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Lim CAE, Bailey J, Oh J, Ibia I, Eiting E, Barnett B, Calderon Y, Cowan E. Comparison of Length of Stay Between Children Admitted to an Observation Versus Inpatient Unit. Pediatr Emerg Care 2024:00006565-990000000-00434. [PMID: 38713841 DOI: 10.1097/pec.0000000000003174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
OBJECTIVES Many children who require hospitalization are ideal candidates for care in pediatric observation units (POUs) rather than inpatient pediatric units. Differences in outcomes between children cared for in these 2 practice settings have not been thoroughly evaluated. METHODS In this retrospective cohort study, children aged 0 to 18 years admitted to a POU at a community hospital or inpatient unit at a children's hospital were enrolled if they met specific clinical criteria. Information regarding the current illness, medical history, and hospital course was collected. Hospital length of stay (LOS) was analyzed as the primary outcome; secondary outcomes included conversion to inpatient care for the POU group and return to pediatric emergency department within 7 days. Subgroup analysis was conducted on children presenting with respiratory illnesses. Propensity scores were used as a predictor in the final model. RESULTS One hundred eighty-one admissions, 92 to POU and 89 to an inpatient unit, were analyzed. Mean LOS was 24.4 hours (95% confidence interval [CI], 21.7-27.1) for observation and 43.2 hours (95% CI, 37.8-48.6) for inpatient (P < 0.01). Among the 126 children admitted for respiratory illnesses, the mean LOS was 32.3 hours (95% CI, 26.0-38.6) for observation and 48.1 hours (95% CI, 42.2-54.0) for inpatient (P < 0.01). Survival analysis demonstrated a 1.61 (95% CI, 1.07-2.42) fold shorter time to discharge among children admitted to observation compared with inpatient (P = 0.02) and a 1.70 (95% CI, 1.07-2.71) fold shorter time to discharge from observation compared with inpatient for respiratory illnesses (P = 0.03). Within 7 days of discharge, 2 (2%) patients from the observation group and 1 (1%) from the inpatient group returned to the pediatric emergency department. CONCLUSIONS These findings suggest that POU may provide the means toward efficient care for children in community settings with illnesses requiring brief hospitalizations. Future work including prospective investigations is needed to ascertain the generalizability of these findings.
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Affiliation(s)
| | - Jennifer Bailey
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA
| | | | - Imikomobong Ibia
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | | | | | | | - Ethan Cowan
- From the Departments of Emergency Medicine and
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Kothari DJ, Sheth SG. Innovative pathways allow safe discharge of mild acute pancreatitis from the emergency room. World J Gastroenterol 2024; 30:1475-1479. [PMID: 38617458 PMCID: PMC11008414 DOI: 10.3748/wjg.v30.i11.1475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/22/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024] Open
Abstract
Acute pancreatitis (AP) is a leading cause of gastrointestinal-related hospitalizations in the United States, resulting in 300000 admissions per year with an estimated cost of over $2.6 billion annually. The severity of AP is determined by the presence of pancreatic complications and end-organ damage. While moderate/severe pancreatitis can be associated with significant morbidity and mortality, the majority of patients have a mild presentation with an uncomplicated course and mortality rate of less than 2%. Despite favorable outcomes, the majority of mild AP patients are admitted, contributing to healthcare cost and burden. In this Editorial we review the performance of an emergency department (ED) pathway for patients with mild AP at a tertiary care center with the goal of reducing hospitalizations, resource utilization, and costs after several years of implementation of the pathway. We discuss the clinical course and outcomes of mild AP patients enrolled in the pathway who were successfully discharged from the ED compared to those who were admitted to the hospital, and identify predictors of successful ED discharge to select patients who can potentially be triaged to the pathway. We conclude that by implementing innovative clinical pathways which are established and reproducible, selected AP patients can be safely discharged from the ED, reducing hospitalizations and healthcare costs, without compromising clinical outcomes. We also identify a subset of patients most likely to succeed in this pathway.
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Affiliation(s)
- Darshan J Kothari
- Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, United States
| | - Sunil G Sheth
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
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Grossman ES, Fradinho J, Chiu D, Wolfe RE, Grossman SA. The effect of increasing emergency department observation volumes on downstream admission rates. Am J Emerg Med 2024; 77:17-20. [PMID: 38096635 DOI: 10.1016/j.ajem.2023.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/23/2023] [Accepted: 11/25/2023] [Indexed: 02/16/2024] Open
Abstract
Rising length of stay and inpatient boarding in emergency departments have directly affected patient satisfaction and nearly all provider-to-patient care metrics. Prior studies suggest that ED observation has significant clinical and financial benefits including decreasing hospitalization and length of stay. ED observation is one method long employed to shorten ED length of stay and to free up inpatient beds, yet many patients continue to be admitted to the hospital with an average hospital length of stay of only one day. The objectives of this study were to evaluate whether vigorous tracking and provider reviews of one day hospital admits affected the utilization of ED observation and whether this correlated with significant change in rates of admission from observation status. Between September 2020 and May 2021, in a tertiary care hospital with an annual ED volume of 55,0000, chart reviews of 24-h inpatient discharges were initiated by two senior EM faculty to determine perceived suitability for ED observation. Non-punitive email reviews were then initiated with ED attending providers in order to encourage evaluation of whether these patients would have benefitted from being placed into observation. We then analyzed ED observation patient volumes and subsequent admission rates to the hospital from ED observation and compared these numbers to baseline ED observation volume and admission rates between September 2018 and May 2019. A total of 1448 reviews were conducted on 24-h discharges which correlated with an increase in utilization of ED observation from 11.77% (95% CI [11.62, 12.31]) of total ED volume in our control period to 14.21% (95% CI [13.84, 14.58]) during the study period. We found that the overall admission rate from ED observation increased from 20.12% (95% CI [18.97, 21.26]) baseline to 23.80% (95% CI [22.60, 25.00]) during the same time periods. Our data suggest that increasing the total number of patients placed into observation by 21% correlated with a relative increase in admission rates from ED observation by 18%. This would suggest that our efforts to potentially include more patients into our observation program led to a significant increase in subsequent admission rates. There is likely a balance that must be struck between under- and over-utilization of ED observation, and expanding ED observation may be an effective solution to hospital boarding and ED overcrowding.
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Affiliation(s)
- Elianna S Grossman
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jorge Fradinho
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David Chiu
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Richard E Wolfe
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Shamai A Grossman
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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4
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Bell J, Lim S, Mikami T, Bahk J, Argiro S, Steiger D. The impact on thirty day readmissions for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease admitted to an observation unit versus an inpatient medical unit: A retrospective observational study. Chron Respir Dis 2024; 21:14799731241242490. [PMID: 38545901 PMCID: PMC10981268 DOI: 10.1177/14799731241242490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/01/2023] [Accepted: 02/19/2024] [Indexed: 04/01/2024] Open
Abstract
OBJECTIVES We aimed to evaluate the utility of an Observation Unit (OU) in management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and to identify the clinical characteristics of patients readmitted within 30-days for AECOPD following index admission to the OU or inpatient floor from the OU. METHODS This is a retrospective observational study of patients admitted from January to December 2017 for AECOPD to an OU in an urban-based tertiary care hospital. Primary outcome was rate of 30-day readmission after admission for AECOPD for patients discharged from the OU versus inpatient service after failing OU management. Regression analyses were used to define risk factors. RESULTS 163 OU encounters from 92 unique patients were included. There was a lower readmission rate (33%) for patients converted from OU to inpatient care versus patients readmitted after direct discharge from the OU (44%). Patients with 30-day readmissions were more likely to be undomiciled, with history of congestive heart failure (CHF), pulmonary embolism (PE), or had previous admissions for AECOPD. Patients with >6 annual OU visits for AECOPD had higher rates of substance abuse, psychiatric diagnosis, and prior PE; when these patients were excluded, the 30-day readmission rate decreased to 13.5%. CONCLUSION Patients admitted for AECOPD with a history of PE, CHF, prior AECOPD admissions, and socioeconomic deprivation are at higher risk of readmission and should be prioritized for direct inpatient admission. Further prospective studies should be conducted to determine the clinical impact of this approach on readmission rates.
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Affiliation(s)
- Jacob Bell
- Department of Pulmonary and Critical Care Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
- Department of Pulmonary and Critical Care Medicine, Mount Sinai West Hospital, New York, NY, USA
| | - Steven Lim
- Department of Pulmonary and Critical Care Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
- Department of Pulmonary and Critical Care Medicine, Mount Sinai West Hospital, New York, NY, USA
| | - Takahisa Mikami
- Department of Pulmonary and Critical Care Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Jeeyune Bahk
- Department of Internal Medicine, Mount Sinai West Hospital, New York, NY, USA
| | - Stephen Argiro
- Department of Pulmonary and Critical Care Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - David Steiger
- Department of Pulmonary and Critical Care Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
- Department of Pulmonary and Critical Care Medicine, Mount Sinai West Hospital, New York, NY, USA
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Baugh CW, Freund Y, Steg PG, Body R, Maron DJ, Yiadom MYAB. Strategies to mitigate emergency department crowding and its impact on cardiovascular patients. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:633-643. [PMID: 37163667 DOI: 10.1093/ehjacc/zuad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
Emergency department (ED) crowding is a worsening global problem caused by hospital capacity and other health system challenges. While patients across a broad spectrum of illnesses may be affected by crowding in the ED, patients with cardiovascular emergencies-such as acute coronary syndrome, malignant arrhythmias, pulmonary embolism, acute aortic syndrome, and cardiac tamponade-are particularly vulnerable. Because of crowding, patients with dangerous and time-sensitive conditions may either avoid the ED due to anticipation of extended waits, leave before their treatment is completed, or experience delays in receiving care. In this educational paper, we present the underlying causes of crowding and its impact on common cardiovascular emergencies using the input-throughput-output process framework for patient flow. In addition, we review current solutions and potential innovations to mitigate the negative effect of ED crowding on patient outcomes.
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Affiliation(s)
- Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Neville House 2nd Floor, Boston, MA 02115, USA
| | - Yonathan Freund
- Emergency Department Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Philippe Gabriel Steg
- Department of Cardiology, Université Paris-Cité, Institut Universitaire de France, FACT, French Alliance for Cardiovascular Trials, INSERM-1148, and Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
- Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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6
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Braaksma A, Copenhaver MS, Zenteno AC, Ugarph E, Levi R, Daily BJ, Orcutt B, Turcotte KM, Dunn PF. Evaluation and implementation of a Just-In-Time bed-assignment strategy to reduce wait times for surgical inpatients. Health Care Manag Sci 2023; 26:501-515. [PMID: 37294365 DOI: 10.1007/s10729-023-09638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/29/2023] [Indexed: 06/10/2023]
Abstract
Early bed assignments of elective surgical patients can be a useful planning tool for hospital staff; they provide certainty in patient placement and allow nursing staff to prepare for patients' arrivals to the unit. However, given the variability in the surgical schedule, they can also result in timing mismatches-beds remain empty while their assigned patients are still in surgery, while other ready-to-move patients are waiting for their beds to become available. In this study, we used data from four surgical units in a large academic medical center to build a discrete-event simulation with which we show how a Just-In-Time (JIT) bed assignment, in which ready-to-move patients are assigned to ready-beds, would decrease bed idle time and increase access to general care beds for all surgical patients. Additionally, our simulation demonstrates the potential synergistic effects of combining the JIT assignment policy with a strategy that co-locates short-stay surgical patients out of inpatient beds, increasing the bed supply. The simulation results motivated hospital leadership to implement both strategies across these four surgical inpatient units in early 2017. In the several months post-implementation, the average patient wait time decreased 25.0% overall, driven by decreases of 32.9% for ED-to-floor transfers (from 3.66 to 2.45 hours on average) and 37.4% for PACU-to-floor transfers (from 2.36 to 1.48 hours), the two major sources of admissions to the surgical floors, without adding additional capacity.
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Affiliation(s)
- Aleida Braaksma
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Martin S Copenhaver
- Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | | | - Elizabeth Ugarph
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Retsef Levi
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | | | | | - Peter F Dunn
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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7
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Welch TD, Smith TB, Niklinski E. Creating a Business Case for Success. Nurs Adm Q 2023; 47:182-194. [PMID: 36862568 DOI: 10.1097/naq.0000000000000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Health care is a highly competitive environment where managers must compete for finite resources. The Centers for Medicare & Medicaid Services-directed reimbursement models such as value-based purchasing and pay-for-performance heavily focused on quality improvement and nursing excellence are having a major impact on financial reimbursement for health care services in the United States. As such, nurse leaders must function in a business-focused environment where decisions regarding resource allocation are driven by quantifiable data, the potential return on investment, and the organization's ability to provide quality patient care in an efficient manner. It is imperative for nurse leaders to recognize the financial impact of potential additional revenue streams, as well as avoidable costs. Nurse leaders must also be skilled at translating the return on investment for nursing-centric programs and initiatives, often hidden in anecdotal terms and cost avoidance rather than revenue generation, to ensure appropriate resource allocation and budgetary assumptions. This article uses a case study framed within the business case to review a structured approach to operationalizing nursing-centric programs and highlights key strategies for success.
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Affiliation(s)
- Teresa D Welch
- Capstone College of Nursing, The University of Alabama, Tuscaloosa
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8
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Sabir R, Umar M, Medarametla V, Sreedhrala A. Impact of an Observation Medicine Educational Intervention on Residents' Confidence, Knowledge, and Attitudes: A Quasi-Experimental Study. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2023; 10:23821205231183220. [PMID: 37362580 PMCID: PMC10286210 DOI: 10.1177/23821205231183220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 05/26/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Driven by innovations in healthcare, observation medicine (OM) is expanding as a medical specialty. Despite exponential growth, education on OM remains underemphasized in the internal medicine (IM) residency programs. We assessed the impact of an educational intervention pairing didactic and experiential learning with an interdepartmental approach on IM residents' confidence, knowledge, and attitudes when providing observation care to patients with neuro-cardiovascular diseases in the hospital setting. METHODS Our multifaceted intervention incorporated OM's principles and practice in a flipped classroom with the team-, case-, lecture- and evidence-based learning model. Kirkpatrick's evaluation model was used to assess the educational intervention's effectiveness according to the first three levels, ie, reaction, learning, and behavior, using quantitative surveys. The surveys were completed pre-intervention, and immediately upon completion of the educational intervention. RESULTS Of 55 eligible residents, 55 (100%) participated in this intervention. Fifty (90%) completed the pre-intervention survey, and 21 (38%) completed the immediate post-intervention survey. Kirkpatrick's evaluation framework showed that the intervention had a positive impact on residents' motivational reaction (attention, relevance, confidence, and satisfaction [ARCS], M = 3.8, SD = 0.87), their knowledge of common observation diagnoses (pre = 49%, post = 63%), particularly on cardiac diagnostic workup and approach to patients with transient neurological symptoms (P < .05), and their behavior and self-assessment of core competency domains (pre-mean = 2.69, post-mean = 3.18, P < .001). CONCLUSIONS Our multimodal intervention provides a framework for a structured OM educational experience that can be incorporated into residency training, even without a formal observation unit rotation. The analysis also offers literary data on the current state of OM education in an IM residency program and supports the need to expand OM's educational resources to counteract the growth in hospital observation services. Future research should include an analysis of residents' knowledge and skills from a longitudinal OM experience and advancing the results to residency programs where observation care is as applicable as ours.
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Affiliation(s)
- Riffat Sabir
- Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield, MA, USA
| | - Muhammad Umar
- Department of Hospital Medicine, University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield, MA, USA
| | - Venkatrao Medarametla
- Department of Hospital Medicine, University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield, MA, USA
| | - Aseesh Sreedhrala
- Department of Hospital Medicine, University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield, MA, USA
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Im DD, Scott KW, Venkatesh AK, Lobon LF, Kroll DS, Samuels EA, Wilson MP, Zeller S, Zun LS, Clifford KC, Zachrison KS. A Quality Measurement Framework for Emergency Department Care of Psychiatric Emergencies. Ann Emerg Med 2022; 81:592-605. [PMID: 36402629 DOI: 10.1016/j.annemergmed.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 11/19/2022]
Abstract
As a primary access point for crisis psychiatric care, the emergency department (ED) is uniquely positioned to improve the quality of care and outcomes for patients with psychiatric emergencies. Quality measurement is the first key step in understanding the gaps and variations in emergency psychiatric care to guide quality improvement initiatives. Our objective was to develop a quality measurement framework informed by a comprehensive review and gap analysis of quality measures for ED psychiatric care. We conducted a systematic literature review and convened an expert panel in emergency medicine, psychiatry, and quality improvement to consider if and how existing quality measures evaluate the delivery of emergency psychiatric care in the ED setting. The expert panel reviewed 48 measures, of which 5 were standardized, and 3 had active National Quality Forum endorsement. Drawing from the measure appraisal, we developed a quality measurement framework with specific structural, process, and outcome measures across the ED care continuum. This framework can help shape an emergency medicine roadmap for future clinical quality improvement initiatives, research, and advocacy work designed to improve outcomes for patients presenting with psychiatric emergencies.
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10
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Muhamed S, Konzelmann J, Reed L, Holstein H. Evaluating the Impact of Protocol-Driven Treatment for COVID-19 in an Emergency Department Observation Unit. Cureus 2022; 14:e29683. [DOI: 10.7759/cureus.29683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
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Marsilio M, Roldan ET, Salmasi L, Villa S. Operations management solutions to improve ED patient flows: evidence from the Italian NHS. BMC Health Serv Res 2022; 22:974. [PMID: 35908053 PMCID: PMC9338603 DOI: 10.1186/s12913-022-08339-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/11/2022] [Indexed: 11/26/2022] Open
Abstract
Background Overcrowding occurs when the identified need for emergency services outweighs the available resources in the emergency department (ED). Literature shows that ED overcrowding impacts the overall quality of the entire hospital production system, as confirmed by the recent COVID-19 pandemic. This study aims to identify the most relevant variables that cause ED overcrowding using the input-process-output model with the aim of providing managers and policy makers with useful hints for how to effectively redesign ED operations. Methods A mixed-method approach is used, blending qualitative inquiry with quantitative investigation in order to: i) identifying and operationalizing the main components of the model that can be addressed by hospital operation management teams and ii) testing and measuring how these components can influence ED LOS. Results With a dashboard of indicators developed following the input-process-output model, the analysis identifies the most significant variables that have an impact on ED overcrowding: the type (age and complexity) and volume of patients (input), the actual ED structural capacity (in terms of both people and technology) and the ED physician-to-nurse ratio (process), and the hospital discharging process (output). Conclusions The present paper represents an original contribution regarding two different aspects. First, this study combines different research methodologies with the aim of capturing relevant information that by relying on just one research method, may otherwise be missed. Second, this study adopts a hospitalwide approach, adding to our understanding of ED overcrowding, which has thus far focused mainly on single aspects of ED operations.
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Affiliation(s)
- Marta Marsilio
- Department of Economics, Management and Quantitative Methods (DEMM), Università degli Studi di Milano, Milano, Italy.
| | - Eugenia Tomas Roldan
- CERISMAS (Research Centre in Health Care Management), Università Cattolica del Sacro Cuore, Milano, Italy
| | - Luca Salmasi
- Department of Economics and Finance, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Stefano Villa
- Department of Management, Università Cattolica del Sacro Cuore, Milano, Italy
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Vitto CM, Lykins V JD, Wiles-Lafayette H, Aurora TK. Blood Pressure Assessment and Treatment in the Observation Unit. Curr Hypertens Rep 2022; 24:311-323. [PMID: 35596047 DOI: 10.1007/s11906-022-01196-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW To review the pathophysiology, diagnosis, and the management of hypertension. Given the paucity of literature regarding the role of the observation unit in the management of hypertension, we will provide our recommendations based on our experience working in an observation unit. RECENT FINDINGS Many patients have limited access to primary care, and hypertension diagnosis often relies on office-based measurements. We will describe situations where that is not necessary to make the diagnosis. We will discuss the current non-pharmacologic treatment guidelines, the education of which should be provided to patients both in the emergency department and observation units. We will provide the current recommendations on what anti-hypertension medications can be initiated in the emergency department and observation units. Hypertension is a leading cause of morbidity and mortality in the USA. The utility of an observation unit in the diagnosis and management of patients with hypertension is beneficial particularly for those with risk factors for atherosclerotic disease. An observation unit stay provides the opportunity to diagnosis hypertension, initiate lifestyle education and pharmacologic treatment if indicated, and help to arrange appropriate follow-up for ongoing management and treatment in individuals with limited access to care.
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13
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The Value Proposition of Observation Medicine in Managing Acute Oncologic Pain. Curr Oncol Rep 2022; 24:595-602. [PMID: 35192121 DOI: 10.1007/s11912-022-01245-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Despite recommended best practice guidelines, pain remains an ongoing but undertreated symptom in patients with cancer, many of whom require emergency department evaluation for acute oncologic pain. A significant proportion of these patients are hospitalized for pain management, which increases healthcare costs and exposes patients to the risks of hospitalization. We reviewed the literature on observation medicine: an emerging mode of healthcare delivery which can offer patients with acute pain access to a hospital's pain management solutions and specialists without an inpatient hospitalization. Specifically, we appraised the role of observation medicine in acute pain management and its financial implications in order to consider its potential impact on the management of acute oncologic pain. RECENT FINDINGS Recent evidence shows that observation medicine has the potential to decrease short-stay hospitalizations in cancer patients presenting with various concerns, including pain. Observation medicine is reported to be successful in providing comprehensive and cost-effective care for non-cancer patients with acute pain, making it a promising alternative to short-stay hospitalizations for cancer patients with acute oncologic pain.
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Chaftari P, Lipe DN, Wattana MK, Qdaisat A, Krishnamani PP, Thomas J, Elsayem AF, Sandoval M. Outcomes of Patients Placed in an Emergency Department Observation Unit of a Comprehensive Cancer Center. JCO Oncol Pract 2021; 18:e574-e585. [PMID: 34905410 PMCID: PMC9014449 DOI: 10.1200/op.21.00478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Emergency department observation units (EDOUs) have been shown to decrease length of stay and improve cost effectiveness. Yet, compared with noncancer patients, patients with cancer are placed in EDOUs less often. In this study, we aimed to describe patients who were placed in a cancer center's EDOU to discern their clinical characteristics and outcomes. Outcomes of patients placed in an emergency department observation unit of a comprehensive cancer center
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Affiliation(s)
- Patrick Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Demis N Lipe
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Monica K Wattana
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Jomol Thomas
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ahmed F Elsayem
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marcelo Sandoval
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Klotz AD, Caterino JM, Durham D, Felipe Rico J, Pallin DJ, Grudzen CR, McNaughton C, Marcelin I, Abar B, Adler D, Bastani A, Bernstein SL, Bischof JJ, Coyne CJ, Henning DJ, Hudson MF, Lyman GH, Madsen TE, Reyes‐Gibby CC, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Jim Yeung S, Yilmaz S, Stutman R, Baugh CW. Observation unit use among patients with cancer following emergency department visits: Results of a multicenter prospective cohort from CONCERN. Acad Emerg Med 2021; 29:174-183. [PMID: 34811858 PMCID: PMC10359998 DOI: 10.1111/acem.14392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED. METHODS We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay. RESULTS Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6-19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index. CONCLUSION In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change.
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Affiliation(s)
- Adam D. Klotz
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Jeffrey M. Caterino
- Departments of Emergency Medicine and Internal Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Danielle Durham
- Department of Radiology School of Medicine University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Juan Felipe Rico
- Department of Pediatrics Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Daniel J. Pallin
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | | | - Isabelle Marcelin
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | - Beau Abar
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - David Adler
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - Aveh Bastani
- Department of Emergency Medicine William Beaumont Hospital Troy Michigan USA
| | - Steven L. Bernstein
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
| | - Jason J. Bischof
- Department of Emergency Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Christopher J. Coyne
- Department of Emergency Medicine University of California San Diego San Diego California USA
| | - Daniel J. Henning
- Department of Emergency Medicine University of Washington Seattle Washington USA
| | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and the Department of Medicine Hutchinson Institute for Cancer Outcomes Research University of Washington School of Medicine Seattle Washington USA
| | - Troy E. Madsen
- Division of Emergency Medicine University of Utah Salt Lake City Utah USA
| | - Cielito C. Reyes‐Gibby
- Department of Emergency Medicine and Biostatistics The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Richard J. Ryan
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Nathan I. Shapiro
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Robert Swor
- Department of Emergency Medicine William Beaumont Hospital Royal Oak Michigan USA
| | - Charles R. Thomas
- Department of Radiation Medicine Knight Cancer Institute Oregon Health & Sciences University Portland Oregon USA
| | - Arvind Venkat
- Department of Emergency Medicine Allegheny Health Network Pittsburgh Pennsylvania USA
| | - Jason Wilson
- Department of Emergency Medicine Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Sai‐Ching Jim Yeung
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Sule Yilmaz
- Department of Geriatric Oncology University of Rochester Medical center Rochester New York USA
| | - Robin Stutman
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Christopher W. Baugh
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
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Wheatley M, Kapil S, Lewis A, O’Sullivan J, Armentrout J, Moran T, Osborne A, Moore B, Morse B, Rhee P, Ahmad F, Atallah H. Management of Minor Traumatic Brain Injury in an ED Observation Unit. West J Emerg Med 2021; 22:943-950. [PMID: 35354002 PMCID: PMC8328171 DOI: 10.5811/westjem.2021.4.50442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/21/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Traumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress. Methods This study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention. Results There were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention. Conclusion Patients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.
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Affiliation(s)
- Matthew Wheatley
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Shikha Kapil
- Georgetown University School of Medicine, Department of Emergency Medicine, Washington, District of Columbia
| | - Amanda Lewis
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Jessica O’Sullivan
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Joshua Armentrout
- Atlanta Medical Center, Department of Emergency Medicine, Atlanta, Georgia
| | - Tim Moran
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Anwar Osborne
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Brooks Moore
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Bryan Morse
- Maine Medical Center, Department of Surgery and Surgical Critical Care, Portland, Maine
| | - Peter Rhee
- Westchester Medical Center, Department of Surgery, Trauma Surgery, and Surgical Critical Care, Valhalla, New York
| | - Faiz Ahmad
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, Georgia
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Schulman-Rosenbaum RC, Hadzibabic N, Cuan K, Jornsay D, Wolff E, Tiberio A, Gottlieb D, Davis F, Silverman RA. Use of Endocrine Consultation for HbA1c ≥ 9.0% as a Standardized Practice in an Emergency Department Observation Unit. Endocr Pract 2021; 27:1133-1138. [PMID: 34237470 DOI: 10.1016/j.eprac.2021.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 06/03/2021] [Accepted: 06/30/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Severely uncontrolled Diabetes Mellitus (DM) is associated with poor long-term outcomes, and may remain unrecognized. A high frequency of uncontrolled DM has been identified in the acute care setting, including the Emergency Department Observation Unit (EDOU). We assess the use of standardized endocrine consultation in the EDOU for Hemoglobin A1c (HbA1c) ≥ 9%. MATERIALS AND METHODS Standard practice in our EDOU includes universal HbA1c screening and endocrine consultation for HbA1c ≥ 9.0%. As part of a quality improvement program, EDOU patients with HbA1c ≥ 9.0% had an endocrinology consult. One month follow up phone calls assessed effects of consultation after discharge. RESULTS 3,688 (95.7%) of 3,853 EDOU patients received an HbA1c test. 7.0% (n=258) were found to have HbA1c ≥ 9% (Mean HbA1c 11.7 ±1.8%; range 9 - 16.6%). Endocrine consults were completed for 190/258 (73.6%) patients with severely uncontrolled DM. Among the 190 patients, 92.1% (n=175) had discharge DM medication adjustments. Known DM patients (n=142) injectable diabetes medication prescriptions increased from 47.2% (67/142) on EDOU arrival to 78.2% (111/142) on discharge. Newly diagnosed DM injectable prescriptions increased from 0% (0/48) on arrival to 72.9% (35/48) on discharge. A total of 72.6% (n=138) were contacted at one-month and 94.9% (n=131) reported taking DM medications compared to 68.2% (n=94) prior to consult. CONCLUSIONS HbA1c screening coupled with endocrine consultation for HbA1c ≥ 9.0% was assessed as a performance improvement study and shown to have valuable results. Further study is recommended to determine long-term clinical impact and cost analysis of this novel approach.
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Affiliation(s)
- Rifka C Schulman-Rosenbaum
- Division of Endocrinology, Department of Medicine, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York.
| | - Nina Hadzibabic
- Department of Emergency Medicine, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Katherine Cuan
- Department of Emergency Medicine, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Donna Jornsay
- Department of Nursing Education, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York
| | - Elissa Wolff
- Department of Emergency Medicine, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Allison Tiberio
- Department of Emergency Medicine, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Dana Gottlieb
- Department of Emergency Medicine, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Frederick Davis
- Department of Emergency Medicine, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Robert A Silverman
- Department of Emergency Medicine, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York; Feinstein Institute for Medical Research, Northwell Health, New Hyde Park, New York
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O'Donnell C, Molitch-Hou E, James K, Leong T, Perry M, Wood D, Masud T, Thomas B, Ross MA, Franks N. Fast track dialysis: Improving emergency department and hospital throughput for patients requiring hemodialysis. Am J Emerg Med 2021; 45:92-99. [PMID: 33677266 DOI: 10.1016/j.ajem.2021.02.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 02/14/2021] [Accepted: 02/16/2021] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To describe the impact of a novel communication and triage pathway called fast track dialysis (FTD) on the length of stay (LOS), resource utilization, and charges for unscheduled hemodialysis for end stage renal disease (ESRD) patients presenting to the emergency department (ED). METHODS Prospective and retrospective cohorts of ESRD patients meeting requirements of routine or urgent hemodialysis at a tertiary academic hospital from September 25th, 2016 to September 25th, 2018 in 1 year cohorts. Two sample t-tests were used to compare most outcomes of the cohorts with a Mann-Whitney U test used for skewed data. Nephrology group outcomes were analyzed by two-way ANOVA and Kruskal-Wallis and chi-square tests. RESULTS There were 98 encounters in the historical cohort and 143 encounters in the fast track dialysis cohort. FTD had significantly lowered median ED LOS (4.05 h, vs 5.3 h, p < 0.001), median hospital LOS (12.8 h vs 27 h, p < 0.001), time to hemodialysis (4.78 h vs 7.29 h, p < 0.001), and median hospital charges ($26,040 vs $30,747, p < 0.016). The FTD cohort had increased 30 day ED return for each encounter compared to the historical cohort (1.85 visits vs 0.73 visits, p < 0.001), however no significant increase in 1 year ED visits (6.52 visits vs 5.80, p = 0.4589) or 1 year readmissions (5.89 readmissions vs 4.81 readmissions, p = 0.3584). Most nephrology groups had significantly lower time to hemodialysis order placement and time to start hemodialysis. CONCLUSION A multidisciplinary approach with key stakeholders using a standard pathway can lead to improved efficiency in throughput, reduced charges, and hospital resource utilization for patients needing urgent or routine hemodialysis. A study with a dedicated geographic observation unit for protocolized short stay patients including conditions ranging from low risk chest pain to transient ischemic events that incorporates FTD patients under this protocol should be considered.
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Affiliation(s)
- Christopher O'Donnell
- Division of Hospital Medicine, Department of Medicine, Emory University, 550 Peachtree St, Atlanta, GA 30319, United States of America.
| | - Ethan Molitch-Hou
- Division of Hospital Medicine, Department of Medicine, Emory University, 550 Peachtree St, Atlanta, GA 30319, United States of America; Section of Hospital Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Ave., MC 5000, Chicago, IL 60637, United States of America
| | - Kyle James
- Division of Hospital Medicine, Department of Medicine, Emory University, 550 Peachtree St, Atlanta, GA 30319, United States of America
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Emory University, Rollins School of Public Health, 1518 Clifton Road, Atlanta, GA 30322, United States of America
| | - Michael Perry
- Department of Emergency Medicine, Emory University, 100 Woodruff Circle, Atlanta, GA 30322, United States of America
| | - Daniel Wood
- Department of Emergency Medicine, Emory University, 100 Woodruff Circle, Atlanta, GA 30322, United States of America
| | - Tahsin Masud
- Division of Nephrology, Department of Medicine, Emory University, 1639 Pierce Dr. NE # 338, Atlanta, GA 30322, United States of America
| | - Brittany Thomas
- Southwest Atlanta Nephrology, 3620 Martin Luther King Jr Dr. S., Atlanta, GA 30331, United States of America
| | - Michael A Ross
- Department of Emergency Medicine, Emory University, 100 Woodruff Circle, Atlanta, GA 30322, United States of America
| | - Nicole Franks
- Department of Emergency Medicine, Emory University, 100 Woodruff Circle, Atlanta, GA 30322, United States of America
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Emergency department associated lung cancer diagnosis: Case series demonstrating poor outcomes and opportunities to improve cancer care. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2021. [DOI: 10.1016/j.cpccr.2021.100059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Emergency Department Observation Versus Readmission Following total Joint Arthroplasty: Can We Avoid the Bundle Buster? J Arthroplasty 2021; 36:833-836. [PMID: 33036843 DOI: 10.1016/j.arth.2020.09.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/10/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND As the Center for Medicare and Medicaid (CMS) moves toward bundled payment plans for total joint arthroplasty (TJA), it becomes necessary to reduce factors that increase cost for an episode of care such as readmissions. The goal of this study is to evaluate the payment for observation stay versus readmission for patients who present to the emergency department. METHODS A retrospective review from 2014-2019 was conducted identifying all Medicare patients who had a primary, elective TJA and visited the ED within 90 days postoperatively. If a readmission was one midnight or less or had an equivalent diagnosis to an observation stay patient, it was characterized as a readmission that could have qualified as an observation stay. Using our institution's average payment for Medicare readmissions and observations, actual and potential savings were calculated. RESULTS Sixty-nine out of 523 (13.2%) patients were placed under observation, while 454 (86.8%) patients were readmitted. Eighty-six out of 523 (18.9%) patients qualified for observation status. There was an actual savings of 11.8% by placing patients on observation status and readmission rate was decreased by 13.2%. Savings could have increased by a total of 27.7% and readmissions decreased by a total of 29.6% if all patients who qualified had been placed on observation status. CONCLUSION At our institution, the implementation of observation stay has led to a savings of 11.8% and a potential total savings of 27.7%. The rate of readmissions was decreased by 13.2% and had the potential to decrease by a total of 29.6%.
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21
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Abdelhadi A. Patients' satisfactions on the waiting period at the emergency units. Comparison study before and during COVID-19 pandemic. J Public Health Res 2021; 10:1956. [PMID: 33708749 PMCID: PMC7941052 DOI: 10.4081/jphr.2021.1956] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 02/22/2021] [Indexed: 11/22/2022] Open
Abstract
Background: This paper analyzes the patients’ experience and satisfaction regarding the waiting period at the emergency unit’s hospital before and during the COVID-19 pandemic. Design and methods: Brainstorming methodology and data analysis from the public domain used on male and female patients in a private hospital in a middle eastern country. The data analyzed seek the patients’ level of satisfaction about the waiting period before entering the treatment area, inside the treatment area before the doctor’s check, and during the rest period after the doctor’s visit. The customer’s satisfaction is a significant measure during the COVID-19 pandemic, as it may affect the patient’s perspective of the facility. A paired t-test at 95% confidence level was conducted. Results and Conclusions: The results indicated no difference in satisfaction of the period spent in the emergency room before and during the pandemic. Significance for public health In any society, patients' experience and satisfaction regarding the waiting period at the emergency unit's hospital is very important. This parameter is particularly significant to measure during the COVID-19 pandemic, because it may affect the patient’s perspective of the facility they are visiting.
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Affiliation(s)
- Abdelhakim Abdelhadi
- Department of Engineering Management, Prince Sultan University, Riyadh, Saudi Arabia
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22
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Shafi OM, Diego Rondon JD, Gulati G. Can the Pediatric Early Warning Score (PEWS) Predict Hospital Length of Stay? Cureus 2020; 12:e11339. [PMID: 33304675 PMCID: PMC7719480 DOI: 10.7759/cureus.11339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: Limited studies have evaluated the utility of scoring systems in the pediatric emergency department (PED) and no studies have evaluated their ability to predict hospital length of stay (LOS) and the usage of Observation units (OUs). Objective: To evaluate the utility of the Pediatric Early Warning Score (PEWS) in predicting LOS in pediatric patients and thus anticipate admission to an OU versus the pediatric ward. Methods: A retrospective study of pediatric inpatients (0 to 18 years) at an inner-city community hospital between January 2014 and December 2014. Patients with psychiatric illness, non-medical reasons for hospital stay, and those not discharged to ‘home’ were excluded. Demographic data, PEWS in the ED, and LOS for each patient were recorded and analyzed. Results: A total of 719 patients were analyzed. PEWS range was 0 to 8. The mean LOS was 56.8 hours for patients with PEWS 0-1 compared to 62.7 hours for patients with PEWS ≥2 (p=0.02). There was a significant difference in PEWS for LOS ≤24 and ≤36 hours in comparison to those with LOS >24 hours and >36 hours, respectively (p<0.001). Overall, the PEWS correlated with LOS (r=0.11, p=0.002). Age correlated inversely with LOS (r=-0.16, p<0.001), without correlation to PEWS (r=-0.002, p= 0.96). Conclusions: PEWS correlated weakly with LOS. A statistically significant lower PEWS was observed for patients who had short stays (both ≤24 and ≤36 hours) in comparison to those requiring longer inpatient care. Therefore, the PEWS is a useful tool to predict LOS and aid ED physicians to determine disposition, although further prospective studies in centers with OUs would better characterize its ability to suggest admission to an OU compared to the wards.
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Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti. Afr J Emerg Med 2020; 10:145-151. [PMID: 32923326 PMCID: PMC7474244 DOI: 10.1016/j.afjem.2020.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 04/27/2020] [Accepted: 05/20/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti. METHODS We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency. RESULTS Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023). CONCLUSION Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.
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Abstract
Emergency department (ED) operations reflect the intersection of factors external and internal to the ED itself, with unique problems posed by community and academic environments. ED crowding is primarily caused by a lack of inpatient beds for patients admitted through the ED. Changes to front-end operations, such as point-of-care testing and putting physicians in triage, can yield benefits in throughput, but require individual cost analyses. Balancing physician workloads can lead to substantial improvements in throughput. Observation pathways can reduce crowding while maintaining safety. Physician and nurse well-being is an underappreciated topic within operations, and demands close attention and further research.
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Abstract
Emergency department crowding is a multifactorial issue with causes intrinsic to the emergency department and to the health care system. Understanding that the causes of emergency department crowding span this continuum allows for a more accurate analysis of its effects and a more global consideration of potential solutions. Within the emergency department, boarding of inpatients is the most appreciable effect of hospital-wide crowding, and leads to further emergency department crowding. We explore the concept of emergency department crowding, and its causes, effects, and potential strategies to overcome this problem.
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Affiliation(s)
- James F Kenny
- Milstein Adult Emergency Department, NewYork-Presbyterian Hospital, Department of Emergency Medicine, Columbia University Irving Medical Center, 622 West 168th Street, Suite VC2-260, New York, NY 10032, USA.
| | - Betty C Chang
- Milstein Adult Emergency Department, NewYork-Presbyterian Hospital, Department of Emergency Medicine, Columbia University Irving Medical Center, 622 West 168th Street, Suite VC2-260, New York, NY 10032, USA
| | - Keith C Hemmert
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Ground Floor Ravdin, Philadelphia PA 19104, USA
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26
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Elliott MJ, Love S, Donald M, Manns B, Donald T, Premji Z, Hemmelgarn BR, Grinman M, Lang E, Ronksley PE. Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD. Am J Kidney Dis 2020; 76:794-805. [PMID: 32479925 DOI: 10.1053/j.ajkd.2020.04.006] [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: 10/07/2019] [Accepted: 04/02/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population. STUDY DESIGN Scoping review of quantitative and qualitative studies. SETTING & POPULATION Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes). SELECTION CRITERIA FOR STUDIES MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019. DATA EXTRACTION Intervention and study characteristics were extracted using standardized tools. ANALYTICAL APPROACH Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews. RESULTS 77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed. LIMITATIONS Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD. CONCLUSIONS Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.
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Affiliation(s)
- Meghan J Elliott
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Shannan Love
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maoliosa Donald
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bryn Manns
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Teagan Donald
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zahra Premji
- Department of Libraries and Cultural Resources, University of Calgary, Calgary, AB, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Michelle Grinman
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Joshi AU, Randolph FT, Chang AM, Slovis BH, Rising KL, Sabonjian M, Sites FD, Hollander JE. Impact of Emergency Department Tele-intake on Left Without Being Seen and Throughput Metrics. Acad Emerg Med 2020; 27:139-147. [PMID: 31733003 DOI: 10.1111/acem.13890] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures. METHODS We conducted a before-and-after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele-intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program. RESULTS Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%). CONCLUSIONS Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.
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Affiliation(s)
- Aditi U. Joshi
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
| | - Frederick T. Randolph
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
| | - Anna Marie Chang
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
| | - Benjamin H. Slovis
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
| | - Kristin L. Rising
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
| | - Megan Sabonjian
- JeffConnect Program and National Academic Center for Telehealth Thomas Jefferson University Philadelphia PA
| | - Frank D. Sites
- JeffConnect Program and National Academic Center for Telehealth Thomas Jefferson University Philadelphia PA
| | - Judd E. Hollander
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth Philadelphia PA
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Ok M, Choi A, Kim MJ, Roh YH, Park I, Chung SP, Kim JH. Emergency short-stay wards and boarding time in emergency departments: A propensity-score matching study. Am J Emerg Med 2019; 38:2495-2499. [PMID: 31859191 DOI: 10.1016/j.ajem.2019.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/05/2019] [Accepted: 12/06/2019] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES This study aimed to validate the effectiveness of an emergency short-stay ward (ESSW) and its impact on clinical outcomes. METHODS This retrospective observational study was performed at an urban tertiary hospital. An ESSW has been operating in this hospital since September 2017 to reduce emergency department (ED) boarding time and only targets patients indicated for admission to the general ward from the ED. Propensity-score matching was performed for comparison with the control group. The primary outcome was ED boarding time, and the secondary outcomes were subsequent intensive care unit (ICU) admission and 30-day in-hospital mortality. RESULTS A total of 7461 patients were enrolled in the study; of them, 1523 patients (20.4%) were admitted to the ESSW. After propensity-score matching, there was no significant difference in the ED boarding time between the ESSW group and the control group (P = 0.237). Subsequent ICU admission was significantly less common in the ESSW group than in the control group (P < 0.001). However, the 30-day in-hospital mortality rate did not differ significantly between the two groups (P = 0.292). When the overall hospital bed occupancy ranged from 90% to 95%, the proportion of hospitalization was the highest in the ESSW group (29%). An interaction effect test using a general linear model confirmed that the ESSW served as an effect modifier with respect to bed occupancy and boarding time (P < 0.001). CONCLUSION An ESSW can alleviate prolonged boarding time observed with hospital bed saturation. Moreover, the ESSW is associated with a low rate of subsequent ICU admission.
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Affiliation(s)
- Min Ok
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Arom Choi
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Min Joung Kim
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Yun Ho Roh
- Department of Biostatistics Collaboration Unit, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Incheol Park
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Emergency Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea.
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Alishahi Tabriz A, Trogdon JG, Fried BJ. Association between adopting emergency department crowding interventions and emergency departments' core performance measures. Am J Emerg Med 2019; 38:258-265. [PMID: 31060861 DOI: 10.1016/j.ajem.2019.04.048] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/12/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES To estimate the association between adopting emergency department (ED) crowding interventions and emergency departments' core performance measures. METHODS We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2007 to 2015. The outcome variables are ED length of stay for discharged and admitted patients, boarding time, wait time and percentage of patients who left ED before being seen (LWBS). The independent variables are whether or not a hospital adopted each of the 20 crowding interventions. Controlling for patient-level, hospital level and temporal confounders we analyze and report results using multivariable logit model. RESULTS Between 2007 and 2015, NHAMCS collected data for 269,721 ED visit encounters, representing a nationwide of about 1.18 billion separate ED visits. Of 20 crowding interventions we tested, using adopting bedside registration (OR = 0.89, 95% CI = 0.75-0.98, P < .05), electronic dashboard (OR = 0.86, 95% CI = 0.76-0.98, P < .05), kiosk check-in technology (OR = 0.56, 95% CI = 0.41-0.83, P < .001), physician based triage (OR = 0.86, 95% CI = 0.73-0.99, P < .05) full capacity protocol (OR = 0.91, 95% CI = 0.79-0.99, P < .05) are associated with decrease in the odds of prolonged wait time. Adopting kiosk check-in (OR = 0.55, 95% CI = 0.35-0.85, P < .05) is associated with a decrease in the odds of prolonged boarding time. Using wireless communication devices (OR = 0.77, 95% CI = 0.57-0.97, P < .05), bedside registration (OR = 0.77, 95% CI = 0.64-0.094, P < .05) and pooled nursing (OR = 0.84, 95% CI = 0.72-0.98, P < .05) are associated with decrease in the odds of a patient LWBS. CONCLUSIONS Majority of interventions did not significantly associated with ED' core performance measures.
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Affiliation(s)
- Amir Alishahi Tabriz
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Bruce J Fried
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Southerland LT, Simerlink SR, Vargas AJ, Krebs M, Nagaraj L, Miller KN, Adkins EJ, Barrie MG. Beyond observation: Protocols and capabilities of an Emergency Department Observation Unit. Am J Emerg Med 2018; 37:1864-1870. [PMID: 30639128 DOI: 10.1016/j.ajem.2018.12.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/04/2018] [Accepted: 12/25/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Emergency Department Observation Units (Obs Units) provide a setting and a mechanism for further care of Emergency Department (ED) patients. Our hospital has a protocol-driven, type 1, complex 20 bed Obs Unit with 36 different protocols. We wanted to understand how the different protocols performed and what types of care were provided. METHODS This was an IRB-approved, retrospective chart review study. A random 10% of ED patient charts with a "transfer to observation" order were selected monthly from October 2015 through June 2017. This database was designed to identify high and low functioning protocols based on length of stays (LOS) and admission rates. RESULTS Over 20 months, a total of 984 patients qualified for the study. The average age was 49.5 ± 17.2 years, 57.3% were women, and 32.3% were non-Caucasian. The admission rate was 23.5% with an average LOS in observation of 13.7 h [95% CI 13.3-14.1]. Thirty day return rate was 16.8% with 5.3% of the patients returning to the ED within the first 72 h. Thirty six different protocols were used, with the most common being chest pain (13.9%) and general (13.2%). Almost 70% received a consultation from another service, and 7.2% required a procedure while in observation. Procedures included fluoroscopic-guided lumbar punctures, endoscopies, dental extractions, and catheter replacements (nephrostomy, gastrostomy, and biliary tubes). CONCLUSIONS An Obs Unit can care for a wide variety of patients who require multiple consultations, procedures, and care coordination while maintaining an acceptable length of stay and admission rate.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA. https://twitter.com/LSGeriatricEM
| | | | - Anthony J Vargas
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Margaret Krebs
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lalitha Nagaraj
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Krystin N Miller
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eric J Adkins
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Michael G Barrie
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Southerland LT, Hunold KM, Carpenter CR, Caterino JM, Mion LC. A National Dataset Analysis of older adults in emergency department observation units. Am J Emerg Med 2018; 37:1686-1690. [PMID: 30563716 DOI: 10.1016/j.ajem.2018.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Emergency Department (ED) Observation Units (Obs Units) are prevalent in the US, but little is known regarding older adults in observation. Our objective was to describe the Obs Units nationally and observation patients with specific attention to differences in care with increasing age. DESIGN This is an analysis of 2010-2013 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national observational cohort study including ED patients. Weighted means are presented for continuous data and weighted percent for categorical data. Multivariable logistic regression was used to identify variables associated with placement in and admission from observation. RESULTS The number of adult ED visits varied from 100 million to 107 million per year and 2.3% of patients were placed in observation. Adults ≥65 years old made up a disproportionate number of Obs Unit patients, 30.6%, compared to only 19.7% of total ED visits (odds ratio 1.5 (95% CI 1.5-1.6), adjusting for sex, race, month, day of week, payer source, and hospital region). The overall admission rate from observation was 35.6%, ranging from 31.3% for ages 18-64 years to 47.5% for adults ≥85 years old (p < 0.001). General symptoms (e.g., nausea, dizziness) and hypertensive disease were the most common diagnoses overall. Older adults varied from younger adults in that they were frequently observed for diseases of the urinary system (ICD-9 590-599) and metabolic disorders (ICD-9 270-279). CONCLUSIONS Older adults are more likely to be cared for in Obs Units. Older adults are treated for different medical conditions than younger adults.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lorraine C Mion
- College of Nursing, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Preventing Hospitalization in Mild Acute Pancreatitis Using a Clinical Pathway in the Emergency Department. J Clin Gastroenterol 2018; 52:734-741. [PMID: 29095424 DOI: 10.1097/mcg.0000000000000954] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
GOALS We created an observation pathway with close outpatient follow-up for patients with mild acute pancreatitis (AP) to determine its effect on admission rates, length of stay (LOS), and costs. BACKGROUND AP is a common reason for hospitalization costing $2.6 billion annually. Majority have mild disease and improve quickly but have unnecessarily long hospital stays. STUDY We performed a pilot prospective cohort study in patients with AP at a tertiary-care center. In total, 90 patients with AP were divided into 2 groups: observation cohort and admitted cohort. Exclusion criteria from observation included end-organ damage, pancreatic complications, and/or severe cardiac, liver, and renal disease. Patients in observation received protocolized hydration and periodic reassessment in the emergency department and were discharged with outpatient follow-up. Using similar exclusion criteria, we compared outcomes with a preintervention cohort composed of 184 patients admitted for mild AP in 2015. Our primary outcome was admission rate, and secondary outcomes were LOS, patient charges, and 30-day readmission. RESULTS Admitted and preintervention cohorts had longer LOS compared with the observation cohort (89.7 vs. 22.6 h, P<0.01 and 72.0 vs. 22.6 h, P<0.01). The observation cohort admission rate was 22.2% lower than the preintervention cohort (P<0.01) and had 43% lower patient charges ($5281 vs. $9279, P<0.01). Moreover there were significantly fewer imaging studies performed (25 vs. 49 images, P=0.03) in the observation cohort. There were no differences in readmission rates and mortality. CONCLUSIONS In this feasibility study, we demonstrate that a robust pathway can prevent hospitalization in those with AP and may reduce resource utilization without a detrimental impact on safety.
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Strøm C, Stefansson JS, Fabritius ML, Rasmussen LS, Schmidt TA, Jakobsen JC. Hospitalisation in short-stay units for adults with internal medicine diseases and conditions. Cochrane Database Syst Rev 2018; 8:CD012370. [PMID: 30102428 PMCID: PMC6513218 DOI: 10.1002/14651858.cd012370.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Short-stay units are hospital units that provide short-term care for selected patients. Studies have indicated that short-stay units might reduce admission rates, time of hospital stays, hospital readmissions and expenditure without compromising the quality of care. Short-stay units are often defined by a target patient category, a target function, and a target time frame. Hypothetically, short-stay units could be established as part of any department, but this review focuses on short-stay units that provide care for participants with internal medicine diseases and conditions. OBJECTIVES To assess beneficial and harmful effects of short-stay unit hospitalisation compared with usual care in people with internal medicine diseases and conditions. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to 13 December 2017 together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several grey literature sources and performed a forward citation search for included studies. SELECTION CRITERIA We included randomised trials and cluster-randomised trials, comparing hospitalisation in a short-stay unit with usual care (hospitalisation in a traditional hospital ward or other services). We defined a short-stay unit to be a hospital ward where the targeted length of stay in hospital for patients was five days or less. We included both multipurpose and specialised short-stay units. Participants were adults admitted to hospital with an internal medicine disease or condition. We excluded surgical, obstetric, psychiatric, gynaecological, and ambulatory participants. Trials were included irrespective of publication status, date, and language. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias of each included trial. We measured intervention effect sizes by meta-analyses for two primary outcomes, mortality and serious adverse events, and one secondary outcome, hospital readmission. We narratively reported the following important outcomes: quality of life, activities of daily living, non-serious adverse events, and costs. We used risk ratio differences of 15% for mortality and of 20% for serious adverse events for minimal relevant clinical consideration. We rated the certainty of the evidence and the strength of recommendations of the outcomes using the GRADE approach. MAIN RESULTS We included 19 records reporting on 14 randomised trials with a total of 2872 participants. One trial was ongoing. Thirteen trials evaluated short-stay unit hospitalisation for six specific conditions (acute decompensated heart failure (one trial), asthma (one trial), atrial fibrillation (one trial), chest pain (seven trials), syncope (two trials), and transient ischaemic attack (one trial)) and one trial investigated participants presenting with miscellaneous internal medicine disease and conditions. The components of the intervention differed among the trials as dictated by the trial participants' condition. All included trials were at high risk of bias.The certainty of the evidence for all outcomes was very low. Consequently, it is uncertain whether hospitalisation in short-stay units compared with usual care reduces mortality (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.47 to 1.15) 5 trials (seven additional trials reporting on 1299 participants reported no deaths in either group)); serious adverse events (RR 0.95, 95% CI 0.59 to 1.54; 7 trials (one additional trial with 108 participants reported no serious adverse events in either group)), and hospital readmission (RR 0.80, 95% CI 0.54 to 1.19, 8 trials (one additional trial with 424 participants did not report results for participants)). There was not enough information to confirm or refute that short-stay unit hospitalisation had relevant effects on quality of life, activities of daily living, non-serious adverse events, and costs. AUTHORS' CONCLUSIONS Overall, the quantity and the certainty of the evidence was very low. Consequently, it is uncertain whether there are any beneficial or harmful effects of short-stay unit hospitalisation for adults with internal medicine diseases and conditions - more trials comparing the effects of short-stay units with usual care are needed. Such trials ought to be conducted with low risk of bias and low risks of random errors to improve the overall confidence in the evidence.
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Affiliation(s)
- Camilla Strøm
- Holbaek Hospital, University of CopenhagenDepartment of Emergency MedicineHolbaekDenmark4300
| | - Jakob S Stefansson
- Rigshospitalet, University of CopenhagenDepartment of Anaesthesia, Centre of Head and OrthopaedicsCopenhagenDenmark
| | - Maria Louise Fabritius
- Rigshospitalet, University of CopenhagenDepartment of Anaesthesia, Centre of Head and OrthopaedicsCopenhagenDenmark
| | - Lars S Rasmussen
- Rigshospitalet, University of CopenhagenDepartment of Anaesthesia, Centre of Head and OrthopaedicsCopenhagenDenmark
| | - Thomas A Schmidt
- Holbaek Hospital, University of CopenhagenDepartment of Emergency MedicineHolbaekDenmark4300
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenSjællandDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
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Motosue MS, Bellolio MF, Van Houten HK, Shah ND, Campbell RL. National trends in emergency department visits and hospitalizations for food-induced anaphylaxis in US children. Pediatr Allergy Immunol 2018; 29:538-544. [PMID: 29663520 DOI: 10.1111/pai.12908] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Food is the leading cause of anaphylaxis in children seen in emergency departments in the United States, yet data on emergency department visits and hospitalizations related to food-induced anaphylaxis are limited. The objective of our study was to examine national time trends of pediatric food-induced anaphylaxis-related emergency department visits and hospitalizations. METHODS We conducted an observational study using a national administrative claims database from 2005 through 2014. Participants were younger than 18 years with an emergency department visit or hospitalization for food-induced anaphylaxis. Outcome measures of our study included time trends of pediatric food-induced anaphylaxis-related emergency department visits and hospitalizations, including observations (in an emergency department or a hospital unit), inpatient admissions, and intensive care unit admissions. RESULTS During the study period, participants had 7310 food-induced anaphylaxis-related emergency department visits. Emergency department visits for food-induced anaphylaxis increased by 214% (P < .001); the highest rates were in infants and toddlers (age 0-2 years). Rates of emergency department visits significantly increased in all age-groups, with the highest increase in adolescents (age 13-17 years: 413%; P < .001). Peanuts accounted for the highest rates (5.85 per 100 000 in 2014) followed by tree nuts/seeds (4.62 per 100 000 in 2014). The greatest increase in rates of emergency department visits for food-induced anaphylaxis occurred with tree nuts/seeds (373.0% increase during the study period). CONCLUSIONS The incidence of food-induced anaphylaxis has significantly increased over time in children of all ages. Food-induced anaphylaxis in children is an important national public health concern.
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Affiliation(s)
- Megan S Motosue
- Division of Allergic Diseases, Mayo Clinic, Rochester, MN, USA
| | - M Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Holly K Van Houten
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.,OptumLabs, Cambridge, MA, USA
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
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Wright B, Martin GP, Ahmed A, Banerjee J, Mason S, Roland D. How the Availability of Observation Status Affects Emergency Physician Decisionmaking. Ann Emerg Med 2018; 72:401-409. [PMID: 29880439 DOI: 10.1016/j.annemergmed.2018.04.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 02/17/2018] [Accepted: 04/19/2018] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE This study seeks to understand how emergency physicians decide to use observation services, and how placing a patient under observation influences physicians' subsequent decisionmaking. METHODS We conducted detailed semistructured interviews with 24 emergency physicians, including 10 from a hospital in the US Midwest, and 14 from 2 hospitals in central and northern England. Data were extracted from the interview transcripts with open coding and analyzed with axial coding. RESULTS We found that physicians used a mix of intuitive and analytic thinking in initial decisions to admit, observe, or discharge patients, depending on the physician's individual level of risk aversion. Placing patients under observation made some physicians more systematic, whereas others cautioned against overreliance on observation services in the face of uncertainty. CONCLUSION Emergency physicians routinely make decisions in a highly resource-constrained environment. Observation services can relax these constraints by providing physicians with additional time, but absent clear protocols and metacognitive reflection on physician practice patterns, this may hinder, rather than facilitate, decisionmaking.
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Affiliation(s)
- Brad Wright
- Department of Health Management and Policy, University of Iowa, Iowa City, IA.
| | - Graham P Martin
- SAPPHIRE Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Jay Banerjee
- Emergency Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Suzanne Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Damian Roland
- Pediatric Emergency Medicine Academic Group, University Hospitals of Leicester NHS Trust, Leicester, UK
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Glover M, Gottumukkala RV, Sanchez Y, Yun BJ, Benzer TI, White BA, Prabhakar AM, Raja AS. Appropriateness of Extremity Magnetic Resonance Imaging Examinations in an Academic Emergency Department Observation Unit. West J Emerg Med 2018; 19:467-473. [PMID: 29760842 PMCID: PMC5942010 DOI: 10.5811/westjem.2018.3.35463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/26/2017] [Accepted: 03/09/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction Emergency departments (ED) and hospitals face increasing challenges related to capacity, throughput, and stewardship of limited resources while maintaining high quality. Appropriate utilization of extremity magnetic resonance imaging (MRI) examinations within the emergency setting is not well known. Therefore, this study aimed to determine indications for and appropriateness of MRI of the extremities for musculoskeletal conditions in the ED observation unit (EDOU). Methods We conducted this institutional review board-approved, retrospective study in a large, quaternary care academic center and Level I trauma center. An institutional database was queried retrospectively to identify all adult patients undergoing an extremity MRI while in the EDOU during the two-year study period from October 2013 through September 2015. We compared clinical history with the American College of Radiology (ACR) Appropriateness Criteria® for musculoskeletal indications. The primary outcome was appropriateness of musculoskeletal MRI exams of the extremities; examinations with an ACR Criteria score of seven or higher were deemed appropriate. Secondary measures included MRI utilization and imaging findings. Results During the study period, 22,713 patients were evaluated in the EDOU. Of those patients, 4,409 had at least one MRI performed, and 88 MRIs met inclusion criteria as musculoskeletal extremity examinations (2% of all patients undergoing an MRI exam in the EDOU during the study period). The most common exams were foot (27, 31%); knee (26, 30%); leg/femur (10, 11%); and shoulder (10, 11%). The most common indications were suspected infection (42, 48%) and acute trauma (23, 26%). Fifty-six percent of exams were performed with intravenous contrast; and 83% (73) of all MRIs were deemed appropriate based on ACR Criteria. The most common reason for inappropriate imaging was lack of performance of radiographs prior to MRI. Conclusion The majority of musculoskeletal extremity MRI examinations performed in the EDOU were appropriate based on ACR Appropriateness Criteria. However, the optimal timing and most-appropriate site for performance of many clinically appropriate musculoskeletal extremity MRIs performed in the EDOU remains unclear. Potential deferral to the outpatient setting may be a preferred population health management strategy.
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Affiliation(s)
- McKinley Glover
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Massachusetts General Physicians Organization, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Ravi V Gottumukkala
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Yadiel Sanchez
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Brian J Yun
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Theodore I Benzer
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Benjamin A White
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Anand M Prabhakar
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Division of Emergency Imaging, Boston, Massachusetts
| | - Ali S Raja
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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Motosue MS, Bellolio MF, Van Houten HK, Shah ND, Li JT, Campbell RL. Outcomes of Emergency Department Anaphylaxis Visits from 2005 to 2014. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1002-1009.e2. [DOI: 10.1016/j.jaip.2017.07.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/12/2017] [Accepted: 07/31/2017] [Indexed: 11/17/2022]
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Gabayan GZ, Liang LJ, Doyle B, Huang DYC, Sarkisian CA. Emergency Department Increased use of Observation Care for Elderly Medicare Patients. ACTA ACUST UNITED AC 2018; 7:9-16. [PMID: 29736199 DOI: 10.5430/jha.v7n3p9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Over the past decade, a growing number of older Medicare beneficiaries visit the Emergency Department (ED) and have been placed in observation care. We investigated and compared the prevalence and factors associated with patients age ≥ 65 years with Medicare insurance who are placed in the hospital, observation care, or discharged following an ED visit. Methods We conducted a retrospective cohort study using data from a nationally representative 5% sample of Medicare patients age ≥ 65 years during the year 2013. We performed multiple generalized estimating equation (GEE) logistic regression analyses to assess the relationship between placement in a hospital vs. discharge, observation care vs. discharge, and observation care vs. admission. Results Of 537,455 Medicare beneficiaries age ≥ 65 years who visited an ED in 2013, 48.0% (N= 258,083) were discharged, 10.5% (N=56,184) placed in observation care, and 41.5% (N=223,188) were admitted to the inpatient service following the ED visit. The top 2 diagnoses associated with placement in the hospital vs. discharge were ischemic heart disease and renal disease. Patients with symptomatic diagnoses such as chest pain and dizziness were more likely to be placed in observation care following an ED visit as compared to admission to the hospital. Conclusion Compared to prior studies, we found a greater number of older Medicare ED patients placed in observation care and a lower number admitted to the hospital. Most common diagnoses of placement in observation care were symptom-based as compared to being admitted to the hospital which were disease-based.
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Affiliation(s)
- Gelareh Z Gabayan
- Department of Emergency Medicine, University of California, Los Angeles, California
| | - Li-Jung Liang
- Divisions of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA
| | - Brian Doyle
- Department of Medicine, Ohio State University
| | - David Yu-Chuang Huang
- Divisions of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA
| | - Catherine A Sarkisian
- Department of Medicine, University of California, Los Angeles, California.,Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
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Wright B, Zhang X, Rahman M, Abir M, Ayyagari P, Kocher KE. Evidence of Racial and Geographic Disparities in the Use of Medicare Observation Stays and Subsequent Patient Outcomes Relative to Short-Stay Hospitalizations. Health Equity 2018; 2:45-54. [PMID: 30272046 PMCID: PMC6071902 DOI: 10.1089/heq.2017.0055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: To examine racial and geographic disparities in the use of—and outcomes associated with—Medicare observation stays versus short-stay hospitalizations. Methods: We used 2007–2010 fee-for-service Medicare claims, including 3,555,994 observation and short-stay hospitalizations for individuals over age 65. We estimated linear probability models with hospital fixed effects to identify within-facility disparities in observation stay use, estimated in-hospital mortality, 30- and 90-day postdischarge mortality, return emergency department (ED) visits, and hospital readmissions as a function of placement in observation using linear probability models, propensity-score matching, and interaction terms. Results: We identified racial and geographic disparities in the likelihood of observation stay use within hospitals (blacks 3.9% points more likely than whites, rural 5.4% points less likely than urban). Observation is associated with an increased likelihood of returning to the ED within 30 or 90 days and a decreased likelihood of readmission or mortality, but there are racial and geographic disparities in these outcomes. Conclusion: While observation generally results in improved outcomes, disparities in these outcomes and the use of observation stays within hospitals are concerning and may be driven by clinical and nonclinical factors.
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Affiliation(s)
- Brad Wright
- Department of Health Management and Policy, University of Iowa; Iowa City, IA.,Public Policy Center, University of Iowa; Iowa City, IA
| | - Xuan Zhang
- Department of Economics, Brown University; Providence, RI
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown University; Providence, RI
| | - Mahshid Abir
- Department of Emergency Medicine, University of Michigan; Ann Arbor, MI.,RAND Corporation, Santa Monica, CA.,Institute for Healthcare Policy and Innovation, University of Michigan; Ann Arbor, MI
| | - Padmaja Ayyagari
- Department of Health Management and Policy, University of Iowa; Iowa City, IA
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan; Ann Arbor, MI.,Institute for Healthcare Policy and Innovation, University of Michigan; Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, University of Michigan; Ann Arbor, MI
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Parwani V, Tinloy B, Ulrich A, D'Onofrio G, Goldenberg M, Rothenberg C, Patel A, Venkatesh AK. Opening of Psychiatric Observation Unit Eases Boarding Crisis. Acad Emerg Med 2018; 25:456-460. [PMID: 29266537 DOI: 10.1111/acem.13369] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 12/08/2017] [Accepted: 12/15/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate the effect of a psychiatric observation unit in reducing emergency department (ED) boarding and length of stay (LOS) for patients presenting with primary psychiatric chief complaints. A secondary outcome was to determine the effect of a psychiatric observation unit on inpatient psychiatric bed utilization. METHODS This study was a before-and-after analysis conducted in a 1,541-bed tertiary care academic medical center including an adult ED with annual census over 90,000 between February 2013 and July 2014. All adult patients (age > 17 years) requiring evaluation by the acute psychiatry service in the crisis intervention unit (CIU) within the ED were included. Patients who left without being seen, left against medical advice, or were dispositioned to the pediatric hospital, hospice, or court/law enforcement were excluded. In December 2013, a 12-bed locked psychiatric observation unit was opened that included dedicated behavioral health staff and was intended for psychiatric patients requiring up to 48 hours of care. The primary outcomes were ED LOS, CIU LOS, and total LOS. Secondary outcomes included the hold rate defined as the proportion of acute psychiatry patients requiring subsequent observation or inpatient admission and the inpatient psychiatric admission rate. For the primary analysis we constructed ARIMA regression models that account for secular changes in the primary outcomes. We conducted two sensitivity analyses, first replicating the primary analysis after excluding patients with concurrent acute intoxication and second by comparing the 3-month period postintervention to the identical 3-month period of the prior year to account for seasonality. RESULTS A total of 3,501 patients were included before intervention and 3,798 after intervention. The median ED LOS for the preintervention period was 155 minutes (interquartile range [IQR] = 19-346 minutes), lower than the median ED LOS for the postintervention period of 35 minutes (IQR = 9-209 minutes, p < 0.0001). Similar reductions were observed in CIU LOS (865 minutes vs. 379 minutes, p < 0.0001) and total LOS (1,112 minutes vs. 920 minutes, p = 0.003). The psychiatric hold rate was statistically higher after intervention (before = 42%, after = 50%, p < 0.0001), however, coupled with a statistically lower psychiatric admission rate (before = 42%, after = 25%, p < 0.0001). CONCLUSIONS Creation of an acute psychiatric observation improves ED and acute psychiatric service throughput while supporting the efficient allocation of scare inpatient psychiatric beds. This novel approach demonstrates the promise of extending successful observation care models from medical to psychiatric illness with the potential to improve the value of acute psychiatric care while minimizing the harms of ED crowding.
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Affiliation(s)
| | | | | | | | - Matthew Goldenberg
- Department of Psychiatry; Yale University School of Medicine; New Haven CT
| | | | - Amitkumar Patel
- Yale New Haven Hospital - Joint Data Analytics Team; New Haven CT
| | - Arjun K. Venkatesh
- Department of Emergency Medicine; New Haven CT
- Yale New Haven Hospital-Center for Outcomes Research and Evaluation; New Haven CT
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Chor WPD, Yong PXL, Lim LL, Chai CY, Sim TB, Kuan WS. Management of dyspepsia-The role of the ED Observation unit to optimize patient outcomes. Am J Emerg Med 2018; 36:1733-1737. [PMID: 29444751 DOI: 10.1016/j.ajem.2018.01.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/15/2018] [Accepted: 01/18/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Dyspepsia is a common complaint that can confer significant burden on one's quality of life and may also be associated with serious underlying conditions. The objective of this study was to determine if patients admitted to the emergency department observation unit (EDOU) for severe or persistent dyspepsia would have cost effective management in terms of investigations performed, length and cost of hospital stay. The secondary objective was to determine if any patient characteristics could predict a need for admission to the inpatient unit. METHODS Retrospective chart reviews of patients admitted to the EDOU under the Dyspepsia protocol between January 2008 and August 2014 were conducted. Baseline demographics, investigations performed, outcomes related to EDOU stay, admission and 30-day re-presentation outcomes were recorded. RESULTS A total of 1304 patients were included. Median length of stay was 1day. Cumulative bed-saved days were 38 per month. Two hundred eighteen (16.7%) patients required admission to the inpatient service for further management, while 533 (40.9%) and 313 (24.0%) patients underwent esophagogastroduodenoscopy and hepatobiliary ultrasonography, respectively. No major adverse events were attributed to the EDOU admissions or delays in treatment. No significant clinically relevant factors were associated with a need for admission from the EDOU to the inpatient unit. Median cost of the EDOU admission was approximately one-third that of a similar admission to the inpatient unit. CONCLUSION The EDOU is an appropriate setting to facilitate investigations and treatment of patients with dyspepsia with considerable bed-saved days.
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Affiliation(s)
- Wei Ping Daniel Chor
- Emergency Medicine Department, National University Hospital, National University Health System, 119074, Singapore.
| | - Pei Xian Lorraine Yong
- Emergency Medicine Department, National University Hospital, National University Health System, 119074, Singapore
| | - Li Lin Lim
- Division of Gastroenterology & Hepatology, National University Hospital, National University Health System, 119074, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
| | - Chew Yian Chai
- Emergency Medicine Department, National University Hospital, National University Health System, 119074, Singapore
| | - Tiong Beng Sim
- Emergency Medicine Department, National University Hospital, National University Health System, 119074, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, 119074, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
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Conley J, Bohan JS, Baugh CW. The Establishment and Management of an Observation Unit. Emerg Med Clin North Am 2017; 35:519-533. [PMID: 28711122 DOI: 10.1016/j.emc.2017.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The current health care landscape and evidence support the establishment of observation units (OUs) for safe and efficient care for observation patients. Careful attention is required in the design of OU process, location, and layout to enable optimal care and finances. Developing and maintaining protocols to guide patient selection and clinical care are critical. OU management requires a strong, collaborative leadership model, appropriate staffing, and a robust monitoring system for quality, safety, and finances. With a better understanding of these principles of OU establishment and management, hospital leaders can generate and sustain service excellence.
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Affiliation(s)
- Jared Conley
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - J Stephen Bohan
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Yiadom MYAB, Liu X, McWade CM, Liu D, Storrow AB. Acute Coronary Syndrome Screening and Diagnostic Practice Variation. Acad Emerg Med 2017; 24:701-709. [DOI: 10.1111/acem.13184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/18/2017] [Accepted: 02/27/2017] [Indexed: 01/16/2023]
Affiliation(s)
| | - Xulei Liu
- Department of Biostatistics; Vanderbilt University; Nashville TN
| | - Conor M. McWade
- Schools of Medicine and Public Health; Vanderbilt University; Nashville TN
| | - Dandan Liu
- Department of Biostatistics; Vanderbilt University; Nashville TN
| | - Alan B. Storrow
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
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Hospital Use of Observation Stays: Cross-sectional Study of the Impact on Readmission Rates. Med Care 2017; 54:1070-1077. [PMID: 27579906 DOI: 10.1097/mlr.0000000000000601] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services publicly reports hospital risk-standardized readmission rates (RSRRs) as a measure of quality and performance; mischaracterizations may occur because observation stays are not captured by current measures. OBJECTIVES To describe variation in hospital use of observation stays, the relationship between hospitals observation stay use and RSRRs. MATERIALS AND METHODS Cross-sectional analysis of Medicare fee-for-service beneficiaries discharged after acute myocardial infarction (AMI), heart failure, or pneumonia between July 2011 and June 2012. We calculated 3 hospital-specific 30-day outcomes: (1) observation rate, the proportion of all discharges followed by an observation stay without a readmission; (2) observation proportion, the proportion of observation stays among all patients with an observation stay or readmission; and (3) RSRR. RESULTS For all 3 conditions, hospitals' observation rates were <2.5% and observation proportions were <12%, although there was variation across hospitals, including 28% of hospital with no observation stay use for AMI, 31% for heart failure, and 43% for pneumonia. There were statistically significant, but minimal, correlations between hospital observation rates and RSRRs: AMI (r=-0.02), heart failure (r=-0.11), and pneumonia (r=-0.02) (P<0.001). There were modest inverse correlations between hospital observation proportion and RSRR: AMI (r=-0.34), heart failure (r=-0.26), and pneumonia (r=-0.21) (P<0.001). If observation stays were included in readmission measures, <4% of top performing hospitals would be recategorized as having average performance. CONCLUSIONS Hospitals' observation stay use in the postdischarge period is low, but varies widely. Despite modest correlation between the observation proportion and RSRR, counting observation stays in readmission measures would minimally impact public reporting of performance.
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Use or Abuse? A Qualitative Study of Emergency Physicians' Views on Use of Observation Stays at Three Hospitals in the United States and England. Ann Emerg Med 2017; 69:284-292.e2. [DOI: 10.1016/j.annemergmed.2016.08.458] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/19/2016] [Accepted: 08/25/2016] [Indexed: 11/22/2022]
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Marshall JR, Katzer R, Lotfipour S, Chakravarthy B, Shastry S, Andrusaitis J, Anderson CL, Barton ED. Use of Physician-in-Triage Model in the Management of Abdominal Pain in an Emergency Department Observation Unit. West J Emerg Med 2017; 18:181-188. [PMID: 28210350 PMCID: PMC5305123 DOI: 10.5811/westjem.2016.10.32042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/26/2016] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Given the nationwide increase in emergency department (ED) visits it is of paramount importance for hospitals to find efficient ways to manage patient flow. The purpose of this study was to determine whether there is a significant difference in success rates, length of stay (LOS), and other demographic factors in two cohorts of patients admitted directly to an ED observation unit (EDOU) under an abdominal pain protocol by a physician in triage (bypassing the main ED) versus those admitted via the traditional pathway (evaluated and treated in the main ED prior to EDOU admission). METHODS This was a retrospective cohort study of patients admitted to a protocol-driven EDOU with a diagnosis of abdominal pain in a single university hospital center ED. We obtained compiled data for all patients admitted to the EDOU with a diagnosis of abdominal pain that met EDOU protocol admission criteria. We divided data for each cohort into age, gender, payer status, and LOS. The data were then analyzed to assess any significant differences between the cohorts. RESULTS A total of 327 patients were eligible for this study (85 triage group, 242 main ED group). The total success rate was 90.8% (n=297) and failure rate was 9.2% (n=30). We observed no significant differences in success rates between those dispositioned to the EDOU by triage physicians (90.6%) and those via the traditional route (90.5 % p) = 0.98. However, we found a significant difference between the two groups regarding total LOS with significantly shorter main ED times and EDOU times among patients sent to the EDOU by the physician-in-triage group (p< .001). CONCLUSION There were no significant differences in EDOU disposition outcomes in patients admitted to an EDOU by a physician-in-triage or via the traditional route. However, there were statistically significant shorter LOSs in patients admitted to the EDOU by triage physicians. The data from this study support the implementation of a physician-in-triage model in combination with the EDOU in improving efficiency in the treatment of abdominal pain. This knowledge may spur action to cut healthcare costs and improve patient flow and timely decision-making in hospitals with EDOUs.
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Affiliation(s)
- John R. Marshall
- University of California, Department of Emergency Medicine, Irvine, California
| | - Robert Katzer
- University of California, Department of Emergency Medicine, Irvine, California
| | - Shahram Lotfipour
- University of California, Department of Emergency Medicine, Irvine, California
| | | | - Siri Shastry
- University of California, Department of Emergency Medicine, Irvine, California
| | - Jessica Andrusaitis
- University of California, Department of Emergency Medicine, Irvine, California
| | - Craig L. Anderson
- University of California, Department of Emergency Medicine, Irvine, California
| | - Erik D. Barton
- University of California, Department of Emergency Medicine, Irvine, California
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Bellolio MF, Sangaralingham LR, Schilz SR, Noel‐Miller CM, Lind KD, Morin PE, Noseworthy PA, Shah ND, Hess EP. Observation Status or Inpatient Admission: Impact of Patient Disposition on Outcomes and Utilization Among Emergency Department Patients With Chest Pain. Acad Emerg Med 2017; 24:152-160. [PMID: 27739128 DOI: 10.1111/acem.13116] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/05/2016] [Accepted: 10/06/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES to compare healthcare utilization including coronary angiography, percutaneous coronary intervention (PCI), rehospitalization, and rate of subsequent acute myocardial infarction (AMI) within 30 days, among patients presenting to the emergency department (ED) with chest pain admitted as short-term inpatient (≤2 days) versus observation (in-ED observation units combined with in-hospital observation). METHODS We identified adults diagnosed with acute chest pain in the ED from 2010 to 2014 using administrative claims from privately insured and Medicare Advantage. Patients having AMI during the index visit were excluded. One-to-one propensity-score matching and logistic regression were used. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported. RESULTS A total of 774,017 chest pain visits were included. After matching, healthcare utilization was lower among observation versus short inpatient, with 10.9% versus 24.4% (OR = 0.38, 95% CI = 0.36 to 0.39) undergoing cardiac catheterization and 1.8% versus 7.6% (OR = 0.23, 95% CI = 0.21 to 0.24) having PCI. The incidence of subsequent AMI within the following 30 days was similar in patients admitted as observation versus short inpatient (0.23% vs. 0.21%; OR = 1.09, 95% CI = 0.84 to 1.42). CONCLUSIONS There were higher rates of cardiac catheterization and PCI among those admitted as a short inpatient compared to observation, while the incidence of subsequent AMI within 30 days was similar.
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Affiliation(s)
- M. Fernanda Bellolio
- Department of Emergency Medicine Mayo Clinic Rochester MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Lindsey R. Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | | | | | | | | | - Peter A. Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
- Division of Cardiovascular Diseases, Department of Internal Medicine Mayo Clinic Rochester MN
| | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
- Department of Health Science Research Mayo Clinic Rochester MN
- OptumLabs Cambridge MA
| | - Erik P. Hess
- Department of Emergency Medicine Mayo Clinic Rochester MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
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Abstract
IMPORTANCE The role of obstetric triage in the care of pregnant women has expanded significantly. Factors driving this change include the Emergency Medical Treatment and Active Labor Act, improved methods of testing for fetal well-being, increasing litigation risk, and changes in resident duty hour guidelines. The contemporary obstetric triage facility must have processes in place to provide a medical screening examination that complies with regulatory statues while considering both the facility's maternal level of care and available resources. OBJECTIVE This review examines the history of the development of obstetric triage, current considerations in a contemporary obstetric triage paradigm, and future areas for consideration. An example of a contemporary obstetric triage program at an academic medical center is presented. RESULT A successful contemporary obstetric triage paradigm is one that addresses the questions of "sick or not sick" and "labor or no labor," for every obstetric patient that presents for care. Failure to do so risks poor patient outcome, poor patient satisfaction, adverse litigation outcome, regulatory scrutiny, and exclusion from federal payment programs. CONCLUSIONS Understanding the role of contemporary obstetric triage in the current health care environment is important for both providers and health care leadership. TARGET AUDIENCE This study is for obstetricians and gynecologists as well as family physicians. LEARNING OBJECTIVES After completing this activity, the learner should be better able to understand the scope of a medical screening examination within the context of contemporary obstetric triage; understand how a facility's level of maternal care influences clinical decision making in a contemporary obstetric triage setting; and understand the considerations necessary for the systematic evaluation of the 2 basic contemporary obstetric questions, "sick or not sick?" and "labor or no labor?"
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Identifying patients with mild traumatic intracranial hemorrhage at low risk of decompensation who are safe for ED observation. Am J Emerg Med 2016; 35:255-259. [PMID: 27838043 DOI: 10.1016/j.ajem.2016.10.064] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 09/29/2016] [Accepted: 10/28/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients with traumatic intracranial hemorrhage and mild traumatic brain injury (mTIH) receive broadly variable care which often includes transfer to a trauma center, neurosurgery consultation and ICU admission. However, there may be a low risk cohort of patients who can be managed without utilizing such significant resources. OBJECTIVE Describe mTIH patients who are at low risk of clinical or radiographic decompensation and can be safely managed in an ED observation unit (EDOU). METHODS Retrospective evaluation of patients age≥16, GCS≥13 with ICH on CT. Primary outcomes included clinical/neurologic deterioration, CT worsening or need for neurosurgery. RESULTS 1185 consecutive patients were studied. 814 were admitted and 371 observed patients (OP) were monitored in the EDOU or discharged from the ED after a period of observation. None of the OP deteriorated clinically. 299 OP (81%) had a single lesion on CT; 72 had mixed lesions. 120 patients had isolated subarachnoid hemorrhage (iSAH) and they did uniformly well. Of the 119 OP who had subdural hematoma (SDH), 6 had worsening CT scans and 3 underwent burr hole drainage procedures as inpatients due to persistent SDH without new deficit. Of the 39 OP who had cerebral contusions, 3 had worsening CT scans and one required NSG admission. No patient returned to the ED with a complication. Follow-up was obtained on 81% of OP. 2 patients with SDH required burr hole procedure >2weeks after discharge. CONCLUSIONS Patients with mTIH, particularly those with iSAH, have very low rates of clinical or radiographic deterioration and may be safe for monitoring in an emergency department observation unit.
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Wright B, O'Shea AM, Glasgow JM, Ayyagari P, Vaughan-Sarrazin M. Patient, hospital, and local health system characteristics associated with the use of observation stays in veterans health administration hospitals, 2005 to 2012. Medicine (Baltimore) 2016; 95:e4802. [PMID: 27603391 PMCID: PMC5023914 DOI: 10.1097/md.0000000000004802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Recent studies have documented that a significant increase in the use of observation stays along with extensive variation in patterns of use across hospitals.The objective of this longitudinal observational study was to examine the extent to which patient, hospital, and local health system characteristics explain variation in observation stay rates across Veterans Health Administration (VHA) hospitals.Our data came from years 2005 to 2012 of the nationwide VHA Medical SAS inpatient and enrollment files, American Hospital Association Survey, and Area Health Resource File. We used these data to estimate linear regression models of hospitals' observation stay rates as a function of hospital, patient, and local health system characteristics, while controlling for time trends and Veterans Integrated Service Network level fixed effects.We found that observation stay rates are inversely related to hospital bed size and that hospitals with a greater proportion of younger or rural patients have higher observation stay rates. Observation stay rates were nearly 15 percentage points higher in 2012 than 2005.Although we identify several characteristics associated with variation in VHA hospital observation stay rates, many factors remain unmeasured.
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Affiliation(s)
- Brad Wright
- Department of Health Management and Policy
- Public Policy Center, University of Iowa
- Correspondence: Brad Wright, Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA (e-mail: )
| | - Amy M.J. O'Shea
- Iowa City Veterans Affairs Healthcare System, The Comprehensive Access and Delivery Research and Evaluation Center (CADRE)
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Justin M. Glasgow
- Christiana Care Health System Department of Internal Medicine and Christiana Care Health System Value Institute, Wilmington, DE
| | | | - Mary Vaughan-Sarrazin
- Iowa City Veterans Affairs Healthcare System, The Comprehensive Access and Delivery Research and Evaluation Center (CADRE)
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA
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