Analyzing Factors Affecting Emergency Department Length of Stay-Using a Competing Risk-accelerated Failure Time Model

Length of stay and associated factors among pediatric patients in the pediatric emergency unit of the Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia

BACKGROUND

Length of stay in the emergency department is used as a quality indicator to gauge the overall efficiency of emergency care. The performance measure was used to evaluate the quality of care provided in the emergency department.

OBJECTIVE

To assess the length of stay and associated factors among pediatric patients admitted to the pediatric emergency unit of Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia.

METHODS

An institution-based prospective cross-sectional study design was employed. A systematic random sampling technique was used to select the study participants. Data were collected via semi-structured, interviewer-administered questionnaires and chart reviews. Analysis was performed via the Statistical Package for Social Science software version 27. Binary logistic regression analysis was conducted to identify variables associated with the length of stay. The study was conducted in the Pediatric Emergency Unit of Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, from March 15 to April 15, 2023.

RESULTS

A total of 268 patients participated in the study, with a response rate of 97.81%. The majority of the participants were male (157, 58.6%), with a median age of 3 years. The study revealed that 180 participants (67.2%) experienced a prolonged length of stay. The variables significantly associated with prolonged length of stay included residency (AOR = 2.04, CI: 1.03, 4.025), triage category (AOR = 3.25, CI: 1.08, 5.974), number of investigations (AOR = 2.381, CI: 1.038, 5.462), and waiting for imaging (AOR = 4.230, CI: 1.638, 10.93).

CONCLUSION

Many pediatric patients stayed in the emergency room for more than 24 h because of factors such as residency, triage category, number of investigations, and the need for imaging. To address this, we recommend streamlining triage processes, increasing imaging resources, providing additional staff training, developing integrated care pathways, and advocating for policy changes to increase emergency room efficiency and improve patient outcomes.

Evaluating the success of an inpatient PA and NP program through trends in ED consults

OBJECTIVE

We investigated the effect of an inpatient physician associate/assistant (PA) and NP program on consult volume, length of stay (LOS), and ED returns.

METHODS

A retrospective observational study of 4,118 orthopedic ED consults was conducted from January 2017 to March 2022. Univariate statistics were used to evaluate outcomes between cohorts and multivariate regression to evaluate the odds of an LOS of less than 24 hours.

RESULTS

After implementation of the PA and NP program, surgeon consults steadily declined and orthopedic consults increased markedly. Statistically significant differences were found in LOS of less than 24 hours and ED arrival-to-discharge time. Adjusting for case mix, patients were 47% more likely to be discharged within 24 hours. Survey results noted that more than 80% of surgeons felt on-call workload, disruptions to clinic and surgical schedules decreased, and quality of care increased.

CONCLUSIONS

Implementation of an inpatient PA and NP program reduced orthopedic surgeon consults and hospital LOS while improving surgeon satisfaction with on-call workload, schedule disruptions, and quality of care.

Association Between the Emergency Department Length of Stay and in-Hospital Mortality: A Retrospective Cohort Study

Purpose

The number of emergency department (ED) visits and prolonged ED length of stay (LOS) are increasing worldwide. Prolonged ED LOS may be associated with a higher risk of in-hospital mortality. Here, we analysed the association between of ED LOS and the risk of in-hospital mortality in a hospital in Jakarta, Indonesia.

Patients and methods

This was a single-centre retrospective cohort study performed in a referral academic hospital in Jakarta, Indonesia. Data on ED visits in 2019 were obtained from the electronic medical records. ED patient was used as the unit of the analysis. The dependent variable was all-cause in-hospital mortality during one's visit. The main independent variable was ED LOS with respect to approval (<8 h) and prolonged (≥8 h). Potential confounders were sex, age, triage categories, trauma-related case, malignancy-related case, labour-related case, and referral patients from other healthcare facilities. Multivariate logistic regression analysis was performed to evaluate the association of ED LOS and in-hospital mortality after adjusting for other confounders.

Results

There were 18,553 participants included in the analysis. The in-hospital mortality was 13.5% among all participants, and 63.5% participants had an ED LOS ≥8 h. Multivariate analysis showed that a prolonged ED LOS was associated with an increased risk of in-hospital mortality (adjusted relative risk, 2.69; 95% confidence interval, 2.40-3.03; P<0.001).

Conclusion

Prolonged ED LOS was associated with risk an increased of in-hospital mortality after adjusting for several confounders. In future, hospital service plans should aim to reduce ED LOS and increase patient flow from the ED to in-patient wards.

Evaluation of factors affecting the length of stay of geriatric patients in the emergency department

OBJECTIVE

The emergency department length of stay (EDLOS) is one of the essential parameters of emergency healthcare management efficacy, and prominent factors that contribute to EDLOS are critical in enhancing emergency department (ED) patient care effectiveness, particularly for older patients, which is rarely investigated.

METHODS

This single-center, prospective cohort study was performed in the ED of a tertiary care hospital. The patients were classified into two groups according to EDLOS (≥4 h vs. <4 h). The chief complaints, consultant branches, the patients' comorbidities, polypharmacy status, time of presentation, laboratory, imaging investigations, EDLOS, Clinical Frailty Score (CFS) score, mini mental examination test, National Early Warning Score 2 (NEWS2), consultations, and outcome of the patients were compared with Spearman and Kendall tau-b correlations.

RESULTS

During the 30-day study period, a total of 222 geriatric patients were included in the study. The mean age of study patients was 79.13±9.43 years, and 47.05% of patients were male. The Median EDLOS was 250 (range, 60-1440) min. The patients who arrived on the night shift (p=0.047), who had chronic heart failure (p=0.025), chronic obstructive pulmonary disease (p=0.03), severe dementia according to the MMSE (p=0.008), higher CFS frailty scores (p=0.03), and higher clinical acuity according to the NEWS2 score, were found to be positively correlated to an EDLOS of >4 h. (p=0.001) Any specialty consultation and specialty consultation number, along with hospitalization, were also positively correlated to an EDLOS of >4 h. (p=0.001).

CONCLUSION

High-acuity patients with frailty and dementia are at increased risk for increased EDLOS via consultations. Emergency and consultation physicians should communicate better about which patients are vulnerable to EDLOS case by case, and the patient outcome must be decided as soon as possible.

The effect of point-of-care ultrasound on length of stay and mortality in patients with chest pain/dyspnea

PURPOSE

This study aims to investigate the effects of point-of-care ultrasound (PoCUS) on length of stay (LOS) and mortality in hemodynamically stable patients with chest pain/dyspnea.

MATERIALS AND METHODS

The prospective study was conducted from June 2020 to May 2021. A convenience sample of adult non-traumatic patients with chest pain/dyspnea was included and evaluated by PoCUS. The primary outcome was the relationship between the door-to-PoCUS time and LOS/mortality categorized by the ST-segment elevation (STE) and non-STE on the initial electrocardiogram. The diagnostic accuracy of PoCUS was computed, compared to the final diagnosis.

RESULTS

A total of 465 patients were included. 3 of 18 patients with STE had unexpected cardiac tamponade and 1 had myocarditis with pulmonary edema. PoCUS had a minimal effect on LOS and mortality in patients with STE. In the non-STE group, the shorter door-to-PoCUS time was associated with a shorter LOS (coefficient, 1.26±0.47, p=0.008). After categorizing the timing of PoCUS as 30, 60, 90, and 120 minutes, PoCUS had a positive effect, especially when performed within 90 minutes of arrival, on LOS of less than 360 minutes (OR, 2.42, 95% CI, 1.61-3.64) and patient survival (OR, 3.32, 95% CI, 1.14-9.71). The overall diagnostic performance of PoCUS was 96.6% (95% CI, 94.9-98.2%), but lower efficacy occurred in pulmonary embolism and myocardial infarction.

CONCLUSION

The use of PoCUS was associated with a shorter LOS and less mortality in patients with non-STE, especially when performed within 90 minutes of arrival. Although the effect on patients with STE was minimal, PoCUS played a role in discovering unexpected diagnoses.

Prolonged length of stay and its associated factors at adult emergency department in amhara region comprehensive specialized hospitals, northwest Ethiopia

Background

Prolonged length of stay at the emergency department interferes with the main goal of emergency care and results in adverse patient outcomes like nosocomial infection, dissatisfaction, morbidity, and mortality. Despite this, little is known about the length of stay and the factors that influence it in Ethiopia’s emergency department.

Methods

An institution-based cross-sectional study was conducted on 495 patients admitted at Amhara region comprehensive specialized hospitals emergency department from May 14 to June 15/2022. A systematic random sampling was employed to select study participants. A pretested structured interview-based questionnaire was used to collect data by using Kobo toolbox software. SPSS version 25 was used for data analysis. Bi-variable logistic regression analysis was carried out to select variables with P-value < 0.25. The significance of association was interpreted using an Adjusted Odds Ratio with a 95% confidence interval. Variables with P-value < 0.05 in the multivariable logistic regression analysis were inferred to be significantly associated with length of stay.

Result

Out of 512 enrolled participants, 495 were participated with a response rate of 96.7%. The prevalence of prolonged length of stay in the adult emergency department was 46.5% (95%CI: 42.1, 51.1). Lack of insurance (AOR: 2.11; 95% CI: 1.22, 3.65), non-communicative presentation (AOR: 1.98; 95% CI: 1.07, 3.68), delayed consultation (AOR: 9.5; 95% CI: 5.00, 18.03), overcrowding (AOR: 4.98; 95% CI: 2.13, 11.68), and shift change experience (AOR: 3.67; 95% CI: 1.30, 10.37) were significantly associated with prolonged length of stay.

Conclusion

The result of this study is found to be high based on Ethiopian target emergency department patient length of stay. Lack of insurance, presentation without communication, delayed consultation, overcrowding, and shift change experience were significant factors for prolonged emergency department length of stay. Therefore, interventions like expansion of organizational setup are needed to decrease the length of stay to an acceptable level.

Factors affecting the length of stay in the emergency department for critically Ill patients transferred to regional emergency medical center

AIM

To identify the factors affecting Emergency Department Length of Stay for transferred critically ill patients.

BACKGROUND

The Length of Stay of the transferred patients is an important indicator of Emergency Department service quality; thus, understanding the factors affecting the Emergency Department Length of Stay of transferred critically ill patients is essential.

METHODS

Using the electronic medical records of 968 transferred critically ill Emergency Department patients of a tertiary hospital in Korea, prediction models for Emergency Department Length of Stay were built using various machine learning algorithms.

RESULTS

The logistic regression (AUROC 0.85) models showed the best performance, followed by random forest (AUROC 0.83) and Naive Bayes (AUROC 0.83). The logistic regression model indicated that fewer consultations, the highest acuity level, need for an emergency operation or angiography, need for ICU admission, severe emergency disease and fewer diagnoses were the statistically significant predictors for Emergency Department Length of Stay of 6 h or less.

CONCLUSIONS

The transferred critically ill patients analysed in this study who required immediate or specialized care tended to receive needed care on time at the study site.

IMPLICATIONS FOR NURSING MANAGEMENT

Understanding the factors affecting the Emergency Department Length of Stay of transferred critically ill patients is crucial for developing strategies to manage the nursing resource of Emergency Department successfully.

Length of stay in the emergency department and its associated factors among pediatric patients attending Wolaita Sodo University Teaching and Referral Hospital, Southern, Ethiopia

BACKGROUND

Globally, there is an increase in the need for emergency department visits, which is exceptionally high in pediatric patients, resulting in longer lengths of stay, which is a global challenge and a hospital bottleneck that increases the risk of patient morbidity and mortality while also lowering satisfaction.

OBJECTIVE

This study aimed to assess the length of stay and associated factors in the pediatric emergency department at Wolaita Sodo University Hospital in 2021.

METHODS

An institution-based cross-sectional investigation was undertaken from March 15 to May 15, 2021. The 422 study participants were chosen using a systematic sampling procedure. The data were collected using semi-structured interviewer-administered questionnaires and chart reviews. Epi Data version 4.6 was used to enter the data, while SPSS version 26 was used to analyze it. With a 95% confidence interval, descriptive statistics were used to describe the prevalence, pediatrics, and emergency department duration of stay. The factors related to the length of stay were identified using bivariable and multivariable logistic regression analysis. On the AOR, a significant level was proclaimed when the p-value was less than 0.05, and the confidence interval was less than 95%.

RESULTS

The proportion of prolonged pediatric emergency department length of stay was 79.70% (95% CI; 75.7, 83.6). Nighttime arrival [AOR = 3.19, 95% CI (1.14, 8.98)], weekend arrival [AOR = 4.25, 95% CI (1.49, 5.35)], not receiving ordered medication in the hospital [AOR = 2.05, 95% CI (1.04, 4.03)], orange triage category [AOR = 4.01, 95% CI (1.60, 10.05)], and duration of pain 13-24 h [AOR = 0.29, 95% CI (0.89,0.98)], were significantly associated with length of stay.

CONCLUSION

The percentage of children who stayed in the pediatric emergency department for an extended period was high. Policymakers should implement evidence-based care, maximize existing resources, provide equal access to care and high-quality care, and make pediatric emergency departments more accessible and operationally efficient.

Earlier point-of-care ultrasound, shorter length of stay in patients with acute flank pain

Background

The effects of early integration of point-of-care ultrasound (PoCUS) into patient care are uncertain. This study aims to investigate the effects of early PoCUS on patients with acute flank pain.

Methods

Adult non-traumatic patients with acute flank pain receiving PoCUS were enrolled. Expert physicians reviewed the medical records and made the “final diagnosis” for the cause of acute flank pain. The primary outcome was the relationship between the door to ultrasound (US) time and length of stay (LOS). The secondary outcomes included the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the sonographic diagnosis, compared with the final diagnosis.

Results

Eight hundred and eighty-eight patients were included in the analysis. Patients receiving early PoCUS (≤120 min) had a shorter LOS (128 vs. 217 min, p < 0.0001). Patients in the late POCUS group (> 120 min) had a trend to receive more CT scans. The disease distribution, sensitivity, specificity, PPV, and NPV were similar in patients receiving early or late PoCUS for target diagnoses. After adjusting for the confounders, early PoCUS (OR, 2.77, 95% CIs, 1.93–3.98) had a positive impact on shorter LOS. In addition, the effect of early PoCUS became more prominent (OR, 4.91, 95% CIs, 3.39–7.13) on LOS in less than 3 h.

Conclusions

Early integration of PoCUS is significantly related to shorter LOS in patients with acute flank pain without increasing morbidity and mortality. Our results suggested “PoCUS early” in these patients to possibly alleviate emergency department crowding.

Trial registration NCT04149041 at the ClinicalTrial.gov.

Assessment of the patients' outcomes after implementation of South African triage scale in emergency department, Egypt

PURPOSE

Overcrowding in emergency department (ED) is a concerning global problem and has been identified as a national crisis in some countries. Several emergency sorting systems designed successfully in the world. Launched in 2004, a group of branches in South African triage scale (SATS) developed. The effectiveness of the case sorting system of SATS was evaluated to reduce the patient's length of stay (LOS) and mortality rate within the ED at Suez Canal University Hospital.

METHODS

The study was designed as an intervention study that included a systematic random sample of patients who presented to the ED in Suez Canal University Hospital. This study was implemented in three phases: pre-intervention phase, 115 patients were assessed by the traditional protocols; intervention phase, a structured training program was provided to the ED staff, including a workshop and lectures; and post-intervention phase, 230 patients were assessed by SATS. All the patients were retriaged 2 h later, calculating the LOS per patient and the mortality. Data was collected and entered using Microsoft Excel software. Collected data from the triage sheet were analyzed using the SPSS software program version 22.0.

RESULTS

The LOS in the ED was about 183.78 min before the intervention; while after the training program and the application of SATS, it was reduced to 51.39 min. About 15.7% of the patients died before the intervention; however, after the intervention the ratio decreased to 10.7% deaths.

CONCLUSION

SATS is better at assessing patients without missing important data. Additionally, it resulted in a decrease in the LOS and reduction in the mortality rate compared to the traditional protocol.

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

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

Factors associated with prolonged hospitalization among patients transported by emergency medical services: A population-based study in Osaka, Japan

The emergency medical system, one of the essential elements of public health, has been around for more than 50 years. Although many studies have assessed the factors associated with overcrowding and prolonged length of stay in emergency departments, whether the clinical characteristics and background of a patient are associated with prolonged hospitalization among patients transported by ambulance is unknown. The purpose of this study was to reveal factors associated with the continuation of hospitalization at 21 days after hospital admission among patients transported by ambulance using a population-based patient registry in Osaka, Japan.This was a retrospective observational study whose study period was the three years from January 2016 to December 2018. In this study, we included patients who were hospitalized after transportation by ambulance in Osaka, Japan. The main outcome was continuation of hospitalization at 21 days after hospital admission. We calculated the adjusted odds ratios (AOR) and 95% confidence interval (CI) with a multivariable logistic regression model to assess factors associated with the outcome.We included 481,886 patients in this study, of whom 158,551 remained hospitalized at 21 days after hospital admission and 323,335 had been discharged home by 21 days after hospital admission. Factors associated with prolonged hospitalization were elderly (AOR: 1.767 [95% CI: 1.730-1.805]), traffic accident (AOR: 1.231 [95% CI: 1.183-1.282]), no fixed address (AOR: 4.494 [95% CI: 3.632-5.314]), need for nursing care (AOR: 1.420 [95% CI: 1.397-1.443]) and solitary person (AOR: 1.085 [95% CI: 1.050-1.120]).In this study, the elderly, traffic accidents, no fixed address, need for nursing care, and solitary person were associated with prolonged hospitalization of patients transported by ambulance in Japan.

Analysis of Factors Associated With Length of Stay of Opioid-Related Emergency Department Visits

Introduction and Objective: Emergency department (ED) length of stay (LOS) is an important indicator of the quality of care in ED and is associated with patients’ outcomes and healthcare costs. However, there is limited data on how the patient characteristics affect the ED LOS of opioid-related visits. This study aims to identify and quantify the effect of patient-related characteristics on LOS of opioid-related ED visits.

Methods: This is a retrospective analysis of electronic health records (EHR) of patients with diagnoses of opioid abuse. The study included patients with a diagnosis of opioid abuse who visited the ED at Christiana Care Hospital from January 1, 2017, to December 31, 2018 (N=5,661). The opioid-related visits were identified using ICD-10 diagnosis codes. We used accelerated failure time (AFT) models, a time-to-event analysis approach to evaluate the relationships of different patient characteristics with ED LOS.

Results: The mean age of the study population was 39 years. The study population had 40% female, 20% Black/African American, and 5% Hispanic or Latino. The prevalence of co-use of cocaine and co-use of alcohol was 11%, and 9%, respectively. Also, 58% had mental health comorbidity, and 1% were homeless. The distribution of ED LOS was right-skewed with a median of 4.3 (IQR: 2.6, 6.8). Co-use of alcohol (time ratio, TR: 1.31, CI: 1.23-1.40), co-use of cocaine (TR: 1.18, CI: 1.11-1.25), the presence of mental health comorbidity (TR: 1.05, CI 1.01-1.09), and homelessness (TR: 1.57, CI: 1.32-1.86) were associated with increased ED LOS.

Conclusions: Co-use of alcohol, co-use of cocaine, homelessness, and mental health comorbidity are associated with the longer LOS of opioid-related ED visits.

Quantifying Dynamic Flow of Emergency Department (ED) Patient Managements: A Multistate Model Approach

Background

Emergency department (ED) crowding and prolonged lengths of stay continue to be important medical issues. It is difficult to apply traditional methods to analyze multiple streams of the ED patient management process simultaneously. The aim of this study was to develop a statistical model to delineate the dynamic patient flow within the ED and to analyze the effects of relevant factors on different patient movement rates.

Methods

This study used a retrospective cohort available with electronic medical data. Important time points and relevant covariates of all patients between January and December 2013 were collected. A new five-state Markov model was constructed by an expert panel, including three intermediate states: triage, physician management, and observation room and two final states: admission and discharge. A day was further divided into four six-hour periods to evaluate dynamics of patient movement over time.

Results

A total of 149,468 patient records were analyzed with a median total length of stay being 2.12 (interquartile range = 6.51) hours. The patient movement rates between states were estimated, and the effects of the age group and triage level on these movements were also measured. Patients with lower acuity go home more quickly (relative rate (RR): 1.891, 95% CI: 1.881–1.900) but have to wait longer for physicians (RR: 0.962, 95% CI: 0.956–0.967) and admission beds (RR: 0.673, 95% CI: 0.666–0.679). While older patients were seen more quickly by physicians (RR: 1.134, 95% CI: 1.131–1.139), they spent more time waiting for the final state (for admission RR: 0.830, 95% CI: 0.821–0.839; for discharge RR: 0.773, 95% CI: 0.769–0.776). Comparing the differences in patient movement rates over a 24-hour day revealed that patients wait longer before seen by physicians during the evening and that they usually move from the ED to admission afternoon. Predictive dynamic illustrations show that six hours after the patients' entry, the probability of still in the ED system ranges from 28% in the evening to 38% in the morning.

Conclusions

The five-state model well described the dynamic ED patient flow and analyzed the effects of relevant influential factors at different states. The model can be used in similar medical settings or incorporate different important covariates to develop individually tailored approaches for the improvement of efficiency within the health professions.

Triage Accuracy and Its Association with Patient Factors Using Emergency Severity Index: Findings from United Arab Emirates

Introduction

The Ministry of Health and Prevention of the UAE acquired an electronic medical record system (Wareed) through which they incorporated the Emergency Severity Index as the standard triaging tool. This raised the need to review population dynamics and the accuracy of triage performed by the health-care providers utilizing the tool.

Objective

This research aimed to study demographics and dynamics of the population presenting to emergency departments (EDs) during 2018, evaluate the accuracy of triage assessment using comparative analysis techniques, and determine relationships between patient factors (severity of illness, age-group) and the accuracy of triage.

Methods

This was an observational study that aimed to ascertain findings from ED data over 1 year (January 2018-December 2018) and explore factors associated with reduced accuracy in acuity assignment. We employed comparative analysis to measure the level of agreement between standard guidelines and local findings.

Results

A total of 576,154 patients visited EDs in 2018, of which 54.4% were male. A statistically significant increase in length of stay with increasing severity of illness was observed (Kruskal-Wallis test). Overall triage accuracy was 41.6%, with a positive association with increasing severity of illness. We found a positive association between severity of illness and accuracy of triage (OR 0.14, p=0). We also found on logistic regression that the age-group 11-20 years had the highest probability of accurate triage acuity (R ²=0.41, p=0).

Conclusion

Conducted on a very large data set from the UAE, our study reflects upon population dynamics and triage accuracy distribution among different variables. This study paves the way for further in-depth analysis of factors that may impact triage accuracy within EDs, and utilizing a similar approach it can be replicated in other settings as well.

Emergency Department Boarding of Non-Trauma Patients Adversely Affects Trauma Patient Length of Stay

Introduction Emergency Department (ED) boarding delays initiation of time-sensitive protocols for trauma patients and makes them susceptible to increased mortality and morbidity. In this study, we compared the ED boarding times of non-trauma patients and ED length of stay (LOS) of trauma patients. Methods This was a single-center retrospective cohort study in a Level 1 trauma center. The median boarding time among non-trauma patients and ED LOS among trauma patients was determined by month between the period of April 2018 to March 2019. Linear regression and Pearson correlation coefficient were used to express the magnitude and direction of the relationship between these two variables. Results During the study period, the mean number of non-trauma patients admitted in our ED per month was 1,154 and trauma patients was 89. The mean of the median boarding time per month for non-trauma patients was 76 minutes, and the mean of the median ED LOS per month for trauma patients was 198 minutes. There was a significant positive correlation between boarding time for non-trauma patients and ED LOS for trauma patients (Pearson correlation coefficient: 0.73; p = 0.007). Conclusion The long boarding times for non-trauma patients is associated with ED LOS for trauma patients, indicating that the total patient volume in the hospital contributes to the trauma patient's stay in the ED. Thus, ED LOS of trauma patients can be minimized by improving overall ED and hospital flow, including non-trauma patients.

Two-step predictive model for early detection of emergency department patients with prolonged stay and its management implications

OBJECTIVE

To develop a novel model for predicting Emergency Department (ED) prolonged length of stay (LOS) patients upon triage completion, and further investigate the benefit of a targeted intervention for patients with prolonged ED LOS.

MATERIALS AND METHODS

A two-step model to predict patients with prolonged ED LOS (>16 h) was constructed. This model was initially used to predict ED resource usage and was subsequently adapted to predict patient ED LOS based on the number of ED resources using binary logistic regressions and was validated internally with accuracy. Finally, a discrete event simulation was used to move patients with predicted prolonged ED LOS directly to a virtual Clinical Decision Unit (CDU). The changes of ED crowding status (Overcrowding, Crowding, and Not-Crowding) and savings of ED bed-hour equivalents were estimated as the measures of the efficacy of this intervention.

RESULTS

We screened a total of 123,975 patient visits with final enrollment of 110,471 patient visits. The overall accuracy of the final model predicting prolonged patient LOS was 67.8%. The C-index of this model ranges from 0.72 to 0.82. By implementing the proposed intervention, the simulation showed a 12% (1044/8760) reduction of ED overcrowded status - an equivalent savings of 129.3 ED bed-hours per day.

CONCLUSIONS

Early prediction of prolonged ED LOS patients and subsequent (simulated) early CDU transfer could lead to more efficiently utilization of ED resources and improved efficacy of ED operations. This study provides evidence to support the implementation of this novel intervention into real healthcare practice.

Patterns of paediatric emergency admissions and predictors of prolonged hospital stay at the children emergency room, University of Calabar Teaching Hospital, Calabar, Nigeria

BACKGROUND

There is a high prevalence of paediatric emergency cases in less developed countries. However, prolonged hospital stay at emergency units may further overstretch the facilities.

OBJECTIVE

To assess the patterns of presentations, services offered and predictors of a prolonged stay at the Children Emergency Room of a tertiary hospital in Southern Nigeria.

METHODS

This prospective cross-sectional, study was conducted at the University of Calabar Teaching Hospital, Nigeria from 1st January-31st December 2014. Socio-demographic and clinical characteristics of consecutively recruited children (n=633) were recorded in a proforma. Binary logistic regression was conducted to determine predictors of prolonged stay (>72 hours).

RESULT

The median age of participants was 2 (1 - 4.6) years. Three-fifths of children were admitted at off-hours and the commonest symptom was fever (73.9%). About 16.4% (95%CI:13.6% - 19.4%, n= 103/633) of the children had prolonged stay while those with sepsis had the longest mean stay (65.5±72.1 hours). Children admitted on account of Sickle cell disease (OR:11.2, 95%CI:1.3-95.1, P-value = 0.03), Malaria (OR:10.7, 95%CI:1.4-82.5, P-value = 0.02) or sepsis (OR:10.5, 95%CI:1.3 - 82.7, P-value = 0.03) had higher odds of prolonged hospital stay. There was no significant difference in hospital stay among children admitted by the consultant as compared to other health personnel (P-value = 0.08).

CONCLUSION

Prevention and proper management of Sickle cell disease and malaria reduces paediatric hospital stay in our environment. Paediatric emergency medicine should be re-organized to cater for high volume of off-hour admissions.

Crowding in the emergency department in the absence of boarding - a transition regression model to predict departures and waiting time

Background

Crowding in the emergency department (ED) is associated with increased mortality, increased treatment cost, and reduced quality of care. Crowding arises when demand exceed resources in the ED and a first sign may be increasing waiting time. We aimed to quantify predictors for departure from the ED, and relate this to waiting time in the ED before departure.

Methods

We utilised administrative data from the ED and calculated number of arrivals, departures, and the resulting queue in 30 min time steps for all of 2013 (N = 17,520). We build a transition model for each time step using the number of past departures and pre-specified risk factors (arrivals, weekday/weekend and shift) to predict the expected number of departures and from this the expected waiting time in the ED. The model was validated with data from the same ED collected March through August 2014.

Results

We found that the number of arrivals had the greatest independent impact on departures with an odds ratio of 0.942 (95%CI: 0.937;0.948) corresponding to additional 7 min waiting time per new arrival in a 30 min time interval with an a priori time spend in the ED of two hours. The serial correlation of departures was present up to one and a half hour previous but had very little effect on the estimates of the risk factors. Boarding played a negligible role in the studied ED.

Conclusions

We present a transition regression model with high predictive power to predict departures from the ED utilising only system level data. We use this to present estimates of expected waiting time and ultimately crowding in the ED. The model shows good internal validity though further studies are needed to determine generalisability to the performance in other settings.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0710-3) contains supplementary material, which is available to authorized users.

Impact of Anesthesia on Hospital Mortality and Morbidities in Geriatric Patients Following Emergency Hip Fracture Surgery

OBJECTIVES

To determine the impact of anesthesia type on in-hospital mortality and morbidity for geriatric fragility hip fracture surgery.

DESIGN

Retrospective cohort study.

SETTING

Integrates health care delivery system across 38 facilities in the United States.

PATIENTS/PARTICIPANTS

We identified 16,695 patients 65 years of age and older who underwent emergent hip fracture repairs between 2009 and 2014 through the Kaiser Permanente hip fracture registry and excluded pathologic or bilateral fractures.

INTERVENTION

Hip fracture surgery with general or regional anesthesia.

MAIN OUTCOMES MEASURES

Data on in-hospital mortality, time to death, discharge disposition, and length of stay (LOS) were analyzed among the following anesthesia types: general anesthesia (GA), regional anesthesia (RA), and intraoperative conversions from regional to general (Cv).

RESULTS

Compared with RA, the hazard ratio for GA for in-hospital mortality was 1.38 and 2.23 for the Cv group; the time ratio for GA-associated time to death was 0.97 and 0.89 for the Cv group. The GA-associated time ratio for LOS before discharge was 1.01, and the hazard ratio for home discharge was 0.86, but no significance was found with the Cv group.

CONCLUSIONS

RA may offer advantages over GA for fragility hip fracture surgeries when possible. In-hospital mortality, time to death, increased LOS, and discharge to an institute rather than home were all adversely influenced by GA. Furthermore, the previously understudied Cv group demonstrated adverse outcomes for in-hospital mortality and time to death.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Emergency department length of stay for ethanol intoxication encounters

BACKGROUND

Emergency Department (ED) encounters for ethanol intoxication are becoming increasingly common. The purpose of this study was to explore factors associated with ED length of stay (LOS) for ethanol intoxication encounters.

METHODS

This was a multi-center, retrospective, observational study of patients presenting to the ED for ethanol intoxication. Data were abstracted from the electronic medical record. To explore factors associated with ED LOS, we created a mixed-effects generalized linear model.

RESULTS

We identified 18,664 eligible patients from 6 different EDs during the study period (2012-2016). The median age was 37years, 69% were male, and the median ethanol concentration was 213mg/dL. Median LOS was 348min (range 43-1658). Using a mixed-effects generalized linear model, independent variables associated with a significant increase in ED LOS included use of parenteral sedation (beta=0.30, increase in LOS=34%), laboratory testing (beta=0.21, increase in LOS=23%), as well as the hour of arrival to the ED, such that patients arriving to the ED during evening hours (between 18:00 and midnight) had up to an 86% increase in LOS. Variables not significantly associated with an increase in LOS included age, gender, ethanol concentration, psychiatric disposition, using the ED frequently for ethanol intoxication, CT use, and daily ED volume.

CONCLUSION

Variables such as diagnostic testing, treatments, and hour of arrival may influence ED LOS in patients with acute ethanol intoxication. Identification and further exploration of these factors may assist in developing hospital and community based improvements to modify LOS in this population.

Overcrowding and Its Association With Patient Outcomes in a Median-Low Volume Emergency Department

Background

Crowding occurs commonly in high volume emergency departments (ED) and has been associated with negative patient care outcomes. We aim to assess ED crowding in a median-low volume setting and evaluate associations with patient care outcomes.

Methods

This was a prospective single-center study from November 14, 2016 until December 14, 2016. ED crowding was measured every 2 h by three different estimation tools: National Emergency Department Overcrowding Score (NEDOCS); Community Emergency Department Overcrowding Score (CEDOCS); and Severely-overcrowding Overcrowding and Not-overcrowding Estimation Tool (SONET) categorized under six different levels of crowding (not busy, busy, extremely busy, overcrowded, severely overcrowded, and dangerously overcrowded). Crowding scores were assigned to each patient upon ED arrival. We evaluated the distributions of crowding and patient ED length of stay (ED LOS) across estimation tools. Accelerated failure time models were utilized to estimate time ratios and their corresponding 95% confidence intervals comparing median LOS across levels of crowding within each estimation tool.

Results

This study comprised 2,557 patients whose median ED LOS was 150 min. Approximately 2% of patients arrived during 2 h time intervals deemed overcrowded regardless of the crowding tool used. Median ED LOS increased with the increased level of ED crowding and prolonged median ED LOS (> 150 min) occurred at ED of extremely busy status. Time ratios ranged from 1.09 to 1.48 for NEDOCS, 1.25 - 1.56 for CEDOCS, and 1.26 - 1.72 for SONET.

Conclusion

Overcrowding rarely occurred in study ED with median-low annual volume and might not be a valuable marker for ED crowding report. Though similar patterns of prolonged ED LOS occurred with increased levels of ED crowding, it seems crowding alerts should be initiated during extremely busy status in this ED setting.

Optimal Measurement Interval for Emergency Department Crowding Estimation Tools

STUDY OBJECTIVE

Emergency department (ED) crowding is a barrier to timely care. Several crowding estimation tools have been developed to facilitate early identification of and intervention for crowding. Nevertheless, the ideal frequency is unclear for measuring ED crowding by using these tools. Short intervals may be resource intensive, whereas long ones may not be suitable for early identification. Therefore, we aim to assess whether outcomes vary by measurement interval for 4 crowding estimation tools.

METHODS

Our eligible population included all patients between July 1, 2015, and June 30, 2016, who were admitted to the JPS Health Network ED, which serves an urban population. We generated 1-, 2-, 3-, and 4-hour ED crowding scores for each patient, using 4 crowding estimation tools (National Emergency Department Overcrowding Scale [NEDOCS], Severely Overcrowded, Overcrowded, and Not Overcrowded Estimation Tool [SONET], Emergency Department Work Index [EDWIN], and ED Occupancy Rate). Our outcomes of interest included ED length of stay (minutes) and left without being seen or eloped within 4 hours. We used accelerated failure time models to estimate interval-specific time ratios and corresponding 95% confidence limits for length of stay, in which the 1-hour interval was the reference. In addition, we used binomial regression with a log link to estimate risk ratios (RRs) and corresponding confidence limit for left without being seen.

RESULTS

Our study population comprised 117,442 patients. The time ratios for length of stay were similar across intervals for each crowding estimation tool (time ratio=1.37 to 1.30 for NEDOCS, 1.44 to 1.37 for SONET, 1.32 to 1.27 for EDWIN, and 1.28 to 1.23 for ED Occupancy Rate). The RRs of left without being seen differences were also similar across intervals for each tool (RR=2.92 to 2.56 for NEDOCS, 3.61 to 3.36 for SONET, 2.65 to 2.40 for EDWIN, and 2.44 to 2.14 for ED Occupancy Rate).

CONCLUSION

Our findings suggest limited variation in length of stay or left without being seen between intervals (1 to 4 hours) regardless of which of the 4 crowding estimation tools were used. Consequently, 4 hours may be a reasonable interval for assessing crowding with these tools, which could substantially reduce the burden on ED personnel by requiring less frequent assessment of crowding.

Predicting Length of Stay among Patients Discharged from the Emergency Department-Using an Accelerated Failure Time Model

Background

Emergency department (ED) crowding continues to be an important health care issue in modern countries. Among the many crucial quality indicators for monitoring the throughput process, a patient’s length of stay (LOS) is considered the most important one since it is both the cause and the result of ED crowding. The aim of this study is to identify and quantify the influence of different patient-related or diagnostic activities-related factors on the ED LOS of discharged patients.

Methods

This is a retrospective electronic data analysis. All patients who were discharged from the ED of a tertiary teaching hospital in 2013 were included. A multivariate accelerated failure time model was used to analyze the influence of the collected covariates on patient LOS.

Results

A total of 106,206 patients were included for analysis with an overall medium ED LOS of 1.46 (interquartile range = 2.03) hours. Among them, 96% were discharged by a physician, 3.5% discharged against medical advice, 0.5% left without notice, and only 0.02% left without being seen by a physician. In the multivariate analysis, increased age (>80 vs <20, time ratio (TR) = 1.408, p<0.0001), higher acuity level (triage level I vs. level V, TR = 1.343, p<0.0001), transferred patients (TR = 1.350, p<0.0001), X-rays obtained (TR = 1.181, p<0.0001), CT scans obtained (TR = 1.515, p<0.0001), laboratory tests (TR = 2.654, p<0.0001), consultation provided (TR = 1.631, p<0.0001), observation provided (TR = 8.435, p<0.0001), critical condition declared (TR = 1.205, p<0.0001), day-shift arrival (TR = 1.223, p<0.0001), and an increased ED daily census (TR = 1.057, p<0.0001) lengthened the ED LOS with various effect sizes. On the other hand, male sex (TR = 0.982, p = 0.002), weekend arrival (TR = 0.928, p<0.0001), and adult non-trauma patients (compared with pediatric non-trauma, TR = 0.687, p<0.0001) were associated with shortened ED LOS. A prediction diagram was made accordingly and compared with the actual LOS.

Conclusions

The influential factors on the ED LOS in discharged patients were identified and quantified in the current study. The model’s predicted ED LOS may provide useful information for physicians or patients to better anticipate an individual’s LOS and to help the administrative level plan its staffing policy.

Does Abnormal Laboratory Results Notification with the Short Message Service Shorten Length of Stay in the Pediatric Emergency Department Observation Unit?

BACKGROUND

A new age in communications began with the entry into use of cell phones and their applications. Cell phones and their various applications must be actively used in patient monitoring in the healthcare system.

INTRODUCTION

The purpose of this study was to determine the length of stay in the pediatric emergency department observation unit (PEDOU) based upon the notification of abnormal laboratory results (ALRs) via the short message service (SMS).

MATERIALS AND METHODS

Patients with ALRs notified through the SMS (April-May-June 2015: study period) were evaluated retrospectively, and those admitted to hospital after such notification were enrolled as the study group (SG). Patients presenting to the pediatric emergency department (April-May-June 2014: control period), whose ALRs were not notified through the SMS, and who were hospitalized for treatment, were enrolled as the control group (CG). Age, sex, length of stay in the PEDOU (min), admission diagnosis, and receiving department were recorded for both groups.

RESULTS

Number of patients monitored in the PEDOU was 8584 during the study period and 8507 during the control period (p = 0.27). Length of stay of patients monitored in the PEDOU during the control period (n = 8507) and study period (n = 8584) was 136.4 and 133.5 min, respectively (p = 0.92). One hundred forty-seven patients were enrolled as the SG and 154 as the CG. Length of stay in the PEDOU was 221.1 ± 86.9 (65-542) min in the CG and 154.8 ± 76.6 (15-442) min in the SG (p < 0.001, 95% confidence interval: 47.5-84.8).

CONCLUSIONS

Notification of ALRs through the SMS does not affect length of stay in the PEDOU. Use of this method reduces length of stay of patients who require more rapid hospitalization.