Factors Associated With First Medication Time for Children Treated in the Emergency Department for Asthma

Assessing the reliability of pediatric emergency medicine billing code assignment for future consideration as a proxy workload measure

OBJECTIVES

Prediction of pediatric emergency department (PED) workload can allow for optimized allocation of resources to improve patient care and reduce physician burnout. A measure of PED workload is thus required, but to date no variable has been consistently used or could be validated against for this purpose. Billing codes, a variable assigned by physicians to reflect the complexity of medical decision making, have the potential to be a proxy measure of PED workload but must be assessed for reliability. In this study, we investigated how reliably billing codes are assigned by PED physicians, and factors that affect the inter-rater reliability of billing code assignment.

METHODS

A retrospective cross-sectional study was completed to determine the reliability of billing code assigned by physicians (n = 150) at a quaternary-level PED between January 2018 and December 2018. Clinical visit information was extracted from health records and presented to a billing auditor, who independently assigned a billing code-considered as the criterion standard. Inter-rater reliability was calculated to assess agreement between the physician-assigned versus billing auditor-assigned billing codes. Unadjusted and adjusted logistic regression models were used to assess the association between covariables of interest and inter-rater reliability.

RESULTS

Overall, we found substantial inter-rater reliability (AC2 0.72 [95% CI 0.64-0.8]) between the billing codes assigned by physicians compared to those assigned by the billing auditor. Adjusted logistic regression models controlling for Pediatric Canadian Triage and Acuity scores, disposition, and time of day suggest that clinical trainee involvement is significantly associated with increased inter-rater reliability.

CONCLUSIONS

Our work identified that there is substantial agreement between PED physician and a billing auditor assigned billing codes, and thus are reliably assigned by PED physicians. This is a crucial step in validating billing codes as a potential proxy measure of pediatric emergency physician workload.

Initial emergency department vital signs may predict PICU admission in pediatric patients presenting with asthma exacerbation

OBJECTIVE

Severe asthma exacerbations account for a large share of asthma morbidity, mortality, and costs. Here, we aim to identify early predictive factors associated with pediatric intensive care unit (PICU) admission.

METHODS

We performed a retrospective observational study of 5,185 emergency department (ED) encounters at a large children's hospital, including 86 (1.7%) resulting in PICU admission between 10/1/2015 and 8/7/2018 with ICD9/ICD10 codes for "asthma," "bronchospasm," or "wheezing." Vital signs and demographic information were obtained from electronic health record data and analyzed for each encounter. Predictive factors were identified using adjusted regression models, and our primary outcome was PICU admission.

RESULTS

Higher mean heart rates (HRs) and respiratory rates (RRs), and lower SpO2 within the first hour of ED presentation were independently associated with PICU admission. Odds of PICU admission increased 70% for each 10 beats/min higher HR, 125% for each 10 breaths/min higher RR, and 34% for each 5% lower SpO2. A binary predictive index using 1-h vitals yielded OR 13.4 (95% CI 8.1-22.1) for PICU admission, area under receiver operator characteristic (AUROC) curve 0.84 and overall accuracy of 80.1%. Results were largely unchanged (AUROC 0.84-0.88) after adjusting for surrogates of asthma severity and initial ED management. In combination with a secondary standardized clinical asthma distress score, positive predictive value increased by sevenfold (6.1%-46%).

CONCLUSIONS

A predictive index using HR, RR, and SpO2 within the first hour of ED presentation accurately predicted PICU admission in this cohort. Automated vital signs trend analysis may help identify vulnerable patients quickly upon presentation.

Emergency department crowding negatively influences outcomes for adults presenting for chronic obstructive pulmonary disease

OBJECTIVES

Emergency department (ED) crowding leads to poor outcomes. Patients with respiratory conditions like chronic obstructive pulmonary disease (COPD) are especially vulnerable to crowding-related delays in care. We aimed to assess the associations of ED crowding metrics with outcomes for patients presenting with COPD.

METHODS

We conducted a population-based cohort study of adult patients presenting with a diagnosis of COPD to 18 high-volume EDs between 2014 and 2019 in Alberta, Canada. Administrative databases provided date and time data on key stages of the presentation including physician initial assessment and disposition decision. Crowding metrics were calculated using facility-specific median physician initial assessment and length of stay. Patient presentations were grouped by acuity and mixed-effects regression models were fit to adjust for the clustering at the facility level.

RESULTS

There were 49,085 presentations for COPD made by 25,734 patients (median age = 73 years). A 1-h increase in the physician initial assessment metric was associated with an increase in physician initial assessment for COPD patients by 23, 53, and 59 min for the high, moderate, and low acuity groups, respectively, adjusted for other predictors. For the low acuity group, this metric was associated with an increased length of stay of 73 min for admitted individuals. Similarly, an increase in the length of stay metric was also associated with an increased likelihood of being admitted for all acuity groups.

CONCLUSIONS

For patients with COPD, ED crowding results in delays in assessment increased length of stay, and increased proportion of patients admitted. These results suggest that ED crowding mitigation efforts to provide timely care for patients with COPD are urgently needed.

TRIAL REGISTRATION

N/A.

Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List

Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.

The Value of Emergency Nursing Mode in the Treatment of Patients with Traumatic Shock

OBJECTIVE

To study the value of emergency nursing mode in patients with traumatic shock.

METHODS

76 patients with traumatic shock in our hospital from March 2019 to February 2021 were selected and divided into study group and control group according to different rescue modes, 38 cases in each group. The study group adopted emergency nursing mode for rescue, while the control group adopted routine nursing mode for rescue. The rescue intervention, emergency stay and preoperative preparation time, rescue success rate, emergency rescue effect, complications, and satisfaction rate of patients and their families for rescue were compared between the two groups.

RESULTS

The rescue intervention, emergency stay and preoperative preparation time of the study group were significantly shorter than those of the control group, and the difference was statistically significant (P < 0.05). The rescue success rate of the study group was 97.37%, which was significantly higher than 84.21% of the control group, and the difference was statistically significant (P < 0.05). The improvement rate of the study group was significantly higher than that of the control group, the disability rate was significantly lower than that of the control group, the overall emergency rescue effect was better than that of the control group, and the difference was statistically significant (P < 0.05). The incidence of complications in the study group was 2.63%, which was significantly lower than 23.68% in the control group (P < 0.05). The satisfaction rate of patients and their families in the study group was 97.37%, which was significantly higher than 84.21% in the control group (P < 0.05).

CONCLUSION

Emergency nursing mode in patients with traumatic shock owns higher rescue value, can buy time for the operation, improve the success rate and effect of rescue, make safety and satisfaction higher. Overall, for patients with traumatic shock, emergency nursing mode is better than conventional rescue nursing.