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Malmer G, Åhlberg R, Svensson P, Af Ugglas B, Westerlund E. Age in addition to RETTS triage priority substantially improves 3-day mortality prediction in emergency department patients: a multi-center cohort study. Scand J Trauma Resusc Emerg Med 2023; 31:55. [PMID: 37853463 PMCID: PMC10585720 DOI: 10.1186/s13049-023-01123-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 09/25/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Previous studies have shown varying results on the validity of the rapid emergency triage and treatment system (RETTS), but have concluded that patient age is not adequately considered as a risk factor for short term mortality. Little is known about the RETTS system's performance between different chief complaints and on short term mortality. We therefore aimed to evaluate how well a model including both RETTS triage priority and patient age (TP and age model) predicts 3-day mortality compared to a univariate RETTS triage priority model (TP model). Secondarily, we aimed to evaluate the TP model compared to a univariate age model (age model) and whether these three models' predictive performance regarding 3-day mortality varies between patients with different chief complaints in an unsorted emergency department patient population. METHODS This study was a prospective historic observational cohort study, using logistic regression on a cohort of patients seeking emergency department care in Stockholm during 2012-2016. Patient visits were stratified into the 10 chief complaint categories (CCC) with the highest number of deceased patients within 3 days of arrival, and to "other chief complaints". Patients with priority 1 were excluded. RESULTS The studied cohort contained 1,690,981 visits by 788,046 different individuals. The TP and age model predicted 3-day mortality significantly and substantially better than both univariate models in the total population and in each studied CCC. The age model predicted 3-day mortality significantly and substantially better than the TP model in the total population and for all but three CCCs and was not inferior in any CCC. There were substantial differences between the studied CCCs in the predictive ability of each of the three models. CONCLUSIONS Adding patient age to the RETTS triage priority system significantly and substantially improves 3-day mortality prediction compared to RETTS priority alone. Age alone is a non-inferior predictor of 3-day mortality compared to RETTS priority. The impact on 3-day mortality prediction of adding patient age to RETTS priority varies between CCCs but is substantial for all CCCs and for the total population. Including age as a variable in future revisions of RETTS could substantially improve patient safety.
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Affiliation(s)
- G Malmer
- Karolinska Institutet Department of Clinical Sciences, Danderyd Hospital Division of Medicine, Stockholm, Sweden.
| | - R Åhlberg
- Department of Emergency Medicine, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - P Svensson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - B Af Ugglas
- Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden
| | - E Westerlund
- Karolinska Institutet Department of Clinical Sciences, Danderyd Hospital Division of Medicine, Stockholm, Sweden
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Herlitz S, Ohm J, Häbel H, Ekelund U, Hofmann R, Svensson P. Socioeconomic status is associated with process times in the emergency department for patients with chest pain. J Am Coll Emerg Physicians Open 2023; 4:e13005. [PMID: 37426554 PMCID: PMC10329481 DOI: 10.1002/emp2.13005] [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: 02/09/2023] [Revised: 06/14/2023] [Accepted: 06/22/2023] [Indexed: 07/11/2023] Open
Abstract
Objective Emergency department length of stay (EDLOS) is linked to crowding and patient outcomes whereas worse prognosis in low socioeconomic status remains poorly understood. We studied whether income was associated with ED process times among patients with chest pain. Methods This was a registry-based cohort study on 124,980 patients arriving at 14 Swedish EDs between 2015 and 2019 with chest pain as their chief complaint. Individual-level sociodemographic and clinical data were linked from multiple national registries. The associations between disposable income quintiles, whether the time to physician assessment exceeded triage priority recommendations as well as EDLOS were evaluated using crude and multivariable regression models adjusted for age, gender, sociodemographic variables, and ED-management circumstances. Results Patients with the lowest income were more likely to be assessed by physician later than triage recommendations (crude odds ratio [OR] 1.25 (95% confidence interval [CI] 1.20-1.29) and have an EDLOS exceeding 6 h (crude OR 1.22 (95% CI 1.17-1.27). Among patients subsequently diagnosed with major adverse cardiac events, patients with the lowest income were more likely to be assessed by a physician later than triage recommendations, crude OR 1.19 (95% CI 1.02-1.40). In the fully adjusted model, the average EDLOS was 13 min (5.6%) longer among patients in the lowest income quintile, 4:11 [h:min], (95% CI 4:08-4:13), compared to patients in the highest income quintile, 3:58 (95% CI 3:56-4:00). Conclusions Among ED chest pain patients, low income was associated with longer time to physician than recommended by triage and longer EDLOS. Longer process times may have a negative impact due to crowding in the ED and delay diagnosis and timely treatment of the individual patient.
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Affiliation(s)
- Sebastian Herlitz
- Department of Clinical Science and Education, SödersjukhusetKarolinska InstitutetStockholmSweden
| | - Joel Ohm
- Department of Medicine, SolnaKarolinska InstitutetStockholmSweden
- Coagulation Unit, Department of HematologyKarolinska University Hospital SolnaStockholmSweden
| | - Henrike Häbel
- Department of Learning, Informatics, Management, and Ethics, SolnaKarolinska InstitutetStockholmSweden
| | - Ulf Ekelund
- Emergency Medicine, Department of Clinical Sciences Lund, Lund UniversitySkåne University HospitalLundSweden
| | - Robin Hofmann
- Department of Clinical Science and Education, SödersjukhusetKarolinska InstitutetStockholmSweden
- Department of CardiologySödersjukhusetStockholmSweden
| | - Per Svensson
- Department of Clinical Science and Education, SödersjukhusetKarolinska InstitutetStockholmSweden
- Department of CardiologySödersjukhusetStockholmSweden
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Kusters RWJ, Peters NALR, van Osch FHM, Simons PCG, Hulsbosch MHHM, Janzing HMJ, Barten DG. Primary care access to radiology: Characteristics of trauma patients referred to the emergency department. J Eval Clin Pract 2023; 29:101-107. [PMID: 35851516 PMCID: PMC10084186 DOI: 10.1111/jep.13738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 01/18/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES Low-urgent Emergency Department (ED) attendances are a known contributing factor to ED crowding. In the Netherlands, general practitioners (GPs) have direct access to radiology facilities during office hours. Patients with radiographically confirmed traumatic injuries are subsequently referred to the ED. We analysed these ED trauma patients' characteristics, provided treatments and ED discharge diagnoses to identify the possibility of alternative care pathways. METHODS Single-centre retrospective observational study of trauma patients referred to the ED by the radiology department during office hours (January 2017-December 2017). Data were obtained from patient records. Descriptive statistics were used to analyse the extracted data. RESULTS A total of 662 patients were included. The median age was 42 years (range: 1-100, interquartile range (IQR): 15-63) and patients presented to the ED with a median delay of 1 day (range: 0-112 days, IQR: 0-5). Most patients were referred for injuries involving the upper extremities (61.5%) and lower extremities (30%). A total of 48 additional diagnoses were made in the ED. The majority of injuries was classified as 'minor' (29.5%) or 'moderate' (68.3%) on the Abbreviated Injury Scale (AIS). The median length of stay in the ED was 65 min (range: 7-297 min, IQR: 43-102). CONCLUSION Most patients presented with low acuity injuries and often with a notable delay to the ED. This suggests that the majority of these patients do not necessarily need ED treatment, which may provide an opportunity to counter ED crowding.
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Affiliation(s)
- Renske W J Kusters
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | | | - Frits H M van Osch
- Department of Clinical Epidemiology, VieCuri Medical Center, Venlo, The Netherlands.,Department of Epidemiology, Maastricht University, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Petra C G Simons
- Department of Radiology, VieCuri Medical Center, Venlo, The Netherlands
| | - Mark H H M Hulsbosch
- Department of Orthopedic Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | | | - Dennis G Barten
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, The Netherlands
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Chou SC, Chang YSC, Chen PC, Schuur JD, Weiner SG. Hospital Occupancy and its Effect on Emergency Department Evaluation. Ann Emerg Med 2021; 79:172-181. [PMID: 34756449 DOI: 10.1016/j.annemergmed.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 08/12/2021] [Accepted: 08/23/2021] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To examine whether hospital occupancy was associated with increased testing and treatment during emergency department (ED) evaluations, resulting in reduced admissions. METHODS We analyzed the electronic health records of an urban academic ED. We linked data from all ED visits from October 1, 2010, to May 29, 2015, with daily hospital occupancy (inpatients/total staffed beds). Outcome measures included the frequency of laboratory testing, advanced imaging, medication administration, and hospitalizations. We modeled each outcome using multivariable negative binomial or logistic regression, as appropriate, and examined their association with daily hospital occupancy quartiles, controlling for patient and visit characteristics. We calculated the adjusted outcome rates and relative changes at each daily hospital occupancy quartile using marginal estimating methods. RESULTS We included 270,434 ED visits with a mean patient age of 48.1 (standard deviation 19.8) years; 40.1% were female, 22.8% were non-Hispanic Black, and 51.5% were commercially insured. Hospital occupancy was not associated with differences in laboratory testing, advanced imaging, or medication administration. Compared with the first quartile, the third and fourth quartiles of daily hospital occupancy were associated with decreases of 1.5% (95% confidence interval [CI] -2.9 to -0.2; absolute change -0.6 percentage points [95% CI -1.2 to -0.1]) and 4.6% (95% CI -6.0 to -3.2; absolute change -1.9 percentage points [95% CI -2.5 to -1.3]) in hospitalizations, respectively. CONCLUSION The lack of association between hospital occupancy and laboratory testing, advanced imaging, and medication administration suggest that changes in ED testing or treatment did not facilitate the decrease in admissions during periods of high hospital occupancy.
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Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI.
| | - Yeu-Shin C Chang
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Paul C Chen
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
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Hoot NR, Banuelos RC, Chathampally Y, Robinson DJ, Voronin BW, Chambers KA. Does crowding influence emergency department treatment time and disposition? J Am Coll Emerg Physicians Open 2021; 2:e12324. [PMID: 33521777 PMCID: PMC7819268 DOI: 10.1002/emp2.12324] [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: 08/29/2020] [Revised: 10/21/2020] [Accepted: 10/28/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The objective of this study was to determine whether crowding influences treatment times and disposition decisions for emergency department (ED) patients. METHODS We conducted a retrospective cohort study at 2 hospitals from January 1, 2014, to July 1, 2014. Adult ED visits with dispositions of discharge, admission, or transfer were included. Treatment times were modeled by linear regression with log-transformation; disposition decisions (admission or transfer vs discharge) were modeled by logistic regression. Both models adjusted for chief complaint, Emergency Severity Index (ESI), and 4 crowding metrics in quartiles: waiting count, treatment count, boarding count, and National Emergency Department Overcrowding Scale. RESULTS We included 21,382 visits at site A (12.9% excluded) and 29,193 at site B (15.0% excluded). Respective quartiles of treatment count increased treatment times by 7.1%, 10.5%, and 13.3% at site A (P < 0.001) and by 4.0%, 6.5%, and 10.2% at site B (P < 0.001). The fourth quartile of treatment count increased estimates of treatment time for patients with chest pain and ESI level 2 from 2.5 to 2.9 hours at site A (20 minutes) and from 3.0 to 3.3 hours at site B (18 minutes). Treatment times decreased with quartiles of waiting count by 5.6%, 7.2%, and 7.3% at site B (P < 0.001). Odds of admission or transfer increased with quartiles of waiting count by 8.7%, 9.6%, and 20.3% at site A (P = 0.011) and for the third (11.7%) and fourth quartiles (27.3%) at site B (P < 0.001). CONCLUSIONS Local crowding influenced ED treatment times and disposition decisions at 2 hospitals after adjusting for chief complaint and ESI.
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Affiliation(s)
- Nathan R. Hoot
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Rosa C. Banuelos
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Yashwant Chathampally
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - David J. Robinson
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Benjamin W. Voronin
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Kimberly A. Chambers
- Department of Emergency MedicineMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonTexasUSA
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Impact of COVID-19 Pandemic on the Overall Diagnostic and Therapeutic Process for Patients of Emergency Department and Those with Acute Cerebrovascular Disease. J Clin Med 2020; 9:jcm9123842. [PMID: 33256204 PMCID: PMC7760535 DOI: 10.3390/jcm9123842] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 01/01/2023] Open
Abstract
(1) Background: During a pandemic, patients and processes in the emergency department (ED) change. These circumstances affect the length of stay (LOS) or degree of crowding in the ED. The processes for patients with acute critical illness, such as cerebrovascular disease (CVD), can be also delayed. Using the process mining (PM) method, this study aimed to evaluate LOS, ED processes for CVD, and delayed processes during the coronavirus disease 2019 (COVID-19) pandemic. (2) Methods: Data were collected from the Clinical Data Warehouse of a medical center. Phase 1 included patients who visited the ED before the COVID-19 outbreak. In Phase 2, post-COVID-19 ED patients were divided into the COVID-19 tested group (CTG) and COVID-19 not tested group (CNTG) according to whether polymerase chain reaction test was performed. We analyzed patients' ED processes before and after COVID-19 using the PM method. We analyzed patients with acute CVD separately to determine whether the process and LOS of patients with acute critical illness were changed or delayed. (3) Results: After the COVID-19 outbreak, the overall LOS was delayed and all processes in CTG patients were delayed. Registration to triage and triage were delayed in both CTG and CNTG patients. The brain imaging process for CTG patients with acute CVD was also delayed. (4) Conclusion: After a pandemic, some processes were changed, new processes were developed, and processes for patients with acute CVD who needed proper time management were not exempted.
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Outcomes of Establishing an Urgent Care Centre in the Same Location as an Emergency Department. SUSTAINABILITY 2020. [DOI: 10.3390/su12198190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The emergency department (ED) is one of the busiest facilities in a hospital, and it is frequently described as a bottleneck that limits space and structures, jeopardising surge capacity during Major Incidents and Disasters (MIDs) and pandemics such as the COVID 19 outbreak. One remedy to facilitate surge capacity is to establish an Urgent Care Centre (UCC), i.e., a secondary ED, co-located and in close collaboration with an ED. This study investigates the outcome of treatment in an ED versus a UCC in terms of length of stay (LOS), time to physician (TTP) and use of medical services. If it was possible to make these parameters equal to or even less than the ED, UCCs could be used as supplementary units to the ED, improving sustainability. The results show reduced waiting times at the UCC, both in terms of TTP and LOS. In conclusion, creating a primary care-like facility in close proximity to the hospitals may not only relieve overcrowding of the hospital’s ED in peacetime, but it may also provide an opportunity for use during MIDs and pandemics to facilitate the victims of the incident and society as a whole.
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Prolonged In-hospital Time to Appendectomy is Associated With Increased Complicated Appendicitis in Children. Ann Surg 2020; 275:1200-1205. [PMID: 32740232 DOI: 10.1097/sla.0000000000004316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the association between prolonged in-hospital time to appendectomy (TTA) and the risk of complicated appendicitis. SUMMARY BACKGROUND DATA Historically, acute appendicitis was treated with emergency appendectomy. More recently, practice patterns have shifted to urgent appendectomy, with acceptable in-hospital delays of up to 24 hours. However, the consequences of prolonged TTA remain poorly understood. Herein, we present the largest individual analysis to date of outcomes associated with prolonged in-hospital delay before appendectomy in children. METHODS Data from patients who underwent appendectomy within 24 hours of hospital presentation were obtained from the American College of Surgeons Pediatric National Surgical Quality Improvement Program Procedure Targeted Appendectomy database from 2016 to 2018. Appendectomy within 16 hours of presentation was considered early, whereas those between 16 to 24 hours were defined as late. The primary outcome was operative findings of complicated appendicitis. Secondary outcomes included 30-day complications and resource utilization. RESULTS This study consisted of 18,927 patients, with 20.6% undergoing late appendectomy. The rate of complicated appendicitis was significantly higher in the late group (Early: 26.3%, Late: 30.3%, P < 0.05). Additionally, the late group had longer operative times, increased need for postoperative percutaneous drainage, antibiotics at discharge, parenteral nutrition, and an extended hospital length of stay (P < 0.05). On multivariate analysis, late appendectomy remained a predictor of complicated disease (odds ratio 1.17 [95% confidence interval, 1.08-1.27]). CONCLUSIONS A significant proportion of pediatric patients with acute appendicitis experience prolonged in-hospital delays before appendectomy, which are associated with modestly increased rates of complicated appendicitis. Although this does not indicate appendectomy needs to be done emergently, prolonged in-hospital TTA should be avoided whenever possible.
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Shah R, Leno R, Sinert R. Impact of Provider-In-Triage in a Safety-Net Hospital. J Emerg Med 2020; 59:459-465. [PMID: 32595053 DOI: 10.1016/j.jemermed.2020.04.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/17/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Increasing emergency department (ED) utilization has contributed to ED overcrowding, with longer ED length of stay (EDLOS) and more patients leaving without being seen (LWBS), and is associated with higher morbidity and mortality rates. Previous studies of provider in triage (PIT) have shown decreased LWBS, but variable improvements in EDLOS. OBJECTIVES We evaluated the impact of PIT implementation in an urban safety-net hospital on commonly reported ED throughput metrics. METHODS This before-and-after study was performed at an academic urban safety hospital. We implemented a PIT team that screened ambulatory ED patients for early discharge or expedited workup. The PIT intervention was implemented 3 days a week from January through April 2019. As controls, we compared throughput metrics from when PIT was unavailable (Group 2) and from 1 year prior (Group 3). RESULTS There were significantly (p < 0.001) lower rates of LWBS in Group 1 (4.8%, 95% confidence interval [CI] 4.1-5.8%) compared with 2 (7.3%, 95% CI 5.5-9.7%) and 3 (7.8%, 95% CI 6.9-9.0%). Door-to-doctor times were significantly (p < 0.001) lower for Group 1 (148 min, interquartile range [IQR] 88, 226 min) compared with 2 (187 min, IQR 95.5, 266 min) and 3 (215 min, IQR 131, 290 min). EDLOS was significantly (p < 0.001) shorter for Group 1 (337 min, IQR 215, 468 min) compared with 2 (385 min, IQR 271, 516 min) and 3 (413 min, IQR 299, 538 min). CONCLUSIONS We found significantly lower LWBS rates, shorter EDLOS, and shorter door-to-doctor times after PIT implementation. Compared with previous studies in a variety of settings, we found that PIT significantly improved LWBS and all throughput metrics in a safety net setting.
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Affiliation(s)
- Rushabh Shah
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, New York; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Richard Leno
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, New York; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Richard Sinert
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, New York; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York
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Zaboli A, Turcato G, Solazzo P, Sorrento D, Zorzi E, Marsoner T, Magnarelli G, Pfeifer N. Effectiveness of Manchester Triage System in risk prioritisation of patients with pulmonary embolism who present dyspnoea, chest pain or collapse. Int Emerg Nurs 2020; 50:100842. [PMID: 32205103 DOI: 10.1016/j.ienj.2020.100842] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 12/17/2019] [Accepted: 01/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Recognising patients with pulmonary embolism continues to be a clinical challenge. In the Emergency Department, up to 50% of patients with pulmonary embolism can be delayed or even misdiagnosed. The ability of a triage system to correctly prioritise suspected embolism in these patients is fundamental for determining diagnostic-therapeutic procedures. AIM To verify the effectiveness of the Manchester Triage System in risk prioritisation of patients with pulmonary embolism who present with dyspnoea, chest pain, or collapse. METHODS In this observational, retrospective, study the sensitivity, specificity, and positive and negative predictive values of the Manchester Triage System were calculated using the triage classification for these patients, and their established diagnoses. The analysis included baseline characteristics and triage evaluations. RESULTS During the two-year study period, 7055 patients were enrolled. Pulmonary embolism episodes were 2.1% of all cases, while severe pulmonary embolisms were 0.8%. The estimated specificity of the Manchester Triage System was 72.5% (CI 95%, 71.5-73.6), and the negative predictive value was 98.1% (CI 95%, 97.7-98.5). The results suggest that clinical characteristics leading to a high Manchester Triage System priority are similar to those characterising a pulmonary embolism episode. CONCLUSIONS Although pulmonary embolism is difficult to diagnose, the Manchester Triage System is an effective tool for prioritising patients with symptoms of this disease.
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Affiliation(s)
- Arian Zaboli
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria dell'Alto Adige, Merano 39012 (BZ), Bolzano, Italy
| | - Gianni Turcato
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria dell'Alto Adige, Merano 39012 (BZ), Bolzano, Italy.
| | - Pasquale Solazzo
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria dell'Alto Adige, Merano 39012 (BZ), Bolzano, Italy; Manchester Triage Group Italy, Merano 39012 (BZ), Bolzano, Italy
| | | | - Elisabetta Zorzi
- Department of Cardiology, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio 37047 (VR), Verona, Italy
| | - Tania Marsoner
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria dell'Alto Adige, Merano 39012 (BZ), Bolzano, Italy
| | - Gabriele Magnarelli
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria dell'Alto Adige, Merano 39012 (BZ), Bolzano, Italy; Manchester Triage Group Italy, Merano 39012 (BZ), Bolzano, Italy
| | - Norbert Pfeifer
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria dell'Alto Adige, Merano 39012 (BZ), Bolzano, Italy; Manchester Triage Group Italy, Merano 39012 (BZ), Bolzano, Italy
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Chen CH, Hsieh JG, Cheng SL, Lin YL, Lin PH, Jeng JH. Early short-term prediction of emergency department length of stay using natural language processing for low-acuity outpatients. Am J Emerg Med 2020; 38:2368-2373. [PMID: 32216994 DOI: 10.1016/j.ajem.2020.03.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/08/2020] [Accepted: 03/09/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Low-acuity outpatients constitute the majority of emergency department (ED) patients, and these patients often experience an unpredictable length of stay (LOS). Effective LOS prediction might improve the quality of ED care and reduce ED crowding. OBJECTIVE The objective of this study was to explore the potential of natural language processing (NLP) of the first ED physicians' clinical notes and to evaluate NLP-based short-term prediction models based on mixed-type clinical data. METHODS A retrospective study was conducted at an ED of a tertiary teaching hospital in Taiwan from January 2017 to June 2017. In total, 12,962 low-acuity outpatients were enrolled. Using structured data (e.g., demographic variables and vital signs) and different sections of the first SOAP notes as predictors, we developed six NLP-based prediction models (i.e., term frequency-inverse document frequency (TF-IDF) and truncated singular value decomposition (SVD)) to predict LOS. The metric for model evaluation is the mean squared error (MSE). RESULTS Of the six NLP-based models, the model using structured data and all the sections of the first SOAP notes processed by the TF-IDF and truncated SVD method performed the best, with an MSE of 3.00 [95% CI: 2.94-3.06]. In addition, ten important topics extracted by the TF-IDF and truncated SVD method had significant effects on the LOS (p < 0.001). CONCLUSION NLP-based models can be used as an early short-term prediction of LOS and have the potential for mixed-type clinical data analysis. The proposed models would likely aid ED physicians' decision-making processes and improve ED quality of care.
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Affiliation(s)
- Chien-Hua Chen
- Department of Electrical Engineering, I-Shou University, Kaohsiung, Taiwan; Department of Emergency Medicine, Taichung Veterans General Hospital Chiayi Branch, Chia-Yi, Taiwan
| | - Jer-Guang Hsieh
- Department of Electrical Engineering, I-Shou University, Kaohsiung, Taiwan
| | - Shu-Ling Cheng
- Department of Multimedia and Game Developing Management, Far East University, Tainan, Taiwan.
| | - Yih-Lon Lin
- Department of Information Engineering, I-Shou University, Kaohsiung, Taiwan
| | - Po-Hsiang Lin
- Department of Electrical Engineering, I-Shou University, Kaohsiung, Taiwan; Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Jyh-Horng Jeng
- Department of Information Engineering, I-Shou University, Kaohsiung, Taiwan
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Ghaleb WEA, Almemari A, Qayyum H. 'See and Treat' Clinic Service Evaluation at a Tertiary Care Hospital in Abu Dhabi. Oman Med J 2020; 35:e104. [PMID: 32181006 PMCID: PMC7060901 DOI: 10.5001/omj.2020.22] [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: 10/25/2018] [Accepted: 05/19/2019] [Indexed: 12/05/2022] Open
Abstract
Objectives We sought to evaluate the performance provided at a ‘See and Treat’ (ST) clinic at a tertiary hospital emergency department (ED) in Abu Dhabi, UAE, and to assess its impact on ED crowding. Methods We conducted a retrospective electronic medical chart review and database analyses. We included patients triaged as triage level 4 (T4) and triage level 5 (T5) as per the Emergency Severity Index treated at ED in the ST clinic and other ED areas, including the off-site Urgent Care Centre (UCC) between 1 June 2016 and 30 June 2017. We analyzed a group of process and outcome measures at our ST clinic and compared them to the same measures in other areas of our ED and the co-located UCC. The process measure analyzed was the door-to-doctor time. In addition, the outcome measures analyzed were the door-to-door time, unplanned return within 72 hours, and feedback from T4 and T5 triaged patients treated at the clinic. Results The number of patients enrolled in the study was 43 109. Of these, 11 329 (26.3%) patients were treated at the ST clinic, 6328 (14.7%) were treated at the UCC, and 25 452 (59.0%) were treated at the main ED. The door-to-doctor time was within 30 minutes for 89.0% of ST clinic patients, and 94.0% of patients experienced a door-to-door time of within two hours; 2.1% of these patients returned within 72 hours. Among these, 78.7% returned for an issue related to their first visit. However, none of the patients were admitted on their return visit. For patients presenting to UCC and other parts of our ED, we recorded a door-to-doctor time of within 30 minutes for 80.5% of patients and a door-to-door time of within two hours for 73.0% of patients. We found the difference in waiting times (i.e., door-to-doctor times between ST clinic patients and the rest of ED) to be statistically significant (p < 0.001, 95% confidence interval (CI): 0.56–0.63). However, on comparing door-to-door times, we found the difference between ST clinic patients and the rest of ED patients was not statistically significant. Conclusions Door-to-doctor times were shorter in ST clinics compared to other parts of our ED, but there was no statistically significant difference in door-to-door times when comparing ST clinics to the rest of the ED. ST clinic patients had a lower rate of unplanned return within 72 hours, of which, none required admission on the return attendance. We believe ST clinics have a positive impact on reducing ED crowding but acknowledge they are one of the many plausible solutions attributing to optimized patient flow in the ED.
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Affiliation(s)
| | - Ayesha Almemari
- Emergency Medicine and Critical Care, Mafraq Hospital, Abu Dhabi, UAE
| | - Hasan Qayyum
- Emergency Medicine, Mafraq Hospital, Abu Dhabi, UAE
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Blood sampling during nurse triage reduces patient length of stay in the emergency department: A propensity score-weighted, population-based study. Int Emerg Nurs 2020; 49:100826. [PMID: 32046951 DOI: 10.1016/j.ienj.2019.100826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/12/2019] [Accepted: 11/29/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Increases in patients' length of stay (LOS) in the emergency department (ED) have led to overcrowding. OBJECTIVES In this study, the implementation of blood sampling during triage in lower priority level patients was assessed as a possible means to reduce LOS. METHODS A retrospective study was performed from January 2018 to January 2019. Lower priority level patients who required blood sampling for further diagnosis were considered. Patients who underwent blood sampling during triage evaluation were compared with those who underwent blood sampling after a physician's initial evaluation. RESULTS During the study period, 15,596 patients were enrolled. LOS was shorter in patients who underwent triage blood sampling, presenting a median value of 154 min in comparison with the 172 min recorded in the control group (p < 0.001). Using a propensity score-matching to control the two groups' differences, LOS remained lower in the triage-sampling group (151 vs. 175 min; p < 0.001). In the adjusted multivariate model, triage blood sampling was found to be an independent factor for a decrease in the LOS, with standardized coefficient β = 0.857 (0.822-0.894; p < 0.001). CONCLUSIONS Performing blood sampling during nurse triage can decrease LOS in ED and also reduce ED permanence after a physician's initial evaluation.
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Steren B, Fleming M, Zhou H, Zhang Y, Pei KY. Predictors of Delayed Emergency Department Throughput Among Blunt Trauma Patients. J Surg Res 2019; 245:81-88. [PMID: 31404894 DOI: 10.1016/j.jss.2019.07.028] [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: 02/26/2019] [Revised: 06/21/2019] [Accepted: 07/12/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Delayed emergency department (ED) LOS has been associated with increased mortality and increased hospital length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, workup, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED for trauma patients remain unclear. METHODS The Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of ED LOS, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS trauma verification level, geographic region), abbreviated injury scale and comorbid status. RESULTS 412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 y resulted in 0.63 increased minutes in the ED (P < 0.001). In multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status, and northeast region were associated with increased ED LOS. Black and Hispanic patients spent on average 41 and 42 more minutes, respectively, in the ED room when compared with white patients (P < 0.001). Patients seen at University hospitals spent 52 more minutes in the ED when compared with community hospitals, whereas patients at nonteaching hospitals spent 31 fewer minutes (P < 0.001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 45, 36, and 89 more minutes, respectively (P < 0.001). Non-Medicaid patients at level 1 trauma centers and those requiring intensive care admission had significantly decreased ED LOS. Medicaid patients took the longest to move through the ED with Medicare, BlueCross, and Private insurance outpacing them by 17, 23, and 23 min, respectively (P < 0.001). ACS level 1 trauma centers moved patients through the ED fastest, whereas ACS level II trauma centers and level III trauma centers moved patients through 50 and 130 min slower when compared with ACS level 1 trauma centers (P < 0.001). CONCLUSIONS ED LOS varied significantly by patient and hospital characteristics. Medicaid patients and those patients at university hospitals were associated with significantly higher ED LOS, whereas ACS trauma verification level status had strong correlation with ED LOS. These results may allow targeted quality improvement programs to enhance ED LOS.
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Affiliation(s)
- Benjamin Steren
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew Fleming
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Haoran Zhou
- Yale University School of Medicine, Section of Surgical Outcomes and Epidemiology, New Haven, Connecticut
| | - Yawei Zhang
- Yale University School of Medicine, Section of Surgical Outcomes and Epidemiology, New Haven, Connecticut
| | - Kevin Y Pei
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut; Department of Surgery, Texas Tech University of Health Sciences Center, School of Medicine, Lubbock, Texas.
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Wabe N, Li L, Dahm MR, Lindeman R, Yimsung R, Clezy K, Thomas J, Varndell W, Westbrook J, Georgiou A. Timing of respiratory virus molecular testing in emergency departments and its association with patient care outcomes: a retrospective observational study across six Australian hospitals. BMJ Open 2019; 9:e030104. [PMID: 31399462 PMCID: PMC6701571 DOI: 10.1136/bmjopen-2019-030104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE A rapid molecular diagnostic test (RMDT) offers a fast and accurate detection of respiratory viruses, but its impact on the timeliness of care in the emergency department (ED) may depend on the timing of the test. The aim of the study was to determine if the timing of respiratory virus testing using a RMDT in the ED had an association with patient care outcomes. DESIGN Retrospective observational study. SETTING Linked ED and laboratory data from six EDs in New South Wales, Australia. PARTICIPANTS Adult patients presenting to EDs during the 2017 influenza season and tested for respiratory viruses using a RMDT. The timing of respiratory virus testing was defined as the time from a patient's ED arrival to time of sample receipt at the hospital laboratory. OUTCOME MEASURES ED length of stay (LOS), >4 hour ED LOS and having a pending RMDT result at ED disposition. RESULTS A total of 2168 patients were included. The median timing of respiratory virus testing was 224 min (IQR, 133-349). Every 30 min increase in the timing of respiratory virus testing was associated with a 24.0 min increase in the median ED LOS (95% CI, 21.8-26.1; p<0.001), a 51% increase in the likelihood of staying >4 hours in ED (OR, 1.51; 95% CI, 1.41 to 1.63; p<0.001) and a 4% increase in the likelihood of having a pending RMDT result at ED disposition (OR, 1.04; 95% CI, 1.02 to 1.05; p<0.001) after adjustment for confounders. CONCLUSION The timing of respiratory virus molecular testing in EDs was significantly associated with a range of outcome indicators. Results suggest the potential to maximise the benefits of RMDT by introducing an early diagnostic protocol such as triage-initiated testing.
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Affiliation(s)
- Nasir Wabe
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, New South Wales, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, New South Wales, Australia
| | - Maria R Dahm
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, New South Wales, Australia
| | - Robert Lindeman
- Clinical Operations, NSW Health Pathology, Chatswood, New South Wales, Australia
| | - Ruth Yimsung
- Clinical Operations, NSW Health Pathology, Chatswood, New South Wales, Australia
| | - Kate Clezy
- Infectious Diseases Department, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Judith Thomas
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, New South Wales, Australia
| | - Wayne Varndell
- Emergency Department, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, New South Wales, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, New South Wales, Australia
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Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS One 2018; 13:e0203316. [PMID: 30161242 PMCID: PMC6117060 DOI: 10.1371/journal.pone.0203316] [Citation(s) in RCA: 571] [Impact Index Per Article: 95.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/17/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Emergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions. AIM The aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding. METHOD The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A structured search of four databases (Medline, CINAHL, EMBASE and Web of Science) was undertaken to identify peer-reviewed research publications aimed at investigating the causes or consequences of, or solutions to, emergency department crowding, published between January 2000 and June 2018. Two reviewers used validated critical appraisal tools to independently assess the quality of the studies. The study protocol was registered with the International prospective register of systematic reviews (PROSPERO 2017: CRD42017073439). RESULTS From 4,131 identified studies and 162 full text reviews, 102 studies met the inclusion criteria. The majority were retrospective cohort studies, with the greatest proportion (51%) trialling or modelling potential solutions to emergency department crowding. Fourteen studies examined causes and 40 investigated consequences. Two studies looked at both causes and consequences, and two investigated causes and solutions. CONCLUSIONS The negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. This review identified a mismatch between causes and solutions. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Solutions aimed at the introduction of whole-of-system initiatives to meet timed patient disposition targets, as well as extended hours of primary care, demonstrated promising outcomes. While the review identified increased presentations by the elderly with complex and chronic conditions as an emerging and widespread driver of crowding, more research is required to isolate the precise local factors leading to ED crowding, with system-wide solutions tailored to address identified causes.
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Affiliation(s)
- Claire Morley
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Maria Unwin
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
| | - Gregory M. Peterson
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Jim Stankovich
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
| | - Leigh Kinsman
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
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