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Kramer AW, Erlich J, Yaphockun K, Roderick D, Farkas K, Bryl AW, Pade KH. Reducing Time from Pediatric Emergency Department Arrival to Dexamethasone Administration in Wheezing Patients. Pediatr Qual Saf 2024; 9:e738. [PMID: 38868756 PMCID: PMC11167218 DOI: 10.1097/pq9.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/16/2024] [Indexed: 06/14/2024] Open
Abstract
Introduction Asthma exacerbations are common presentations to pediatric emergency departments. Standard treatment for moderate-to-severe exacerbations includes administration of oral corticosteroids concurrently with bronchodilators. Early administration of corticosteroids has been shown to decrease emergency department length of stay (LOS) and hospitalizations. Our SMART aim was to reduce the time from arrival to oral corticosteroids (dexamethasone) administration in pediatric patients ≥2 years of age with an initial Pediatric Asthma Severity Score >6 from 60 to 30 minutes within 6 months. Methods We used the model for improvement with collaboration between ED physicians, nursing, pharmacy, and respiratory therapists. Interventions included nursing education, dosage rounding in the electronic medical record, supplying triage with 1-mg tablets and a pill crusher, updates to an asthma nursing order set and pertinent chief complaints triggering nurses to document a Pediatric Asthma Severity Score in the electronic medical record and use the order set. Our primary outcome measure was the time from arrival to dexamethasone administration. Secondary outcome measures included ED LOS for discharged patients and admission rate. We used statistical process control to analyze changes in measures over time. Results From October 2021 to March 2022, the average time for dexamethasone administration decreased from 59 to 38 minutes. ED LOS for discharged asthma exacerbation patients rose with overall ED LOS for all patients during the study period. There was no change in the admission rate. Conclusions Using quality improvement methodology, we successfully decreased the time from ED arrival to administration of dexamethasone in asthma exacerbation patients from 59 to 38 minutes over 10 months.
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Scallon K, Lee J, Spencer M, Schissel M, Timmons Z, Hanna A, Sneller H. Nurse-Initiated Protocol to Improve Timely Antibiotic Administration in Pediatric Open Fractures. J Trauma Nurs 2024; 31:158-163. [PMID: 38742724 DOI: 10.1097/jtn.0000000000000789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND Early administration of antibiotics in the presence of open fractures is critical in reducing infections and later complications. Current guidelines recommend administering antibiotics within 60 min of patient arrival to the emergency department, yet trauma centers often struggle to meet this metric. OBJECTIVES This study aims to evaluate the impact of a nurse-initiated evidence-based treatment protocol on the timeliness of antibiotic administration in pediatric patients with open fractures. METHODS A retrospective pre-post study of patients who met the National Trauma Data Standard registry inclusion criteria for open fractures of long bones, amputations, or lawn mower injuries was performed at a Midwestern United States Level II pediatric trauma center. The time of patient arrival and time of antibiotic administration from preimplementation (2015-2020) to postimplementation (2021-2022) of the protocol were compared. Patients transferred in who received antibiotics at an outside facility were excluded. RESULTS A total of N = 73 participants met the study inclusion criteria, of which n = 41 were in the preimplementation group and n = 32 were in the postimplementation group. Patients receiving antibiotics within 60 min of arrival increased from n = 24/41 (58.5%) preimplementation to n = 26/32 (84.4%) postimplementation (p< .05). CONCLUSIONS Our study demonstrates that initiating evidence-based treatment orders from triage helped decrease the time from arrival to time of antibiotic administration in patients with open fractures. We sustained improvement for 24 months after the implementation of our intervention.
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Affiliation(s)
- Kylie Scallon
- Author Affiliations: Department of Trauma (Mss Scallon and Lee), Children's Nebraska, Omaha, Nebraska; Department of Emergency (Ms Spencer), Children's Nebraska, Omaha, Nebraska; Division of Emergency Medicine (Drs Timmons and Sneller), Children's Nebraska, Omaha, Nebraska; Division of Pediatric Surgery (Dr Hanna), Children's Nebraska, Omaha, Nebraska; Department of Biostatistics (Ms Schissel), University of Nebraska Medical Center, Omaha, Nebraska; Department of Pediatrics (Drs Timmons and Sneller), University of Nebraska Medical Center, Omaha, Nebraska; Department of Surgery (Dr Hanna), University of Nebraska Medical Center, Omaha, Nebraska
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Antonino L, Van Hoorenbeeck K, van Olmen J, Vanharen Y, Janssens N, Verhulst S, Goossens E. Breathing across ages: a systematic review on challenges and components of transitional care for young people with asthma. Front Pediatr 2024; 12:1348963. [PMID: 38450298 PMCID: PMC10915074 DOI: 10.3389/fped.2024.1348963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/09/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction Asthma is a chronic condition that affects millions of adolescents and young adults (AYA) worldwide. The transition from pediatric to adult care presents unique challenges for this population, affecting their self-management, quality of life and overall health outcomes. This systematic review aims to consolidate the available evidence on challenges encountered by AYA with asthma during the transition period from child to AYA and on the key elements of transitional care for AYAs with asthma including the outcomes achieved, ultimately enhancing outcomes. Methodology A systematic literature search was performed in PubMed, Embase, Medline, Scopus, and Web of Science from their inception to October 2, 2023, to provide an overview of currently available literature. Primary quantitative and qualitative studies, published in peer-reviewed journals that focused on AYA with a confirmed diagnosis of asthma were considered if they focused on challenges encountered by AYA with asthma during the transition process and/or components of transitional care and their outcomes assessed. Results A total of 855 studies were initially identified and 6 articles were included in this systematic literature review. Several challenges experienced by AYA with asthma were identified including maintaining medication adherence, the need to take responsibility and being involved, understanding their condition and its severity, feeling left out of the care system, and experiencing a lack of engagement. The identified transitional care components included a standardized form for medical data transmission, a joint consultation and to offer several longer consultations. Conclusion Several international guidelines for asthma care recommend implementing transition programs in the care for AYA with asthma. Such transition programs should include a comprehensive and individualized approach addressing several challenges faced, to ensure optimal outcomes post-transition. However, to date, data on effective components of transitional care facilitating good outcomes were found to be limited. This systematic review underscores the need for larger studies evaluating the effect of the components of transition programs.
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Affiliation(s)
- Luna Antonino
- Centre for Research and Innovation in Care (CRIC), Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Kim Van Hoorenbeeck
- Laboratory of Experimental Medicine and Pediatrics (LEMP), Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Pediatric Pulmonology, Antwerp University Hospital (UZA), Antwerp, Belgium
| | - Josefien van Olmen
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Yaël Vanharen
- Centre for Research and Innovation in Care (CRIC), Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Natwarin Janssens
- Centre for Research and Innovation in Care (CRIC), Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Stijn Verhulst
- Laboratory of Experimental Medicine and Pediatrics (LEMP), Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Pediatric Pulmonology, Antwerp University Hospital (UZA), Antwerp, Belgium
| | - Eva Goossens
- Centre for Research and Innovation in Care (CRIC), Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Department of Patient Care, Antwerp University Hospital (UZA), Antwerp, Belgium
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Antonino L, Goossens E, van Olmen J, Bael A, Hellinckx J, Van Ussel I, Wouters A, Jonckheer T, Martens T, Van Nuijs S, Van Rossem C, Driesen Y, Jouret N, Ter Haar E, Rozenberg S, Vanderschaeghe E, van Steijn S, Verhulst S, Van Hoorenbeeck K. Managing Pediatric Asthma Exacerbations: The Role of Timely Systemic Corticosteroid Administration in Emergency Care Settings-A Multicentric Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2024; 11:164. [PMID: 38397276 PMCID: PMC10886780 DOI: 10.3390/children11020164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Asthma is the most prevalent chronic respiratory condition in children. An asthma exacerbation (AE) is a frequent reason for emergency department (ED) visits. An important step in the management of a moderate to severe AE is the administration of systemic corticosteroids (SCS) within 1 h after ED presentation. This study aimed to determine the timing of SCS administration and correlate this with the length of stay and oxygen therapy duration and to explore factors predicting timely administration. METHODS This study used a retrospective multicenter observational design based on electronic medical records review. Children aged < 18 years, presenting to the ED with a moderate to severe AE were included. RESULTS 205 patients were included. Only 28 patients received SCS within 60 min after ED arrival. The median time to SCS administration was 169 min (Q1 92-Q3 380). A correlation was found between timing and oxygen treatment duration (r = 0.363, p < 0.001) and length of stay (r = 0.368, p < 0.001). No patient characteristics predicted timely SCS administration. CONCLUSIONS Three in four children who presented with a moderate to severe AE at the ED did not receive SCS within the first hour. A prolonged timing of SCS administration correlated with a prolonged length of stay and extended need for oxygen support.
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Affiliation(s)
- Luna Antonino
- Laboratory of Experimental Medicine and Pediatrics, Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (L.A.); (S.V.)
- Centre for Research and Innovation in Care, Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium;
| | - Eva Goossens
- Centre for Research and Innovation in Care, Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium;
- Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
- Department of Patient Care, Antwerp University Hospital, 2610 Antwerp, Belgium
| | - Josefien van Olmen
- Department of Family Medicine and Population Health, University of Antwerp, 2610 Antwerp, Belgium;
| | - An Bael
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
- Translational Science, Department of Immunology and Inflammation, 2610 Antwerp, Belgium
| | - Johan Hellinckx
- Department of Pediatrics, General Hospital Klina (AZ Klina), 2930 Brasschaat, Belgium;
| | - Isabelle Van Ussel
- Department of Pediatrics, General Hospital Voorkempen (AZ Voorkempen), 2390 Malle, Belgium; (I.V.U.); (A.W.)
- Department of Pediatric Pulmonology, Antwerp University Hospital, 2610 Antwerp, Belgium;
| | - An Wouters
- Department of Pediatrics, General Hospital Voorkempen (AZ Voorkempen), 2390 Malle, Belgium; (I.V.U.); (A.W.)
| | - Tijl Jonckheer
- Department of Pediatrics, GasthuisZusters Antwerp, 2610 Antwerp, Belgium (T.M.); (S.V.N.)
| | - Tine Martens
- Department of Pediatrics, GasthuisZusters Antwerp, 2610 Antwerp, Belgium (T.M.); (S.V.N.)
| | - Sascha Van Nuijs
- Department of Pediatrics, GasthuisZusters Antwerp, 2610 Antwerp, Belgium (T.M.); (S.V.N.)
| | - Carolin Van Rossem
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
- Department of Pediatric Pulmonology, Antwerp University Hospital, 2610 Antwerp, Belgium;
| | - Yentl Driesen
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
| | - Nathalie Jouret
- Department of Pediatric Pulmonology, Antwerp University Hospital, 2610 Antwerp, Belgium;
| | - Eva Ter Haar
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
| | - Sabine Rozenberg
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
| | - Els Vanderschaeghe
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
| | - Susanne van Steijn
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
| | - Stijn Verhulst
- Laboratory of Experimental Medicine and Pediatrics, Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (L.A.); (S.V.)
- Department of Pediatric Pulmonology, Antwerp University Hospital, 2610 Antwerp, Belgium;
| | - Kim Van Hoorenbeeck
- Laboratory of Experimental Medicine and Pediatrics, Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (L.A.); (S.V.)
- Department of Pediatric Pulmonology, Antwerp University Hospital, 2610 Antwerp, Belgium;
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Kaplan C, Kranidis A, Saint-Fleur AL, Christophides A, Kier C. Bridging the Gap from Acute to Chronic Care: Partnerships and Tools for Pediatric Asthma. Pediatr Rev 2023; 44:578-584. [PMID: 37777653 DOI: 10.1542/pir.2022-005599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
- Carl Kaplan
- Stony Brook Children's Hospital, Stony Brook, NY
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Kaplan C, Saint-Fleur AL, Kranidis AM, Christophides AH, Kier C. Quality improvement for paediatric asthma care in acute settings. Curr Opin Pediatr 2023; 35:281-287. [PMID: 36749141 DOI: 10.1097/mop.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW This is a summative review of recent trends and novel programming integrated into various clinical settings (i.e. emergency departments, urgent care centres and paediatric clinics) to enhance the quality of care received by paediatric asthma patients Asthma is the most common chronic disease in paediatric patients and despite recognized national management guidelines, implementation and aftercare, especially in the emergency room, remain challenging. RECENT FINDINGS Outcome-based systematic quality improvement initiatives are described as well as evidence-based recommendations to enhance the education of providers, patients and caregivers. SUMMARY Many of the care initiatives described in the literature have been integrated into the emergency room. The authors feel some of these process improvements, such as pathway-based care, reducing time to delivery of medications, and personalized asthma education, may also be applicable and add value to clinical practice in additional community-based acute care settings such as urgent care centers and paediatric clinics.
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Affiliation(s)
- Carl Kaplan
- Department of Pediatrics, Stony Brook Children's Hospital, Stony Brook, New York
| | - Ashley L Saint-Fleur
- Department of Pediatrics, Stony Brook Children's Hospital, Stony Brook, New York
| | | | | | - Catherine Kier
- Department of Pediatrics, Stony Brook Children's Hospital, Stony Brook, New York
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Kosoko AA, Khoei AA, Khose S, Genisca AE, Mackey JM. Evaluating the Clinical Impact of a Novel Pediatric Emergency Medicine Curriculum on Asthma Outcomes in Belize. Pediatr Emerg Care 2022; 38:598-604. [PMID: 36314861 PMCID: PMC9640288 DOI: 10.1097/pec.0000000000002850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Respiratory-related complaints prompt most pediatric visits to Karl Heusner Memorial Hospital Authority's (KHMHA) Emergency Department (ED) in Belize. We developed and taught a novel pediatric respiratory emergencies module for generalist practitioners there. We assessed the curriculum's clinical impact on pediatric asthma emergency management. OBJECTIVE This study assesses the clinical impact of a pediatric emergency medicine curriculum on management of pediatric asthma emergencies at KHMHA in Belize City, Belize. METHODS We conducted a randomized chart review of pediatric (aged 2-16 y) visits for asthma-related diagnosis at the KHMHA ED between 2015 and 2018 to assess the training module's clinical impact. Primary outcomes included time to albuterol and steroids. Secondary outcomes included clinical scoring tool (Pediatric Respiratory Assessment Measure [PRAM]) usage, ED length of stay, usage of chest radiography, return visit within 7 days, and hospital admission rates. Kaplan-Meier survival analysis and Cox proportional hazard regression were used. RESULTS Two hundred eighty-three pediatric asthma-related diagnoses met our inclusion criteria. The patients treated by trained and untrained physician groups were demographically and clinically similar. The time to albuterol was significantly faster in the trained (intervention) group compared with the untrained (control) physician group when evaluating baseline of the group posttraining (P < 0.05). However, the time to steroids did not reach statistical significance posttraining (P = 0.93). The PRAM score utilization significantly increased among both control group and intervention group. The untrained physician group was more likely to use chest radiography or admit patients. The trained physician group had higher return visit rates within 7 days and shorter ED length of stay, but this did not reach statistical significance. CONCLUSIONS The curriculum positively impacted clinical outcomes leading to earlier albuterol administration, increased PRAM score use, obtaining less chest radiographs, and decreased admission rates. The timeliness of systemic steroid administration was unaffected.
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Affiliation(s)
- Adeola A. Kosoko
- From the Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | | | - Swapnil Khose
- From the Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Alicia E. Genisca
- Departments of Emergency Medicine and Pediatrics, The Warren Alpert Medical School of Medicine, Brown University/Hasbro Children's Hospital, Providence, RI
| | - Joy M. Mackey
- Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
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Evaluating the transitions in care for children presenting with acute asthma to emergency departments: a retrospective cohort study. BMC Emerg Med 2021; 21:153. [PMID: 34876025 PMCID: PMC8650289 DOI: 10.1186/s12873-021-00550-z] [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: 01/26/2021] [Accepted: 11/17/2021] [Indexed: 12/02/2022] Open
Abstract
Background Acute asthma is a common presentation to emergency departments (EDs) worldwide and, due to overcrowding, delays in treatment often occur. This study deconstructs the total ED length of stay into stages and estimates covariate effects on transition times for children presenting with asthma. Methods We extracted ED presentations in 2019 made by children in Alberta, Canada for acute asthma. We used multivariable Cox regressions in a multistate model to model transition times among the stages of start, physician initial assessment (PIA), disposition decision, and ED departure. Results Data from 6598 patients on 8270 ED presentations were extracted. The individual PIA time was longer (i.e., HR < 1) when time to the crowding metric (hourly PIA) was above 1 h (HR = 0.32; 95% CI:0.30,0.34), for tertiary (HR = 0.65; 95% CI:0.61,0.70) and urban EDs (HR = 0.77; 95% CI:0.70,0.84), for younger patients (HR = 0.99 per year; 95% CI:0.99,1.00), and for patients triaged less urgent/non-urgent (HR = 0.89; 95% CI:0.84,0.95). It was shorter for patients arriving by ambulance (HR = 1.22; 95% CI:1.04,1.42). Times from PIA to disposition decision were longer for tertiary (HR = 0.47; 95% CI:0.44,0.51) and urban (HR = 0.69; 95% CI:0.63,0.75) EDs, for patients triaged as resuscitation/emergent (HR = 0.51; 95% CI:0.48,0.54), and for patients arriving by ambulance (HR = 0.78; 95% CI:0.70,0.87). Times from disposition decision to ED departure were longer for patients who were admitted (HR = 0.16; 95% CI:0.13,0.20) or transferred (HR = 0.42; 95% CI:0.35,0.50), and for tertiary EDs (HR = 0.93; 95% CI:0.92,0.94). Conclusions All transition times were impacted by ED presentation characteristics. The sole key patient characteristic was age and it only impacted time to PIA. ED crowding demonstrated strong effects of time to PIA but not for the transition times involving disposition decision and ED departure stages. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00550-z.
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