How does fast track affect quality of care in the emergency department?

Queueing Problems in Emergency Departments: A Review of Practical Approaches and Research Methodologies

Problems related to patient scheduling and queueing in emergency departments are gaining increasing attention in theory, in the fields of operations research and emergency and healthcare services, and in practice. This paper aims to provide an extensive review of studies addressing queueing-related problems explicitly related to emergency departments. We have reviewed 229 articles and books spanning seven decades and have sought to organize the information they contain in a manner that is accessible and useful to researchers seeking to gain knowledge on specific aspects of such problems. We begin by presenting a historical overview of applications of queueing theory to healthcare-related problems. We subsequently elaborate on managerial approaches used to enhance efficiency in emergency departments. These approaches include bed management, fast-track, dynamic resource allocation, grouping/prioritization of patients, and triage approaches. Finally, we discuss scientific methodologies used to analyze and optimize these approaches: algorithms, priority models, queueing models, simulation, and statistical approaches.

The influence of a fast-track service on case flow and client satisfaction in a high-volume veterinary emergency department

OBJECTIVE

To assess the benefit of a fast-track service in the emergency department of a large, high-volume veterinary hospital.

DESIGN

Prospective, observational, clinical study.

SETTING

Emergency department of an urban, tertiary referral veterinary hospital.

ANIMALS

All animals presented to the emergency department between April 1 and April 30 in 2017 and 2018 were eligible for inclusion. Only patients seen on days in 2017 corresponding to those days of 2018 during which the fast-track service was available were studied.

MEASUREMENT AND MAIN RESULTS

Triage case logs were collected and reviewed for April 2017 (prefast-track) and 2018 (fast-track). The fast-track service was launched as a pilot program in April 2018 to provide expedited care to low acuity patients presented to the emergency department. The median number of daily emergency department cases did not differ between 2017 (45, range 26-64) and 2018 (47, range 38-64; P = 0.3). The median time from presentation until first discussion with a doctor for low acuity cases was lower in April 2017 (29 min, range 1-163) than in April 2018 (24 min, range 1-100; P < 0.001). This reduction in wait time was observed despite a 40% increase in low acuity case presentations in 2018. Wait times for high acuity patients did not differ between study periods. The number of cases that left without being seen was higher in April 2017 compared to April 2018 (77 and 45 cases, respectively P < 0.001).

CONCLUSIONS

Implementation of a fast-track service reduced wait time for low acuity cases without adversely impacting wait times for sicker patients and led to a reduction in clients leaving without being seen. By introducing the fast-track service in a large volume veterinary hospital, limited resources can be distributed to improve speed of care, case flow, and client satisfaction in the emergency department.

Comparison of Clinical Outcomes Between Chinese Patients Receiving Hepatectomy With or Without Enhanced Recovery After Surgery Strategy

Purposes: For the first time in China, the current study was designed to compare the clinical outcomes between Chinese patients receiving hepatectomy with or without the enhanced recovery after surgery (ERAS) strategy. Methods: The current study enrolled 250 patients who would receive hepatectomy. Patients were randomized into two groups: ERAS group (n = 125, ERAS strategy) and control (n = 125, conventional care). Mortality, length of hospital stay, readmission, and complications were assessed over 30 days after the operation. Results: The average age of the whole cohort was 65 (63-68) years, with 152 males (60.8%). There was no difference between two groups in baseline features, such as age, sex, medical history, Child-Pugh hepatic function, American Society of Anaesthesiologists physical status, operative type, hepatectomy type, and hepatic pathology (P > 0.05 for all). There was no occurrence of death in the two groups. Patients in the ERAS group had significantly less occurrence of post-operative complications and a shorter length of hospital stay (P < 0.05 for all). Deep vein thrombosis occurred in seven patients in the control group, but did not occur in the ERAS group (P < 0.05). Patients in the two groups had similar occurrence of readmission (P > 0.05). Conclusions: ERAS strategy significantly decreased the occurrence of operative complications and shortened the length of hospital stay without any increase in mortality or readmission in Chinese patients receiving hepatectomy.

NO WAIT: new organised well-adapted immediate triage: a lean improvement project

Long waiting times in the emergency department (ED) are associated with decreased patient satisfaction and increased morbidity and mortality. Triage may be a contributing factor to prolonged wait times in the ED. At Alhada Armed Forces Hospital (Taif, Saudi Arabia), patients other than level 1 and 2 on the Canadian Triage and Acuity Scale are requested to wait until triage. During peak hours (08:00−22:00), the waiting time prior to triage is prolonged, and several patients leave the ED before triage. In this project, a multidisciplinary team was assembled to revise patient flow from the time of arrival at the ED to the time of triage. Lean methodology was used to identify the redundancies and design a seamless flow process for ED patients. Through reorganising the triage area using minimal additional resources, the project team devised a novel floor plan for the triage area which provided a unique patient flow in the ED. The median patient wait time from arrival to triage was reduced from 27 min to 4.09 min and the percentage of patients leaving the ER before triage was reduced to 0%. This project is the first of its kind in Saudi Arabia, as well as in the Gulf region, and provides a radical solution to the problem of patient waiting in the ED during peak hours.

Interprofessional teamwork versus fast track streaming in an emergency department-An observational cohort study of two strategies for enhancing the throughput of orthopedic patients presenting limb injuries or back pain

Objective

To compare two strategies, interprofessional teams versus fast track streaming, for orthopedic patients with limb injuries or back pain, the most frequent orthopedic complaints in an emergency department.

Methods

An observational before-and-after study at an adult emergency department from May 2012 to Nov 2015. Patients who arrived on weekdays from 8 am to 9 pm and presented limb injury or back pain during one year of each process were included, so that 11,573 orthopedic presentations were included in the fast track period and 10,978 in the teamwork period. Similarly, another 11,020 and 10,760 arrivals presenting the six most frequent non-orthopedic complaints were included in the respective periods, altogether 44,331 arrivals. The outcome measures were the time to physician (TTP) and length of stay (LOS). The LOS was adjusted for predictors, including imaging times, by using linear regression analysis.

Results

The overall median TTP was shorter in the teamwork period, 76.3 min versus 121.0 min in the fast track period (-44.7 min, 95% confidence interval (CI): -47.3 to -42.6). The crude median LOS for orthopedic presentations was also shorter in the teamwork period, 217.0 min versus 230.0 min (-13.0 min, 95% CI: -18.0 to -8.0), and the adjusted LOS was 22.8 min shorter (95% CI: -26.9 to -18.7). For non-orthopedic presentations, the crude median LOS did not differ significantly between the periods (2.0 min, 95% CI: -3.0 to 7.0). However, the adjusted LOS was shorter in the teamwork period (-20.1 min, 95% CI: -24.6 to -15.7).

Conclusions

The median TTP and LOS for orthopedic presentations were shorter in the teamwork period. For non-orthopedic presentations, the TTP and adjusted LOS were also shorter in the teamwork period. Therefore, interprofessional teamwork may be an alternative approach to improve the patient flow in emergency departments.

Characterization of emergency department abandonment using a real-time location system

BACKGROUND

Patients who present to emergency departments (EDs) for evaluation but are noted to have left without being seen (LWBS) are potentially at great risk. Governmental agencies, such as the Centers for Medicare and Medicaid, as well as hospitals and health organizations, are examining the factors which drive LWBS, including accurately quantifying patient tolerance to wait times and targeting interventions to improve patient tolerance to waiting.

OBJECTIVE

Compare traditional methods of estimating time to LWBS with an objective method using a real-time location tracking system (RTLS); examine temporal factors associated with greater LWBS rates.

METHODS

This is a retrospective cohort study of all ED visits to a large, suburban, quaternary care hospital in one calendar year. LWBS was calculated as patient registration to nurse recognition and documentation of patient abandonment (traditional method) vs registration to last onsite RTLS timestamp (study method). Descriptives of patterns of patient abandonment rates and patient demographic data were also included.

RESULTS

Our study shows that traditional methods of measuring LWBS times significantly overestimate actual patient tolerance to waiting times (median 70, mean 92 min). Patients triaged to resource intensive categories (Emergency Severity Index (ESI) 2, 3) wait longer than patients triaged to less resource intensive categories (ESI 4, 5).

CONCLUSION

Compared to traditional methods, RTLS is an efficient and accurate way to measure LWBS rates and helps set the stage for assessing the efficacy of interventions to reduce LWBS and reduce the gap between those seeking evaluation at emergency departments and those ultimately receiving it.

The French Emergency National Survey: A description of emergency departments and patients in France

INTRODUCTION

Some major changes have occurred in emergency department (ED) organization since the early 2000s, such as the establishment of triage nurses and short-track systems. The objectives of this study were to describe the characteristics of French EDs organization and users, based on a nationwide cross-sectional survey.

METHODS

The French Emergency Survey was a nationwide cross-sectional survey. All patients presenting to all EDs during a 24-hr period of June 2013 were included. Data collection concerned ED characteristics as well as patient characteristics.

RESULTS

Among the 736 EDs in France, 734 were surveyed. Triage nurses and short-track systems were respectively implemented in 73% and 41% of general EDs. The median proportion of patients aged > 75 years was 14% and median hospitalisation rate was 20%. During the study period, 48,711 patients presented to one of the 734 EDs surveyed. Among them, 7% reported having no supplementary health or universal coverage (for people with lower incomes). Overall, 50% of adult patients had been seen by the triage nurse in less than 5 minutes, 74% had a time to first medical contact shorter than one hour and 55% had an ED length of stay shorter than 3 hours.

CONCLUSION

The French Emergency Survey is the first study to provide data on almost all EDs in France. It underlines how ED organization has been redesigned to face the increase in the annual census. French EDs appear to have a particular role for vulnerable people: age-related vulnerability and socio-economic vulnerability with an over-representation of patients without complementary health coverage.

Adjusting patients streaming initiated by a wait time threshold in emergency department for minimizing opportunity cost

Purpose Two different systems for streaming patients were considered to improve efficiency measures such as waiting times (WTs) and length of stay (LOS) for a current emergency department (ED). A typical fast track area (FTA) and a fast track with a wait time threshold (FTW) were designed and compared effectiveness measures from the perspective of total opportunity cost of all patients' WTs in the ED. The paper aims to discuss these issues. Design/methodology/approach This retrospective case study used computerized ED patient arrival to discharge time logs (between July 1, 2009 and June 30, 2010) to build computer simulation models for the FTA and fast track with wait time threshold systems. Various wait time thresholds were applied to stream different acuity-level patients. National average wait time for each acuity level was considered as a threshold to stream patients. Findings The fast track with a wait time threshold (FTW) showed a statistically significant shorter total wait time than the current system or a typical FTA system. The patient streaming management would improve the service quality of the ED as well as patients' opportunity costs by reducing the total LOS in the ED. Research limitations/implications The results of this study were based on computer simulation models with some assumptions such as no transfer times between processes, an arrival distribution of patients, and no deviation of flow pattern. Practical implications When the streaming of patient flow can be managed based on the wait time before being seen by a physician, it is possible for patients to see a physician within a tolerable wait time, which would result in less crowded in the ED. Originality/value A new streaming scheme of patients' flow may improve the performance of fast track system.

Non-urgent adult patients in the emergency department: Causes and patient characteristics

Objective

Non-urgent patients are one of the important causes of emergency department (ED) overcrowding. In this study, it is aimed to identify the characteristics of these patients and the reasons why they prefer the ED.

Method

This study was conducted during regular office hours. The characteristics of non-urgent patients, their complaints, the frequency of visits to family physicians (FPs), the frequency of using the Central Hospital Appointment System (CHAS) and reasons for preferring the ED were questioned by a questionnaire.

Results

This study was conducted on 624 patients. Among them, 326 (52.2%) were male. The mean age was 38.4 years (SD: 14.4). It was identified that 80.3% of the patients had no chronic disease and that 97.4% had health insurance. The most common complaints at presentation were musculoskeletal system pain (25.2%) and upper respiratory tract infections symptoms (19.7%). It was identified that 28.7% of the patients did not prefer to visit their FPs and that 48.6% did not use the CHAS. The reasons of preferring ED were as follows: rapid physical examination (36.4%), not being able to book an earlier appointment at alternative health facilities (30.9%), being close to the facility (12.8%) and being at the hospital for a different reason (12.3%). Among the patients, 20.2% did not express any particular reason.

Conclusions

Non-urgent patients who admitted to the ED are mostly middle-aged patients with no chronic disease. They usually visit the ED for preventable reasons. The use of alternative health facilities and CHAS should be encouraged.

The effect of vertical split-flow patient management on emergency department throughput and efficiency

BACKGROUND

To address emergency department overcrowding operational research seeks to identify efficient processes to optimize flow of patients through the emergency department. Vertical flow refers to the concept of utilizing and assigning patients virtual beds rather than to an actual physical space within the emergency department to care of low acuity patients. The aim of this study is to evaluate the impact of vertical flow upon emergency department efficiency and patient satisfaction.

METHODS

Prospective pre/post-interventional cohort study of all intend-to-treat patients presenting to the emergency department during a two-year period before and after the implementation of a vertical flow model.

RESULTS

In total 222,713 patient visits were included in the analysis with 107,217 patients presenting within the pre-intervention and 115,496 in the post-intervention groups. The results of the regression analysis demonstrate an improvement in throughput across the entire ED patient population, decreasing door to departure time by 17 min (95% CI 15-18) despite an increase in patient volume. No statistically significant difference in patient satisfaction scores were found between the pre- and post-intervention.

CONCLUSIONS

Initiation of a vertical split flow model was associated with improved ED efficiency.

Holiday Fast-Track Reduced Medical Cost and Length of Emergency Department Stay: Preliminary Report from a Single Secondary Care Hospital

Introduction

The aims of this study were to compare the effect of a Holiday Fast-Track (HFT) unit on medical costs and emergency department (ED) length of stay (LOS) associated with low acuity patients attended during the same timeframe in two consecutive years in a single secondary care hospital ED.

Methods

Two groups (non-HFT vs. HFT), before and after the fast-track unit was implemented, were compared. The HFT unit was operated to improve the flow of low acuity patients, which were defined as the patients classified as level 4 or 5 by the modified Canadian Triage and Acuity Scale. Data were collected from March 1 to April 30, 2011 for the non-HFT group and during the same period in 2012 for the HFT group.

Results

A total of 894 (431 for non-HFT period and 463 for HFT period) patients of acuity level 4 or 5 visited the ED during the study period. Compared to the non-HFT group, the ED LOS of the HFT group decreased by 27 min and 3.5 min in the patients with acuity levels 4 and 5, respectively (p=0.005 and p=0.003, respectively). Furthermore, total medical costs and laboratory fees were also reduced significantly in the HFT group (p<0.001, p=0.038). However, there was no difference in the other variables between those two groups.

Conclusions

The HFT system decreases the medical costs and LOS in low acuity patients visiting the ED of a secondary care hospital. (Hong Kong j.emerg.med. 2015;22:84-92)

A Queue-Based Monte Carlo Analysis to Support Decision Making for Implementation of an Emergency Department Fast Track

Emergency departments (EDs) are seeking ways to utilize existing resources more efficiently as they face rising numbers of patient visits. This study explored the impact on patient wait times and nursing resource demand from the addition of a fast track, or separate unit for low-acuity patients, in the ED using a queue-based Monte Carlo simulation in MATLAB. The model integrated principles of queueing theory and expanded the discrete event simulation to account for time-based arrival rates. Additionally, the ED occupancy and nursing resource demand were modeled and analyzed using the Emergency Severity Index (ESI) levels of patients, rather than the number of beds in the department. Simulation results indicated that the addition of a separate fast track with an additional nurse reduced overall median wait times by 35.8 ± 2.2 percent and reduced average nursing resource demand in the main ED during hours of operation. This novel modeling approach may be easily disseminated and informs hospital decision-makers of the impact of implementing a fast track or similar system on both patient wait times and acuity-based nursing resource demand.

The impact of computerized provider order entry on emergency department flow

Objectives

Computerized provider order entry (CPOE) has been established as a method to improve patient safety by avoiding medication errors; however, its effect on emergency department (ED) flow remains undefined. We examined the impact of CPOE implementation on three measures of ED throughput: wait time (WT), length of stay (LOS), and the proportion of patients that left without being seen (LWBS).

Methods

We conducted a retrospective cohort study of all ED patients of 18 years and older presenting to London Health Sciences Centre during July and August 2013 and 2014, before and after implementation of a CPOE system. The three primary variables were compared between time periods. Subgroup analyses were also conducted within each Canadian Triage and Acuity Scale (CTAS) level (1–5) individually, as well as for admitted patients only.

Results

A significant increase in WT of 5 minutes (p=0.036) and LOS of 10 minutes (p=0.001), and an increase in LWBS from 7.2% to 8.1% (p=0.002) was seen after CPOE implementation. Admitted patients’ LOS increased by 63 minutes (p<0.001), the WT of CTAS 3 and 5 patients increased by 6 minutes (p=0.001) and 39 minutes (p=0.005), and LWBS proportion increased significantly for CTAS 3–5 patients, from 24.3% to 42.0% (p<0.001) for CTAS 5 patients specifically.

Conclusions

CPOE implementation detrimentally impacted all patient flow throughput measures that we examined. The most striking clinically relevant result was the increase in LOS of 63 minutes for admitted patients. This raises the question as to whether the potential detrimental effects to patient safety of CPOE implementation outweigh its benefits.

Enhanced Recovery Program Versus Traditional Care in Laparoscopic Hepatectomy

Enhanced recovery after surgery (ERAS) has shown effectiveness in terms of reducing the hospital stay and cost associated with open liver resection. However, the benefit of ERAS in patients undergoing laparoscopic liver resection is still unclear, and clinical studies on this topic are limited.The ERAS program for laparoscopic liver resection was used in a group of 80 patients (ERAS group). The results were compared with those in a control group of 107 patients. All patients underwent laparoscopic liver resection. The primary endpoints were the postoperative hospital stay, defined as the number of days from surgery to discharge, and the hospitalization expense. The secondary endpoints were resumption of oral intake, readmissions, and complications.The median postoperative hospital stay was 6.2 ± 2.6 days in the ERAS group, which was significantly shorter than that in the control group (9.9 ± 5.9 d; P < 0.001). The hospitalization cost was $6871 ± 2571 in the ERAS group and $7948 ± 3630 in the control group (P = 0.020). The morbidity rate was 22.5% (18 of 80 patients) in the ERAS group and 43.9% (47 of 107 patients) in the control group (P = 0.002). There were no significant differences the in rate of readmission between the 2 groups.Enhanced recovery after surgery for laparoscopic liver resection is safe and effective. Patients in the ERPS group had a shorter hospital stay, fewer complications, and lower hospital costs.

The Impact of Standardized Acuity Assessment and a Fast-Track on Length of Stay in Obstetric Triage: A Quality Improvement Study

To prospectively assess the impact of a standardized 5-category Obstetrical Triage Acuity Scale (OTAS) and a fast-track for lower-acuity patients on patient flow. Length of stay (LOS) data of women presenting to obstetric triage were abstracted from the electronic medical record prior to (July 1, 2011, to March 30, 2012) and following OTAS implementation (April 1 to December 31, 2012). Following computerized simulation modeling, a fast-track for lower acuity women was implemented (January 1, 2013, to February 28, 2014). Prior to OTAS implementation (8085 visits), the median LOS was 105 (interquartile range [IQR] = 52-178) minutes. Following OTAS implementation (8131 visits), the median LOS decreased to 101 (IQR = 49-175) minutes (P = .04). The LOS did not correlate well with acuity. Simulation modeling predicted that a fast-track for OTAS 4 and 5 patients would reduce the LOS. The LOS for lower-acuity patients in the fast-track decreased to 73 (IQR = 40-140) minutes (P = .005). In addition, the overall LOS (12 576 visits) decreased to 98 (IQR = 47-172) minutes (6.9% reduction; P < .001). Standardized assessment of acuity and a fast-track for lower acuity pregnant women decreased the overall LOS and the LOS of lower-acuity patients.

Fast-track protocols in devascularization for cirrhotic portal hypertension

INTRODUCTION/OBJECTIVE

fast-tract surgery (FTS) has been rapidly embraced by surgeons as a mechanism for improving patient care and driving down complications and costs. The aim of this study was to determine if any improvement in outcomes occurred after FTS protocol for selective double portazygous disconnection with preserving vagus (SDPDPV) compared with non-FTS postoperative care.

METHODS

patients eligible for SDPDPV in the period January 2012-April 2014 were randomly selected for the FTS group or non-FTS group. A designed protocol was used in the FTS group with emphasis on an interdisciplinary approach. The non-FTS group was treated using previously established standard procedures. The number of postoperative complications, time of functional recovery and duration of hospital stay were recorded.

RESULTS

patients in the FTS group (n=59) and non-FTS group (n=57) did not differ in terms of preoperative data and operative details (p>0.05). The FTS procedure led to significantly better control and faster restoration of gastrointestinal functions, food tolerance, rehabilitation and hospital discharge (p<0.05). Postoperative complications, including nausea/vomiting, severe ascites, wound infection, urinary tract infection and pulmonary infection were all significantly lower in the FTS group (p<0.05). According to the postoperative morbidity classification used by Clavien, overall complications and grade I complications were both significantly lower in the FTS group compared with the non-FTS group (p<0.05).

CONCLUSION

adopting the FTS protocol helped to recover gastrointestinal functions, to reduce frequency of postoperative complications and to reduce hospital stay. The FTS strategy is safe and effective in improving postoperative outcomes.

A Daytime Fast Track Improves Throughput in a Single Physician Coverage Emergency Department

OBJECTIVES

Fast tracks are one approach to reduce emergency department (ED) crowding. No studies have assessed the use of fast tracks in smaller hospitals with single physician coverage. Our study objective was to determine if implementation of an ED fast track in a single physician coverage setting would improve wait times for low-acuity patients without negatively impacting those of higher acuity.

METHODS

A daytime fast track opened in 2010 at Strathroy Middlesex General Hospital, a southwestern Ontario community hospital. Before and after intervention groups comprised of ED visits in 2009 and 2011 were compared. Pooled comparison of all Canadian Triage and Acuity Scale (CTAS) patients in each period, and between subgroups CTAS 2-5 comparisons were performed for: wait time (WT), length of stay (LOS), WTs that met national CTAS time guidelines (MNCTG), and proportion of patients that left without being seen (LWBS).

RESULTS

WT and LOS were six minutes (88 min to 82 min, p=0.002) and 15 minutes (158 min to 143 min, p<0.001) lower, respectively, in the post-intervention period. Subgroup analysis showed CTAS 4 had the most pre- to post-intervention decrease in WT, of 13 minutes (98 min to 85 min, p<0.001). There was statistical improvement in MNCTG in the post-intervention period. No differences were found in outcome measures for higher-acuity patients or LWBS rates.

CONCLUSIONS

Implementation of a fast track in a medium-volume community hospital with single physician coverage can improve patient throughput by decreasing WT and LOS without negatively impacting high-acuity patients. This may be clinically relevant, particularly for hospital administrators, given the improvement in meeting national WT standards we found post-intervention.

Improving process quality for pediatric emergency department

PURPOSE

Overcrowding in emergency departments (EDs) leads to longer waiting times and results in higher number of patients leaving the ED without being seen by a physician. EDs need to improve quality for patients' waiting time and length of stay (LoS) from the perspective of process and flow control management. The paper aims to discuss these issues.

DESIGN/METHODOLOGY/APPROACH

The retrospective case study was performed using the computerized ED patient time logs from arrival to discharge between July 1, 2009 and June 30, 2010. Patients were divided into two groups either adult or pediatric with a cutoff age of 18. Patients' characteristics were measured by arrival time periods, waiting times before being seen by a physician, total LoS and acuity levels. A discrete event simulation was applied to the comparison of quality performance measures.

FINDINGS

Statistically significant differences were found between the two groups in terms of arrival times, acuity levels, waiting time stratified for various arrival times and acuity levels. The process quality for pediatric patients could be improved by redesign of patient flow management and medical resource.

RESEARCH LIMITATIONS/IMPLICATIONS

The results are limited to a case of one community and ED. This study did not analyze the characteristic of leaving the ED without being seen by a physician.

PRACTICAL IMPLICATIONS

Separation of pediatric patients from adult patients in an ED can reduce the waiting time before being seen by a physician and the total staying time in the ED for pediatric patients. It can also lessen the chances for pediatric patients to leave the ED without being seen by a physician.

ORIGINALITY/VALUE

A process and flow control management scheme based on patient group characteristics may improve service quality and lead to a better patient satisfaction in ED.

Implementing an obstetric triage acuity scale: interrater reliability and patient flow analysis

A 5-category Obstetric Triage Acuity Scale (OTAS) was developed with a comprehensive set of obstetrical determinants. The objectives of this study were as follows: (1) to test the interrater reliability of OTAS and (2) to determine the distribution of patient acuity and flow by OTAS level. To test the interrater reliability, 110 triage charts were used to generate vignettes and the consistency of the OTAS level assigned by 8 triage nurses was measured. OTAS performed with substantial (Kappa, 0.61 - 0.77, OTAS 1-4) and near perfect correlation (0.87, OTAS 5). To assess patient flow, the times to primary and secondary health care provider assessments and lengths of stay stratified by acuity were abstracted from the patient management system. Two-thirds of triage visits were low acuity (OTAS 4, 5). There was a decrease in length of stay (median [interquartile range], minutes) as acuity decreased from OTAS 1 (120.0 [156.0] minutes) to OTAS 3 (75.0 [120.8]). The major contributor to length of stay was time to secondary health care provider assessment and this did not change with acuity. The percentage of patients admitted to the antenatal or birthing unit decreased from 80% (OTAS 1) to 12% (OTAS 5). OTAS provides a reliable assessment of acuity and its implementation has allowed for triaging of obstetric patients based on acuity, and a more in-depth assessment of the patient flow. By standardizing assessment, OTAS allows for opportunities to improve performance and make comparisons of patient care and flow across organizations.

Improvement in emergency department length of stay using an early senior medical assessment and streaming model of care: A cohort study

OBJECTIVE

Australian EDs are required to conform to the National Emergency Access Target (NEAT): patients must be discharged within 4 h of arrival. The aim of the present study was to determine if a model of care called Senior Assessment and Streaming (SAS) would increase the proportion of patients achieving NEAT.

METHODS

Stable, ambulant patients considered to have problems that early consultant-level assessment was likely to improve processing efficiency were streamed through a dedicated clinical area staffed by an ED physician, intern and nurse. The proportion of patients achieving NEAT were compared between days with or without SAS, adjusted for confounding variables.

RESULTS

The 18 962 patients presented during the study, 6828 on days with SAS, 12 134 on days without. On days with SAS, there were more presentations, more admissions, lower access to ward beds and fewer staff working hours. After controlling for confounding, the odds of meeting NEAT on days with SAS was 15% higher compared with days without (odds ratio, 1.15; 95% confidence interval [CI], 1.07-1.24; P < 0.001). For the subgroups of patients admitted, discharged, triage category 3, 4, 5, or presentation 12.00-18.00 the odds of meeting NEAT on days with SAS was, respectively, 1.10 (95% CI, 0.98-1.23; P = 0.10), 1.17 (95% CI, 1.07-1.28; P < 0.001), 1.17 (95% CI, 1.08-1.27; P < 0.001) and 1.19 (95% CI, 1.06-1.35; P = 0.003). The odds of a patient not waiting to be seen on days with SAS was 28% lower compared with days without (odds ratio, 0.72; 95% CI, 0.58-0.90; P = 0.003).

CONCLUSION

Through the introduction of SAS, the present study has demonstrated that providing early senior medical assessment can improve an ED's ability to meet NEAT.

Fast-track surgery improves postoperative recovery in patients undergoing partial hepatectomy for primary liver cancer: A prospective randomized controlled trial

BACKGROUND AND AIM

Fast-track surgery (FTS), combining several techniques with evidence-based adjustments, has shown its effectiveness to accelerate recovery, reduce morbidity and shorten hospital stay in many operations. This randomized controlled study was carried out aiming to compare the short-term outcomes of partial hepatectomy for liver cancer managed with FTS or with conventional surgery (CS).

METHODS

To compare the short-term effects between FTS and CS, a randomized controlled trial was carried out for liver cancer patients undergoing partial hepatectomy from September 2010 to June 2012.

RESULTS

Patients with liver cancers before receiving partial hepatectomy were randomized into the FTS group (n = 80) and the CS group (n = 80). Compared with the CS group, the FTS group had significantly less complications (P < 0.05), shorter durations of nausea/vomiting, paralytic ileus and hospital stay, higher general comfort questionnaire measures (GCQ) by Kolcaba Line (all P < 0.05), and lower serum levels of C-reactive protein on postoperative days 1, 3, and 5.

CONCLUSIONS

FTS was safe and efficacious. It lessened postoperative stress reactions and accelerated recovery for patients undergoing partial hepatectomy for liver cancer.

Missing the boat: odds for the patients who leave ED without being seen

BACKGROUND

A patient left without being seen is a well-recognized indicator of Emergency Department overcrowding. The aim of this study was to define the characteristics of LWBS patients, their rates and associated factors from a tertiary care hospital of Pakistan.

METHODS

A retrospective patient record review was undertaken. All patients presenting to the Aga Khan University Hospital, Karachi, between April and December of the year 2010, were included in the study. Information was collected on age, sex, presenting complaints, ED capacity, month, time, shift, day of the week, and waiting times in the ED. A basic descriptive analysis was made and the rates of LWBS patients were determined among the patient subgroups. Logistic regression analysis was used to assess the risk factors associated with a patient not being seen in the ED.

RESULTS

A total of 38,762 patients visited ED during the study period. Among them 5,086 (13%) patients left without being seen. Percentage of leaving was highest in the night shift (20%). The percentage was twice as high when the ED was on diversion (19.8%) compared to regular periods of operation (9.8%). Mean waiting time before leaving the ED in pediatric patients was 154 minutes while for adults it was 171 minutes. More than 32% of patients had waited for more than 180 minutes before they left without being seen, compared to the patients who were seen in ED. Important predictors for LWBS included; Triage category P4 i.e. walk -in-patients had an OR of 13.62(8.72-21.3), Diversion status, OR 1.49(1.26-1.76), night shift , OR 2.44(1.95-3.05) and Pediatric age, OR 0.57(0.48-0.66).

CONCLUSIONS

Our study elucidates the LWBS population characteristics and identifies the risk factors for this phenomenon. Targeted interventions should be planned and implemented to decrease the waiting time and alternate services should be provided for high-risk patients (for LWBS) to minimize their number.

Using Data to Drive Emergency Department Design: A Metasynthesis

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Effect of a triage team on length of stay in a pediatric emergency department

OBJECTIVE

This study aimed to determine the impact of a triage team on patient length of stay (LOS) overall and by patient acuity in a pediatric emergency department (ED).

METHODS

We conducted a cluster randomized controlled trial in which existing ED staffing was reallocated to include a triage team. The study was conducted in an urban children's ED Monday through Friday, from 6:00 P.M. to 2:00 A.M., for 4 weeks in February 2008. Twenty study periods were randomized according to the absence or presence of a triage team (physician, nurse, and nurse assistant) that initiated evaluations of nonurgent and urgent patients. We compared patient LOS between study periods with and without triage teams, using generalized estimating equations to allow for the clustering of effects by day.

RESULTS

Of the 1726 patients, 843 were seen during nontriage team times and 883 during triage team times. Overall, there was a 21-minute decrease in LOS during triage team times compared with nontriage team times, but this was not statistically significant. Stratifying by patient acuity level, LOS was significantly decreased during triage team times for nonurgent (25 minutes, P = 0.001) and urgent patients (50 minutes, P = 0.047) but prolonged for emergent patients (79 minutes, P = 0.019) and unchanged for critically ill patients.

CONCLUSIONS

Overall, although we did not find a statistically significant decrease in the LOS with the use of a dedicated triage team, we did find statistically significant decreases in the stratified analysis for urgent, nonurgent patient, and discharged patients. An important reason statistical significance may not have been reached in this study may have been our hospital's current staffing model, and therefore, the use of a triage team as additional staffing versus reallocation of existing staffing may depend on an institution's current level of staffing and its ability to meet patient demand.

A systematic review of triage-related interventions to improve patient flow in emergency departments

BACKGROUND

Overcrowding in emergency departments is a worldwide problem. A systematic literature review was undertaken to scientifically explore which interventions improve patient flow in emergency departments.

METHODS

A systematic literature search for flow processes in emergency departments was followed by assessment of relevance and methodological quality of each individual study fulfilling the inclusion criteria. Studies were excluded if they did not present data on waiting time, length of stay, patients leaving the emergency department without being seen or other flow parameters based on a nonselected material of patients. Only studies with a control group, either in a randomized controlled trial or in an observational study with historical controls, were included. For each intervention, the level of scientific evidence was rated according to the GRADE system, launched by a WHO-supported working group.

RESULTS

The interventions were grouped into streaming, fast track, team triage, point-of-care testing (performing laboratory analysis in the emergency department), and nurse-requested x-ray. Thirty-three studies, including over 800,000 patients in total, were included. Scientific evidence on the effect of fast track on waiting time, length of stay, and left without being seen was moderately strong. The effect of team triage on left without being seen was relatively strong, but the evidence for all other interventions was limited or insufficient.

CONCLUSIONS

Introducing fast track for patients with less severe symptoms results in shorter waiting time, shorter length of stay, and fewer patients leaving without being seen. Team triage, with a physician in the team, will probably result in shorter waiting time and shorter length of stay and most likely in fewer patients leaving without being seen. There is only limited scientific evidence that streaming of patients into different tracks, performing laboratory analysis in the emergency department or having nurses to request certain x-rays results in shorter waiting time and length of stay.

Exploring strategies to improve emergency department intake

BACKGROUND

The emergency department (ED) is the point of entry for nearly two-thirds of patients admitted to the average United States (US) hospital. Due to unacceptable waits, 3% of patients will leave the ED without being seen by a physician.

OBJECTIVES

To study intake processes and identify new strategies for improving patient intake.

METHODS

A year-long learning collaborative was created to study innovations involving the intake of ED patients. The collaborative focused on the collection of successful innovations for ED intake for an "improvement competition." Using a qualitative scoring system, finalists were selected and their innovations were presented to the members of the collaborative at an Association for Health Research Quality-funded conference.

RESULTS

Thirty-five departments/organizations submitted abstracts for consideration involving intake innovations, and 15 were selected for presentation at the conference. The innovations were presented to ED leaders, researchers, and policymakers. Innovations were organized into three groups: physical plant changes, technological innovations, and process/flow changes.

CONCLUSION

The results of the work of a learning collaborative focused on ED intake are summarized here as a qualitative review of new intake strategies. Early iterations of these new and unpublished innovations, occurring mostly in non-academic settings, are presented.

"Be quick": a systems response to overcrowding in the pediatric emergency department

OBJECTIVE

The purpose of this study was to evaluate the combined effects of focused system changes on several key measures of emergency department (ED) quality (length of stay, waiting time, rate of leaving without being seen, and patient satisfaction) in a children's hospital ED.

METHODS

System-wide ED changes were made and implemented during a 6-month period. The combined changes are called "be quick"--BEQK. The components were bedside registration, the Bed-ahead program, electronic medical records and tracking board, quick triage, and Kids Express. Three study periods were evaluated: before BEQK (2005) and the 2 periods after BEQK (2006 and 2007).

RESULTS

The primary outcome measures, namely wait time, length of stay, and leaving without being seen rates, were all decreased during the 2 post-BEQK periods compared with the pre-BEQK period (2005). The mean waiting time was 46 minutes (95% confidence interval [CI], 39-53 minutes) in 2005 and this decreased to 22 minutes (95% CI, 21-23 minutes) and 14 minutes (95% CI, 13-15 minutes) in 2006 and 2007, respectively. The mean length of stay was 151 minutes (95% CI, 139-163 minutes) in 2005 and this decreased to 136 minutes (95% CI, 135-137 minutes) and 115 minutes (95% CI, 114-116 minutes) in 2006 and 2007, respectively. The rate of leaving without being seen was 2.45% of patient visits per month in 2005 and this decreased to 1.67% in 2006 and to 0.92% in 2007.

CONCLUSIONS

In our pediatric ED, focused system changes significantly decreased wait time, leaving without being seen, and length of stay and improved patient satisfaction.

The impact of a fast track area on quality and effectiveness outcomes: a Middle Eastern emergency department perspective

BACKGROUND

Emergency department (ED) overcrowding is a ubiquitous problem with serious public health implications. The fast track area is a novel method which aims to reduce waiting time, patient dissatisfaction and morbidity. |The study objective was to determine the impact of a fast track area (FTA) on both effectiveness measures (i.e. waiting times [WT] and length of stay [LOS]) and quality measures (i.e. LWBS rates and mortality rates) in non-urgent patients. The secondary objective was to assess if a FTA negatively impacted on urgent patients entering the ED.

METHODS

The study took place in a 500 bed, urban, tertiary care hospital in Abu Dhabi, United Arab Emirates. This was a quasi-experimental, which examined the impact of a FTA on a pre-intervention control group (January 2005) (n = 4,779) versus a post-intervention study group (January 2006) (n = 5,706).

RESULTS

Mean WTs of Canadian Triage Acuity Scale (CTAS) 4 patients decreased by 22 min (95% CI 21 min to 24 min, P < 0.001). Similarly, mean WTs of CTAS 5 patients decreased by 28 min (95% CI 19 min to 37 min, P < 0.001) post FTA. The mean WTs of urgent patients (CTAS 2/3) were also significantly reduced after the FTA was opened (P < 0.001). The LWBS rate was reduced from 4.7% to 0.7% (95% CI 3.37 to 4.64; P < 0.001). Opening a FTA had no significant impact on mortality rates (P = 0.88).

CONCLUSION

The FTA improved ED effectiveness (WTs and LOS) and quality measures (LWBS rates) whereas mortality rate remained unchanged.

Low acuity abdominal pain in the emergency department: still a long wait

BACKGROUND

There are many pressures placed on Emergency Departments (EDs) and anecdotally patients with low acuity abdominal pain can spend a long time in ED waiting for treatment.

AIMS

This paper examines the practices in two EDs in Melbourne, Australia. Firstly, the characteristics of low acuity abdominal pain presentations in each ED is presented followed by a statistical comparison of these characteristics in the two EDs in terms of administration of medication, taking bloods and the length of time patients waited to see the nurse and doctor. A random convenience sample of 10 abdominal presentations was taken from medical records of each hospital from October 2006.

FINDINGS

Comparing the two EDs in terms of abdominal pain presentations demonstrated no statistically significant differences in terms of patient characteristics. Low acuity abdominal presentations waited a significant amount of time for initiation of treatment such as initiation of analgesia and having bloods taken (on average 80-90 min) and these delays negatively impact on overall treatment times (over 4h).

CONCLUSION

Low acuity abdominal presentations waited a significant amount of time for initiation of treatment. This convenience sample demonstrates the lack of a standardized protocol for abdominal pain presentations in the ED.