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Napoli AM, Ali S, Baird J, Shanin D, Jouriles N. Extremes of Emergency Department Boarding are Associated With Poorer Financial Performance Among Hospitals. J Healthc Manag 2024; 69:219-230. [PMID: 38728547 DOI: 10.1097/jhm-d-23-00150] [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: 05/12/2024]
Abstract
GOAL Boarding emergency department (ED) patients is associated with reductions in quality of care, patient safety and experience, and ED operational efficiency. However, ED boarding is ultimately reflective of inefficiencies in hospital capacity management. The ability of a hospital to accommodate variability in patient flow presumably affects its financial performance, but this relationship is not well studied. We investigated the relationship between ED boarding and hospital financial performance measures. Our objective was to see if there was an association between key financial measures of business performance and limitations in patient progression efficiency, as evidenced by ED boarding. METHODS Cross-sectional ED operational data were collected from the Emergency Department Benchmarking Alliance, a voluntarily self-reporting operational database that includes 54% of EDs in the United States. Freestanding EDs, pediatric EDs and EDs with missing boarding data were excluded. The key operational outcome variable was boarding time. We reviewed the financial information of these nonprofit institutions by accessing their Internal Revenue Service Form 990. We examined standard measures of financial performance, including return on equity, total margin, total asset turnover, and equity multiplier (EM). We studied these associations using quantile regressions of added ED volume, ED admission percentage, urban versus nonurban ED site location, trauma status, and percentage of the population receiving Medicare and Medicaid as covariates in the regression models. PRINCIPAL FINDINGS Operational data were available for 892 EDs from 31 states. Of those, 127 reported a Form 990 in the year corresponding to the ED boarding measures. Median boarding time across EDs was 148 min (interquartile range [IQR]: 100-216). A significant relationship exists between boarding and the EM, along with a negative association with the hospital's total profit margin in the highest-performing hospitals (by profit margin percentage). After adjusting for the covariates in the regression model, we found that for every 10 min above 90 min of boarding, the mean EM for the top quartile increased from 245.8% to 249.5% (p < .001). In hospitals in the top 90th percentile of total margin, every 10 min beyond the median ED boarding interval led to a decrease in total margin of 0.24%. PRACTICAL APPLICATIONS Using the largest available national registry of ED operational data and concordant nonprofit financial reports, higher boarding among the highest-profitability hospitals (i.e., top 10%) is associated with a drag on profit margin, while hospitals with the highest boarding are associated with the highest leverage (i.e., indicated by the EM). These relationships suggest an association between a key ED indicator of hospital capacity management and overall institutional financial performance.
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Affiliation(s)
- Anthony M Napoli
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Shihab Ali
- Department of Emergency Medicine, HCA Houston Healthcare Northwest, Houston, Texas
| | | | - Dan Shanin
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nick Jouriles
- Department of Emergency Medicine, Northeast Ohio Medical University, Rootstown, Ohio
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Hsuan C, Vanness DJ, Zebrowski A, Carr BG, Norton EC, Buckler DG, Wang Y, Leslie DL, Dunham EF, Rogowski JA. Racial and ethnic disparities in emergency department transfers to public hospitals. Health Serv Res 2024; 59:e14276. [PMID: 38229568 PMCID: PMC10915485 DOI: 10.1111/1475-6773.14276] [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] [Indexed: 01/18/2024] Open
Abstract
OBJECTIVE To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences. DATA SOURCES AND STUDY SETTING ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018). STUDY DESIGN Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means. DATA COLLECTION/EXTRACTION METHODS We examined 1,265,588 adult ED patients transferred from 187 hospitals. PRINCIPAL FINDINGS Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer. CONCLUSIONS Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.
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Affiliation(s)
- Charleen Hsuan
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - David J. Vanness
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Alexis Zebrowski
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Brendan G. Carr
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Edward C. Norton
- Department of Health Management and PolicyUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
- Department of EconomicsUniversity of MichiganAnn ArborMichiganUSA
| | - David G. Buckler
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Yinan Wang
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Douglas L. Leslie
- Department of Public Health Sciences, College of MedicinePennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Eleanor F. Dunham
- Department of Emergency Medicine, College of MedicinePennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Jeannette A. Rogowski
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
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Agarwal AK, Gonzales R, Scott K, Merchant R. Investigating the Feasibility of Using a Wearable Device to Measure Physiologic Health Data in Emergency Nurses and Residents: Observational Cohort Study. JMIR Form Res 2024; 8:e51569. [PMID: 38386373 PMCID: PMC10921319 DOI: 10.2196/51569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/20/2023] [Accepted: 01/07/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Emergency departments play a pivotal role in the US health care system, with high use rates and inherent stress placed on patients, patient care, and clinicians. The impact of the emergency department environment on the health and well-being of emergency residents and nurses can be seen in worsening rates of burnout and cardiovascular health. Research on clinician health has historically been completed outside of clinical areas and not personalized to the individual. The expansion of digital technology, specifically wearable devices, may enhance the ability to understand how health care environments impact clinicians. OBJECTIVE The primary objective of this pilot study was to assess the feasibility and acceptability of using wearable devices to measure and record physiologic data from emergency nurses and resident physicians. Understanding strategies that are accepted and used by clinicians is critical prior to launching larger investigations aimed at improving outcomes. METHODS This was a longitudinal pilot study conducted at an academic, urban, level 1 trauma center. A total of 20 participants, including emergency medicine resident physicians and nurses, were equipped with a wearable device (WHOOP band) and access to a mobile health platform for 6 weeks. Baseline surveys assessed burnout, mental health, and expectations of the device and experience. Participants provided open-ended feedback on the device and platform, contributing to the assessment of acceptance, adoption, and use of the wearable device. Secondary measures explored early signs and variations in heart rate variability, sleep, recovery, burnout, and mental health assessments. RESULTS Of the 20 participants, 10 consistently used the wearable device. Feedback highlighted varying experiences with the device, with a preference for more common wearables like the Apple Watch or Fitbit. Resident physicians demonstrated higher engagement with the device and platform as compared with nurses. Baseline mental health assessments indicated mild anxiety and depressive symptoms among participants. The Professional Fulfillment Index revealed low professional fulfillment, moderate workplace exhaustion, and interpersonal disengagement. CONCLUSIONS This pilot study underscores the potential of wearable devices in monitoring emergency clinicians' physiologic data but reveals challenges related to device preferences and engagement. The key takeaway is the necessity to optimize device and platform design for clinician use. Larger, randomized trials are recommended to further explore and refine strategies for leveraging wearable technology to support the well-being of the emergency workforce.
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Affiliation(s)
- Anish K Agarwal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Center for Health Care Transformation and Innovation, Penn Medicine, Philadelphia, PA, United States
| | - Rachel Gonzales
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Center for Health Care Transformation and Innovation, Penn Medicine, Philadelphia, PA, United States
| | - Kevin Scott
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Raina Merchant
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Center for Health Care Transformation and Innovation, Penn Medicine, Philadelphia, PA, United States
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Savioli G, Ceresa IF, Bavestrello Piccini G, Gri N, Nardone A, La Russa R, Saviano A, Piccioni A, Ricevuti G, Esposito C. Hypothermia: Beyond the Narrative Review-The Point of View of Emergency Physicians and Medico-Legal Considerations. J Pers Med 2023; 13:1690. [PMID: 38138917 PMCID: PMC10745126 DOI: 10.3390/jpm13121690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/14/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Hypothermia is a widespread condition all over the world, with a high risk of mortality in pre-hospital and in-hospital settings when it is not promptly and adequately treated. In this review, we aim to describe the main specificities of the diagnosis and treatment of hypothermia through consideration of the physiological changes that occur in hypothermic patients. Hypothermia can occur due to unfavorable environmental conditions as well as internal causes, such as pathological states that result in reduced heat production, increased heat loss or ineffectiveness of the thermal regulation system. The consequences of hypothermia affect several systems in the body-the cardiovascular system, the central and peripheral nervous systems, the respiratory system, the endocrine system and the gastrointestinal system-but also kidney function, electrolyte balance and coagulation. Once hypothermia is recognized, prompt treatment, focused on restoring body temperature and supporting vital functions, is fundamental in order to avert preventable death. It is important to also denote the fact that CPR has specificities related to the unique profile of hypothermic patients.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Iride Francesca Ceresa
- Emergency Department and Internal Medicine, Istituti Clinici di Pavia e Vigevano, Gruppo San Donato, 27029 Vigevano, Italy;
| | | | - Nicole Gri
- Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Alba Nardone
- Emergency Department, Ospedale Civile, 27058 Voghera, Italy
| | - Raffaele La Russa
- Department of Clinical and Experimental Medicine, Section of Forensic Pathology, University of Foggia, 71122 Foggia, Italy
| | - Angela Saviano
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy; (A.S.); (A.P.)
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy; (A.S.); (A.P.)
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, 27100 Pavia, Italy;
| | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
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Martínez B, Aranda MP, Sanko S, Aguilar I, Vega WA. Older Adult Frequent 9-1-1 Callers for Emergency Medical Services in a Large Metropolitan City: Individual- and System-Level Considerations. J Emerg Med 2023; 65:e522-e530. [PMID: 37852810 PMCID: PMC10871157 DOI: 10.1016/j.jemermed.2023.07.006] [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: 12/09/2022] [Revised: 06/22/2023] [Accepted: 07/15/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND High utilizers of 9-1-1 place a substantial burden on emergency medical services (EMS). Results of a retrospective review of records data of the City of Los Angeles Fire Department (LAFD) showed a significant increase in older adult high utilizers of 9-1-1. OBJECTIVE The objective of this study was to explore individual- and system-level factors implicated in EMS use among older adults, and to provide system recommendations to mitigate overuse. METHODS A phenomenological study was conducted, drawing from LAFD EMS records between 2012 and 2016 to identify and contact high-utilizing patients older than 50 years, their family, agency representatives, and LAFD personnel. Interviews were recorded, transcribed, and coded and a thematic analysis was completed. RESULTS We conducted in-depth interviews with 27 participants, including patients (n = 8), their families (n = 6), social service agency representatives (n = 3), and LAFD personnel (n = 10). The following cross-cutting themes emerged: nature of 9-1-1 calls, barriers to access, and changing the system. In addition, LAFD and social service agency representatives identified the role of EMS responders and social agency representatives. Patients and their families agreed that previous encounters and interactions with emergency care responders were relevant factors. CONCLUSIONS This study described reasons for 9-1-1 calls related to medical and social service needs, including mental health care. Our analysis offers insight from different stakeholders' perspectives on access to medical care and types of barriers that interfere with medical care. All groups shared recommendations to advance access to medical and mental health care.
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Affiliation(s)
- Beatrice Martínez
- USC Edward R. Roybal Institute on Aging, Los Angeles, California; USC Suzanne Dworak-Peck School of Social Work, Los Angeles, California; University of Southern California, Los Angeles, California
| | - María P Aranda
- USC Edward R. Roybal Institute on Aging, Los Angeles, California; USC Suzanne Dworak-Peck School of Social Work, Los Angeles, California; University of Southern California, Los Angeles, California
| | - Stephen Sanko
- Keck School of Medicine of University Southern California, Los Angeles, California; Los Angeles Fire Department, Los Angeles, California
| | - Iris Aguilar
- USC Edward R. Roybal Institute on Aging, Los Angeles, California; USC Suzanne Dworak-Peck School of Social Work, Los Angeles, California; University of Southern California, Los Angeles, California
| | - William A Vega
- USC Edward R. Roybal Institute on Aging, Los Angeles, California
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Lee S, Park HJ, Hwang J, Lee SW, Han KS, Kim WY, Jeong J, Kang H, Kim A, Lee C, Kim SJ. Machine Learning-Based Models for Prediction of Critical Illness at Community, Paramedic, and Hospital Stages. Emerg Med Int 2023; 2023:1221704. [PMID: 37404873 PMCID: PMC10317605 DOI: 10.1155/2023/1221704] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 05/08/2023] [Accepted: 06/02/2023] [Indexed: 07/06/2023] Open
Abstract
Overcrowding of emergency department (ED) has put a strain on national healthcare systems and adversely affected the clinical outcomes of critically ill patients. Early identification of critically ill patients prior to ED visits can help induce optimal patient flow and allocate medical resources effectively. This study aims to develop ML-based models for predicting critical illness in the community, paramedic, and hospital stages using Korean National Emergency Department Information System (NEDIS) data. Random forest and light gradient boosting machine (LightGBM) were applied to develop predictive models. The predictive model performance based on AUROC in community stage, paramedic stage, and hospital stage was estimated to be 0.870 (95% CI: 0.869-0.871), 0.897 (95% CI: 0.896-0.898), and 0.950 (95% CI: 0.949-0.950) in random forest and 0.877 (95% CI: 0.876-0.878), 0.899 (95% CI: 0.898-0.900), and 0.950 (95% CI: 0.950-0.951) in LightGBM, respectively. The ML models showed high performance in predicting critical illness using variables available at each stage, which can be helpful in guiding patients to appropriate hospitals according to their severity of illness. Furthermore, a simulation model can be developed for proper allocation of limited medical resources.
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Affiliation(s)
- Sijin Lee
- Department of Emergency Medicine, Korea University, College of Medicine, Seoul, Republic of Korea
| | - Hyun Ji Park
- Department of Industrial and Management Engineering, Korea University, Seoul, Republic of Korea
| | - Jumi Hwang
- Department of Industrial and Management Engineering, Korea University, Seoul, Republic of Korea
| | - Sung Woo Lee
- Department of Emergency Medicine, Korea University, College of Medicine, Seoul, Republic of Korea
| | - Kap Su Han
- Department of Emergency Medicine, Korea University, College of Medicine, Seoul, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jinwoo Jeong
- Department of Emergency Medicine, Dong-A University, College of Medicine, Busan, Republic of Korea
| | - Hyunggoo Kang
- Department of Emergency Medicine, Hanyang University, College of Medicine, Seoul, Republic of Korea
| | - Armi Kim
- Department of Industrial and Management Engineering, Korea University, Seoul, Republic of Korea
| | - Chulung Lee
- School of Industrial and Management Engineering, Korea University, Seoul, Republic of Korea
| | - Su Jin Kim
- Department of Emergency Medicine, Korea University, College of Medicine, Seoul, Republic of Korea
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Ortiz SS, Huang Y, Rowe BH, Zheng B, Rosychuk RJ. Emergency department crowding negatively influences outcomes for adults presenting for chronic obstructive pulmonary disease. CAN J EMERG MED 2023; 25:411-420. [PMID: 37087522 DOI: 10.1007/s43678-023-00502-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 03/25/2023] [Indexed: 04/24/2023]
Abstract
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.
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Affiliation(s)
- Silvia S Ortiz
- Department of Pediatrics, Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB, Canada
| | - Yifu Huang
- Department of Pediatrics, Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Bo Zheng
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Rhonda J Rosychuk
- Department of Pediatrics, Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB, Canada.
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Bigdeli Shamloo MB, Elahi N, Zarea K. Lived Experience of Caring for Dying Muslim Patients in Emergency Room: A Phenomenological Study. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231153254. [PMID: 36775852 DOI: 10.1177/00302228231153254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Death is a natural part of life, which mostly occurs in the ER. This study described the meaning of nurses' lived experience of caring for critical and dying patients in the ERs. In this qualitative study, 13 nurses who was purposefully selected. Data were collected using in-depth individual interviews. Data analysis used van Manen's hermeneutic phenomenological approach. The experiences of caring for the dying patient were divided into two parts: experiences in patients with acute and chronic problems. In patients with acute problems, four themes were extracted: fight to the death, no time for palliative and spiritual care, lacking support for the family, no privacy for peaceful death. In patients with acute problems, four themes were extracted: Facilitating a peaceful death, Allocating time for palliative and spiritual care, support for the family, Attention to privacy. Therefore, attention should be paid to the fields of care and its inadequacies.
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Affiliation(s)
- Marzieh Beigom Bigdeli Shamloo
- Clinical Research Development Unit, Ganjavian Hospital, Dezful University Medical Sciences, Dezful, Iran
- Student Research Committee, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nasrin Elahi
- Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Kourosh Zarea
- Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Hu Y, Cato KD, Chan CW, Dong J, Gavin N, Rossetti SC, Chang BP. Use of Real-Time Information to Predict Future Arrivals in the Emergency Department. Ann Emerg Med 2023; 81:728-737. [PMID: 36669911 DOI: 10.1016/j.annemergmed.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 10/01/2022] [Accepted: 11/08/2022] [Indexed: 01/20/2023]
Abstract
STUDY OBJECTIVE We aimed to build prediction models for shift-level emergency department (ED) patient volume that could be used to facilitate prediction-driven staffing. We sought to evaluate the predictive power of rich real-time information and understand 1) which real-time information had predictive power and 2) what prediction techniques were appropriate for forecasting ED demand. METHODS We conducted a retrospective study in an ED site in a large academic hospital in New York City. We examined various prediction techniques, including linear regression, regression trees, extreme gradient boosting, and time series models. By comparing models with and without real-time predictors, we assessed the potential gain in prediction accuracy from real-time information. RESULTS Real-time predictors improved prediction accuracy on models without contemporary information from 5% to 11%. Among extensive real-time predictors examined, recent patient arrival counts, weather, Google trends, and concurrent patient comorbidity information had significant predictive power. Out of all the forecasting techniques explored, SARIMAX (Seasonal Autoregressive Integrated Moving Average with eXogenous factors) achieved the smallest out-of-sample the root mean square error (RMSE) of 14.656 and mean absolute prediction error (MAPE) of 8.703%. Linear regression was the second best, with out-of-sample RMSE and MAPE equal to 15.366 and 9.109%, respectively. CONCLUSION Real-time information was effective in improving the prediction accuracy of ED demand. Practice and policy implications for designing staffing paradigms with real-time demand forecasts to reduce ED congestion were discussed.
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Affiliation(s)
- Yue Hu
- Decision, Risk, and Operations Division, Columbia Business School, New York, NY.
| | - Kenrick D Cato
- School of Nursing, Columbia University, New York, NY; Office of Nursing Research, EBP, and Innovation, New York-Presbyterian Hospital, New York, NY; Department of Emergency Medicine, New York, NY
| | - Carri W Chan
- Decision, Risk, and Operations Division, Columbia Business School, New York, NY
| | - Jing Dong
- Decision, Risk, and Operations Division, Columbia Business School, New York, NY
| | | | - Sarah C Rossetti
- School of Nursing, Columbia University, New York, NY; Department of Biomedical Informatics, Columbia University, New York, NY, USA
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Trisyani Y, Emaliyawati E, Prawesti A, Mirwanti R, Mediani HS. Emergency Nurses' Competency in the Emergency Department Context: A Qualitative Study. Open Access Emerg Med 2023; 15:165-175. [PMID: 37197564 PMCID: PMC10183472 DOI: 10.2147/oaem.s405923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/18/2023] [Indexed: 05/19/2023] Open
Abstract
Background The availability of clear emergency nurses' competencies is critical for safe and effective emergency health care services. The study regarding emergency nurses' competencies remained virtually limited. Purpose This study aimed to explore the emergency nurses' competencies in the clinical emergency department (ED) context as needed by society. Methods This qualitative study involved focus group discussions in six groups of 54 participants from three EDs. The data were analysed using grounded theory approach including the constant comparative, interpretations, and coding procedures; initial coding, focused coding and categories. Results This study revealed 8 core competencies of emergency nurses: Shifting the nursing practice, Caring for acute critical patients, Communicating and coordinating, Covering disaster nursing roles, Reflecting on the ethical and legal standards, Researching competency, Teaching competencies and Leadership competencies. The interconnection of the 8 core competencies has resulted in 2 concepts of extending the ED nursing practice and demanding the advanced ED nursing role. Conclusion The finding reflected the community needs of nurses who work in ED settings and the need for competency development of emergency nurses.
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Affiliation(s)
- Yanny Trisyani
- Department of Critical Care Nursing and Emergency Nursing Faculty of Nursing, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Correspondence: Yanny Trisyani, Email ;
| | - Etika Emaliyawati
- Department of Critical Care Nursing and Emergency Nursing Faculty of Nursing, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Ayu Prawesti
- Department of Critical Care Nursing and Emergency Nursing Faculty of Nursing, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Ristina Mirwanti
- Department of Critical Care Nursing and Emergency Nursing Faculty of Nursing, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Henny Suzana Mediani
- Department of Pediatric Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, West Java, Indonesia
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Harder SJ, Mathis H, Warsi M, Odedosu K, Hanna RC, Chu ES. Engineering a Clinical Microsystem to Decrease Workplace Violence for Medically and Psychiatrically Concurrently Decompensated Patients. Jt Comm J Qual Patient Saf 2023; 49:53-61. [PMID: 36456435 DOI: 10.1016/j.jcjq.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hospitalized medical patients with concurrently decompensated psychiatric and medical conditions experience worse clinical outcomes. Health care providers caring for this patient population are at increased risk of workplace violence. The authors sought to understand the effects of a clinical microsystem specifically designed to care for patients too psychiatrically ill for medical units and too medically ill for psychiatry units. METHODS The research team performed a quality improvement study in which a medicine-psychiatry co-managed clinical microsystem incorporating high performance teamwork principles was engineered in an urban academic medical center to improve patient and staff safety, as well as operational outcomes. Poisson regression was performed to determine differences between workplace violence events, falls, 30-day emergency department (ED) revisits, and hospital readmissions, comparing the baseline period to the intervention period. RESULTS There were 321 patients discharged in the baseline period and 310 during the intervention period. Workplace violence events decreased by 65.6% (incidence rate ratio [IRR] 0.34, 95% confidence interval [CI] 0.20-0.57, p < 0.001) after implementation of the clinical microsystem when compared to the baseline period. The rate of ED utilization at 30 days postdischarge also decreased from 30.6% at baseline to 21.0% postintervention (adjusted odds ratio [aOR] 0.60, 95% CI 0.42-0.87, p = 0.006). No differences were detected in falls and 30-day readmissions. CONCLUSION For patients with concurrently decompensated medical and psychiatric conditions, the incidence of workplace violence and postdischarge ED utilization can be improved by creating a clinical microsystem that integrates changes to both the physical environment and teamwork processes.
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Bouchibti S, Maul T, Rivera-Sepulveda A. Comparison Between Physicians' and Nurse Practitioners' Resource Utilization in the Diagnosis and Management of Bronchiolitis in the Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e1564-e1568. [PMID: 36040473 PMCID: PMC11061880 DOI: 10.1097/pec.0000000000002608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to describe the resource utilization of nurse practitioners (NPs) in the pediatric emergency department (ED) and compare among physicians. METHODS A retrospective cross-sectional study of secondary data analysis in a level 1 academic pediatric trauma center was conducted. Patients were aged 1 to 24 months, evaluated in the ED between January 1, 2014, and November 30, 2018, with a diagnosis of bronchiolitis or wheezing. Data included age group, length of stay, disposition, diagnostic tests (chest radiography [CXR], viral testing, respiratory syncytial virus test), treatment (bronchodilator, corticosteroid, antibiotic), and medical provider (physician, NP, combination of both). Resources were evaluated before (early era) and after (late era) the implementation of an institutional clinical practice guideline.Comparisons between groups were done through χ2, Fisher exact, or Kruskal-Wallis test, as appropriate. RESULTS A total of 5311 cases were treated by a physician (65.3%), an NP (30.3%), or a combination of both (4.3%). The was a difference in the use of CXR, respiratory syncytial virus testing, bronchodilators, and corticosteroids among providers (P = 0.001). In the late era, NPs were less likely to order a bronchodilator (odds ratio [OR], 0.390 [95% confidence interval, 0.318-0.478; P < 0.001]), whereas physicians were less likely to order a CXR (OR, 0.772 [0.667-0.894, P = 0.001]), bronchodilator (OR, 0.518 [0.449-0.596, P < 0.001]), or a corticosteroid (OR, 0.630 [0.531-0.749, P < 0.001]). CONCLUSIONS Nurse practitioners made fewer diagnostic and therapeutic orders. A clinical practice guideline on the diagnosis and management of children with bronchiolitis successfully decreased the use of nonrecommended tests and therapies among NP and physicians.
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Yazdanyar A, Greenberg MR, Chen Z, Li S, Greenberg MR, Buonanno AP, Burmeister DB, Jarjous S. A customized early warning score enhanced emergency department patient flow process and clinical outcomes in a COVID‐19 pandemic. J Am Coll Emerg Physicians Open 2022; 3:e12783. [PMID: 35919510 PMCID: PMC9338822 DOI: 10.1002/emp2.12783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/02/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022] Open
Abstract
Objective Methods Results Conclusion
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Affiliation(s)
- Ali Yazdanyar
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine/USF Morsani College of Medicine Bethlehem Pennsylvania USA
| | - Megan R. Greenberg
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine/USF Morsani College of Medicine Bethlehem Pennsylvania USA
| | - Zhe Chen
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine/USF Morsani College of Medicine Bethlehem Pennsylvania USA
| | - Shuisen Li
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine/USF Morsani College of Medicine Bethlehem Pennsylvania USA
| | - Marna Rayl Greenberg
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine/USF Morsani College of Medicine Bethlehem Pennsylvania USA
| | - Anthony P. Buonanno
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine/USF Morsani College of Medicine Bethlehem Pennsylvania USA
| | - David B. Burmeister
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine/USF Morsani College of Medicine Bethlehem Pennsylvania USA
| | - Shadi Jarjous
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine/USF Morsani College of Medicine Bethlehem Pennsylvania USA
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Jiang R, Xie H, Xu E, Luo L, Di J, Tang J. Developing a Quality Improvement Initiative to Reduce Emergency Department Length of Stay in a Large-Scale Hospital Under Routinized Prevention and Control of COVID-19. Am J Med Qual 2022; 37:375-376. [PMID: 35617458 DOI: 10.1097/jmq.0000000000000065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ruo Jiang
- Department of Medical Affairs, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hui Xie
- Clinical Research Unit, Shanghai Eye Hospital, Shanghai, China
| | - Enze Xu
- Department of Medical Affairs, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, China
| | - Li Luo
- China Institute of Hospital Development, Shanghai Jiao Tong University, China
| | - Jianzhong Di
- Hospital Office, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, China
| | - Jianfei Tang
- Department of Orthopaedics, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Hannon C, Roland D, O'Sullivan R. Prediction of Pediatric Patient Admission/Discharge in the Emergency Department: Irish Pediatric Early Warning Score, Pediatric Observation Priority Score, and Irish Children's Triage System. Pediatr Emerg Care 2022; 38:e1320-e1326. [PMID: 35639436 DOI: 10.1097/pec.0000000000002639] [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: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the ability of the Irish Paediatric Early Warning Score (PEWS), the Paediatric Observation Priority Score (POPS), and the Irish Children's Triage System (ICTS) to predict patient disposition pathways in an emergency department (ED) setting. METHODS Data were prospectively collected on patients aged less than 16 years presenting to an Irish mixed adult/pediatric ED over 3 weeks during December 2018. After calculating a once-off PEWS, POPS, and ICTS, we investigated the ability of the scoring systems to predict admission or discharge from the ED. Primary comparison of the index tests was conducted using receiver operating characteristic (ROC) curves. RESULTS A total of 550 patients were included in this study. There were 114 admissions (20.7%) and 436 discharges (79.3%). The POPS had an area under the ROC curve of 0.7 [95% confidence interval (CI), 0.65-0.75]. The PEWS had an area under the ROC curve of 0.58 (95% CI, 0.53-0.64). The ICTS had an area under the ROC curve of 0.58 (95% CI, 0.53-0.63). CONCLUSIONS The POPS has greater accuracy as a predictor of admission from the ED than PEWS and ICTS. Possible future implementation of POPS into pediatric EDs as a cognitive prompt before admission decision seems to be merited. Further multicenter validation in Ireland would be helpful.
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Affiliation(s)
- Colm Hannon
- From the School of Medicine, University College Cork, Cork, Ireland
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Machine learning-based triage to identify low-severity patients with a short discharge length of stay in emergency department. BMC Emerg Med 2022; 22:88. [PMID: 35596154 PMCID: PMC9123815 DOI: 10.1186/s12873-022-00632-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 04/14/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Overcrowding in emergency departments (ED) is a critical problem worldwide, and streaming can alleviate crowding to improve patient flows. Among triage scales, patients labeled as "triage level 3" or "urgent" generally comprise the majority, but there is no uniform criterion for classifying low-severity patients in this diverse population. Our aim is to establish a machine learning model for prediction of low-severity patients with short discharge length of stay (DLOS) in ED. METHODS This was a retrospective study in the ED of China Medical University Hospital (CMUH) and Asia University Hospital (AUH) in Taiwan. Adult patients (aged over 20 years) with Taiwan Triage Acuity Scale level 3 were enrolled between 2018 and 2019. We used available information during triage to establish a machine learning model that can predict low-severity patients with short DLOS. To achieve this goal, we trained five models-CatBoost, XGBoost, decision tree, random forest, and logistic regression-by using large ED visit data and examined their performance in internal and external validation. RESULTS For internal validation in CMUH, 33,986 patients (75.9%) had a short DLOS (shorter than 4 h), and for external validation in AUH, there were 13,269 (82.7%) patients with short DLOS. The best prediction model was CatBoost in internal validation, and area under the receiver operating cha racteristic curve (AUC) was 0.755 (95% confidence interval (CI): 0.743-0.767). Under the same threshold, XGBoost yielded the best performance, with an AUC value of 0.761 (95% CI: 0.742- 0.765) in external validation. CONCLUSIONS This is the first study to establish a machine learning model by applying triage information alone for prediction of short DLOS in ED with both internal and external validation. In future work, the models could be developed as an assisting tool in real-time triage to identify low-severity patients as fast track candidates.
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Hitzek J, Fischer-Rosinský A, Möckel M, Kuhlmann SL, Slagman A. Influence of Weekday and Seasonal Trends on Urgency and In-hospital Mortality of Emergency Department Patients. Front Public Health 2022; 10:711235. [PMID: 35530732 PMCID: PMC9068998 DOI: 10.3389/fpubh.2022.711235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 03/07/2022] [Indexed: 11/21/2022] Open
Abstract
Background Given the scarcity of resources, the increasing use of emergency departments (ED) represents a major challenge for the care of emergency patients. Current health policy interventions focus on restructuring emergency care with the help of patient re-direction into outpatient treatment structures. A precise analysis of ED utilization, taking into account treatment urgency, is essential for demand-oriented adjustments of emergency care structures. Methods Temporal and seasonal trends in the use of EDs were investigated, considering treatment urgency and hospital mortality. Secondary data of 287,119 ED visits between 2015 and 2017 of the two EDs of Charité Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum were analyzed. Result EDs were used significantly more frequently on weekends than on weekdays (Mdn = 290 vs. 245 visits/day; p < 0.001). The proportion of less urgent, outpatient emergency visits on weekends was above average. Holiday periods were characterized by at least 6, and at most 176 additional ED visits. In a comparison of different holidays, most ED visits were observed at New Year (+68% above average). In addition, a significant increase in in-hospital mortality on holidays was evident among inpatients admitted to hospital via the ED (3.0 vs. 3.2%; p < 0.001), with New Year's Day being particularly striking (5.4%). Conclusion These results suggest that, in particular, the resource planning of outpatient emergency treatment capacities on weekends and holidays should be adapted to the increased volume of non-urgent visits in EDs. Nevertheless, treatment capacities for the care of urgent, inpatient emergencies should not be disregarded and further research projects are necessary to investigate the causes of increased mortality during holiday periods.
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Affiliation(s)
- Jennifer Hitzek
- Emergency and Acute Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
- *Correspondence: Jennifer Hitzek
| | | | - Martin Möckel
- Emergency and Acute Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Stella Linnea Kuhlmann
- Emergency and Acute Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Slagman
- Emergency and Acute Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
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Mohr NM, Wu C, Ward MJ, McNaughton CD, Faine B, Pomeranz K, Richardson K, Kaboli PJ. Transfer boarding delays care more in low-volume rural emergency departments: A cohort study. J Rural Health 2022; 38:282-292. [PMID: 33644911 PMCID: PMC8715860 DOI: 10.1111/jrh.12559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Emergency department (ED) crowding is increasing and is associated with adverse patient outcomes. The objective of this study was to measure the relative impact of ED boarding on timeliness of early ED care for new patient arrivals, with a focus on the differential impact in low-volume rural hospitals. METHODS A retrospective cohort of all patients presenting to a Veterans Health Administration (VHA) ED between 2011 and 2014. The primary exposure was the number of patients in the ED at the time of ED registration, stratified by disposition (admit, discharge, or transfer) and mental health diagnosis. The primary outcome was time-to-provider evaluation, and secondary outcomes included time-to-EKG, time-to-laboratory testing, time-to-radiography, and total ED length-of-stay. Rurality was measured using the Rural-Urban Commuting Areas. FINDINGS A total of 5,912,368 patients were included from all 123 VHA EDs. Adjusting for acuity, new patients had longer time-to-provider when more patients were in the ED, and patients awaiting transfer for nonmental health conditions impacted time-to-provider for new patients (16.6 min delays, 95% CI: 12.3-20.7 min) more than other patient types. Rural patients saw a greater impact of crowding on care timeliness than nonrural patients (additional 5.3 min in time-to-provider per additional patient in ED, 95% CI: 4.3-6.4), and the impact of additional patients in all categories was most pronounced in the lowest-volume EDs. CONCLUSIONS Patients seen in EDs with more crowding have small, but additive, delays in early elements of ED care, and transferring patients with nonmental health diagnoses from rural facilities were associated with the greatest impact.
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Affiliation(s)
- Nicholas M. Mohr
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA;,Department of Emergency Medicine, University of Iowa Carver College of Medicine;,Department of Anesthesia, University of Iowa Carver College of Medicine
| | - Chaorong Wu
- Institute for Clinical and Translational Sciences, University of Iowa, Iowa City, Iowa
| | - Michael J. Ward
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee;,Department of Emergency Medicine, Vanderbilt University Medical Center
| | - Candace D. McNaughton
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee;,Department of Emergency Medicine, Vanderbilt University Medical Center
| | - Brett Faine
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA;,Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Kaila Pomeranz
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Kelly Richardson
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA
| | - Peter J. Kaboli
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA;,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Ouyang H, Wang J, Sun Z, Lang E. The impact of emergency department crowding on admission decisions and patient outcomes. Am J Emerg Med 2021; 51:163-168. [PMID: 34741995 DOI: 10.1016/j.ajem.2021.10.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/23/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES The objective of this study is to evaluate the impact of emergency department (ED) crowding levels on patient admission decisions and outcomes. METHODS A retrospective study was performed based on 2-year electronic health record data from a tertiary care hospital ED in Alberta, Canada. Using modified Poisson regression models, we studied the association of patient admission decisions and 7-day revisit probability with ED crowding levels measured by: 1) the total number of patients waiting and in treatment (ED census), 2) the number of boarding patients (boarder census), and 3) the average physician workload, calculated by the total number of ED patients divided by the number of physicians on duty (physician workload census). The control variables included age, gender, treatment area, triage level, and chief complaint. A subgroup analysis was performed to evaluate the heterogeneous effects among patients of different acuity levels. RESULTS Our dataset included 141,035 patient visit records after cleaning from August 2013 to July 2015. The patient admission probability was positively correlated with ED census (relative risk [RR] = 1.006, 95% confidence interval [CI] = 1.005 to 1.007) and physician workload census (RR = 1.029, 95% CI = 1.027 to 1.032), but inversely correlated with boarder census (RR = 0.991, 95% CI = 0.989 to 0.993). We further found that the 7-day revisit probability of discharged patients was positively associated with boarder census (RR = 1.009, 95% CI = 1.004 to 1.014). CONCLUSIONS Patient admission probability was found to be directly associated with ED census and physician workload census, but inversely associated with the boarder census. The effects of boarder census and physician workload census were stronger for patients of triage levels 3-5. Our results suggested that (i) insufficient physician staffing may lead to unnecessary patient admissions; (ii) too many boarding patients in ED leads to an increase in unsafe discharges, and as a result, an increase in 7-day revisit probability.
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Affiliation(s)
- Huiyin Ouyang
- Faculty of Business and Economics, The University of Hong Kong, Hong Kong.
| | - Junyan Wang
- Department of Management Sciences, College of Business, City University of Hong Kong, Hong Kong.
| | - Zhankun Sun
- Department of Management Sciences, College of Business, City University of Hong Kong, Hong Kong.
| | - Eddy Lang
- Alberta Health Services, Alberta, Canada; Department of Emergency Medicine, University of Calgary, Alberta, Canada.
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Corkery N, Avsar P, Moore Z, O'Connor T, Nugent L, Patton D. What is the impact of team triage as an intervention on waiting times in an adult emergency department? - A systematic review. Int Emerg Nurs 2021; 58:101043. [PMID: 34352705 DOI: 10.1016/j.ienj.2021.101043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 04/27/2021] [Accepted: 06/10/2021] [Indexed: 12/01/2022]
Abstract
AIM To examine the impact of team triage on waiting times in adult emergency departments. DESIGN A systematic review using narrative analysis. METHOD Systematic review methodology, which included quantitative research papers consisting of randomized control trials, cohort or quasi-experimental studies. The PICO framework was used to formulate the question. Using a structured search, databases were used to source the research papers. Databases searched were Cochrane, CINAHL and MEDLINE. Twelve (12) research papers met the inclusion criteria. Each of the 12 papers were quality appraised using a recognised checklist. Data extraction was carried out and the findings were analysed using a narrative approach. RESULTS It was found that senior emergency doctors in triage alongside the triage nurse allows for more timely decision making and appropriate investigation orders. Early bed requesting or referral to specialist consultation were also found to improve waiting times. Reduced numbers of patients who leave without being seen and lower mortality rates were recorded when using team triage. Patient satisfaction is also improved by team triage. CONCLUSION Team triage improves waiting times in the emergency department.
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Affiliation(s)
- Nessa Corkery
- St. Vincent's University Hospital, Dublin 4, Ireland; School of Nursing, The Royal College of Surgeons of Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland.
| | - Pinar Avsar
- Skin Wounds and Trauma Research Centre, The Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland
| | - Zena Moore
- Head of School of Nursing and Midwifery and Director of the Skin Wounds and Trauma Research Centre, The Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland; Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Belgium; Lida Institute, Shanghai, China
| | - Tom O'Connor
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; Lida Institute, Shanghai, China; Director of Academic Affairs and Deputy Head of School, School of Nursing and Midwifery and Lead Researcher, Skin Wounds and Trauma Research Centre, The Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland
| | - Linda Nugent
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; Lecturer and Programme Director, School of Nursing and Midwifery. The Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland
| | - Declan Patton
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; Director of Nursing and Midwifery Research and Deputy Director of the Skin, Wounds and Trauma Research Centre, School of Nursing and Midwifery, The Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland; Honorary Senior Fellow, Faculty of Science, Medicine and Health, University of Wollongong, Australia
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Hughes JA, Alexander KE, Spencer L, Yates P. Factors associated with time to first analgesic medication in the emergency department. J Clin Nurs 2021; 30:1973-1989. [PMID: 33829583 DOI: 10.1111/jocn.15750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 02/08/2021] [Accepted: 02/25/2021] [Indexed: 11/30/2022]
Abstract
AIM AND OBJECTIVE To examine the factors associated with time to first analgesic medication in the emergency department. BACKGROUND Pain is the most common symptom presenting to the emergency department, and the time taken to deliver analgesic medication is a common outcome measure. Factors associated with time to first analgesic medication are likely to be multifaceted, but currently poorly described. DESIGN Retrospective cohort study. METHODS Cox proportional hazards regression modelling was undertaken to evaluate the associations between person, environment, health and illness variables within Symptom Management Theory and time to first analgesic medication in a sample of adult patients presenting with moderate-to-severe pain to an emergency department over twelve months. This study was completed in line with the STROBE statement. RESULTS 383 patients were included in the study, 290 (75.92%) of these patients received an analgesic medication in a median time of 45 minutes (interquartile range, 70 minutes). A model containing nine explanatory variables associated with time to first analgesic medication was identified. These nine variables (employment status, discharge location, triage score, Charlson score, arrival pain score, socio-economic status, first location, daily total treatment time and patient time to be seen) represent all of the domains of the Symptom Management Theory. CONCLUSIONS Person, environment, health and illness factors are associated with the time taken to deliver analgesic medication to those in pain in the emergency department. This study demonstrates the complexity of factors associated with pain care and the applicability of Symptom Management Theory to pain care in the emergency department. RELEVANCE TO CLINICAL PRACTICE Identifying a model of factors that are associated with the time in which the most common symptom presenting to the emergency department is treated allows for targeted interventions to groups likely to receive poor care and a framework for its evaluation.
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Affiliation(s)
- James A Hughes
- School of Nursing, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, Brisbane, Qld., Australia.,Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street Herston, Herston, Qld., Australia
| | - Kimberly E Alexander
- School of Nursing, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, Brisbane, Qld., Australia.,St Vincent's Private Hospital Northside, Chermside, Qld., Australia
| | - Lyndall Spencer
- Emergency Department, Princess Alexandra Hospital, Ipswich Road Woolloongabba, Woolloongabba, Qld., Australia
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, Brisbane, Qld., Australia
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do Nascimento Rocha HM, da Costa Farre AGM, de Santana Filho VJ. Adverse Events in Emergency Department Boarding: A Systematic Review. J Nurs Scholarsh 2021; 53:458-467. [PMID: 33792131 DOI: 10.1111/jnu.12653] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Overcrowding in emergency departments (EDs) is a worldwide challenge. As a result of the increased demand for EDs, slow internal patient flow, and unavailability of hospital beds, patients are kept in the corridors, causing a boarding effect. Studies have associated boarding in EDs with unfavorable clinical outcomes and adverse events. Thus, the purpose of this systematic review was to describe the effects of ED boarding on the occurrence of adverse events. DESIGN We followed the Meta-Analysis of Observational Studies in Epidemiology checklist and registered this systematic review with PROSPERO (CRD42020117915). METHODS Literature searches were performed using the databases PubMed, Scopus, Latin American and Caribbean Center on Health Sciences Information (LILACS), Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane, as well as Google Scholar, OpenThesis, and the Brazilian Digital Library of Theses and Dissertations from September to November 2019. Cohort or case control studies that evaluated the occurrence of adverse events in patients who remained in an ED, waiting for a hospital bed, were included in the review. RESULTS Seven studies met our eligibility criteria. Boarding in EDs may be related to a reduction in the quality of care, resulting in unfavorable clinical outcomes and adverse events. CONCLUSIONS Boarding in EDs may be related to increases in adverse incidents and events. CLINICAL RELEVANCE The evidence in this review suggests that ED boarding increases the occurrence of unfavorable outcomes and identifies important considerations for future research.
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Kemmler CB, Sangal RB, Rothenberg C, Li SX, Shofer FS, Abella BS, Venkatesh AK, Foster SD. Delays in antibiotic redosing: Association with inpatient mortality and risk factors for delay. Am J Emerg Med 2021; 46:63-69. [PMID: 33735698 DOI: 10.1016/j.ajem.2021.02.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Although timely administration of antibiotics has an established benefit in serious bacterial infection, the majority of studies evaluating antibiotic delay focus only on the first dose. Recent evidence suggests that delays in redosing may also be associated with worse clinical outcome. In light of the increasing burden of boarding in Emergency Departments (ED) and subsequent need to redose antibiotic in the ED, we examined the association between delayed second antibiotic dose administration and mortality among patients admitted from the ED with a broad array of infections and characterized risk factors associated with delayed second dose administration. METHODS We performed a retrospective cohort study of patients admitted through five EDs in a single healthcare system from 1/2018 through 12/2018. Our study included all patients, aged 18 years or older, who received two intravenous antibiotic doses within a 30-h period, with the first dose administered in the ED. Patients with end stage renal disease, cirrhosis and extremes of weight were excluded due to a lack of consensus on antibiotic dosing intervals for these populations. Delay was defined as administration of the second dose at a time-point greater than 125% of the recommended interval. The primary outcome was in-hospital mortality. RESULTS A total of 5605 second antibiotic doses, occurring during 4904 visits, met study criteria. Delayed administration of the second dose occurred during 21.1% of visits. After adjustment for patient characteristics, delayed second dose administration was associated with increased odds of in-hospital mortality (OR 1.50, 95%CI 1.05-2.13). Regarding risk factors for delay, every one-hour increase in allowable compliance time was associated with a 18% decrease in odds of delay (OR 0.82 95%CI 0.75-0.88). Other risk factors for delay included ED boarding more than 4 h (OR 1.47, 95%CI 1.27-1.71) or a high acuity presentation as defined by emergency severity index (ESI) (OR 1.54, 95%CI 1.30-1.81 for ESI 1-2 versus 3-5). CONCLUSIONS Delays in second antibiotic dose administration were frequent in the ED and early hospital course, and were associated with increased odds of in-hospital mortality. Several risk factors associated with delays in second dose administration, including ED boarding, were identified.
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Affiliation(s)
- Charles B Kemmler
- Department of Emergency Medicine, Prisma Health, University of South Carolina School of Medicine Greenville, 701 Grove Rd, Greenville, SC 29605, USA.
| | - Rohit B Sangal
- Department of Emergency Medicine, Yale University, 464 Congress Ave, New Haven, CT 06510, USA.
| | - Craig Rothenberg
- Department of Emergency Medicine, Yale University, 464 Congress Ave, New Haven, CT 06510, USA.
| | - Shu-Xia Li
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, 1 Church St #200, New Haven, CT 06510, USA.
| | - Frances S Shofer
- Department of Emergency Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA.
| | - Benjamin S Abella
- Department of Emergency Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA.
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University, 464 Congress Ave, New Haven, CT 06510, USA; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, 1 Church St #200, New Haven, CT 06510, USA.
| | - Sean D Foster
- Department of Emergency Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA.
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Zimmerman A, Fox S, Griffin R, Nelp T, Thomaz EBAF, Mvungi M, Mmbaga BT, Sakita F, Gerardo CJ, Vissoci JRN, Staton CA. An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country. PLoS One 2020; 15:e0240528. [PMID: 33045030 PMCID: PMC7549769 DOI: 10.1371/journal.pone.0240528] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/29/2020] [Indexed: 11/12/2022] Open
Abstract
Background Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting. Methods We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes. Results Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery. Conclusions Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.
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Affiliation(s)
- Armand Zimmerman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Samara Fox
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Randi Griffin
- Department of Evolutionary Anthropology, Duke University, Durham, North Carolina, United States of America
| | - Taylor Nelp
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | | | - Mark Mvungi
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Charles J Gerardo
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Catherine A Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
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25
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Martin N, Bergs J. Patient flow data registration: A key barrier to the data-driven and proactive management of an emergency department. Int Emerg Nurs 2020; 53:100932. [PMID: 33035879 DOI: 10.1016/j.ienj.2020.100932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Niels Martin
- Faculty of Business Economics, Hasselt University, Hasselt, Belgium; Data Analytics Laboratory, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation Flanders (FWO), Brussels, Belgium.
| | - Jochen Bergs
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium; Department of Healthcare, PXL University of Applied Sciences and Arts, Hasselt, Belgium.
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Stoyanov KM, Biener M, Hund H, Mueller-Hennessen M, Vafaie M, Katus HA, Giannitsis E. Effects of crowding in the emergency department on the diagnosis and management of suspected acute coronary syndrome using rapid algorithms: an observational study. BMJ Open 2020; 10:e041757. [PMID: 33033102 PMCID: PMC7545662 DOI: 10.1136/bmjopen-2020-041757] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Fast diagnostic algorithms using high-sensitivity troponin (hsTn) in suspected acute coronary syndrome (ACS) are regarded as beneficial to expedite diagnosis and safe discharge of patients in crowded emergency departments (ED). This study investigates the effects of crowding on process times related to the diagnostic protocol itself or other time delays, and outcomes. DESIGN Prospective single-centre observational study. SETTING ED (Germany). PARTICIPANTS Final study population of 2525 consecutive patients with suspected ACS within 12 months, after exclusion of patients with ST-elevation myocardial infarction, missing blood samples, referral from other hospitals or repeated visits. INTERVENTIONS Use of fast algorithms as per 2015 European Society of Cardiology guidelines. MAIN OUTCOME MEASURES Crowding was defined as mismatch between patient numbers and monitoring capacities, or mean physician time per case, categorised as normal, high and very high crowding. Outcome measures were length of ED stay, direct discharge from ED, laboratory turn around times (TAT), utilisation of fast algorithms, absolute and relative non-laboratory time, as well as mortality. RESULTS Crowding was associated with increased length of ED stay (3.75-4.89 hours, p<0.001). While median TAT of the first hsTnT increased (53-57 min, p<0.001), total TAT of serial hsTnT did not increase significantly with higher crowding (p=0.170). Lower utilisation of fast algorithms (p=0.009) and increase of additional hsTnT measurements after diagnosis (p=0.001) were observed in higher crowding. Most importantly, crowding was significantly associated with prolonged absolute (p<0.001), and particularly relative non-laboratory time (63.3%-71.3%, p<0.001). However, there was no significant effect of crowding on mortality, even after adjustment for relevant clinical variables. CONCLUSIONS Process times, and particularly non-laboratory times, are prolonged in a crowded ED diminishing some positive effects of fast diagnostic algorithms in suspected ACS. Higher crowding levels were not significantly associated with higher all-cause mortality rates. TRIAL REGISTRATION NUMBER NCT03111862.
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Affiliation(s)
- Kiril M Stoyanov
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz Biener
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hauke Hund
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
- Faculty of Informatics, Heilbronn University of Applied Sciences, Heilbronn, Germany
| | - Matthias Mueller-Hennessen
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Mehrshad Vafaie
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
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Andersson J, Nordgren L, Cheng I, Nilsson U, Kurland L. Long emergency department length of stay: A concept analysis. Int Emerg Nurs 2020; 53:100930. [PMID: 33035877 DOI: 10.1016/j.ienj.2020.100930] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 08/31/2020] [Accepted: 09/10/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Emergency Department (ED) Length of stay (LOS) has been associated with poor patient outcomes, which has led to the implementation of time targets designed to keep EDLOS below a specific limit. The cut-offs defining long EDLOS varies across settings and seem to be arbitrarily chosen. This study aimed to clarify the meaning of long EDLOS. METHODS A concept analysis using the Walker and Avant approach was conducted. It included a literature search aiming to identify all uses of the concept, resulting in a set of defining attributes and a way of measuring the concept empirically. RESULTS Long EDLOS was primarily used as proxy for other phenomena, e.g. boarding or crowding. The definitions had cut-offs ranging between 4 and 48 h. The attributes defining long EDLOS was waiting, a crowded ED environment and an inefficient organization. DISCUSSION Time targets are probably more suitable when directed towards and tailored for specific sub-groups of the ED population.
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Affiliation(s)
- Jonas Andersson
- School of Medical Sciences, Örebro University, Örebro, Sweden; Centre for Clinical Research Sörmland/Uppsala University, Mälarsjukhuset, Eskilstuna, Sweden.
| | - Lena Nordgren
- Centre for Clinical Research Sörmland/Uppsala University, Mälarsjukhuset, Eskilstuna, Sweden; Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Ivy Cheng
- School of Medical Sciences, Örebro University, Örebro, Sweden; University of Toronto, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Ulrica Nilsson
- Division of Nursing, Department of Neurobiology, Care Sciences, and Society, Karolinska Institute, Stockholm, Sweden
| | - Lisa Kurland
- School of Medical Sciences, Örebro University, Örebro, Sweden
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28
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Moth G, Christensen MB, Christensen HC, Carlsen AH, Riddervold IS, Huibers L. Age-related differences in motives for contacting out-of-hours primary care: a cross-sectional questionnaire study in Denmark. Scand J Prim Health Care 2020; 38:272-280. [PMID: 32700648 PMCID: PMC7470132 DOI: 10.1080/02813432.2020.1794160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Demands for out-of-hours primary care (OOH-PC) services are increasing. Many citizens call because of non-urgent health problems. Nevertheless, the patients' motives for requesting medical help outside office hours remains an understudied area. This study aimed to examine motives for calling OOH-PC services in various age groups. DESIGN Cross-sectional paper based questionnaire study conducted during two weeks in 2015. SETTING The OOH-PC services in two Danish regions. SUBJECTS Randomly selected patients calling the two healthcare services and accepting to participate in the study received a questionnaire on patient characteristics, health problems, and 26 pre-defined motives based on the Andersen Behavioural Model. Multivariate regression analyses were conducted for various age groups to calculate the probability of each motive to be a significant factor for the decision to call. RESULTS A total of 1,871 patients were included in the study; half were parents of children aged 0-12 years. Young adults (18 to 39 years) differed significantly from other age groups as they more often stated perceived barriers and benefits such as "Own GP no time available soon enough" and "Need for quick help because of work". CONCLUSION Young adults more often perceive barriers and benefits, which may suggest af difference in expectations regarding the purpose of out-of-hours services and accessibility. Further research is needed to address this issue and further explore the potential gap between the citizens' expectations to the OOH-PC services and the prevailing health policies. Key points The out-of-hours primary healthcare services are increasingly contacted for non-urgent problems, but little is known about the citizens' motives for calling. Age is associated with differences in the perceived importance of various motives for calling out-of-hours care. Young adults are more often than other age groups motivated to call due to logistical issues, such as their job.
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Affiliation(s)
- Grete Moth
- Research Unit for General Practice, Aarhus, Denmark
- CONTACT Grete Moth Research Unit for General Practice, Aarhus, Denmark
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Akman C, Kuru T. Analysis of Emergency Department Presentations due to Injuries From Motor Vehicle Crashes and Pedestrian Strikes. Cureus 2020; 12:e9468. [PMID: 32879812 PMCID: PMC7456745 DOI: 10.7759/cureus.9468] [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: 07/04/2020] [Accepted: 07/29/2020] [Indexed: 11/05/2022] Open
Abstract
Objective The objective of this study was to analyze the causes and outcomes of presentations to the emergency department (ED) due to injuries from motor vehicle crashes and pedestrian strikes along several parameters. Methods Data from 798 patients who were injured due to motor vehicle crashes or pedestrian strikes that occurred in Canakkale Province were retrospectively analyzed. Patient demographic data such as age and gender, emergency service outcomes, and the consulted clinics were also recorded. Distributions of the crashes by weekdays or weekends, national and religious holidays, official holidays, and Ramadan month were comparatively analyzed. Results A total of 253 people injured in motor vehicle crashes and 395 people injured in pedestrian strikes were directly brought to the ED from the crash or strike scene. While 656 patients were discharged from the ED, 142 patients were referred to other clinics for surgery. A total of 538 crashes occurred on weekdays and 206 on weekends, and 54 crashes occurred during official and religious holidays. Most crashes occurred in summer, and the second most occurred in autumn. The rate of pedestrian strikes that occurred in summer and autumn was statistically significantly higher than the rate of injuries from motor vehicle crashes observed in the same seasons. The majority of the weekend crashes were caused by persons who had not consumed alcohol. Conclusion Traffic crashes occur more commonly among young men and in the summer season, while national, official, and religious holidays do not seem to play a role in the frequency of traffic crashes.
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Affiliation(s)
- Canan Akman
- Emergency Medicine, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, TUR
| | - Tolgahan Kuru
- Orthopaedics and Traumatology, Canakkale Onsekiz Mart University, Canakkale, TUR
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30
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Sharma S, Rafferty AM, Boiko O. The role and contribution of nurses to patient flow management in acute hospitals: A systematic review of mixed methods studies. Int J Nurs Stud 2020; 110:103709. [PMID: 32745787 DOI: 10.1016/j.ijnurstu.2020.103709] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 06/16/2020] [Accepted: 06/25/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Increased overcrowding in the emergency department is a potential threat to the quality and safety of patient care. Innovative ways are needed to explore overcrowding, the variables affecting patient flow and interventions necessary for future flow improvement. AIMS AND OBJECTIVES The aim of this review is to explore nurses' role(s) and their contribution to maintaining patient flow in acute hospitals through emergency departments. METHODOLOGY A systematic review of mixed studies (qualitative, quantitative and mixed-method) using narrative synthesis was undertaken. Five major databases-PubMed, CINHAL, BNI, ASSIA and SCOPUS-were searched to identify appropriate primary and secondary studies. Selected studies were critically appraised with a modified CASP tool. Data extraction and analysis was undertaken using narrative synthesis. RESULTS In total, 34 articles (31 primary studies and three systematic reviews) met the inclusion criteria. This systematic review is informed by studies from several countries, including the UK, US, Australia, Canada, and the Netherlands. The qualitative arm of this review explored both the role and function of nurses, as well as their experiences and perspectives of the patient flow process, while the quantitative arm investigated nurses' contribution to patient flow in terms of length of stay (LOS), triage time, and other associated performance data. FINDINGS Nurses' contribution to patient flow spanned their operational, strategic, and expanded roles. Strategic and expanded nursing roles offered the possibility of reducing LOS, triage time, and ED crowding in addition to improving the experience of patients and staff. Nurses in operational roles deployed experiential knowledge pertaining to several invisible aspects of patient flow challenges thereby facilitating decision-making for strategic flow improvement. The experiential knowledge and skills of these nursing roles are central to the success of flow-related interventions. However, the effects of emotional labour (e.g. conflicts, frustrations) of patient flow processes on nurses are significant and may have unaccounted for transaction costs and consequences that need acknowledging in order to be addressed by managers and policy makers. CONCLUSIONS AND RECOMMENDATIONS Policy-makers and senior managers need to capitalise on nurses' experiential knowledge and skills to enhance the strategic design and development of flow management in acute hospitals. Recommendations from this review have potential to deploy those skills and knowledge in flow improvement.
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Affiliation(s)
- Shrawan Sharma
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, England, United Kingdom; London North West University Healthcare NHS Trust Harrow, HA1 3UJ London, England, United Kingdom.
| | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, England, United Kingdom
| | - Olga Boiko
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, England, United Kingdom
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Wang S, Gao JY, Li X, Wu Y, Huo XX, Han CX, Kang MJ, Sun H, Ge BL, Liu Y, Liu YQ, Zhou JP, Wang Z. Correlation between crowdedness in emergency departments and anxiety in Chinese patients. World J Clin Cases 2020; 8:2802-2816. [PMID: 32742990 PMCID: PMC7360700 DOI: 10.12998/wjcc.v8.i13.2802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/13/2020] [Accepted: 06/02/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Emergency department (ED) overcrowding is a severe health care concern, while anxiety and depression rates among ED patients have been reported to be substantially higher compared to the general population. We hypothesized that anxiety due to over crowdedness may lead to adverse events in EDs.
AIM To investigate correlations between crowdedness in EDs and anxiety of patients and nurses, and to identify factors affecting their anxiety.
METHODS In this prospective observational study, a total 43 nurses and 389 emergency patients from two tier III hospitals located in Beijing were included from January 2016 to August 2017. Patients were grouped into inpatients when they were hospitalized after diagnoses, or into outpatients when they were discharged after treatments. The State Trait Anxiety Inventory (STAI Form Y) questionnaire was used to investigate patient and nurse anxieties, while crowdedness of EDs was evaluated with the National Emergency Department Over Crowding Score.
RESULTS The present results revealed that state anxiety scores (49.50 ± 6.00 vs 50.80 ± 2.80, P = 0.005) and trait anxiety scores (45.40 ± 5.70 vs 46.80 ± 2.70, P = 0.002) between inpatients (n = 173) and outpatients (n = 216) were significantly different, while the state anxiety of nurses (44.70 ± 5.80) was different from those of both patient groups. Generalized linear regression analysis demonstrated that multiple factors, including crowdedness in the ED, were associated with state and trait anxieties for both inpatients and outpatients. In addition, there was an interaction between state anxiety and trait anxieties. However, multivariable regression analysis showed that while overcrowding in the ED did not directly correlate with patients’ and nurses’ anxiety levels, the factors that did correlate with state and trait anxieties of inpatients were related to crowdedness. These factors included waiting time in the ED, the number of patients treated, and the number of nurses in the ED, whereas for nurses, only state and trait anxieties correlated significantly with each other.
CONCLUSION Waiting time, the number of patients treated, and the number of nurses present in the ED correlate with patient anxiety in EDs, but crowdedness has no effect on nurse or patient anxiety.
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Affiliation(s)
- Shuang Wang
- Department of Emergency Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Jun-Yi Gao
- Department of Cardiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Xiang Li
- Emergency Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yu Wu
- Department of Orthopedic Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Xiao-Xia Huo
- Department of Emergency Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Chao-Xia Han
- Department of Emergency Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Meng-Jie Kang
- Emergency Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Hong Sun
- Department of Emergency Medicine, Peking University People’s Hospital, Beijing 100044, China
| | - Bao-Lan Ge
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Yu Liu
- Department of Emergency Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Ying-Qing Liu
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Jian-Ping Zhou
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhen Wang
- Department of Emergency Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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Bittencourt RJ, Stevanato ADM, Bragança CTNM, Gottems LBD, O'Dwyer G. Interventions in overcrowding of emergency departments: an overview of systematic reviews. Rev Saude Publica 2020; 54:66. [PMID: 32638885 PMCID: PMC7319499 DOI: 10.11606/s1518-8787.2020054002342] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/15/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To present an overview of systematic reviews on throughput interventions to solve the overcrowding of emergency departments. METHODS Electronic searches for reviews published between 2007 and 2018 were made on PubMed, Cochrane Library, EMBASE, Health Systems Evidence, CINAHL, SciELO, LILACS, Google Scholar and the CAPES periodicals portal. Data of the included studies was extracted into a pre-formatted sheet and their methodological quality was assessed using AMSTAR 2 tool. Eventually, 15 systematic reviews were included for the narrative synthesis. RESULTS The interventions were grouped into four categories: (1) strengthening of the triage service; (2) strengthening of the ED’s team; (3) creation of new care zones; (4) change in ED’s work processes. All studies observed positive effect on patient’s length of stay, expect for one, which had positive effect on other indicators. According to AMSTAR 2 criteria, eight revisions were considered of high or moderate methodological quality and seven, low or critically low quality. There was a clear improvement in the quality of the studies, with an improvement in focus and methodology after two decades of systematic studies on the subject. CONCLUSIONS Despite some limitations, the evidence presented on this overview can be considered the cutting edge of current scientific knowledge on the topic.
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Affiliation(s)
- Roberto José Bittencourt
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Angelo de Medeiros Stevanato
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Carolina Thomé N M Bragança
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Leila Bernarda Donato Gottems
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Gisele O'Dwyer
- Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
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Yiadom MYAB, Napoli A, Granovsky M, Parker RB, Pilgrim R, Pines JM, Schuur J, Augustine J, Jouriles N, Welch S. Managing and Measuring Emergency Department Care: Results of the Fourth Emergency Department Benchmarking Definitions Summit. Acad Emerg Med 2020; 27:600-611. [PMID: 32248605 DOI: 10.1111/acem.13978] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND A shared language and vocabulary are essential for managing emergency department (ED) operations. This Fourth Emergency Department Benchmarking Alliance (EDBA) Summit brought together experts in the field to review, update, and add to key definitions and metrics of ED operations. OBJECTIVE Summit objectives were to review and revise existing definitions, define and characterize new practices related to ED operations, and introduce financial and regulatory definitions affecting ED reimbursement. METHODS Forty-six ED operations, data management, and benchmarking experts were invited to participate in the EDBA summit. Before arrival, experts were provided with documents from the three prior summits and assigned to update the terminology. Materials and publications related to standards of ED operations were considered and discussed. Each group submitted a revised set of definitions prior to the summit. Significantly revised, topical, or controversial recommendations were discussed among all summit participants. The goal of the in-person discussion was to reach consensus on definitions. Work group leaders made changes to reflect the discussion, which was revised with public and stakeholder feedback. RESULTS The entire EDBA dictionary was updated and expanded. This article focuses on an update and discussion of definitions related to specific topics that changed since the last summit, specifically ED intake, boarding, diversion, and observation care. In addition, an extensive new glossary of financial and regulatory terminology germane to the practice of emergency medicine is included. CONCLUSIONS A complete and precise set of operational definitions, time intervals, and utilization measures is necessary for timely and effective ED care. A common language of financial and regulatory definitions that affect ED operations is included for the first time. This article and its companion dictionary should serve as a resource to ED leadership, researchers, informatics and health policy leaders, and regulatory bodies.
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Affiliation(s)
- Maame Y. A. B. Yiadom
- From the Department of Emergency Medicine Emergency Care Health Services Research Data Coordinating Center Vanderbilt University Nashville TNUSA
| | - Anthony Napoli
- the Department of Emergency Medicine Brown University Providence RIUSA
| | | | | | | | | | - Jeremiah Schuur
- the Department of Emergency Medicine Brown University Providence RIUSA
| | - James Augustine
- National Clinical Governance BoardUS Acute Care Solutions CantonOHUSA
| | - Nicholas Jouriles
- the Department of Emergency Medicine Northeast Ohio Medical University Rootstown OHUSA
| | - Shari Welch
- and the Center for Health Design Intermountain Healthcare Salt Lake City UT USA
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Mowbray FI, DeLaroche AM, Parker SJ, Jones A, Ravichandran Y. Examining the clinical management of asthma exacerbations by nurse practitioners in a pediatric emergency department. Int Emerg Nurs 2020; 50:100844. [PMID: 32205105 DOI: 10.1016/j.ienj.2020.100844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 11/17/2019] [Accepted: 01/13/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little is known about the clinical management or quality of asthma care provided by nurse practitioners (NP) in a pediatric emergency setting. OBJECTIVE To describe the clinical management of asthma by NPs in our institution's emergency department, and to compare the treatment strategies between NPs, pediatricians, and pediatric emergency physicians. METHODS We conducted a retrospective chart review at a level-one pediatric trauma center. Data were extracted from electronic medical records for all patients between 2 and 18 years of age presenting to the emergency department with an asthma exacerbation. Data were analyzed using binary logistic regression with generalized estimating equations. RESULTS NPs evaluated 18% of all children presenting for asthma care. When compared to pediatric emergency physicians, patients treated by NPs had approximately twice the odds of receiving a β2-agonist (OR = 2.02; 95% CI 1.02 - 3.99) or a systemic corticosteroid (OR = 2.31; 95% CI 1.35 - 3.95) within 60 minutes of clinical evaluation. Adherence rates were similar for the other asthma quality measures between these two clinician groups. CONCLUSIONS NPs were best able to meet time-sensitive asthma quality measures in the emergency department. The addition of NPs to emergency staffing models may improve access to timely care for children with asthma.
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Affiliation(s)
- Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. West., L8S 4L8 Hamilton, Ontario, Canada.
| | - Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien St., 48201 Detroit, Michigan, United States.
| | - Sarah J Parker
- Department of Family Medicine and Public Health Sciences, Wayne State University, 42 W Warren Avenue, 48202 Detroit, Michigan, United States.
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. West., L8S 4L8 Hamilton, Ontario, Canada.
| | - Yagnaram Ravichandran
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien St., 48201 Detroit, Michigan, United States.
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Huibers L, Carlsen AH, Moth G, Christensen HC, Riddervold IS, Christensen MB. Patient motives for contacting out-of-hours care in Denmark: a cross-sectional study. BMC Emerg Med 2020; 20:20. [PMID: 32183705 PMCID: PMC7079359 DOI: 10.1186/s12873-020-00312-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 02/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients in need of acute health care do not always contact the most suitable health care service provider. Contacting out-of-hours primary care for an urgent problem may delay care, whereas contacting emergency medical services for a non-urgent problem could ultimately affect patient safety. More insight into patient motives for contacting a specific health care provider may help optimise patient flows. This study aims to explore patient motives for contacting out-of-hours primary care and the emergency medical services in Denmark. METHODS We conducted a cross-sectional observational study by sending a questionnaire to patients contacting out-of-hours primary care and emergency medical services, both of which can be directly contacted by patients, in two of five Danish regions in 2015. As we aimed to focus on the first access point, the emergency department was not included. The questionnaire included items on patient characteristics, health problem and 26 pre-defined motives. Descriptive analyses of patient characteristics and motives were conducted, stratified by the two health care service providers. Factors associated with contacting each of the two service providers were explored in a modified Poisson regression analysis, and adjusted risk ratios were calculated. RESULTS Three key motives for contacting the two service providers were identified: 'unpleasant symptoms', 'perceived need for prompt action' and 'perceived most suitable health care provider'. Other important motives were 'need arose outside office hours' and 'wanted to talk to a physician' (out-of-hours primary care) and 'expected need for ambulance' and 'worried' (emergency medical services). Higher probability of contacting the emergency medical services versus out-of-hours primary care was seen for most motives relating to own assessment and expectations, previous experience and knowledge, and own needs and wishes. Lower probability was seen for most motives relating to perceived barriers and benefits. CONCLUSIONS Patient motives for contacting the two health care service providers were partly overlapping. The study contributes with new knowledge on the complex decision-making process of patients in need of acute health care. This knowledge could help optimise existing health care services, such as patient safety and the service level, without increasing health care costs.
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Affiliation(s)
- Linda Huibers
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark.
| | - Anders H Carlsen
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Grete Moth
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Helle C Christensen
- Emergency Medical Services, Telegrafvej 5, 2750, Ballerup, Denmark.,Danish Clinical Quality Program (RKKP), Frederiksberg Hospital, Ndr. Fasanvej 57, 2000, Frederiksberg, Denmark
| | - Ingunn S Riddervold
- Prehospital Emergency Medical Services, Central Denmark Region, Olof Palmes Allé 34, 8200, Aarhus, N, Denmark
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Woodworth L. Swamped: Emergency Department Crowding and Patient Mortality. JOURNAL OF HEALTH ECONOMICS 2020; 70:102279. [PMID: 32062054 DOI: 10.1016/j.jhealeco.2019.102279] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 12/06/2019] [Accepted: 12/14/2019] [Indexed: 06/10/2023]
Abstract
U.S. emergency departments are experiencing extreme levels of crowding. This study estimates the impact of emergency department crowding on patient mortality. Identification relies on the abrupt crowding shocks felt by "old" emergency departments at the time a new emergency department opens nearby. Using death records linked to hospital administrative records, I find that a 10% alleviation of emergency department patient volume significantly lowers the average patient's chance of mortality. Improvements appear to be realized both inside the hospital and after the patient has left.
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Affiliation(s)
- Lindsey Woodworth
- Department of Economics, University of South Carolina, 1014 Greene Street, Columbia, SC, 29208, United States.
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Abbadessa MKF. Call to Action: The Need for Best Practices for Boarding the Pediatric Intensive Care Patient in the Emergency Department. J Emerg Nurs 2020; 46:150-153. [PMID: 31983462 DOI: 10.1016/j.jen.2019.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/21/2019] [Accepted: 10/11/2019] [Indexed: 11/18/2022]
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Klug M, Barash Y, Bechler S, Resheff YS, Tron T, Ironi A, Soffer S, Zimlichman E, Klang E. A Gradient Boosting Machine Learning Model for Predicting Early Mortality in the Emergency Department Triage: Devising a Nine-Point Triage Score. J Gen Intern Med 2020; 35:220-227. [PMID: 31677104 PMCID: PMC6957629 DOI: 10.1007/s11606-019-05512-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 07/12/2019] [Accepted: 10/01/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency departments (ED) are becoming increasingly overwhelmed, increasing poor outcomes. Triage scores aim to optimize the waiting time and prioritize the resource usage. Artificial intelligence (AI) algorithms offer advantages for creating predictive clinical applications. OBJECTIVE Evaluate a state-of-the-art machine learning model for predicting mortality at the triage level and, by validating this automatic tool, improve the categorization of patients in the ED. DESIGN An institutional review board (IRB) approval was granted for this retrospective study. Information of consecutive adult patients (ages 18-100) admitted at the emergency department (ED) of one hospital were retrieved (January 1, 2012-December 31, 2018). Features included the following: demographics, admission date, arrival mode, referral code, chief complaint, previous ED visits, previous hospitalizations, comorbidities, home medications, vital signs, and Emergency Severity Index (ESI). The following outcomes were evaluated: early mortality (up to 2 days post ED registration) and short-term mortality (2-30 days post ED registration). A gradient boosting model was trained on data from years 2012-2017 and examined on data from the final year (2018). The area under the curve (AUC) for mortality prediction was used as an outcome metric. Single-variable analysis was conducted to develop a nine-point triage score for early mortality. KEY RESULTS Overall, 799,522 ED visits were available for analysis. The early and short-term mortality rates were 0.6% and 2.5%, respectively. Models trained on the full set of features yielded an AUC of 0.962 for early mortality and 0.923 for short-term mortality. A model that utilized the nine features with the highest single-variable AUC scores (age, arrival mode, chief complaint, five primary vital signs, and ESI) yielded an AUC of 0.962 for early mortality. CONCLUSION The gradient boosting model shows high predictive ability for screening patients at risk of early mortality utilizing data available at the time of triage in the ED.
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Affiliation(s)
- Maximiliano Klug
- Department of Diagnostic Imaging , The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yiftach Barash
- Department of Diagnostic Imaging , The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | - Avi Ironi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Emergency Room, The Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Shelly Soffer
- Department of Diagnostic Imaging , The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Zimlichman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hospital Management, The Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Eyal Klang
- Department of Diagnostic Imaging , The Chaim Sheba Medical Center, Ramat Gan, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Hesselink G, Sir Ö, Schoon Y. Effectiveness of interventions to alleviate emergency department crowding by older adults: a systematic review. BMC Emerg Med 2019; 19:69. [PMID: 31747917 PMCID: PMC6864956 DOI: 10.1186/s12873-019-0288-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 11/06/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The growing demand for elderly care often exceeds the ability of emergency department (ED) services to provide quality of care within reasonable time. The purpose of this systematic review is to assess the effectiveness of interventions on reducing ED crowding by older patients, and to identify core characteristics shared by successful interventions. METHODS Six major biomedical databases were searched for (quasi)experimental studies published between January 1990 and March 2017 and assessing the effect of interventions for older patients on ED crowding related outcomes. Two independent reviewers screened and selected studies, assessed risk of bias and extracted data into a standardized form. Data were synthesized around the study setting, design, quality, intervention content, type of outcome and observed effects. RESULTS Of the 16 included studies, eight (50%) were randomized controlled trials (RCTs), two (13%) were non-RCTs and six (34%) were controlled before-after (CBA) studies. Thirteen studies (81%) evaluated effects on ED revisits and four studies (25%) evaluated effects on ED throughput time. Thirteen studies (81%) described multicomponent interventions. The rapid assessment and streaming of care for older adults based on time-efficiency goals by dedicated staff in a specific ED unit lead to a statistically significant decrease of ED length of stay (LOS). An ED-based consultant geriatrician showed significant time reduction between patient admission and geriatric review compared to an in-reaching geriatrician. CONCLUSION Inter-study heterogeneity and poor methodological quality hinder drawing firm conclusions on the intervention's effectiveness in reducing ED crowding by older adults. More evidence-based research is needed using uniform and valid effect measures. TRIAL REGISTRATION The protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017075575).
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Affiliation(s)
- Gijs Hesselink
- Emergency Department, Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, P.O. Box 9101, 114 IQ healthcare, Nijmegen, HB 6500 The Netherlands
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ health care, P.O. Box 9101, 114 IQ healthcare, Nijmegen, HB 6500 the Netherlands
| | - Özcan Sir
- Emergency Department, Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, P.O. Box 9101, 114 IQ healthcare, Nijmegen, HB 6500 The Netherlands
| | - Yvonne Schoon
- Emergency Department, Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, P.O. Box 9101, 114 IQ healthcare, Nijmegen, HB 6500 The Netherlands
- Department of Geriatrics, Radboud university medical center, Nijmegen, The Netherlands
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[Predictors of Utilization of Cardiovascular and Respiratory Emergency Department Visits - what Impact does the Environment have?]. DAS GESUNDHEITSWESEN 2019; 83:105-113. [PMID: 31614385 DOI: 10.1055/a-1005-7161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIM There has been an increasing number of emergency department (ED) visits recently. It is unclear whether, in addition to a shift in services from the outpatient to the inpatient sector, other causes, (e. g. environmental factors), play a role. The aim was to investigate associations between the number of cardiovascular and respiratory ED visits and environmental variables. METHODS Highly correlated environmental data were subjected to a principal component analysis. By using cross-correlation functions, environmental variables with time lags that showed the highest correlation with the number of ED visits were taken into consideration in the UNIANOVA analysis model, together with, among others, the day of the week and interaction terms. RESULTS The final regression model explained 47% of the variation in respiratory ED visits demonstrating main effects for Mondays (B=10.69; p<0.001). Season showed significant effects with highest ED visits in autumn. No direct associations between environmental variables and number of respiratory ED visits were found. The results for the cardiovascular outcome were less expressive (R2=0.20). Again, the day of the week had the main effect on cardiovascular ED visits (p<0.001). CONCLUSIONS The results suggest that weekdays had the main effect on ED visits. In future, we will collect and analyze environmental data at the micro level to achieve a higher model quality and better interpretability.
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Promoting head CT exams in the emergency department triage using a machine learning model. Neuroradiology 2019; 62:153-160. [DOI: 10.1007/s00234-019-02293-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 09/10/2019] [Indexed: 12/19/2022]
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Matifat E, Méquignon M, Cunningham C, Blake C, Fennelly O, Desmeules F. Benefits of Musculoskeletal Physical Therapy in Emergency Departments: A Systematic Review. Phys Ther 2019; 99:1150-1166. [PMID: 31505674 DOI: 10.1093/ptj/pzz082] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 02/21/2019] [Indexed: 11/12/2022]
Abstract
BACKGROUND Over the past few decades, physical therapists have emerged as key health care providers in emergency departments (EDs), especially for patients with musculoskeletal disorders (MSKD). PURPOSE The purpose of this review was to update the current evidence regarding physical therapist care for patients with MSKD in EDs and to update current recommendations for these models of care. DATA SOURCES Systematic searches were conducted in 5 bibliographic databases. STUDY SELECTION The studies selected presented quantitative data related to the care of patients with MSKD by physical therapists in an ED setting. DATA EXTRACTION Raters reviewed studies and used the Effective Public Health Practice Project Quality Assessment Tool to assess their methodological quality. DATA SYNTHESIS Fifteen studies were included. Two studies, 1 of weak and 1 of strong quality, demonstrated that physical therapist care in EDs was as effective as or more effective than usual medical care for pain reduction, and 6 studies of varying quality reported that physical therapist care in EDs was as effective as usual care in EDs in reducing disability. Eight studies of varying quality reported that physical therapist care could significantly reduce waiting time in EDs. Four studies of varying quality reported that physical therapists ordered no more, or even fewer, medical images than physicians. In terms of health care costs, 2 studies of moderate to high quality found no significant differences in costs between physical therapist care and usual care in EDs. Finally, 6 studies of varying quality reported that patients were as satisfied or more satisfied with physical therapist care as with usual medical care in EDs. LIMITATIONS The roles of physical therapists in EDs vary depending on the setting, legislation, and training of providers. Only a limited number of high-quality studies were identified. CONCLUSIONS Although the quality of the evidence is heterogeneous, physical therapist care for patients with MSKD in EDs may be beneficial.
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Affiliation(s)
- Eveline Matifat
- Maisonneuve-Rosemont Hospital Research Center, University of Montréal Affiliated Research Center, Montréal, Québec, Canada
| | - Marianne Méquignon
- Maisonneuve-Rosemont Hospital Research Center, University of Montréal Affiliated Research Center; and Kinesitherapie, Université de Picardie Jules Verne, Amiens, France
| | - Caitriona Cunningham
- School of Public Health, Physiotherapy and Sports Science, Health Sciences Center, University College Dublin, Belfield, Dublin, Ireland
| | - Catherine Blake
- School of Public Health, Physiotherapy and Sports Science, Health Sciences Center, University College Dublin, Belfield, Dublin, Ireland
| | - Oma Fennelly
- School of Public Health, Physiotherapy and Sports Science, Health Sciences Center, University College Dublin, Belfield, Dublin, Ireland
| | - François Desmeules
- Maisonneuve-Rosemont Hospital Research Center, University of Montréal Affiliated Research Center, 5415 Boul. L'Assomption, Porte 4163 Pav. Rachel Tourigny, Montréal, Quebec, Canada H1T 2M4; and School of Rehabilitation, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada
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Nursing driven approaches to improving emergency department discharge. Am J Emerg Med 2019; 37:1784-1787. [DOI: 10.1016/j.ajem.2019.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 02/11/2019] [Accepted: 02/11/2019] [Indexed: 11/20/2022] Open
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Analysis of factors influencing length of stay in the Emergency Department in public hospital, Yogyakarta, Indonesia. Australas Emerg Care 2019; 22:174-179. [DOI: 10.1016/j.auec.2019.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 11/19/2022]
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The impact of a multimodal intervention on emergency department crowding and patient flow. Int J Emerg Med 2019; 12:21. [PMID: 31455260 PMCID: PMC6712614 DOI: 10.1186/s12245-019-0238-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/15/2019] [Indexed: 11/16/2022] Open
Abstract
Objective The objective of this study is to assess the impact of a multimodal intervention on emergency department (ED) crowding and patient flow in a Dutch level 1 trauma center. Methods In this cross-sectional study, we compare ED crowding and patient flow between a 9-month pre-intervention period and a 9-month intervention period, during peak hours and overall (24/7). The multimodal intervention included (1) adding an emergency nurse practitioner (ENP) and (2) five medical specialists during peak hours to the 24/7 available emergency physicians (EPs), (3) a Lean programme to improve radiology turnaround times, and (4) extending the admission offices’ openings hours. Crowding is measured with the modified National ED OverCrowding Score (mNEDOCS). Furthermore, radiology turnaround times, patients’ length of stay (LOS), proportion of patients leaving without being seen (LWBS) by a medical provider, and unscheduled representations are assessed. Results The number of ED visits were grossly similar in the two periods during peak hours (15,558 ED visits in the pre-intervention period and 15,550 in the intervention period) and overall (31,891 ED visits in the pre-intervention period vs. 32,121 in the intervention period). During peak hours, ED crowding fell from 18.6% (pre-intervention period) to 3.5% (intervention period), radiology turnaround times decreased from an average of 91 min (interquartile range 45–256 min) to 50 min (IQR 30–106 min., p < 0.001) and LOS reduced with 13 min per patient from 167 to 154 min (p < 0.001). For surgery, neurology and cardiology patients, LOS reduced significantly (with 17 min, 25 min, and 8 min. respectively), while not changing for internal medicine patients. Overall, crowding, radiology turnaround times and LOS also decreased. Less patients LWBS in the intervention period (270 patients vs. 348 patients, p < 0.001) and less patients represented unscheduled within 1 week after the initial ED visit: 864 (2.7%) in the pre-intervention period vs. 645 (2.0%) patients in the intervention period, p < 0.001. Conclusions In this hospital, a multimodal intervention successfully reduces crowding, radiology turnaround times, patients’ LOS, number of patients LWBS and the number of unscheduled return visits, suggesting improved ED processes. Further research is required on total costs of care and long-term effects.
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Muche-Borowski C, Boczor S, Schäfer I, Kazek A, Hansen H, Oltrogge J, Giese S, Lühmann D, Scherer M. [Patients with chronic diseases in emergency rooms in Germany : Cross-sectional analysis of consultations, reasons for use, and discharge diagnosis]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:1103-1112. [PMID: 31428831 DOI: 10.1007/s00103-019-03000-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The number of patients in emergency rooms without a medical emergency is increasing. Outpatient services for mutual support and relief between the in-patient and out-patient sector are not yet fully established. AIM OF THE WORK The aim was to determine the extent to which patients in emergency rooms have real medical emergencies by comparing patients with at least two and those with a maximum of one chronic illness. An additional aim was to identify factors influencing the previous use of outpatient structures. MATERIAL AND METHODS The study participants included emergency room patients from the cross-sectional study "PiNo-Nord." All persons in five emergency rooms in northern Germany between October 2015 and July 2016 who were not treated as "immediate" or "very urgent" were interviewed. An exploratory data analysis and multivariate logistic regression were performed. RESULTS The 293 patients with ≥2 chronic diseases were just as often a medical emergency compared to the 847 patients with a maximum of 1 chronic disease. The most frequent occasions for consultation were musculoskeletal trauma (33%, n = 293 vs. 42%, n = 847) or trauma of the skin (11%, n = 293 vs. 13%, n = 847). In both groups, the general practitioner or specialist caregiver, as well as diagnostic or treatment options, rarely played a role in visiting the emergency department. The strongest predictors of previous outpatient treatment were the duration of the appeal in the last six months, a high subjective treatment urgency, the presence of at least two chronic conditions, and a consultation event concerning the musculoskeletal injuries. CONCLUSIONS In both patient groups, no evidence of unnecessary visits to the emergency room was found. For the most part, outpatient structures are used in advance and the emergency department is only visited in the event of an actual medical emergency.
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Affiliation(s)
- Cathleen Muche-Borowski
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - Sigrid Boczor
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Ingmar Schäfer
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Agata Kazek
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Heike Hansen
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Jan Oltrogge
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Stefanie Giese
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Dagmar Lühmann
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Martin Scherer
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
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Mentzoni I, Bogstrand ST, Faiz KW. Emergency department crowding and length of stay before and after an increased catchment area. BMC Health Serv Res 2019; 19:506. [PMID: 31331341 PMCID: PMC6647148 DOI: 10.1186/s12913-019-4342-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/11/2019] [Indexed: 11/10/2022] Open
Abstract
Background Emergency department (ED) crowding and prolonged length of stay (LOS) are associated with delays in treatment, adverse outcomes and decreased patient satisfaction. Hospital restructuring and mergers are often associated with increased ED crowding. The aim of this study was to explore ED crowding and LOS in Norway’s largest ED before and after an increased catchment area. Methods The catchment area of Akershus University Hospital increased by approximately 150,000 inhabitants in 2011, from 340,000 to 490,000. In this retrospective study, admissions to the ED during a six-year period, from Jan 1st 2010 to Dec 31st 2015 were included and analyzed. Results A total of 179,989 admissions were included (51.0% men). The highest occupancy rate was in the age group 70–79 years. Following the increase in the catchment area, the annual ED admissions increased by 8343 (40.9%) from 2010 to 2011, and peaked in 2013 (34,002). Mean LOS increased from 3:59 h in 2010 to 4:17 in 2012 (highest), and decreased to 3:45 h in 2015 after staff, capacity and organizational measures. In 2010, 37.9% of the ED patients experienced crowding, and this proportion increased to between 52.9–77.6% in 2011–2015. Crowding peaked between 4 and 5 PM. Conclusions LOS increased and crowding was more frequent after a major increase in the hospital’s catchment area in Norway’s largest emergency department. Even after 5 years, the LOS was higher than before the expansion, mainly because of the throughput and output components, which were not properly adapted to the changes in input. Electronic supplementary material The online version of this article (10.1186/s12913-019-4342-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ida Mentzoni
- Emergency Department, Akershus University Hospital, Lørenskog, Norway.,Lovisenberg Diaconal University College, Oslo, Norway
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Section of Drug Abuse Research, Oslo University Hospital, Oslo, Norway.,Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Kashif Waqar Faiz
- Health Services Research Unit, Akershus University Hospital, PO Box 1000, N-1478, Lørenskog, Norway. .,Department of Neurology, Akershus University Hospital, Lørenskog, Norway.
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Gomes ATDL, Ferreira MA, Salvador PTCO, Bezerril MDS, Chiavone FBT, Santos VEP. Safety of the patient in an emergency situation: perceptions of the nursing team. Rev Bras Enferm 2019; 72:753-759. [PMID: 31269142 DOI: 10.1590/0034-7167-2018-0544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 02/12/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To know the perception of nursing professionals about the essential aspects to provide safe care to polytraumatized patients in emergency services. METHOD Descriptive and mixed study, performed with a focus group and projective techniques. The sample was made of seven nursing professionals. Data analysis took place through the Interface de R pour Analyses Multidimensionnelles de Textes et de Questionneires and SPSS 22.0 softwares. RESULTS Based on the analysis of participants' speeches, three content partitions emerged in the Descending Hierarchical Classification. 1) Structure: need for changes; 2) The process: safe actions by the nursing team; and 3) Care free from damage as the sought result. CONCLUSION Patient safety in emergency situations must rely on a proper environment and an organized sector, good conditions to transport patients, use of routines and protocols, identification and organization of the beds.
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The effects of emergency department crowding on triage and hospital admission decisions. Am J Emerg Med 2019; 38:774-779. [PMID: 31288959 DOI: 10.1016/j.ajem.2019.06.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/11/2019] [Accepted: 06/21/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Emergency department (ED) crowding is a recognized issue and it has been suggested that it can affect clinician decision-making. OBJECTIVES Our objective was to determine whether ED census was associated with changes in triage or disposition decisions made by ED nurses and physicians. METHODS We performed a retrospective study using one year of data obtained from a US academic center ED (65,065 patient encounters after cleaning). Using a cumulative logit model, we investigated the association between a patient's acuity group (low, medium, and high) and ED census at triage time. We also used multivariate logistic regression to investigate the association between the disposition decision for a patient (admit or discharge) and the ED census at the disposition decision time. In both studies, control variables included census, age, gender, race, place of treatment, chief complaint, and certain interaction terms. RESULTS We found statistically significant correlation between ED census and triage/disposition decisions. For each additional patient in the ED, the odds of being assigned a high acuity versus medium or low acuity at triage is 1.011 times higher (95% confidence interval [CI] for Odds Ratio [OR] = [1.009,1.012]), and the odds of being assigned medium or high acuity versus low acuity at triage is 1.009 times higher (95% CI for OR = [1.008,1.010]). Similarly, the odds of being admitted versus discharged increases by 1.007 times (95% CI for OR = [1.006,1.008]) per additional patient in the ED at the time of disposition decision. CONCLUSION Increased ED occupancy was found to be associated with more patients being classified as higher acuity as well as higher hospital admission rates. As an example, for a commonly observed patient category, our model predicts that as the ED occupancy increases from 25 to 75 patients, the probability of a patient being triaged as high acuity increases by about 50% and the probability of a patient being categorized as admit increases by around 25%.
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Lee MO, Arthofer R, Callagy P, Kohn MA, Niknam K, Camargo CA, Shen S. Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds. Am J Emerg Med 2019; 38:272-277. [PMID: 31085010 DOI: 10.1016/j.ajem.2019.04.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/12/2019] [Accepted: 04/30/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Inpatient hallway beds are one solution to mitigate emergency department (ED) crowding due to boarding of admitted patients. Alternative Care Areas (AltCA) beds are located in inpatient hallways, cardiac catheterization lab, and endoscopy. We examined whether AltCA beds were associated with increased risk of patient safety and quality outcomes: transfer to Intensive Care Unit (ICU), mortality, hospital-acquired infections (HAI), falls, and 72-hour hospital readmission. METHODS Retrospective cohort study of patients age >18 years admitted from the ED to non-ICU beds at an urban, academic hospital. AltCA bed exclusion criteria: dementia, frequent respiratory interventions, contact or airborne isolation, psychiatric admission, and inability to ambulate. The study periods were: pre-intervention 9/1/2014-3/31/2015, transition 9/1/2015-3/31/2016, and post-intervention 9/1/2016-3/31/2017. Data analysis used unadjusted and multivariable analyses which controlled for age, sex, race, ethnicity, insurance, ED triage Emergency Service Index (ESI) level, and telemetry order. RESULTS The study included 16,801 patients, with 622 (3.7%) patients in AltCA beds. AltCA beds had younger patients than standard inpatient beds, 57.7 years and 61.7 years; fewer telemetry order, 48.4% and 59.3%; and fewer ESI level 2, 16.1% and 26.2%. AltCA beds had shorter hospital LOS than standard inpatient beds, 2.7 days and 3.4 days. AltCA beds had decreased risk of transfer to ICU -10.6 (95%CI: -18.3, -2.8) and HAI -13.4 (95%CI: -20.3, -6.5) compared to standard inpatient beds. CONCLUSION Patients in AltCA beds did not have increased risk of patient safety and quality outcomes but rather decreased risk of transfer to ICU and HAI than standard inpatient beds.
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Affiliation(s)
- Moon O Lee
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, MC 5119, Suite 350, Stanford, CA 94304, United States of America.
| | - Rudolph Arthofer
- Stanford Hospital and Clinics, 300 Pasteur Drive, Stanford, CA 94305, United States of America.
| | - Patrice Callagy
- Stanford Hospital and Clinics, 300 Pasteur Drive, Stanford, CA 94305, United States of America.
| | - Michael A Kohn
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, MC 5119, Suite 350, Stanford, CA 94304, United States of America.
| | - Kian Niknam
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, MC 5119, Suite 350, Stanford, CA 94304, United States of America.
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston, MA 02114, United States of America..
| | - Sam Shen
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, MC 5119, Suite 350, Stanford, CA 94304, United States of America.
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