Golden hours wasted: the human cost of intensive care unit and emergency department inefficiency

Impact of Early Urine Specimen Collection on Emergency Department Time to Disposition: A Randomized Controlled Trial

Background

Diagnostic testing in the ED increases the length of stay (LOS). Urinalysis testing is highlighted specifically as a source of delays. We aim to determine whether a triage-initiated urine specimen collection process decreases ED time to disposition (TTD) in ambulatory patients with abdominal pain.

Methods

This prospective, randomized controlled study was implemented at a Suburban Level One trauma ED with greater than 120,000 annual visits. A convenience sample of patients was recruited. Adult, non-ambulance patients presenting with abdominal pain were eligible. Participants were randomized into experimental and control groups. Patients in the control group provided a urine sample after physician evaluation, if ordered by the provider. Patients in the experimental group were prompted to provide a urine sample in the triage restrooms immediately after screening at the greeter desk. The UA sample was transported to the treatment area and sent to the laboratory after physician evaluation.

Results

A total of 125 control patients and 124 experimental patients were enrolled. Forty-two patients were excluded because they were unable to provide a urine sample. Patients who had a urinalysis ordered were included in statistical analysis. Final data set included 65 patients in the experimental group and 96 patients in the control group. No significant difference (p=0.5072) in disposition time between subjects in the experimental group (n=65, mean=5:17 [hours:min]) and subjects in the control group (n=96, mean=5:30) was found.

Conclusions

The triage protocol for urine specimen collection did not significantly reduce ED TTD. Further research in overcrowded EDs with long patient waiting room times may benefit from implementing a triage protocol for urine specimen collection.

Difference in patient outcomes coming from public and private hospitals in an intensive care unit in Brazil

Background

Compare demographic data, mortality and intensive care unit length of stay (ICU LOS) in patients coming from public hospitals of the Brazilian Unified Health System and patients coming from private hospitals of the Brazilian Supplementary Health System in a single private general ICU.

Methods

A retrospective cohort study was performed on patients in the ICU of Hospital Anchieta in Brasilia, DF, Brazil, over a period of 2 years. The patients were divided into 2 groups: patients from public hospitals of the Unified Health System group (PUBH, N = 75) and patients from private hospitals of the Brazilian Supplementary Health System group (PRIH, N = 1,614).

Results

In total, 1,689 patients were admitted. For the entire cohort, the median age was 62 ± 17 years, and the mean APACHE II score was 13 ± 7. The PUBH had a higher APACHE II score (18 ± 9 versus 12 ± 7, P = 0.00), were younger (53 ± 2 versus 63 ± 16 years, P = 0.00), and had higher incidence of circulatory shock (19.2 versus 11.4%, P = 0.01), and kidney injury or renal failure (38.4 versus 25.5%, P = 0.01) at the time of ICU admission, compared to the PRIH. The ICU LOS was longer for the PUBH compared to the PRIH (18 ± 18 versus 6 ± 14 days, P = 0.00). The overall mortality rate was higher for the PUBH compared to the PRIH (33.3 versus 9.7%, P = 0.00).

Conclusions

In a single ICU, where patients had access to the same human and technological resources, patients from the PUBH had a higher APACHE II score, ICU LOS, and mortality rate than those from the PRIH.

Association between ICU admission during morning rounds and mortality

BACKGROUND

No previous study has evaluated the association between admission to ICUs during round time and patient outcome. The objective of this study was to determine the association between round-time ICU admission and patient outcome.

METHODS

This retrospective study included 49,844 patients admitted from October 1994 to December 2007 to four ICUs (two surgical, one medical, and one multispecialty) of an academic medical center. Of these patients, 3,580 were admitted to the ICU during round time (8:00 am to 10:59 am) and 46,264 were admitted during nonround time (from 1:00 pm to 6:00 am). The medical ICU had 24-h/7-day per week intensivist coverage during the last 2 years of the study. We compared the baseline characteristics and outcome of patients admitted to the ICU between the two groups. Data were abstracted from the acute physiology and chronic health evaluation (APACHE) III database.

RESULTS

The round-time and non-round-groups were similar in gender, ethnicity, and age. The predicted hospital mortality rate of the round time group was higher (17.4% vs 12.3% predicted, respectively; p < 0.001). The hospital length of stay was similar between the two groups. The round-time group had a higher hospital mortality rate (16.2% vs 8.8%, respectively; p < 0.001). Most of the round-time ICU admissions and deaths occurred in the medical ICU. Round-time admission was an independent risk factor for hospital death (odds ratio, 1.321; 95% CI, 1.178 to 1.481). This independent association was present for the whole study period except for the last 2 years.

CONCLUSIONS

Patients admitted to the ICU during morning rounds have higher severity of illness and mortality rates.

Increasing length of stay among adult visits to U.S. Emergency departments, 2001-2005

BACKGROUND

Emergency departments (EDs) are traditionally designed to provide rapid evaluation and stabilization and are neither staffed nor equipped to provide prolonged care. Longer ED length of stay (LOS) may compromise quality of care and contribute to delays in the emergency evaluation of other patients.

OBJECTIVES

The objective was to determine whether ED LOS increased between 2001 and 2005 and whether trends varied by patient and hospital factors.

METHODS

This was a retrospective analysis of a nationally representative sample of 138,569 adult ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2001 to 2005. ED LOS was measured from registration to discharge.

RESULTS

Median ED LOS increased 3.5% per year from 132 minutes in 2001 to 154 minutes in 2005 (p-value for trend < 0.001). There was a larger increase among critically ill patients for whom ED LOS increased 7.0% annually from 185 minutes in 2001 to 254 minutes in 2005 (p-value for trend < 0.01). ED LOS was persistently longer for black/African American, non-Hispanic patients (10.6% longer) and Hispanic patients (13.9% longer) than for non-Hispanic white patients, and these differences did not diminish over time. Among factors potentially associated with increasing ED LOS, a large increase was found (60.1%, p-value for trend < 0.001) in the use of advanced diagnostic imaging (computed tomography [CT], magnetic resonance imaging [MR], and ultrasound [US]) and in the proportion of ED visits at which five or more diagnostic or screening tests were ordered (17.6% increase, p-value for trend = 0.001). The proportion of uninsured patients was stable throughout the study period, and EDs with predominately privately insured patients experienced significant increases in ED LOS (4.0% per year from 2001 to 2005, p-value for trend < 0.01).

CONCLUSIONS

Emergency department LOS in the United States is increasing, especially for critically ill patients for whom time-sensitive interventions are most important. The disparity of longer ED LOS for African Americans and Hispanics is not improving.

Recently published papers: delivery, volume and outcome--what is best for our patient?

Many studies have demonstrated that prompt appropriate treatment for the critically ill patient improves outcome. Moving patients to the best place for instituting care, however, is not always associated with improved outcome. Recent studies on delivering patients to the best place for treatment as well as further work on the effects of volume are discussed. Finally, a large retrospective cohort study comparing outcomes of patients treated with continuous venovenous haemofiltration or intermittent haemodialysis is outlined.