Emergency Department Multimarker Point-of-care Testing Reduces Time to Cardiac Marker Results Without Loss of Diagnostic Accuracy

Implementation and validation of a new method to model voluntary departures from emergency departments. Running Title: Modeling Voluntary departures from emergency departments

In the literature, several organizational solutions have been proposed for determining the probability of voluntary patient discharge from the emergency department. Here, the issue of self-discharge is analyzed by Markov theory-based modeling, an innovative approach diffusely applied in the healthcare field in recent years. The aim of this work is to propose a new method for calculating the rate of voluntary discharge by defining a generic model to describe the process of first aid using a "behavioral" Markov chain model, a new approach that takes into account the satisfaction of the patient. The proposed model is then implemented in MATLAB and validated with a real case study from the hospital "A. Cardarelli" of Naples. It is found that most of the risk of self-discharge occurs during the wait time before the patient is seen and during the wait time for the final report; usually, once the analysis is requested, the patient, although not very satisfied, is willing to wait longer for the results. The model allows the description of the first aid process from the perspective of the patient. The presented model is generic and can be adapted to each hospital facility by changing only the transition probabilities between states.

Implementation of a rapid chest pain protocol in the emergency department: A quality improvement project

PURPOSE

The purpose of this quality improvement (QI) project is to compare the effectiveness of a rapid 90-min chest pain screening and evaluation protocol to a 120-min screening and evaluation protocol in determining patient readiness for hospital admission or discharge home.

DATA SOURCES

The existing chest pain protocol utilized in the emergency department (ED) was revised based on a review of current research changing initial screening and reevaluation times from 120 to 90 min. A prospective comparative study of patients presenting to the ED with chest pain was performed comparing the existing chest pain protocol of 120 min (standard care) with a rapid screening evaluation protocol of 90 min. A total of 128 patients presenting to an ED in Texas with chest pain comprised the sample for this study.

CONCLUSIONS

There was a significant difference in the number of minutes between the groups for readiness for disposition. The average time from chest pain evaluation to readiness for disposition home, observation, or admission decreased from an average of 191 min in the standard care group to an average of 118 min in the rapid screening group.

IMPLICATIONS FOR PRACTICE

Use of the rapid screening and evaluation protocol decreased the time to disposition by an average of 73 min, which enhanced ED flow without influencing disposition and patient safety.

Point-of-care testing in the overcrowded emergency department--can it make a difference?

Emergency departments (EDs) face several challenges in maintaining consistent quality care in the face of steadily increasing public demand. Improvements in the survival rate of critically ill patients in the ED are directly related to the advancement of early recognition and treatment. Frequent episodes of overcrowding and prolonged waiting times force EDs to operate beyond their capacity and threaten to impact upon patient care. The objectives of this review are as follows: (a) to establish overcrowding as a threat to patient outcomes, person-centered care, and public safety in the ED; (b) to describe scenarios in which point-of-care testing (POCT) has been found to ameliorate factors thought to contribute to overcrowding; and (c) to discuss how POCT can be used directly, and indirectly, to expedite patient care and improve outcomes. Various studies have shown that overcrowding in the ED has profound effects on operational efficiency and patient care. Several reports have quantified overcrowding in the ED and have described a relationship between heightened periods of overcrowding and delays in treatment, increased incidence of adverse events, and an even greater probability of mortality. In certain scenarios, POCT has been found to increase the number of patients discharged in a timely manner, expedite triage of urgent but non-emergency patients, and decrease delays to treatment initiation. This review concludes that POCT, when used effectively, may alleviate the negative impacts of overcrowding on the safety, effectiveness, and person-centeredness of care in the ED.

Use of a 90-minute protocol to evaluate patients presenting to the emergency department with chest pain: a case study

Frustration with emergency department wait times may contribute to patient delays in seeking care for subsequent episodes of chest pain and lower patient satisfaction ratings. In response to patient feedback and the dissemination of new knowledge, the existing emergency chest pain protocol was updated to include point-of-care laboratory testing and evaluation at baseline and 90 minutes. A case study was utilized to illustrate implementation of this protocol in the management of a patient presenting to the emergency department with chest pain.

Estimating the clinical impact of bringing a multimarker cardiac panel to the bedside in the ED

OBJECTIVES

We examined the use of point-of-care (POC) testing of cardiac biomarkers against standard core laboratory testing to determine the time-savings and estimate a cost-benefit ratio at our institution.

METHODS

We prospectively enrolled 151 patients presenting to the emergency department undergoing evaluation for acute coronary syndrome and conducted both central laboratory troponin T (TnT) testing at baseline and 6 hours as well as POC assays of creatine kinase MB, troponin I (TnI), and myoglobin at baseline and 2 hours. Sensitivity/specificity was calculated to measure the ability of the POC-accelerated pathway to identify enzyme elevations at rates parallel to our core laboratory. The time-savings were calculated as the difference between the median of the current protocol and the accelerated POC pathway.

RESULTS

Troponin T tests were elevated in 12 patients, which were all detected by the accelerated pathway yielding a relative sensitivity of 100%. Time-saving between the accelerated pathway and core laboratory showed a saving of 390 minutes (6.5 hours). The accelerated POC pathway would have benefited 60% (95% confidence interval [CI], 52%-68%) of our patients with an estimated cost of $7.40 (95% CI, $6.40-$8.70) per direct patient care hour saved.

CONCLUSION

Our data suggest that the use of an accelerated cardiac POC pathway could have dramatically impacted the care provided to a large percentage of our patients at a minimal cost per direct patient care hour saved.

Decreasing lab turnaround time improves emergency department throughput and decreases emergency medical services diversion: a simulation model

BACKGROUND

The effect of decreasing lab turnaround times on emergency department (ED) efficiency can be estimated through system-level simulation models and help identify important outcome measures to study prospectively. Furthermore, such models may suggest the advantage of bedside or point-of-care testing and how they might affect efficiency measures.

OBJECTIVES

The authors used a sophisticated simulation model in place at an adult urban ED with an annual census of 55,000 patient visits. The effect of decreasing turnaround times on emergency medical services (EMS) diversion, ED patient throughput, and total ED length of stay (LOS) was determined.

METHODS

Data were generated by using system dynamics analytic modeling and simulation approach on 90 separate days from December 2, 2007, through February 29, 2008. The model was a continuous simulation of ED flow, driven by real-time actual patient data, and had intrinsic error checking to assume reasonable goodness-of-fit. A return of complete laboratory results incrementally at 120, 100, 80, 60, 40, 20, and 10 minutes was compared. Diversion calculation assumed EMS closure when more than 10 patients were in the waiting room and 100% ED bed occupancy had been reached for longer than 30 minutes, as per local practice. LOS was generated from data insertion into the patient flow stream and calculation of time to specific predefined gates. The average accuracy of four separate measurement channels (waiting room volume, ED census, inpatient admit stream, and ED discharge stream), all across 24 hours, was measured by comparing the area under the simulated curve against the area under the measured curve. Each channel's accuracy was summed and averaged for an overall accuracy rating.

RESULTS

As lab turnaround time decreased from 120 to 10 minutes, the total number of diversion days (maximum 57 at 120 minutes, minimum 29 at 10 minutes), average diversion hours per day (10.8 hours vs. 6.0 hours), percentage of days with diversion (63% vs. 32%), and average ED LOS (2.77 hours vs. 2.17 hours) incrementally decreased, while average daily throughput (104 patients vs. 120 patients) increased. All runs were at least 85% accurate.

CONCLUSIONS

This simulation model suggests compelling improvement in ED efficiency with decreasing lab turnaround time. Outcomes such as time on EMS diversion, ED LOS, and ED throughput represent important but understudied areas that should be evaluated prospectively. EDs should consider processes that will improve turnaround time, such as point-of-care testing, to obtain these goals.

The value of bedside cardiac multibiomarker assay in rapid and accurate diagnosis of acute coronary syndromes

For emergency department physicians, timely triage and risk stratification of chest pain patients remains a challenge. Faced with an aging population and the growing prevalence of heart disease, clinicians are seeking more effective ways to diagnose acute coronary syndromes rapidly and accurately. Emergency department physicians must make critical and time-sensitive decisions based on patient history, physical examination, and 12-lead electrocardiogram as justification for diagnosis of acute coronary syndromes. But because most of these tools are not reliable independently, these incomplete strategies can result in costly and inappropriate treatment decisions.