI: 10.6705/j.jacme.202112_11(4).0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/24/2020] [Accepted: 09/29/2020] [Indexed: 06/14/2023]
Abstract
In 2017, the Taiwan Ministry of Health and Welfare established a regional electronic referral system in Central Taiwan to streamline transfers of critically ill patients from the intensive care unit (ICU) of a regional hospital to a medical hospital center. Moreover, in 2018, a one-hour rule for the boarding of referral of critically ill patients from emergency department (ED) to ICU was implemented. This pre- and post-implementation study enrolled consecutive critically ill referral patients from a single academic medical center hospital from January 1, 2017 to December 31, 2018. After implementation of the one-hour rule, two interventions, namely, active bed management before patient arrival and no requirement for laboratory test results to be completed before ICU admissions, were used to improve patient flow in the ED. After implementation of one-hour rule, the proportion of patients transferred to the ICU within 1 hour increased from 3.1% to 65.9% (p < 0.001). Median ED length of stay (LOS) reduced from 129.5 minutes to 52.0 minutes (p < 0.001). The overall mortality rate decreased from 34.4% to 26.8%, without a significant difference. In conclusion, the implementation of the one-hour rule for the boarding of referral of critically ill patients in the ED is safe and possible. Achieving the target significantly reduced ED LOS by 77.5 minutes without an increase in patient mortality rate.
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Affiliation(s)
- Chia-Fen Yang
- Chung Shan Medical University Hospital Department of Emergency Medicine Taichung Taiwan
- Chung Shan Medical University Department of Emergency Medicine Taichung Taiwan
| | - Kuang-Leei Chang
- Chung Shan Medical University Hospital Department of Emergency Medicine Taichung Taiwan
- Chung Shan Medical University Department of Emergency Medicine Taichung Taiwan
| | - Chee-Seong Phan
- Chung Shan Medical University Hospital Department of Emergency Medicine Taichung Taiwan
- Chung Shan Medical University Department of Emergency Medicine Taichung Taiwan
| | - Fei-Yi Lin
- Chung Shan Medical University Hospital Department of Nursing Taichung Taiwan
- Chung Shan Medical University Department of Nursing Taichung Taiwan
| | - Yao-Dong Wang
- Chung Shan Medical University Hospital Division of Chest, Department of Internal Medicine Taichung Taiwan
| | - Sai-Wai Ho
- Chung Shan Medical University Hospital Department of Emergency Medicine Taichung Taiwan
- Chung Shan Medical University Department of Emergency Medicine Taichung Taiwan
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Stamy C, Shane DM, Kannedy L, Van Heukelom P, Mohr NM, Tate J, Montross K, Lee S. Economic Evaluation of the Emergency Department After Implementation of an Emergency Psychiatric Assessment, Treatment, and Healing Unit. Acad Emerg Med 2021; 28:82-91. [PMID: 32869891 DOI: 10.1111/acem.14118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/04/2020] [Accepted: 08/21/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit on emergency department (ED) revenue, psychiatric boarding time, and length of stay (LOS). METHODS We conducted a before-and-after economic evaluation of a single academic midwestern ED (60,000 annual visits) for all adult (≥18 years) patients before (December 2017-May 2018) and after (December 2018-May 2019) opening an EmPATH unit. These are outpatient hospital-based programs that provide emergent treatment and stabilization for mental health emergencies from ED patients. The Holt-Winters method was used to forecast pre-EmPATH expected ED levels of patients leaving without being seen, leaving against medical advice, eloping, or being transferred using 3 years of ED visits. ED revenues were calculated by finding the difference of pre-EmPATH expected and post-EmPATH observed values and multiplying by the revenue per visit. ED boarding time and LOS were obtained from the hospital's electronic medical record. RESULTS There were 23,231 and 23,336 ED visits evaluated during the pre- and post-EmPATH unit periods. The ED generated an estimated additional $404,954 in the 6 months and $861,065 annually after the implementation of the EmPATH unit. The median (interquartile range [IQR]) psychiatric boarding time decreased from 212 (119-536) minutes to 152 (86-307) minutes (mean difference = 189 minutes, 95% confidence interval [CI] = 150 to 228 minutes) and median (IQR) LOS decreased from 351 (204-631) minutes to 334 (212-517) minutes (mean difference = 114 minutes, 95% CI = 87 to 143 minutes). CONCLUSION The EmPATH unit had a positive impact on ED revenue and decreased ED boarding time and LOS for psychiatric patients.
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Affiliation(s)
- Chris Stamy
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Dan M. Shane
- the Department of Health Management and PolicyUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Levi Kannedy
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Paul Van Heukelom
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Nicholas M. Mohr
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
- the Division of Critical Care Department of AnesthesiaUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Jodi Tate
- and the Department of Psychiatry University of Iowa Carver College of Medicine Iowa City IAUSA
| | - Kelsey Montross
- and the Department of Psychiatry University of Iowa Carver College of Medicine Iowa City IAUSA
| | - Sangil Lee
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
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Savioli G, Ceresa IF, Novara E, Persiano T, Grulli F, Ricevuti G, Bressan MA, Oddone E. Brief intensive observation areas in the management of acute heart failure in elderly patients leading to high stabilisation rate and less admissions. JOURNAL OF GERONTOLOGY AND GERIATRICS 2021. [DOI: 10.36150/2499-6564-446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Hayden EM, Boggs KM, Espinola JA, Camargo CA, Zachrison KS. Telemedicine Facilitation of Transfer Coordination From Emergency Departments. Ann Emerg Med 2020; 76:602-608. [PMID: 32534835 PMCID: PMC7252127 DOI: 10.1016/j.annemergmed.2020.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 03/30/2020] [Accepted: 04/14/2020] [Indexed: 11/05/2022]
Abstract
STUDY OBJECTIVE Interhospital transfers are costly to patients and to the health care system. The use of telemedicine may enable more efficient systems by decreasing transfers or diverting transfers from crowded referral emergency departments (EDs) to alternative appropriate facilities. Our primary objective is to describe the prevalence of telemedicine for transfer coordination among US EDs, the ways in which it is used, and characteristics of EDs that use telemedicine for transfer coordination. METHODS We used the 2016 National Emergency Department Inventory-USA survey to identify telemedicine-using EDs. We then surveyed all EDs using telemedicine for transfer coordination and a sample of EDs using telemedicine for other clinical applications. We used a multivariable logistic regression model to identify characteristics independently associated with use of telemedicine for transfer coordination. RESULTS Of the 5,375 EDs open in 2016, 4,507 responded to National Emergency Department Inventory-USA (84%). Only 146 EDs used telemedicine for transfer coordination; of these, 79 (54%) used telemedicine to assist with clinical care for local admission, 117 (80%) to assist with care before transfer, and 92 (63%) for arranging transfer to a different hospital. Among telemedicine-using EDs, lower ED annual visit volume (odds ratio 5.87, 95% CI 2.79 to 12.36) was independently associated with use of telemedicine for transfer coordination. CONCLUSION Although telemedicine has potential to improve efficiency of regional emergency care systems, it is infrequently used for coordination of transfer between EDs. When used, it is most often to assist with clinical care before transfer.
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Affiliation(s)
- Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
| | - Krislyn M Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Janice A Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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Tolestam Heyman E, Engström M, Baigi A, Dahlén Holmqvist L, Lingman M. Likelihood of admission to hospital from the emergency department is not universally associated with hospital bed occupancy at the time of admission. Int J Health Plann Manage 2020; 36:353-363. [PMID: 33037715 PMCID: PMC8048858 DOI: 10.1002/hpm.3086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 11/27/2022] Open
Abstract
Background The decision to admit into the hospital from the emergency department (ED) is considered to be important and challenging. The aim was to assess whether previously published results suggesting an association between hospital bed occupancy and likelihood of hospital admission from the ED can be reproduced in a different study population. Methods A retrospective cohort study of attendances at two Swedish EDs in 2015 was performed. Admission to hospital was assessed in relation to hospital bed occupancy together with other clinically relevant variables. Hospital bed occupancy was categorized and univariate and multivariate logistic regression were performed. Results In total 89,503 patient attendances were included in the final analysis. Of those, 29.1% resulted in admission within 24 h. The mean hospital bed occupancy by the hour of the two hospitals was 87.1% (SD 7.6). In both the univariate and multivariate analysis, odds ratio for admission within 24 h from the ED did not decrease significantly with an increasing hospital bed occupancy. Conclusions A negative association between admission to hospital and occupancy level, as reported elsewhere, was not replicated. This suggests that the previously shown association might not be universal but may vary across sites due to setting specific circumstances.
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Affiliation(s)
- Ellen Tolestam Heyman
- Emergency Department, Region Halland, Varberg, Sweden.,Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Martin Engström
- Department of Healthcare, Region Halland Central Office, Region Halland, Sweden.,Department of Anaesthesia and Intensive Care, Medicine, Lund University, Lund, Sweden
| | - Amir Baigi
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Research and Development, Region Halland, Halmstad, Sweden
| | - Lina Dahlén Holmqvist
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Emergency Department, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Markus Lingman
- Halland Hospital Group, Region Halland, Sweden.,Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Savioli G, Ceresa IF, Maggioni P, Lava M, Ricevuti G, Manzoni F, Oddone E, Bressan MA. Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care. MEDICINES 2020; 7:medicines7100060. [PMID: 32987644 PMCID: PMC7598623 DOI: 10.3390/medicines7100060] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/07/2020] [Accepted: 09/11/2020] [Indexed: 02/07/2023]
Abstract
Background: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients’ characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient’s clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients’ management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusions: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-340-9070-001
| | - Iride Francesca Ceresa
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
| | - Paolo Maggioni
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
| | - Massimiliano Lava
- Neuro Radiodiagnostic, Irccs Policlinico San Matteo, 27100 Pavia, Italy;
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, Italy, Saint Camillus International University of Health Sciences, 00131 Rome, Italy;
| | - Federica Manzoni
- Clinical Epidemiology and Biometry Unit, Irccs Policlinico San Matteo, 27100 Pavia, Italy;
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy;
| | - Maria Antonietta Bressan
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
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Jaffe TA, Kim J, DePesa C, White B, Kaafarani HMA, Saillant N, Mendoza A, King D, Fagenholz P, Velmahos G, Lee J. One-way-street revisited: Streamlined admission of critically-ill trauma patients. Am J Emerg Med 2020; 38:2028-2033. [PMID: 33142169 DOI: 10.1016/j.ajem.2020.06.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/10/2020] [Accepted: 06/14/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Emergency department (ED) crowding is associated with increased mortality and delays in care. We developed a rapid admission pathway targeting critically-ill trauma patients in the ED. This study investigates the sustainability of the pathway, as well as its effectiveness in times of increased ED crowding. MATERIALS & METHODS This was a retrospective cohort study assessing the admission of critically-ill trauma patients with and without the use of a rapid admission pathway from 2013 to 2018. We accessed demographic and clinical data from trauma registry data and ED capacity logs. Statistical analyses included univariate and multivariate testing. RESULTS A total of 1700 patients were included. Of this cohort, 434 patients were admitted using the rapid admission pathway, whereas 1266 were admitted using the traditional pathway. In bivariate analysis, mean ED LOS was 1.54 h (95% Confidence Interval [CI]: 1.41, 1.66) with the rapid pathway, compared with 5.88 h (95% CI: 5.64, 6.12) with the traditional pathway (p < 0.01). We found no statistically significant relationship between rapid admission pathway use and survival to hospital discharge. During times of increased crowding, rapid pathway use continued to be associated with reduction in ED LOS (p < 0.01). The reduction in ED LOS was sustained when comparing initial results (2013-2014) to recent data (2015-2018). CONCLUSION This study found that a streamlined process to admit critically-ill trauma patients is sustainable and associated with reduction in ED LOS. As ED crowding remains pervasive, these findings support restructured care processes to limit prolonged ED boarding times for critically-ill patients.
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Affiliation(s)
- Todd A Jaffe
- Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital and Brigham and Women's Hospital, United States of America
| | - Jungyeon Kim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Christopher DePesa
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America
| | - Benjamin White
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America
| | - April Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America
| | - David King
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America
| | - Jarone Lee
- Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital and Brigham and Women's Hospital, United States of America; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America; Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States of America.
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10
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Savioli G, Ceresa IF, Manzoni F, Ricevuti G, Bressan MA, Oddone E. Role of a Brief Intensive Observation Area with a Dedicated Team of Doctors in the Management of Acute Heart Failure Patients: A Retrospective Observational Study. ACTA ACUST UNITED AC 2020; 56:medicina56050251. [PMID: 32455837 PMCID: PMC7279411 DOI: 10.3390/medicina56050251] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 12/22/2022]
Abstract
Background and objectives: Acute heart failure (AHF) is one of the main causes of hospitalization in Western countries. Usually, patients cannot be admitted directly to the wards (access block) and stay in the emergency room. Holding units are clinical decision units, or observation units, within the ED that are able to alleviate access block and to contribute to a reduction in hospitalization. Observation units have also been shown to play a role in specific clinical conditions, like the acute exacerbation of heart failure. This study aimed to analyze the impact of a brief intensive observation (OBI) area on the management of acute heart failure (AHF) patients. The OBI is a holding unit dedicated to the stabilization of unstable patients with a team of dedicated physicians. Materials and Methods: We conducted a retrospective and single-centered observational study with retrospective collection of the data of all patients who presented to our emergency department with AHF during 2017. We evaluated and compared two cohorts of patients, those treated in the OBI and those who were not, in terms of the reduction in color codes at discharge, mortality rate within the emergency room (ER), hospitalization rate, rate of transfer to less intensive facilities, and readmission rate at 7, 14, and 30 days after discharge. Results: We enrolled 920 patients from 1st January to 31st December. Of these, 61% were transferred to the OBI for stabilization. No statistically significant difference between the OBI and non-OBI populations in terms of age and gender was observed. OBI patients had worse clinical conditions on arrival. The patients treated in the OBI had longer process times, which would be expected, to allow patient stabilization. The stabilization rate in the OBI was higher, since presumably OBI admission protected patients from “worse condition” at discharge. Conclusions: Data from our study show that a dedicated area of the ER, such as the OBI, has progressively allowed a change in the treatment path of the patient, where the aim is no longer to admit the patient for processing but to treat the patient first and then, if necessary, admit or refer. This has resulted in very good feedback on patient stabilization and has resulted in a better management of beds, reduced admission rates, and reduced use of high intensity care beds.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia 27100, Italy
- Correspondence: ; Tel.: +39-3409070001
| | | | - Federica Manzoni
- Clinical Epidemiology and Biometry Unit, IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Giovanni Ricevuti
- Former Professor of Geriatric and Emergency Medicine, University of Pavia, 27100 Pavia, Italy;
| | | | - Enrico Oddone
- Assistant Professor, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy;
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Moore N, Middleton PM, Ren S. Lost capacity in emergency departments and its economic implications: A simulation study and economic analysis. Emerg Med Australas 2020; 32:974-979. [PMID: 32431066 DOI: 10.1111/1742-6723.13526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the effect of lost bed capacity (LBC) on the overall capacity of an ED, and to estimate the costs attributable to excess stay in the ED beyond that required for actual emergency care. METHODS This was a retrospective simulation and health economic evaluation, using data from a single-centre tertiary level ED. Data from all patients who presented to the ED during a 1-month period and triaged to receive an acute bed in order to undergo their emergency care were included. The main outcomes measured were the change in overall ED length of stay, and costs attributable to LBC, in both discharged and admitted patients. RESULTS Overall daily median ED length of stay decreased by 182 min (95% confidence interval 165-198; P < 0.01) in the simulated cohort when LBC was removed. Within the admitted cohort, the median cost attributable to LBC was AUD$202.99 (95% confidence interval $186.50-$216.70) per patient. We estimate the cost of an ED bed to be AUD$164.59 per hour. CONCLUSIONS A substantial amount of ED length of stay is due to patients remaining in the ED for time after their emergency care is concluded. This likely represents a substantial overall monetary cost to the Australian healthcare system.
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Affiliation(s)
- Nicholas Moore
- South Western Emergency Research Institute, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Paul M Middleton
- South Western Emergency Research Institute, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shiquan Ren
- South Western Emergency Research Institute, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
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Adjusting Daily Inpatient Bed Allocation to Smooth Emergency Department Occupancy Variation. Healthcare (Basel) 2020; 8:healthcare8020078. [PMID: 32231146 PMCID: PMC7349152 DOI: 10.3390/healthcare8020078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/22/2020] [Accepted: 03/27/2020] [Indexed: 11/16/2022] Open
Abstract
Study Objective: Overcrowding in emergency departments (ED) is an increasingly common problem in Taiwanese hospitals, and strategies to improve efficiency are in demand. We propose a bed resource allocation strategy to overcome the overcrowding problem. Method: We investigated ED occupancy using discrete-event simulation and evaluated the effects of suppressing day-to-day variations in ED occupancy by adjusting the number of empty beds per day. Administrative data recorded at the ED of Taichung Veterans General Hospital (TCVGH) in Taiwan with 1500 beds and an annual ED volume of 66,000 visits were analyzed. Key indices of ED quality in the analysis were the length of stay and the time in waiting for outward transfers to in-patient beds. The model is able to analyze and compare several scenarios for finding a feasible allocation strategy. Results: We compared several scenarios, and the results showed that by reducing the allocated beds for the ED by 20% on weekdays, the variance of daily ED occupancy was reduced by 36.25% (i.e., the percentage of reduction in standard deviation). Conclusions: This new allocation strategy was able to both reduce the average ED occupancy and maintain the ED quality indices.
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Motamed M, Yahyavi ST, Sharifi V, Alaghband-Rad J, Aghajannashtaei F. Emergency psychiatric services in Roozbeh Hospital: A qualitative study of the staff's experiences. Perspect Psychiatr Care 2019; 55:249-254. [PMID: 30637760 DOI: 10.1111/ppc.12348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 11/26/2018] [Accepted: 12/09/2018] [Indexed: 11/27/2022] Open
Abstract
PURPOSE This study aims to explore how psychiatric residents and nurses experience the conditions of psychiatric emergency services. DESIGN AND METHODS This qualitative study was carried out using content analysis. Data were collected through unstructured interviews conducted during three focus groups. FINDINGS The results of the focus groups were classified into the following five categories of issues influencing the staff's experiences: repetitive problems, long wait times, ambiguity, insecurity, and stability. PRACTICE IMPLICATIONS Improving the staff's communication skills and educating them on how to manage violence, establishing a well-functional system of triage, and optimizing bed management and discharge planning are among several potential strategies that might be considered to improve the quality of care in psychiatric emergency services.
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Affiliation(s)
- Mahtab Motamed
- Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyyed Taha Yahyavi
- Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran
| | - Vandad Sharifi
- Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Alaghband-Rad
- Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran
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Manolitzas P, Stylianou N. Modelling Waiting Times in an Emergency Department in Greece During the Economic Crisis. JOURNAL OF HEALTH MANAGEMENT 2018. [DOI: 10.1177/0972063418799212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Overcrowding is one of the most common phenomenon at the emergency departments of the hospitals across the world. The aforementioned phenomenon causes many problems such as long waiting times for patients, increasing length of stay, patient dissatisfaction, ambulance diversions in some cities, prolonged pain and suffering, violence and miscommunication between the medical staff and the patients, patients leaving the emergency department without been seen and decreased physician productivity. This article analyses the problem of the increased waiting times in a Greek emergency department during the economic crisis. We use statistical models in order to reveal the factors that can lead to a decrease in waiting times. Our findings suggest that Greece’s Department of Health should standardize an uppermost waiting time for emergency departments which could help improve health care.
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Affiliation(s)
- Panagiotis Manolitzas
- Department of Production Engineering and Management, Technical University of Crete, Decision Support Systems Laboratory, Kounoupidiana University Campus, Chania, Crete, Greece
| | - Neophytos Stylianou
- School of Management, Bath Centre for Health Care Innovation and Improvement (CHI2), University of Bath, Bath, UK
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Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS One 2018; 13:e0203316. [PMID: 30161242 PMCID: PMC6117060 DOI: 10.1371/journal.pone.0203316] [Citation(s) in RCA: 560] [Impact Index Per Article: 93.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/17/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Emergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions. AIM The aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding. METHOD The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A structured search of four databases (Medline, CINAHL, EMBASE and Web of Science) was undertaken to identify peer-reviewed research publications aimed at investigating the causes or consequences of, or solutions to, emergency department crowding, published between January 2000 and June 2018. Two reviewers used validated critical appraisal tools to independently assess the quality of the studies. The study protocol was registered with the International prospective register of systematic reviews (PROSPERO 2017: CRD42017073439). RESULTS From 4,131 identified studies and 162 full text reviews, 102 studies met the inclusion criteria. The majority were retrospective cohort studies, with the greatest proportion (51%) trialling or modelling potential solutions to emergency department crowding. Fourteen studies examined causes and 40 investigated consequences. Two studies looked at both causes and consequences, and two investigated causes and solutions. CONCLUSIONS The negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. This review identified a mismatch between causes and solutions. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Solutions aimed at the introduction of whole-of-system initiatives to meet timed patient disposition targets, as well as extended hours of primary care, demonstrated promising outcomes. While the review identified increased presentations by the elderly with complex and chronic conditions as an emerging and widespread driver of crowding, more research is required to isolate the precise local factors leading to ED crowding, with system-wide solutions tailored to address identified causes.
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Affiliation(s)
- Claire Morley
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Maria Unwin
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
| | - Gregory M. Peterson
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Jim Stankovich
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
| | - Leigh Kinsman
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
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16
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Artenstein AW, Rathlev NK, Neal D, Townsend V, Vemula M, Goldlust S, Schmidt J, Visintainer P. Decreasing Emergency Department Walkout Rate and Boarding Hours by Improving Inpatient Length of Stay. West J Emerg Med 2017; 18:982-992. [PMID: 29085527 PMCID: PMC5654890 DOI: 10.5811/westjem.2017.7.34663] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/17/2017] [Accepted: 07/27/2017] [Indexed: 11/28/2022] Open
Abstract
Introduction Patient progress, the movement of patients through a hospital system from admission to discharge, is a foundational component of operational effectiveness in healthcare institutions. Optimal patient progress is a key to delivering safe, high-quality and high-value clinical care. The Baystate Patient Progress Initiative (BPPI), a cross-disciplinary, multifaceted quality and process improvement project, was launched on March 1, 2014, with the primary goal of optimizing patient progress for adult patients. Methods The BPPI was implemented at our system’s tertiary care, academic medical center, a high-volume, high-acuity hospital that serves as a regional referral center for western Massachusetts. The BPPI was structured as a 24-month initiative with an oversight group that ensured collaborative goal alignment and communication of operational teams. It was organized to address critical aspects of a patient’s progress through his hospital stay and to create additional inpatient capacity. The specific goal of the BPPI was to decrease length of stay (LOS) on the inpatient adult Hospital Medicine service by optimizing an interdisciplinary plan of care and promoting earlier departure of discharged patients. Concurrently, we measured the effects on emergency department (ED) boarding hours per patient and walkout rates. Results The BPPI engaged over 300 employed clinicians and non-clinicians in the work. We created increased inpatient capacity by implementing daily interdisciplinary bedside rounds to proactively address patient progress; during the 24 months, this resulted in a sustained rate of discharge orders written before noon of more than 50% and a decrease in inpatient LOS of 0.30 days (coefficient: −0.014, 95% CI [−0.023, −0.005] P< 0.005). Despite the increase in ED patient volumes and severity of illness over the same time period, ED boarding hours per patient decreased by approximately 2.1 hours (coefficient: −0.09; 95% CI [−0.15, −0.02] P = 0.007). Concurrently, ED walkout rates decreased by nearly 32% to a monthly mean of 0.4 patients (coefficient: 0.4; 95% CI [−0.7, −0.1] P= 0.01). Conclusion The BPPI realized significant gains in patient progress for adult patients by promoting earlier discharges before noon and decreasing overall inpatient LOS. Concurrently, ED boarding hours per patient and walkout rates decreased.
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Affiliation(s)
- Andrew W Artenstein
- University of Massachusetts Medical School-Baystate, Department of Medicine, Division of Infectious Disease, Springfield, Massachusetts
| | - Niels K Rathlev
- University of Massachusetts Medical School-Department of Emergency Medicine, Baystate, Springfield, Massachusetts
| | - Douglas Neal
- Baystate Health, Healthcare Quality and Process Improvement, Springfield, Massachusetts
| | - Vernette Townsend
- Baystate Health, Baystate Medical Center, Springfield, Massachusetts
| | - Michael Vemula
- Baystate Health, Department of Medicine, Springfield, Massachusetts
| | - Sheila Goldlust
- Baystate Health, Baystate Medical Center, Springfield, Massachusetts
| | - Joseph Schmidt
- University of Massachusetts Medical School-Department of Emergency Medicine, Baystate, Springfield, Massachusetts
| | - Paul Visintainer
- University of Massachusetts Medical School-Baystate, Office of Research, Springfield, Massachusetts
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A systematic review of the impact of nurse-initiated medications in the emergency department. ACTA ACUST UNITED AC 2017; 20:53-62. [PMID: 28462830 DOI: 10.1016/j.aenj.2017.04.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/16/2017] [Accepted: 04/03/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Nurse-initiated medications are one of the most important strategies used to facilitate timely care for people who present to Emergency Departments (EDs). The purpose of this paper was to systematically review the evidence of nurse-initiated medications to guide future practice and research. METHODS A systematic review of the literature was conducted to locate published studies and Grey literature. All studies were assessed independently by two independent reviewers for relevance using titles and abstracts, eligibility dictated by the inclusion criteria, and methodological quality. RESULTS Five experimental studies were included in this review: one randomised controlled trial and four quasi-experimental studies conducted in paediatric and adult EDs. The nurse-initiated medications were salbutamol for respiratory conditions and analgesia for painful conditions, which enabled patients to receive the medications quicker by half-an-hour compared to those who did not have nurse-initiated medications. The intervention had no effect on adverse events, doctor wait time and length of stay. Nurse-initiated analgesia was associated with increased likelihood of receiving analgesia, achieving clinically-relevant pain reduction, and better patient satisfaction. CONCLUSION Nurse-initiated medications are safe and beneficial for ED patients. However, randomised controlled studies are required to strengthen the validity of results.
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Nugus P, McCarthy S, Holdgate A, Braithwaite J, Schoenmakers A, Wagner C. Packaging Patients and Handing Them Over: Communication Context and Persuasion in the Emergency Department. Ann Emerg Med 2017; 69:210-217.e2. [DOI: 10.1016/j.annemergmed.2016.08.456] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 08/11/2016] [Accepted: 08/24/2016] [Indexed: 11/15/2022]
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Hughes JA, Cabilan CJ, Staib A. Effect of the 4-h target on time-to-analgesia in an Australian emergency department: a pilot retrospective observational study. AUST HEALTH REV 2017; 41:185-191. [DOI: 10.1071/ah16025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 04/14/2016] [Indexed: 11/23/2022]
Abstract
Objectives
The aim of the present study was to assess the relationship between and the effect of the 4-h target or National Emergency Access Target (NEAT) on the time-to-analgesia (TTA), as well as the provision of analgesia in an adult emergency department (ED).
Methods
The present study was a pilot descriptive explorative retrospective cohort study conducted in a public metropolitan ED. Eligible presentations for analysis were adults presenting with a documented pain score of ≥4 out of 10 between 1 and 14 September 2014. Triage Category 1, pregnant, chest pain and major trauma cases were excluded from the study. As a result, data for 260 patients were analysed.
Results
Of 260 patients, 176 had analgesia with a median TTA of 49 min. Increased NEAT compliance did not significantly decrease TTA. However, when the factors that affected the provision of analgesia were analysed, an association was demonstrated between Admitted and Short Stay NEAT performance and the provision of analgesia. The likelihood of receiving analgesia at all increased as Admitted and Short Stay NEAT compliance improved.
Conclusion
NEAT is a significant health policy initiative with little clinical evidence supporting its implementation. However, as the Admitted NEAT compliance increases, the probability of receiving analgesia increases, demonstrating a possible link between hospital function and clinical care provision that needs to be explored further.
What is known about the topic?
The 4-h target or NEAT is a widely used initiative in EDs to allay crowding and access block. However, little is known of its impact on clinical endpoints, such as TTA.
What does this paper add?
TTA was not significantly reduced as NEAT compliance increased. However, when the focus was on the probability of receiving analgesia, the results demonstrated that an improvement in Admitted and Short Stay NEAT compliance was associated with an increase in the likelihood of patients receiving analgesia.
What are the implications for practitioners?
NEAT is a relatively recent initiative, hence evidence of its effect on clinically orientated outcomes is limited. Nevertheless, evidence of safety and effectiveness is emerging. The results of the present pilot study provide preliminary data on the timeliness of patient-centred care as demonstrated by TTA and administration of analgesia when required. Further, the results would seem to suggest that the provision of analgesia is affected by how timely patients are moved out of the ED to the in-patient setting. As for future investigations on TTA as a result of NEAT, a wider time period should be considered so that the accurate effect of compliance thresholds (e.g. ≥90%, 81–89%, ≤80%) of NEAT can be explored.
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Li CJ, Syue YJ, Kung CT, Hung SC, Lee CH, Wu KH. Seniority of Emergency Physician, Patient Disposition and Outcome Following Disposition. Am J Med Sci 2016; 351:582-8. [DOI: 10.1016/j.amjms.2016.02.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/27/2016] [Accepted: 02/02/2016] [Indexed: 01/15/2023]
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21
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Mahmoudian-Dehkordi A, Sadat S. Sustaining critical care: using evidence-based simulation to evaluate ICU management policies. Health Care Manag Sci 2016; 20:532-547. [PMID: 27216611 DOI: 10.1007/s10729-016-9369-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 05/10/2016] [Indexed: 10/21/2022]
Abstract
Intensive Care Units (ICU) are costly yet critical hospital departments that should be available to care for patients needing highly specialized critical care. Shortage of ICU beds in many regions of the world and the constant fire-fighting to make these beds available through various ICU management policies motivated this study. The paper discusses the application of a generic system dynamics model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to explore the dynamics of intended and unintended consequences of such ICU management policies under a natural disaster crisis scenario. ICU management policies that can be implemented by a single hospital on short notice, namely premature transfer from ICU, boarding in ward, and general ward admission control, along with their possible combinations, are modeled and their impact on managerial and health outcome measures are investigated. The main insight out of the study is that the general ward admission control policy outperforms the rest of ICU management policies under such crisis scenarios with regards to reducing total mortality, which is counter intuitive for hospital administrators as this policy is not very effective at alleviating the symptoms of the problem, namely high ED and ICU occupancy rates that are closely monitored by hospital management particularly in times of crisis. A multivariate sensitivity analysis on parameters with diverse range of values in the literature found the superiority of the general ward admission control to hold true in every scenario.
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Affiliation(s)
| | - Somayeh Sadat
- Health Systems Engineering Program, Faculty of Industrial and Systems Engineering, Tarbiat Modares University, Tehran, Iran.
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22
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Boh C, Li H, Finkelstein E, Haaland B, Xin X, Yap S, Pasupathi Y, Ong MEH. Factors Contributing to Inappropriate Visits of Frequent Attenders and Their Economic Effects at an Emergency Department in Singapore. Acad Emerg Med 2015; 22:1025-33. [PMID: 26284824 DOI: 10.1111/acem.12738] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 01/20/2015] [Accepted: 05/01/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study aimed to determine which factors contribute to frequent visits at the emergency department (ED) and what proportion were inappropriate in comparison with nonfrequent visits. METHODS This study was a retrospective, case-control study comparing a random sample of frequent attenders and nonfrequent attenders, with details of their ED visits recorded over a 12-month duration. Frequent attenders were defined as patients with four or more visits during the study period. RESULTS In comparison with nonfrequent attenders (median age = 45.0 years, interquartile range [IQR] = 28.0 to 61.0 years), frequent attenders were older (median = 57.5 years, IQR = 34.0 to 74.8 years; p = 0.0003). They were also found to have more comorbidities, where 53.3% of frequent attenders had three or more chronic illnesses compared to 14% of nonfrequent attenders (p < 0.0001), and were often triaged to higher priority (more severe) classes (frequent 52.2% vs. nonfrequent 37.6%, p = 0.0004). Social issues such as bad debts (12.7%), heavy drinking (3.3%), and substance abuse (2.7%) were very low in frequent attenders compared to Western studies. Frequent attenders had a similar rate of appropriate visits to the ED as nonfrequent attenders (55.2% vs. 48.1%, p = 0.0892), but were more often triaged to P1 priority triage class (6.7% vs. 3.2%, p = 0.0014) and were more often admitted for further management compared to nonfrequent attenders (47.5% vs. 29.6%, p < 0.001). The majority of frequent attender visits were appropriate (55.2%), and of these, 81.1% resulted in admission. For the same number of patients, total visits made by frequent attenders ($174,247.60) cost four times as much as for nonfrequent attenders ($40,912.40). This represents a significant economic burden on the health care system. CONCLUSIONS ED frequent attenders in Singapore were associated with higher age and presence of multiple comorbidities rather than with social causes of ED use. Even in integrated health systems, repeat ED visits are frequent and expensive, despite minimal social causes of acute care. EDs in aging populations must anticipate the influx of vulnerable, elderly patients and have in place interventional programs to care for them.
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Affiliation(s)
- Connie Boh
- Duke-NUS Graduate Medical School Singapore; Singapore
| | - Huihua Li
- Health Services Research and Biostatistics Unit; Division of Research; Singapore General Hospital; Singapore
| | - Eric Finkelstein
- Health Services & Systems Research Program; Duke-NUS Graduate Medical School Singapore; Singapore
| | - Benjamin Haaland
- Office of Clinical Sciences; Duke-NUS Graduate Medical School Singapore; Singapore
| | - Xiaohui Xin
- Division of Medicine; Singapore General Hospital; Singapore
| | - Susan Yap
- Department of Emergency Medicine; Singapore General Hospital; Singapore
| | | | - Marcus EH Ong
- Department of Emergency Medicine; Singapore General Hospital; Singapore
- Office of Clinical Sciences; Duke-NUS Graduate Medical School Singapore; Singapore
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Whyne M, Whyne G, Rowe BH. Variations in monetary distribution among Ontario’s Alternative Funding Agreement workload model hospitals. CAN J EMERG MED 2015; 9:21-5. [PMID: 17391596 DOI: 10.1017/s148180350001469x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACT
Objectives:
Alternative Funding Agreements (AFAs) were in place in 41 hospital emergency departments (EDs) in Ontario at the time of this survey (May to August 2005). Each of these 41 hospitals works with its own internal administrative model. The primary objective of this paper was to document the administrative models used in these Ontario EDs. The secondary objective was to inform current and future AFA EDs of the potential models.
Methods:
Telephone surveys were conducted with a member of each of the 41 AFA workload model hospitals.
Results:
All hospitals provided at least 1 emergency physician to answer the questionnaire. Although most AFA hospitals divide the AFA fund pool on an hourly basis, there is impressive variation on premium values awarded for day, evening, weekend and night shifts. Other variations included holdback of funds for bonuses, distribution of non-OHIP (Ontario Health Insurance Plan) dollars, on-call allowances, and different pay scales for the general practitioners and locums working in some departments.
Conclusions:
Allowing flexibility in distribution of AFA dollars to physicians in each group has helped make this program more acceptable. Many issues unrelated to funding remain to be resolved in order to stabilize ED recruitment and retention as well as improve work satisfaction. Further research on these latter topics is required to develop a fair and equitable funding arrangement that supports and enhances physician coverage in EDs across Canada.
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Affiliation(s)
- Mitchell Whyne
- Emergency AFA Group, Royal Victoria Hospital, Barrie, Ontario, Canada
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Jones P, Sopina E, Ashton T. Resource implications of a national health target: The New Zealand experience of a Shorter Stays in Emergency Departments target. Emerg Med Australas 2014; 26:579-84. [DOI: 10.1111/1742-6723.12312] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Peter Jones
- School of Population Health; University of Auckland; Auckland New Zealand
- Adult Emergency Department; Auckland City Hospital; Auckland New Zealand
| | - Elizaveta Sopina
- School of Population Health; University of Auckland; Auckland New Zealand
| | - Toni Ashton
- School of Population Health; University of Auckland; Auckland New Zealand
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25
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Davis RA, Dinh MM, Bein KJ, Veillard AS, Green TC. Senior work-up assessment and treatment team in an emergency department: A randomised control trial. Emerg Med Australas 2014; 26:343-9. [DOI: 10.1111/1742-6723.12256] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Rebecca A Davis
- Emergency Department; Royal Prince Alfred Hospital; NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
| | - Michael M Dinh
- Emergency Department; Royal Prince Alfred Hospital; NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
| | - Kendall J Bein
- Emergency Department; Royal Prince Alfred Hospital; NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
| | - Anne-Sophie Veillard
- Emergency Department; Royal Prince Alfred Hospital; NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
| | - Timothy C Green
- Emergency Department; Royal Prince Alfred Hospital; NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
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26
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Talleshi Z, Hosseininejad SM, Khatir G, Bozorghi F, Gorji AMH, Gorji MAH. The effect of new emergency program on patient length of stay in a teaching hospital emergency department of Tehran. Niger Med J 2014; 55:134-8. [PMID: 24791047 PMCID: PMC4003716 DOI: 10.4103/0300-1652.129645] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background and Aim: Ideally, the period of patients admitting in the Emergency Department (ED) should not exceed 6 hours. Prolonged of the patients admitting time affects the ED overcrowding, quality of patient care and patient satisfaction. To evaluate the efficacy of new programs and suggest new strategies to reduce the overcrowding in a typical overcrowded ED of general teaching hospital in Tehran city. Materials and Methods: In this descriptive case study, charts of patients held over 24 hours, in Imam Hossein Hospital affiliated to the Shaheed Beheshti Medical University, were reviewed from April 21rd on August 23rd, 2008. Results: Of 15,477 patients, 151 (1%) have been held in the ED over 24 hours. Reasons for this long-stay included:lack of available bed in Intensive Care Unit (ICU) (125 patients), lack of available bed in related wards (18 patients), poor final decision — making by physician (eight patient) Conclusion: Long-term stay of patients in ED of teaching hospital is a major problem. The most frequent cause is a limitation of inpatient beds. The long stay time had not been affected by paraclinic procedures, multispecialities involvement or the lack of obvious diagnosis. The following solution is proposed: (1) creation of a holding unit, (2) active inter-facility transfer and (3) governing admittance of patients who need ICU care to related wards.
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Affiliation(s)
- Z Talleshi
- Department of Emergency Medicine, Mazandaran University of Medical Science, Sari, Iran
| | - S M Hosseininejad
- Department of Emergency Medicine, Mazandaran University of Medical Science, Sari, Iran
| | - Goli Khatir
- Department of Emergency Medicine, Mazandaran University of Medical Science, Sari, Iran
| | - F Bozorghi
- Department of Nursing, Nasibeh Nursing and Midwifery, Mazandaran University of Medical Science, Sari, Iran
| | - A M Heidari Gorji
- Education Development Center, Mazandaran University of Medical Science, Sari, Iran
| | - M A Heidari Gorji
- Department of Nursing and Midwifery, Traditional and Complementary Medicine Research Center, Mazandaran University of Medical Science, Sari, Iran
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Green J, Dawber J, Masso M, Eagar K. Emergency department waiting times: Do the raw data tell the whole story? AUST HEALTH REV 2014; 38:65-9. [PMID: 24433850 DOI: 10.1071/ah13065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 11/15/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine whether there are real differences in emergency department (ED) performance between Australian states and territories. METHODS Cross-sectional analysis of 2009-10 attendances at an ED contributing to the Australian non-admitted patient ED care database. The main outcome measure was difference in waiting time across triage categories. RESULTS There were more than 5.8 million ED attendances. Raw ED waiting times varied by a range of factors including jurisdiction, triage category, geographic location and hospital peer group. All variables were significant in a model designed to test the effect of jurisdiction on ED waiting times, including triage category, hospital peer group, patient socioeconomic status and patient remoteness. When the interaction between triage category and jurisdiction entered the model, it was found to have a significant effect on ED waiting times (P<0.001) and triage was also significant (P<0.001). Jurisdiction was no longer statistically significant (P=0.248 using all triage categories and 0.063 using only Australian Triage Scale 2 and 3). CONCLUSIONS Although the Council of Australian Governments has adopted raw measures for its key ED performance indicators, raw waiting time statistics are misleading. There are no consistent differences in ED waiting times between states and territories after other factors are accounted for. WHAT IS KNOWN ABOUT THE TOPIC? The length of time patients wait to be treated after presenting at an ED is routinely used to measure ED performance. In national health agreements with the federal government, each state and territory in Australia is expected to meet waiting time performance targets for the five ED triage categories. The raw data indicate differences in performance between states and territories. WHAT DOES THIS PAPER ADD? Measuring ED performance using raw data gives misleading results. There are no consistent differences in ED waiting times between the states and territories after other factors are taken into account. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Judgements regarding differences in performance across states and territories for triage waiting times need to take into account the mix of patients and the mix of hospitals.
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Affiliation(s)
- Janette Green
- Australian Health Services Research Institute, Sydney Business School, iC Enterprise 1, Innovation Campus, University of Wollongong, NSW 2522, Australia. ,
| | - James Dawber
- Australian Health Services Research Institute, Sydney Business School, iC Enterprise 1, Innovation Campus, University of Wollongong, NSW 2522, Australia. ,
| | - Malcolm Masso
- Australian Health Services Research Institute, Sydney Business School, iC Enterprise 1, Innovation Campus, University of Wollongong, NSW 2522, Australia. ,
| | - Kathy Eagar
- Australian Health Services Research Institute, Sydney Business School, iC Enterprise 1, Innovation Campus, University of Wollongong, NSW 2522, Australia. ,
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Emergency department crowding in The Netherlands: managers' experiences. Int J Emerg Med 2013; 6:41. [PMID: 24156298 PMCID: PMC4016265 DOI: 10.1186/1865-1380-6-41] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 09/16/2013] [Indexed: 11/26/2022] Open
Abstract
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.
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Gilligan P, Joseph D, Bartlett M, Morris A, Mahajan A, McHugh K, Hillary F, O'Kelly P. The 'who are all these people?' study. Emerg Med J 2013; 32:109-11. [PMID: 24123167 DOI: 10.1136/emermed-2013-202478] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Overcrowding of emergency departments (EDs) adversely affects the delivery of emergency care and results in increased patient mortality. OBJECTIVE AND METHODS To examine what contributes to the ED crowd and to specifically examine the patient associated population. The ED in which the research was performed is consistently one of the most overcrowded in Ireland. RESULTS On average 66.7% of the patients in the ED during the study period were boarded awaiting a hospital bed following full processing by the ED staff and agreement by the on-call team that admission was required. The most overcrowded part of the department was the majors area. In this area 55.5% of those present were patients, visitors accounted for 16.6% of occupants, nursing staff 11%, on-call teams 7% and the ED doctors 6.3%. CONCLUSIONS Knowing who the people in the crowd are helps to guide management decisions about how the crowd might be reduced. Our department now has a strict accompanying person/visitor policy that limits the number of visitors to patients and limits visiting times for those relatives with a patient who is experiencing a prolonged stay in the ED.
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Affiliation(s)
| | - Danny Joseph
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Aoife Morris
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ajay Mahajan
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Karen McHugh
- Emergency Department, Beaumont Hospital, Dublin, Ireland
| | - Fiona Hillary
- Emergency Department, Beaumont Hospital, Dublin, Ireland
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Freund Y. Saturation des urgences : parallèle et paradoxe. ANNALES FRANCAISES DE MEDECINE D URGENCE 2013. [DOI: 10.1007/s13341-013-0295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Forero R, Hillman KM, McCarthy S, Fatovich DM, Joseph AP, Richardson DB. Access block and ED overcrowding. Emerg Med Australas 2012; 22:119-35. [PMID: 20534047 DOI: 10.1111/j.1742-6723.2010.01270.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20-30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998-1999) to 2.4 beds per 1000 (2002-2007) in 2002, and has remained steady at between 2.5-2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998-1999 rates, the number of available beds in 2006-2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.
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Affiliation(s)
- Roberto Forero
- Simpson Centre for Health Services Research Affiliated with The Australian Institute of Health Innovation, University of New South Wales, Kensington, New South Wales, Australia.
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Pines JM, Hilton JA, Weber EJ, Alkemade AJ, Al Shabanah H, Anderson PD, Bernhard M, Bertini A, Gries A, Ferrandiz S, Kumar VA, Harjola VP, Hogan B, Madsen B, Mason S, Ohlén G, Rainer T, Rathlev N, Revue E, Richardson D, Sattarian M, Schull MJ. International perspectives on emergency department crowding. Acad Emerg Med 2011; 18:1358-70. [PMID: 22168200 DOI: 10.1111/j.1553-2712.2011.01235.x] [Citation(s) in RCA: 386] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes.
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Affiliation(s)
- Jesse M Pines
- Center for Health Care Quality, George Washington University, Washington, DC, USA.
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Abstract
Background: Emergency Department (ED) overcrowding is an important healthcare issue facing increasing public and regulatory scrutiny in Canada and around the world. Many approaches to alleviate excessive waiting times and lengths of stay have been studied. In theory, optimal ED patient flow may be assisted via balancing patient loads between EDs (in essence spreading patients more evenly throughout this system). This investigation utilizes simulation to explore “Crowdinforming” as a basis for a process control strategy aimed to balance patient loads between six EDs within a mid-sized Canadian city. Methods: Anonymous patient visit data comprising 120,000 ED patient visits over six months to six ED facilities were obtained from the region’s Emergency Department Information System (EDIS) to (1) determine trends in ED visits and interactions between parameters; (2) to develop a process control strategy integrating crowdinforming; and, (3) apply and evaluate the model in a simulated environment to explore the potential impact on patient self-redirection and load balancing between EDs. Results: As in reality, the data available and subsequent model demonstrated that there are many factors that impact ED patient flow. Initial results suggest that for this particular data set used, ED arrival rates were the most useful metric for ED ‘busyness’ in a process control strategy, and that Emergency Department performance may benefit from load balancing efforts. Conclusions: The simulation supports the use of crowdinforming as a potential tool when used in a process control strategy to balance the patient loads between EDs. The work also revealed that the value of several parameters intuitively expected to be meaningful metrics of ED ‘busyness’ was not evident, highlighting the importance of finding parameters meaningful within one’s particular data set. The information provided in the crowdinforming model is already available in a local context at some ED sites. The extension to a wider dissemination of information via an Internet web service accessible by smart phones is readily achievable and not a technological obstacle. Similarly, the system could be extended to help direct patients by including future estimates or predictions in the crowdinformed data. The contribution of the simulation is to allow for effective policy evaluation to better inform the public of ED ‘busyness’ as part of their decision making process in attending an emergency department. In effect, this is a means of providing additional decision support insights garnered from a simulation, prior to a real world implementation.
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Forero R, McCarthy S, Hillman K. Access block and emergency department overcrowding. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:216. [PMID: 21457507 PMCID: PMC3219412 DOI: 10.1186/cc9998] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Roberto Forero
- The Simpson Center for Health Systems Research, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.
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INDIG D, WARNER A, SAXTON A. Emergency department presentations for problems in early pregnancy. Aust N Z J Obstet Gynaecol 2011; 51:257-61. [DOI: 10.1111/j.1479-828x.2011.01301.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bastiampillai TJ, Bidargaddi NP, Dhillon RS, Schrader GD, Strobel JE, Galley PJ. Implications of bed reduction in an acute psychiatric service. Med J Aust 2010; 193:383-6. [PMID: 20919966 DOI: 10.5694/j.1326-5377.2010.tb03963.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Accepted: 05/10/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the impact of psychiatric inpatient bed closures, accompanied by a training program aimed at enhancing team effectiveness and incorporating data-driven practices, in a mental health service. DESIGN AND SETTING Retrospective comparison of the changes in services within three consecutive financial years: baseline period - before bed reduction (2006-07); observation period - after bed reduction (2007-08); and intervention period - second year after bed reduction (2008-09). The study was conducted at Cramond Clinic, Queen Elizabeth Hospital, Adelaide. MAIN OUTCOME MEASURES Length of stay, 28-day readmission rates, discharges, bed occupancy rates, emergency department (ED) presentations, ED waiting time, seclusions, locality of treatment, and follow-up in the community within 7days. RESULTS Reduced bed numbers were associated with reduced length of stay, fewer referrals from the community and subsequently shorter waiting times in the ED, without significant change in readmission rates. A higher proportion of patients was treated in the local catchment area, with improved community follow-up and a significant reduction in inpatient seclusions. CONCLUSION Our findings should reassure clinicians concerned about psychiatric bed numbers that service redesign with planned bed reductions will not necessarily affect clinical care, provided data literacy and team training programs are in place to ensure smooth transition of patients across ED, inpatient and community services.
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Vertesi L. Does the Canadian Emergency Department Triage and Acuity Scale identify non-urgent patients who can be triaged away from the emergency department? CAN J EMERG MED 2010; 6:337-42. [PMID: 17381991 DOI: 10.1017/s1481803500009611] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Non-urgent visits comprise a significant proportion of visits to most emergency departments (EDs). Given the severe overcrowding issues faced by many EDs, the use of the Canadian Emergency Department Triage and Acuity Scale (CTAS) to identify patients who could be managed elsewhere seems to be an obvious way to reduce the pressure on the ED and "solve" the overcrowding problem. OBJECTIVE To quantify the resource implications, in terms of stretcher use and waiting times, related to non-urgent patient visits and to estimate the potential impact on ED flow of redirecting these patients to alternate primary care settings. METHODS Retrospective database audit in an urban referral hospital ED. For this study, patients triaged as either CTAS Levels IV or V were considered "non-urgent." RESULTS Non-urgent patients comprised 30% of ED visits, but less than 5% of all those needing stretchers, along with their associated nursing resources. The longer waits consisted almost entirely of waits for available stretchers and would therefore have remained essentially unaffected. In spite of being labelled "non-urgent" by CTAS criteria, 7.3% of all patients requiring admission came from this group. CONCLUSIONS Non-urgent patients consume a small fraction of the ED stretchers and acute-care resources; therefore, strategies aimed at diverting non-urgent patients are unlikely to improve access for more urgent patients. Using the CTAS to identify patients for diversion away from the ED is measurably unsafe and will lead to inappropriate refusal of care for many patients requiring hospital treatment.
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Affiliation(s)
- Les Vertesi
- Institute for Health Research and Education, Simon Fraser University, Burnaby BC, Canada.
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Nugus P, Forero R. Understanding interdepartmental and organizational work in the emergency department: an ethnographic approach. Int Emerg Nurs 2010; 19:69-74. [PMID: 21459348 DOI: 10.1016/j.ienj.2010.03.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 03/04/2010] [Indexed: 02/06/2023]
Abstract
Social scientific and nursing studies, and the experiences of emergency department staff, have attested to the complex organisational and communicative work that accompanies emergency clinical work. Yet, little attention has been paid to developing a research framework to examine and develop communicative and organisational work in emergency departments (EDs). This paper explores the role of nurses in plugging gaps in the care of ED patients, and summarises the findings of a large, 3-year ethnographic study comprising 12 months of ethnography in two EDs in Sydney, Australia, and 2 years of analysis. The findings of the large study are summarised and exemplified here as part of a broader conceptual argument for the importance of ethnographic research in EDs. Ethnography involves capturing the moment-to-moment action of life when and where it happens, and in the context of, reflecting and amending, broader social patterns. The findings report on the relationship of communication, organisational and, in particular, interdepartmental and interorganizational work, to emergency clinical work and demonstrate that nurses play an important role in articulating and reconciling patients' and medical staff activities. The paper concludes that emergency nurses are well placed to use ethnographic research to advance the understanding and delivery of emergency care.
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Affiliation(s)
- Peter Nugus
- Centre for Clinical Governance Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, Australia.
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Chong A, Weiland TJ, Mackinlay C, Jelinek GA. The capacity of Australian ED to absorb the projected increase in intern numbers. Emerg Med Australas 2010; 22:100-7. [DOI: 10.1111/j.1742-6723.2010.01268.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Saracino A, Weiland TJ, Jolly B, Dent AW. Verbal dyspnoea score predicts emergency department departure status in patients with shortness of breath. Emerg Med Australas 2010; 22:21-9. [PMID: 20136641 DOI: 10.1111/j.1742-6723.2009.01254.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We examined whether a previously validated verbal dyspnoea rating scale, and/or other demographic and clinical parameters, could predict ED departure status, among ED patients presenting with shortness of breath. METHODS In this prospective observational study, a convenience sample of patients presenting to an inner urban adult tertiary hospital ED with shortness of breath were assessed at triage using objective and subjective breathlessness parameters. These included respiratory rate, oxygen saturation, heart rate, systolic blood pressure and verbal dyspnoea scores. A verbal dyspnoea score for worst dyspnoea during the current episode and basic demographic and presentation characteristics were also collected. These variables were assessed as predictors of ED departure status (inpatient admission or ED discharge) using logistic regression. RESULTS From a sample of 253 participants, verbal dyspnoea scores > or =8 predicted inpatient admission 89% specificity (95% confidence interval [CI] 82.1-93.4), and scores < or =3 predicted discharge with 95% specificity (95% CI 89.5-98.0). For patients with shortness of breath as the primary complaint, the combination of verbal dyspnoea score > or =6, heart rate > or =94 bpm at triage and ambulance arrival predicted admission with 90% sensitivity (95% CI 82-95%) and 84% specificity (95% CI 73-92%). These same variables predicted admission for all patients with 84% sensitivity (95% CI 75.8-89.2) and 79% specificity (95% CI 71.5-85.5). CONCLUSION Verbal dyspnoea score, alone and in combination with heart rate and arrival transport, can accurately predict admission. Once validated they might be useful in assessing, prioritizing and making rapid site of care decisions for breathless patients presenting to the ED.
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Affiliation(s)
- Amanda Saracino
- Emergency Practice Innovation Centre, St. Vincent's Hospital, Melbourne, Victoria 3068, Australia
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Richardson D, McMahon KLH. Emergency Department access block occupancy predicts delay to surgery in patients with fractured neck of femur. Emerg Med Australas 2009; 21:304-8. [PMID: 19682016 DOI: 10.1111/j.1742-6723.2009.01201.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The present study aimed to identify any relationship between existing access block occupancy (ABO) at the time of patient presentation and delay to definitive procedure. METHODS Retrospective descriptive cohort study of all patients aged over 50 years with an ED diagnosis of fractured neck of femur admitted through a tertiary ED over 2 years. The independent variable was the ABO at the start of the hour in which the patient presented, derived from existing ED records, and expressed as the quartile for that hour of the day. The dependent variable was start of surgery more than 24 h after arrival without a documented reason for delay. The data abstractor was blinded to the ABO. RESULTS All 442 diagnoses of fractured neck of femur recorded in the ED were reviewed, 73 were excluded (16 age, 5 misdiagnosis, 31 no surgery, 21 documented medical reasons for delay). There was a significant relationship between ABO quartile and the rate of delay to surgery ranging from 54% (95% CI 43-63%) for those presenting in the lowest ABO quartile to 77% (68-85%) in the highest (P= 0.006, chi(2)). Subgroup analysis showed that arrival ABO predicted patient access block, and that patient access block was associated with delay to surgery and longer postoperative length of stay (geometric mean 12.9 vs 9.9 days, P < 0.01, t-test). CONCLUSIONS The number of access block patients at the time of arrival directly predicts delay to operation in this setting. This suggests that access block occupancy is a marker of hospital dysfunction.
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Affiliation(s)
- Drew Richardson
- Medical School, Australian National University, Australian Capital Territory, Australia.
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Forecasting emergency department crowding: an external, multicenter evaluation. Ann Emerg Med 2009; 54:514-522.e19. [PMID: 19716629 DOI: 10.1016/j.annemergmed.2009.06.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 05/20/2009] [Accepted: 06/01/2009] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE We apply a previously described tool to forecast emergency department (ED) crowding at multiple institutions and assess its generalizability for predicting the near-future waiting count, occupancy level, and boarding count. METHODS The ForecastED tool was validated with historical data from 5 institutions external to the development site. A sliding-window design separated the data for parameter estimation and forecast validation. Observations were sampled at consecutive 10-minute intervals during 12 months (n=52,560) at 4 sites and 10 months (n=44,064) at the fifth. Three outcome measures-the waiting count, occupancy level, and boarding count-were forecast 2, 4, 6, and 8 hours beyond each observation, and forecasts were compared with observed data at corresponding times. The reliability and calibration were measured following previously described methods. After linear calibration, the forecasting accuracy was measured with the median absolute error. RESULTS The tool was successfully used for 5 different sites. Its forecasts were more reliable, better calibrated, and more accurate at 2 hours than at 8 hours. The reliability and calibration of the tool were similar between the original development site and external sites; the boarding count was an exception, which was less reliable at 4 of 5 sites. Some variability in accuracy existed among institutions; when forecasting 4 hours into the future, the median absolute error of the waiting count ranged between 0.6 and 3.1 patients, the median absolute error of the occupancy level ranged between 9.0% and 14.5% of beds, and the median absolute error of the boarding count ranged between 0.9 and 2.8 patients. CONCLUSION The ForecastED tool generated potentially useful forecasts of input and throughput measures of ED crowding at 5 external sites, without modifying the underlying assumptions. Noting the limitation that this was not a real-time validation, ongoing research will focus on integrating the tool with ED information systems.
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Lucas R, Farley H, Twanmoh J, Urumov A, Olsen N, Evans B, Kabiri H. Emergency department patient flow: the influence of hospital census variables on emergency department length of stay. Acad Emerg Med 2009; 16:597-602. [PMID: 19438415 DOI: 10.1111/j.1553-2712.2009.00397.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The objective was to evaluate the association between hospital census variables and emergency department (ED) length of stay (LOS). This may give insights into future strategies to relieve ED crowding. METHODS This multicenter cohort study captured ED LOS and disposition for all ED patients in five hospitals during five 1-week study periods. A stepwise multiple regression analysis was used to examine associations between ED LOS and various hospital census parameters. RESULTS Data were analyzed on 27,325 patients on 161 study days. A significant positive relationship was demonstrated between median ED LOS and intensive care unit (ICU) census, cardiac telemetry census, and the percentage of ED patients admitted each day. There was no relationship in this cohort between ED LOS and ED volume, total hospital occupancy rate, or the number of scheduled cardiac or surgical procedures. CONCLUSIONS In multiple hospital settings, ED LOS is correlated with the number of admissions and census of the higher acuity nursing units, more so than the number of ED patients each day, particularly in larger hospitals with busier EDs. Streamlining ED admissions and improving availability of inpatient critical care beds may reduce ED LOS.
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Affiliation(s)
- Ray Lucas
- Departments of Emergency Medicine, The George Washington University, Washington, DC, USA.
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Bittencourt RJ, Hortale VA. Intervenções para solucionar a superlotação nos serviços de emergência hospitalar: uma revisão sistemática. CAD SAUDE PUBLICA 2009; 25:1439-54. [PMID: 19578565 DOI: 10.1590/s0102-311x2009000700002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 01/22/2009] [Indexed: 11/22/2022] Open
Abstract
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.
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Richardson DB, Mountain D. Myths versus facts in emergency department overcrowding and hospital access block. Med J Aust 2009; 190:369-74. [PMID: 19351311 DOI: 10.5694/j.1326-5377.2009.tb02451.x] [Citation(s) in RCA: 174] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 01/27/2009] [Indexed: 11/17/2022]
Abstract
Overcrowding occurs when emergency department (ED) function is impeded, primarily by overwhelming of ED staff resources and physical capacity by excessive numbers of patients needing or receiving care. Access block occurs when there is excessive delay in access to appropriate inpatient beds (> 8 hours total time in the ED). Access block for admitted patients is the principal cause of overcrowding, and is mainly the result of a systemic lack of capacity throughout health systems, and not of inappropriate presentations by patients who should have attended a general practitioner. Overcrowding is most strongly associated with excessive numbers of admitted patients being kept in the ED. Excessive numbers of admitted patients in the ED are associated with diminished quality of care and poor patient outcomes. These include (but are not limited to) adverse events, errors, delayed time-critical care, increased morbidity and excess deaths (estimated as at least 1500 per annum in Australia). There is no evidence that telephone advice lines or collocated after-hours GP services assist in reducing ED workloads. Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding. They are also rapidly overwhelmed by increasing access block. The causes of overcrowding, and hence the solutions, lie outside the ED. Solutions will mainly be found in managing hospital bedstock and systemic capacity (including the use of step-down and community resources) so that appropriate inpatient beds remain available for acutely sick patients.
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Affiliation(s)
- Drew B Richardson
- Emergency Department, Australian National University Medical School, Canberra, ACT, Australia.
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Bartlett S, Fatovich DM. Emergency department patient preferences for waiting for a bed. Emerg Med Australas 2009; 21:25-30. [DOI: 10.1111/j.1742-6723.2008.01147.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chu K, Brown A. Association between access block and time to parenteral opioid analgesia in renal colic: A pilot study. Emerg Med Australas 2009; 21:38-42. [DOI: 10.1111/j.1742-6723.2008.01146.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med 2008; 52:126-36. [PMID: 18433933 DOI: 10.1016/j.annemergmed.2008.03.014] [Citation(s) in RCA: 876] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Revised: 01/26/2008] [Accepted: 03/11/2008] [Indexed: 11/20/2022]
Abstract
Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. We conducted a comprehensive PubMed search to identify articles that (1) studied causes, effects, or solutions of ED crowding; (2) described data collection and analysis methodology; (3) occurred in a general ED setting; and (4) focused on everyday crowding. Two independent reviewers identified the relevant articles by consensus. We applied a 5-level quality assessment tool to grade the methodology of each study. From 4,271 abstracts and 188 full-text articles, the reviewers identified 93 articles meeting the inclusion criteria. A total of 33 articles studied causes, 27 articles studied effects, and 40 articles studied solutions of ED crowding. Commonly studied causes of crowding included nonurgent visits, "frequent-flyer" patients, influenza season, inadequate staffing, inpatient boarding, and hospital bed shortages. Commonly studied effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and financial effect. Commonly studied solutions of crowding included additional personnel, observation units, hospital bed access, nonurgent referrals, ambulance diversion, destination control, crowding measures, and queuing theory. The results illustrated the complex, multifaceted characteristics of the ED crowding problem. Additional high-quality studies may provide valuable contributions toward better understanding and alleviating the daily crisis. This structured overview of the literature may help to identify future directions for the crowding research agenda.
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Saracino A. Review of dyspnoea quantification in the emergency department: is a rating scale for breathlessness suitable for use as an admission prediction tool? Emerg Med Australas 2008; 19:394-404. [PMID: 17919211 DOI: 10.1111/j.1742-6723.2007.00999.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute shortness of breath is a potential marker of serious cardiopulmonary disease and requires rapid assessment. In our current health-care system, increasing pressure on the ED to limit costs and waiting times has resulted in the development of many clinical decision aids and admission prediction tools designed to assist ED physicians in meeting these demands. However, most of these tools are disease specific, and none are currently available for application to patients presenting to the ED with shortness of breath. Although somewhat limited, current evidence supports the utilization of a simple dyspnoea rating scale, to assist in the streamlining of clinical severity assessments and urgency evaluations, and to potentially provide useful information to facilitate rapid and accurate site-of-care decisions in this setting.
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Affiliation(s)
- Amanda Saracino
- Emergency Practice Innovation Centre, Emergency Medicine, St Vincent's Health Melbourne, Fitzroy, Australia.
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