Safety net research in emergency medicine: proceedings of the Academic Emergency Medicine Consensus Conference on "The Unraveling Safety Net"

Reducing the length of stay of cardiac patients in the Adult Emergency department by using a Quality improvement framework

BACKGROUND

Crowding is now a familiar challenge in the Emergency Department that can lead to significant adverse outcomes, including reduced quality of care and increased length of stay.

OBJECTIVE

Reduce cardiac patient length of stay from 72 h to 48 h in the Tikur Anbessa Specialized Hospital Adult Emergency department from August 16, 2021, to January 29, 2022, in Addis Ababa, Ethiopia.

METHODS

Process mapping was done by members of the team working in the emergency department on patient treatment and divided into three categories. Problems were then identified in each category that contributed to prolonged stay length. The run chart was then used to display the data for analysis, and nonrandom variation was looked for using the four-run chart rules.

RESULTS

Improved patient throughput in the Emergency Department (ED) was achieved, reducing the average length of stay from 78 h to 25 h by implementing the following change strategies: Streamlining morning discharge times by adjusting from the baseline of 9:10 AM to 9:00 AM; Enhancing patient handover processes to ensure 100% of patients are included on the handover form during transition hours; and Consistently assigning residents to the waiting area, resulting in a 100% presence rate. These changes effectively decreased the prolonged patient length of stay in the ED.

CONCLUSION

Poor management support and staff integration were identified as the leading cause of prolonged patient stay. In conclusion, a bundle of interventions is necessary to reduce the prolonged patient length of stay.

Expanding Contraceptive Access for Teens-Leveraging the Pediatric Emergency Department

PURPOSE

Adolescents have limited access to sexual healthcare services, and the emergency department (ED) may be the only place some will seek care. We implemented an ED-based contraception counseling intervention to assess intervention feasibility, and adolescent intention to initiate contraception, contraception initiation, and follow-up visit completion.

METHODS

This prospective cohort study trained advanced practice providers in the EDs of two pediatric urban academic medical centers to deliver brief contraception counseling. A convenience sample of patients enrolled from 2019 to 2021 included females aged 15-18 not pregnant/desiring pregnancy and/or using hormonal contraception/an intrauterine device. Participants completed surveys to assess demographics and intention to initiate contraception (yes/no). Sessions were audiotaped and reviewed for fidelity. We ascertained contraception initiation and follow-up visit completion via medical record review and participant survey at 8 weeks.

RESULTS

Twenty-seven advanced practice providers were trained, and 96 adolescents were counseled/responded to surveys (mean age 16.7 years; 19% non-Hispanic White, 56% non-Hispanic Black; 18% Hispanic). Mean counseling duration was 12 minutes and >90% of reviewed sessions maintained fidelity to content/style. Most participants (61%) reported intention to initiate contraception, and these participants were older and more likely to report prior contraceptive use, compared to those without intention. One-third (33%) initiated contraception in the ED or after the follow-up visit.

DISCUSSION

Contraceptive counseling was feasible to integrate in the ED visit. Intention to initiate contraception was common and many adolescents initiated contraception. Future work should increase the pool of trained providers and supports for same-day contraception initiation for those desiring in this novel setting.

Interest in Serving the Underserved: Role of Race, Gender, and Medical Specialty Plans

Introduction

Medical students often express their plans to care for medically underserved populations, but little is known about how this interest remains during medical school (MS). This study examined how self-reported interest in working with medically underserved communities may change during MS training based on several student characteristics.

Methods

A secondary data analysis of all student records in the Electronic Residency Application Service (ERAS) from 2005 to 2010 is presented. Predictors included gender, under-represented in medicine (URiM) status, age, academic metrics, career interest, and medical specialty choice. Outcomes included interest in caring for medically underserved populations when entering MS, graduating MS, and graduating MS controlling for entering interest.

Results

The total population included 6890 student records (49.5% women and 18.2% URiM). Women had a higher likelihood of being interested in practicing in underserved communities when entering and graduating MS (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.37-1.77; OR 1.24, 95% CI 1.09-1.40). For all outcomes, URiM students had a higher likelihood of planning on a career with underserved populations compared with their non-URiM peers. Compared with Emergency Medicine, Internal Medicine/Pediatrics and Family Medicine had a higher likelihood of plans to work with underserved populations upon entering, graduating, and at graduation controlling for entering interest.

Discussion

Gender, race, and specialty choice all had meaningful associations with a student's plans on practice in an underserved community. This study's findings can help support efforts to improve MS diversity nationally and drive study on cultural effects embedded within medical specialty identity.

Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement

OBJECTIVES

Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.

METHODS

GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research.

RESULTS

Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research.

CONCLUSIONS

ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.

Practice Pattern Variation in Test Ordering for Low-Acuity Pediatric Emergency Department Patients

OBJECTIVES

Rising costs in healthcare have focused attention on interventions to optimize efficiency of patient care, including decreasing unnecessary diagnostic testing. The primary objective of this study was to determine the variability of laboratory and radiology testing among licensed independent providers (LIPs) with different training backgrounds treating low-acuity patients in a pediatric emergency department (PED).

METHODS

We performed a retrospective review of the electronic health records of all encounters with patients 21 years or younger, triaged as low-acuity, visiting 2 urban, academic PEDs from January 2012 to December 2013. We calculated frequency of orders for specific tests, including complete blood counts, aerobic blood cultures, urine cultures, and chest radiographs. Bivariable analyses were used to measure associations of test ordering between these LIP dyad groups: physician versus nurse practitioner (NP); physicians with pediatric emergency medicine fellowship training (PEM) versus physicians without PEM training and physicians with at least 5 years since residency graduation versus less than 5 years. We used multivariable logistic regression to adjust for potential confounders, including ED location, trainee co-management, and patient characteristics. We also performed sensitivity analyses by location.

RESULTS

There were 148,570 total encounters treated by 12 NPs and 144 physicians, of whom 60 were PEM physicians. Seventy-three physicians had 5 or more years of experience. Testing rates per patient encounter ranged from 0% to 40% for individual providers. In bivariable analyses, testing was more likely when the LIP was a physician (odds ratio [OR] = 1.2, 95% confidence interval = 1.1-1.2) or PEM trained (OR = 1.3, 1.2-1.3). In multivariable analyses, testing was more likely for encounters with PEM providers (adjusted OR [AdjOR] = 1.2, 1.1-1.3). A sensitivity analysis on a subset of encounters seen exclusively at our PED-based urgent care revealed that testing was also more likely for encounters seen by PEM physicians (AdjOR = 1.5, 1.4-1.7) and with NPs (AdjOR = 1.2, 1.1-1.4) compared with physicians.

CONCLUSIONS

Our study identified substantial variation in test ordering patterns for LIPs treating low-acuity patients. There were significant differences in ordering practices between providers from different training backgrounds, most significantly when comparing PEM with non-PEM providers. Further research should examine interventions to standardize practice across disciplines.

Influence of Overcrowding in the Emergency Department on Return Visit within 72 Hours

This study was conducted to determine whether overcrowding in the emergency department (ED) affects the occurrence of a return visit (RV) within 72 h. The crowding indicator of index visit was the average number of total patients, patients under observation, and boarding patients during the first 1 and 4 h from ED arrival time and the last 1 h before ED departure. Logistic regression analysis was conducted to determine whether each indicator affects the occurrence of RV and post-RV admission. Of the 87,360 discharged patients, 3743 (4.3%) returned to the ED within 72 h. Of the crowding indicators pertaining to total patients, the last 1 h significantly affected decrease in RV (p = 0.0046). Boarding patients were found to increase RV occurrence during the first 1 h (p = 0.0146) and 4 h (p = 0.0326). Crowding indicators that increased the likelihood of admission post-RV were total number of patients during the first 1 h (p = 0.0166) and 4 h (p = 0.0335) and evaluating patients during the first 1 h (p = 0.0059). Overcrowding in the ED increased the incidence of RV and likelihood of post-RV admission. However, overcrowding at the time of ED departure was related to reduced RV.

Factors associated with inappropriate attendances at the emergency department of a tertiary hospital in Singapore

INTRODUCTION

Inappropriate attendances (IAs) at emergency departments (ED) are contributed by patients with mild or moderate medical conditions that can be effectively managed by primary care physicians. IAs strain limited ED resources and have an adverse impact on efficiency. This study aimed to identify factors associated with IA at the ED of a tertiary hospital in Singapore.

METHODS

We conducted a retrospective cohort study of all eligible visits to the aforementioned ED between 1 January 2015 and 31 December 2015. The appropriateness of each attendance was estimated using criteria based on investigations or procedures that were performed on the attendee and the discharge type of that attendance. IAs were then compared against appropriate attendances in these areas: attendee demographics; referral source; time of ED visit; proximity to ED and 24-hour general practitioner clinics; and history of ED visits in 2014. Multivariate analysis was performed on significant variables associated with IAs.

RESULTS

Among 120,606 attendances, 11,631 (9.6%) were IAs. Multivariate analysis showed that gender, ethnicity, referral source, time of ED visit, nationality and history of frequent visits to the ED were factors associated with IAs. Moreover, the odds of IA were found to be higher among attendees who were younger, were self-referred, or had at least one IA in 2014.

CONCLUSION

This study identified subgroups in the population who were more likely to contribute to IAs at the ED. These findings offer relevant insights into future research directions and strategies that might potentially reduce avoidable IAs.

Patient Dissatisfaction With Primary Care and Nonurgent Emergency Department Use

A well-functioning primary care system will have the capacity to provide timely, adequate, and effective care for patients to avoid nonurgent emergency department (ED) use. This study advances academic discussion by examining whether patient negative experiences during their encounter with a primary care physician (PCP) are associated with nonurgent ED use nationwide in the United States. This retrospective cohort study used data from the 2010-2011 Medical Expenditure Panel Survey. The independent measures were patient perceptions of PCPs' communication and care quality in 2010. The multivariate logit model was employed to analyze the nonurgent ED use as opposed to no ED use in 2011, after controlling for age, gender, race and ethnicity, rural/urban location, marital status, and education levels in 2010. All predictors were treated as dummy variables. We employed the lagged time effect and controlled health status to account for the endogeneity between outcomes and the main independent variables. The weights and variance were adjusted using the survey procedures to yield nationally representative results. The study sample consisted of 5242 adults, which represented 131 317 908 weighted people in the total population. While the measure of patient satisfaction with providers' communication was not associated with nonurgent ED use (P = .750), patient perceived poor and intermediary levels of primary care quality had higher odds of a nonurgent ED visit (OR = 1.75, P = .049, and OR = 1.48, P = .050, respectively) compared with high levels of care quality. For PCPs, endeavors may be considered in improving health care quality to reduce nonurgent ED use. Whenever possible, PCPs' efforts may want to be devoted to both communication and care quality to improve patients' health outcomes and satisfaction and to reduce nonurgent ED use.

Effect of triage nurse-led application of the Ottawa Ankle Rules on number of radiographic tests and length of stay in selected emergency departments in Oman

AIM

Ankle injuries are commonly seen in the emergency department (ED) and contribute to overcrowding. In Oman, injuries are a leading cause of years of life lost, disability-adjusted life years, and pose a burden to the healthcare system. This study aimed to evaluate the effectiveness of ED triage nurse-led application of the Ottawa Ankle Rules (OARs) toward improving the healthcare outcomes of ankle injury patients.

METHODS

A quasi-experimental design was used to collect data (demographic characteristics, waiting time, length of stay, and number of radiographic tests) from 96 patients. The intervention group (n = 46) received ED triage nurse-led assessment and initiation of radiographic tests based on the OARs. The control group (n = 50) received usual care.

RESULTS

The participants' mean age was 26.4 ± 7.90 years. The main causes of ankle injuries were football (36%), falls (31%) and twisting while walking (24%). There was a significant difference in number of ankle X-rays (t = 6.19; p < .001); length of stay (U = 549; p < .001); and waiting time (U = 167; p < .001) between the control and intervention group. The intervention reduced the mean waiting time and length of stay by 25.09 and 41.01 min, respectively.

CONCLUSION

Application of the OARs by the ED triage nurse can decrease the number of unnecessary radiographic tests, waiting time and length of stay in the ED. Nurses' utilization of evidence-based clinical decision-making tools can improve ED care outcomes of common acute conditions such as ankle injuries.

Overcrowding in a neonatal intermediate care unit: impact on the incidence of multidrug-resistant gram-negative organisms

BACKGROUND

Overcrowding, reduced nurse to patient ratio, limited distance between incubators and absence of microbiological surveillance have been shown to promote spread of multidrug-resistant gram-negative organisms (MDRGN) in patients with birthweight < 1500 g. Patients > 1500 g treated on an intermediate care unit are unrepresented in recent literature. We therefore intended to present data obtained from a short-term overcrowded neonatal intermediate care unit (NIMCU) at a level III (international categorization) perinatal center at University Hospital Frankfurt, Germany.

METHODS

During a 25 day overcrowding (OV) and 28 day post-overcrowding period (POST-OV) on NIMCU, epidemiological data obtained from continuously hold microbiological surveillance were investigated and compared to the last 12 months of ward-regular bed occupancy preceding OV (PRAE-OV).

RESULTS

During OV, the number of patients simultaneously treated at the NIMCU increased from 18 to 22, resulting in a reduced bed-to-bed space. Nurse: patient ratio was 4:22 during OV compared to 3:18 during PRAE-OV. Cumulative incidence of MDRGN was 4.7% in OV and 2.4% POST-OV compared to 4.8% to PRAE-OV, respectively, without any significant variations. During OV and POST-OV, septic episodes due to MDRGN were not observed. In one case, potential nosocomial transmission of Enterobacter cloacae resistant to Piperacillin and 3rd/4th generation cephalosporins was observed.

CONCLUSIONS

Prevention of nosocomial spread of MDRGN in an overcrowded NIMCU is based on staff's diligent training and adequate staffing. Concise microbiological surveillance should be guaranteed to escort through overcrowding periods. In our setting, impact of bed-to-bed distance on MDRGN transmission seemed to be less strong.

High-cost sharing policies and non-urgent emergency department visits

PURPOSE

The purpose of this paper is to examine whether high-cost-sharing ambulatory care policies affect non-urgent emergency department (ED) care utilization differently among individuals with and without chronic conditions.

DESIGN/METHODOLOGY/APPROACH

This retrospective cohort study used 2010-2011 US Medical Expenditure Panel Survey data. Difference-in-difference methods, multivariate logit model and survey procedures were employed. Time lag effect was used to address endogeneity concerns.

FINDINGS

The sample included 4,347 individuals. Difference in non-urgent ED visits log odds between high- and low-cost-sharing policies was not significantly different between chronically ill and non-chronically ill individuals ( β=-0.48, p=0.42). Sensitivity analysis with 15 and 25 percent cost-sharing levels also generated consistent insignificant results ( p=0.33 and p=0.31, respectively). Ambulatory care incidence rates were not significantly different between high- and low-cost-sharing groups among chronically ill people (incidence rate ratio=0.849, p=0.069).

PRACTICAL IMPLICATIONS

High-cost-sharing ambulatory care policies were not associated with increased non-urgent ED care utilization among chronically ill and healthy people. The chronically ill patients may have retained sizable ambulatory care that was necessary to maintain their health. Health plans or employers may consider low-level cost-sharing policies for ambulatory care among chronically ill enrollees or employees.

ORIGINALITY/VALUE

Findings contribute to insurance benefit design; i.e., whether high-cost-sharing ambulatory care policies should be implemented among chronically ill enrollees to maintain their health and save costs for health plans.

Improving Low-acuity Patient Flow in a Pediatric Emergency Department: A System Redesign

Background

Children's National Health Systems pediatric emergency department (ED), is a level 1 trauma center in Washington, DC, which treats over 90 000 patients annually. Approximately 50% of arriving patients are triaged as low acuity, Emergency Severity Index level 4 or 5. With limited space and resources, these patients are treated inefficiently, with average delays from arrival to provider time of 1.3 hours and length of stays (LOS) close to 2.5 hours.

Objectives

In July 2016, Children's National Health Systems ED initiated a focused approach to improve both patient flow and experience for these low-acuity patients.

Methods

We assembled a multidisciplinary ED-based task force. The quality improvement initiative began in January 2017 and consisted of 4 steps: (1) front-end space redesign; (2) implementation of a new front-end patient triage and assessment process; (3) increased doctor and nurse staffing; and (4) dissemination of data updates to reinforce awareness and adherence to workflow. Our process outcomes were arrival-to-provider time and LOS for low-acuity patients. Our balancing measures were the rate of return to the ED within 72 hours and arrival to provider times for high-acuity patients. We used statistical process control methodology to measure the effects of our interventions over time. We performed a secondary analysis to measure the response of wait times to total daily volume comparing preintervention to postintervention.

Results

We decreased the LOS by 11 minutes (9%) and arrival to MD times 21 minutes (35%) for the same period 1 year apart.

Pediatric Referrals to an Emergency Department From Urgent Care Centers

OBJECTIVE

The aims of this study were to describe pediatric emergency department (ED) referrals from urgent care centers and to determine the percentage of referrals considered essential and serious.

METHODS

A prospective study was conducted between April 2013 and April 2015 on patients younger than 21 years referred directly to an ED in central Pennsylvania from surrounding urgent care centers. Referrals were considered essential or serious based on investigations/procedures performed or medications/consultations received in the ED.

RESULTS

Analysis was performed on 455 patient encounters (mean age, 8.7 y), with 347 (76%) considered essential and 40 (9%) considered serious. The most common chief complaints were abdominal pain (83 encounters), extremity injury (76), fever (39), cough/cold (29), and head/neck injury (29). Thirty-three percent of the patients received laboratory diagnostic investigations (74% serum, 56% urine), and 52% received radiologic investigations (67% x-ray, 17% computed tomography scan, 13% ultrasound, 11% magnetic resonance imaging). Forty-four percent of the patients received a procedure, with the most common being intravenous (IV) placement (66%); reduction, casting, or splinting of extremity fracture/dislocation (18%); and laceration repair (14%). The most common medications administered were IV fluids (33%), oral analgesics (30%), and IV analgesics (26%). Eighty-three percent of the patients were discharged home, 12% were hospitalized, and 4% had emergent surgical intervention. The most common primary diagnoses were closed extremity fracture (60 encounters), gastroenteritis (42), brain concussion (28), upper respiratory infection (24), and nonsurgical, unspecified abdominal pain (24).

CONCLUSIONS

Many ED referrals directed from urgent care centers in our sample were considered essential, and few were considered serious. Urgent care centers should develop educational and preparedness strategies based on the epidemiology of emergencies that may occur.

Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department

OBJECTIVES

To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED).

DESIGN

Preplanned, secondary analysis of a prospective observational study.

SETTING

Tertiary care, academic ED.

PARTICIPANTS

A total of 424 patients in the ED, 65 years or older, including all chief complaints.

MEASUREMENTS

We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection.

RESULTS

Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40-2.53) or malaise/lethargy (PLR range, 1.25-1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15-18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79-0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms.

CONCLUSIONS

The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484-492, 2019.

Assessing effective methods to educate caregivers on fever in children aimed at reducing input to the paediatric emergency department

Introduction:

Many paediatric emergency departments face a significant proportion of non-urgent attendances, leading to problems for both patients and healthcare systems. Our primary aim was to compare the effectiveness of pamphlet versus video in educating caregivers regarding fever management in children. Our secondary aim was to assess caregivers’ sentiments towards these methods.

Methods:

A randomized controlled trial was conducted with 50 participants over a four-week period (May–June 2015) in the KK Hospital Paediatric Emergency Department. The control group was exposed to the standard pamphlet available in the KK Hospital Paediatric Emergency Department, which provided basic information on fever management. The intervention group watched a video produced by our team, containing similar content. The same five-question questionnaire assessing fever management knowledge was issued to participants before and immediately following exposure to intervention.

Results:

The pamphlet group had a mean pre-intervention score=2.8 (out of five), post-intervention score=3.84, amounting to an improvement of 1.04. The video group had a mean pre-intervention score=2.56, post-intervention score=4.12, giving an improvement of 1.36. The study was powered at 80%, with calculated p-value=0.111, hence the results were statistically insignificant. Both groups had increased self-reported awareness post-exposure, found the intervention useful, would rely on it for future management and would recommend it to others.

Conclusion:

While the sample size was limited, this study demonstrates the potential that both pamphlet and video interventions have in educating caregivers, as participants reported favourable sentiments towards the methods. It would be worthwhile to conduct the study on a larger scale to yield statistically significant results.

Application of time series analysis in modelling and forecasting emergency department visits in a medical centre in Southern Taiwan

OBJECTIVE

Emergency department (ED) overcrowding is acknowledged as an increasingly important issue worldwide. Hospital managers are increasingly paying attention to ED crowding in order to provide higher quality medical services to patients. One of the crucial elements for a good management strategy is demand forecasting. Our study sought to construct an adequate model and to forecast monthly ED visits.

METHODS

We retrospectively gathered monthly ED visits from January 2009 to December 2016 to carry out a time series autoregressive integrated moving average (ARIMA) analysis. Initial development of the model was based on past ED visits from 2009 to 2016. A best-fit model was further employed to forecast the monthly data of ED visits for the next year (2016). Finally, we evaluated the predicted accuracy of the identified model with the mean absolute percentage error (MAPE). The software packages SAS/ETS V.9.4 and Office Excel 2016 were used for all statistical analyses.

RESULTS

A series of statistical tests showed that six models, including ARIMA (0, 0, 1), ARIMA (1, 0, 0), ARIMA (1, 0, 1), ARIMA (2, 0, 1), ARIMA (3, 0, 1) and ARIMA (5, 0, 1), were candidate models. The model that gave the minimum Akaike information criterion and Schwartz Bayesian criterion and followed the assumptions of residual independence was selected as the adequate model. Finally, a suitable ARIMA (0, 0, 1) structure, yielding a MAPE of 8.91%, was identified and obtained as Visit_t=7111.161+(a_t+0.37462 a_t-1).

CONCLUSION

The ARIMA (0, 0, 1) model can be considered adequate for predicting future ED visits, and its forecast results can be used to aid decision-making processes.

The association of duration of boarding in the emergency room and the outcome of patients admitted to the intensive care unit

BACKGROUND

The demand for critical care beds is increasing out of proportion to bed availability. As a result, some critically ill patients are kept in the Emergency Department (ED boarding) awaiting bed availability. The aim of our study is to examine the impact of boarding in the ED on the outcome of patients admitted to the Intensive Care Unit(ICU).

METHODS

This was a retrospective analysis of ICU data collected prospectively at King Abdulaziz Medical City, Riyadh from ED between January 2010 and December 2012 and all patients admitted during this time were evaluated for their duration of boarding. Patients were stratified into three groups according to the duration of boarding from ED. Those admitted less than 6 h were classified as Group I, between 6 and 24 h, Group II and more than 24 h as Group III. We carried out multivariate analysis to examine the independent association of boarding time with the outcome adjusting for variables like age, sex, APACHE, Mechanical ventilation, Creatinine, Platelets, INR.

RESULTS

During the study period, 940 patients were admitted from the ED to ICU, amongst whom 227 (25%) were admitted to ICU within 6 h, 358 (39%) within 6-24 h and 355 (38%) after 24 h. Patients admitted to ICU within 6 h were younger [48.7 ± 22.2(group I) years, 50.6 ± 22.6 (group II), 58.2 ± 20.9 (group III) (P = 0.04)]with less mechanical ventilation duration[5.9 ± 8.9 days (Group I), 6.5 ± 8.1 (Group II) and 10.6 ± 10.5 (Group III), P = 0.04]. There was a significant increase in hospital mortality [51(22.5), 104(29.1), 132(37.2), P = 0.0006) and the ICU length of stay(LOS) [9.55 days (Group I), 9.8 (Group II) and 10.6 (Group III), (P = 0.002)] with increase in boarding duration. In addition, the delay in admission was an independent risk factor for ICU mortality(OR for group III vs group I is 1.90, P = 0.04) and hospital mortality(OR for group III vs Group I is 2.09, P = 0.007).

CONCLUSION

Boarding in the ED is associated with higher mortality. This data highlights the importance of this phenomenon and suggests the need for urgent measures to reduce boarding and to improve patient flow.

A survey of the perception of well-being among emergency physicians in Taiwan

Objectives:

The objective of this study is to investigate the feelings (well-being) of emergency physicians in Taiwan regarding their job and the relationship between these feelings and the work environment.

Materials and Methods:

A questionnaire was used to survey emergency physicians across Taiwan from January to June 2014. The questionnaire contents were categorized into five specific factors that could affect well-being, including “emergency quality, emergency safety, support environment, workload, and salary and benefits.” Well-being was rated directly on a scale of 1–10, with 10 indicating the highest level of happiness. Physician retention was also surveyed. The correlations among the five factors, well-being, and physician retention were analyzed. The five factors were quantified as a “happiness index” and compared between religious and nonreligious hospitals and medical centers and regional hospitals.

Results:

A total of 398 questionnaires were received, and the response rate was 39%. Of these, 42.7% of responders reported high ratings for well-being (scores of 7–10, 1 is the worse, and 10 is the best) and 40.3% felt neutral (scores of 5–6). Only 12.3% doctors did not think they would stay at the same position for the next 3 years. All five factors had moderately significant correlations with each other (γ = 0.195–0.534, P < 0.01). All five factors also significantly correlated with well-being. Emergency safety (γ = 0.121, P < 0.05), salary and benefits (γ = 0.143, P < 0.05), and well-being (γ = 0.189, P < 0.01) were correlated with physician retention. The happiness indices of emergency quality, support environment, and workload were significantly higher in regional hospitals than medical centers.

Conclusions:

All five indicators had impacts on well-being. The respondents reported heavy workloads, including high stress and even poorly met physiological needs. In addition, the threat of violence, salaries, and well-being correlated with physician retention. Hospital administrators can make efforts to improve the well-being of doctors and physician retention by adjusting environmental factors.

Is Access to and Use of Patient Perceived Patient-Centered Medical Homes Associated With Reduced Nonurgent Emergency Department Use?

This study examined whether access to and use of patient-centered medical home (PCMH) practices is associated with reduced nonurgent emergency department (ED) use, especially among the uninsured population. This retrospective study used 2010-2011 Medical Expenditure Panel Survey data. Difference-in-difference methods, multivariate logit model, marginal effect, and survey procedures were employed. A total of 1287 adults had any ED visit in 2011, which represented weighted 29 463 684 people in the population. Reductions in odds of nonurgent ED use between the full PCMH group and the “no regular provider” group was significantly larger for the uninsured group than publicly and privately insured groups (β = −1.70, P = .009, and β = −1.04, P = .040, respectively). Similar results were found between the partial PCMH group and the “no regular provider” group for the uninsured group compared to the public group (β = −1.67, P = .019). PCMH models demonstrate higher odds of reduced nonurgent ED use among uninsured individuals compared to public and private enrollees nationwide.

Reasons for Overcrowding in the Emergency Department: Experiences and Suggestions of an Education and Research Hospital

Objectives

In this study, we aimed to determine the causes of overcrowding in the Emergency Department (ED) and make recommendations to help reduce length of stay (LOS) of patients in the ED.

Methods

We analyzed the medical data of patients admitted to our ER in a one-year period. Demographic characteristics, LOS, revisit frequency, and consultation status of the patients were determined.

Results

A total of 163,951 patients were admitted to our ED between January 1, 2013, and December 31, 2013. In this period 1,210 patients revisited the ED within 24 hours. A total of 38,579 patients had their treatment in the observation room (OR) of the ED and mean LOS was found to be 164.1 minutes. Cardiology was the most frequently consulted specialty. Mean arrival time of the consultants in ED was 64 minutes.

Conclusions

Similar to EDs in other parts of the world, prolonged length of stay in the ED, delayed laboratory and imaging tests, delay of consultants, and lack of sufficient inpatient beds are the most important causes of overcrowding in the ED. Some drastic measures must be taken to minimize errors and increase satisfaction ratio.

Factors Associated With Interest in Same-Day Contraception Initiation Among Females in the Pediatric Emergency Department

PURPOSE

The purposes were to describe interest in hormonal contraception initiation among female adolescent in the emergency department (ED) and to assess for associations with factors known to increase pregnancy risk such as violence victimization.

METHODS

We used a computerized survey to assess sexual and dating practices, pregnancy history/likelihood, contraception use (including long-acting reversible contraception [LARC]) and concerns, contraception initiation interest, violence victimization, medical utilization, and demographics among sexually experienced females aged 14-19 years in our ED. The primary outcome was interest in contraception initiation. We compared responses between subgroups using the chi-square test.

RESULTS

A total of 168 adolescents participated (82% of approached; mean age 16.6 years; 41% white; 48% black; 21% commercial insurance). Interest in contraception initiation was high: 60% overall and 70% among those not using hormonal contraception (n = 96). Among those using non-LARC contraception (n = 59), 29% were interested in LARC initiation. Contraception/LARC interest was positively associated with lack of recent well care (p < .06) and concerns about cost (p < .01), privacy (p = .03), and where to obtain contraception (p < .01). Nearly all planned on avoiding pregnancy, although many (23%) used no contraception at last intercourse. One third (36%) reported violence victimization. Most (70%) reported ≥1 concern about contraception (most commonly cost).

CONCLUSIONS

Many reported behaviors and exposures, including violence victimization, that increase their risk for pregnancy and most expressed interest in same-day initiation of hormonal contraception, including LARC. These findings may inform novel strategies for increased adolescent access to contraception and pregnancy prevention through use of nontraditional sites such as EDs.

Effectiveness of Five-Level Emergency Severity Index Triage System Compared With Three-Level Spot Check: An Iranian Experience

Background:

Triage for patients’ prioritization in the emergency department is a suitable solution to decrease overcrowding. Different methods are used for prioritization that needs effectiveness evaluation.

Objectives:

The aim of this study was to assess the effectiveness of the emergency severity index (ESI) 5-level triage system in contrast with spot check triage.

Patients and Methods:

Data for this quasi-experimental study were extracted using a form to review 770 records of patients referred to emergency department of Imam Khomeini hospital (in Sari, north of Iran) during two separated periods each for four months; the first from 20th March to 19th July 2010 and the other from 21 March to 20 July 2011. The method used in the first time was spot check triage and the second one ESI triage. Data were processed with descriptive statistics and analyzed using independent samples t-test (CI = 95%).

Results:

Increase from 6.46 to 8.92 minutes in the average time from patient arrival to being visited by a physician (P < 0.001) and increase in average time from physician visit to receive the first nursing care from 7.68 to 15.89 minutes were significant (P < 0.001). The average waiting time for laboratory services was significantly decreased from 112.3 to 84.1 (P = 0.033). Increase in the average waiting time for radiology, decrease in average waiting time for sonography, average length of stay in the emergency department, and number of patients per emergency bed were not significant.

Conclusions:

Between the two systems of triage, ESI was more effective than the spot check and in the spatial and temporal domain of research, was a successful method in improving some indicators of emergency and improving the performance indices. Hospital managers by implementation of ESI system can take a step toward new health policies and improve the processes as key tools of continuous quality improvement system.

The Robustness and Effectiveness of the Triage System at Times of Overcrowding and the Extra Costs due to Inappropriate Use of Emergency Departments

BACKGROUND

Overcrowding is one of the most harmful problems for Emergency Department (ED) management and the correct estimation of time resource absorption by each type of patient plays a strategic role in dealing with overcrowding and correctly programming ED activity.

OBJECTIVE

We aimed to investigate how overcrowding may affect urgent patients' waiting times (i.e., the robustness of the triage patient priority system) and to evaluate the extra costs due to inappropriate use of EDs.

METHODS

Data referring to 54,254 patients who accessed the ED of a major Italian hospital in 2011 were analyzed to study patient flows and overcrowding. To define an average per-patient cost, according to the severity of his or her health condition, the 2010 profit and loss account of the aforementioned hospital was studied and the time devoted by physicians to each type of patient was estimated by means of a self-reported survey.

RESULTS

Empirical findings confirm a positive correlation between overcrowding and the time a patient has to wait before receiving treatment. This effect is relevant only for non-urgent patients who are responsible for the overcrowding itself. However, urgent patients' waiting times do not increase in the presence of overcrowding, confirming that the triage priority system is robust against the overcrowding situation. The analysis estimates, using 2010 data, that the actual per patient cost incurred by the hospital when treating white-coded patients is, on average, 36.54 euros; a green code costs 93.17, yellow 170.62, and red 227.62. It emerges that 4% of all the personnel costs are attributable to white color-code assistance, 67% to green codes, 23% to yellow codes, and the remaining 6% to red codes.

CONCLUSION

The implementation of effective policies intended to improve both efficiency and quality in providing emergency health services has to deal with the systemic problem of inappropriate use of EDs. Policy-makers should be aware of the fact that there is a considerable portion of ED demand for assistance that is inappropriate and that oversizing EDs with respect to the true, appropriate, urgent patients' demands, could bring about a further and undesirable rise in inappropriate assistance demands and, therefore, an increase in ED costs that are not consistent with their objectives.

ED crowding is associated with inpatient mortality among critically ill patients admitted via the ED: post hoc analysis from a retrospective study

BACKGROUND

Adverse effects of emergency department (ED) crowding among critically ill patients are not well known.

OBJECTIVES

We evaluated the association between ED crowding and inpatient mortality among critically ill patients admitted via the ED, and analyzed subsets of patients according to admission diagnosis.

METHODS

We performed a post hoc analysis using data from a previous retrospective study. We enrolled admitted patients via the ED with an initial systolic blood pressure of 90 mm Hg or lower when presenting to the ED. The ED occupancy ratio was used as a measure of crowding. The primary outcome was inpatient mortality. Multivariable logistic regression models adjusted for potential confounding variables were constructed for the entire cohort and for subsets according to admission diagnosis (infection, cardiac and vascular disease, trauma, gastrointestinal bleeding, and other factors).

RESULTS

A total of 1801 patients were enrolled, with a mortality rate of 14.6% (262 patients). The mortality rate by ED occupancy ratio quartile was 9.7% for the first quartile, 15.9% for the second quartile, 18.2% for the third quartile, and 14.4% for the fourth quartile. This resulted in adjusted odds ratios of 1.95, 2.51, and 1.93 and corresponding 95% confidence intervals of 1.23-3.12, 1.58-3.99, and 1.21-3.09 for the second, third, and fourth quartiles, respectively, compared with the first quartile. The effect of ED crowding was highest in the trauma subset, followed by the infection subset, whereas ED crowding did not appear to have any effect on the cardiac and vascular disease subsets.

CONCLUSION

Emergency department crowding was associated with increased inpatient mortality among critically ill patients admitted via the ED.

Triage-based resource allocation and clinical treatment protocol on outcome and length of stay in the emergency department

OBJECTIVE

The present study aimed to determine the relationship between the triage-based resource allocation and clinical treatment (TRACT) protocol and mortality and length of stay (LOS) in ED.

METHODS

This before-and-after study was conducted in an adult, tertiary, teaching hospital ED from August 2008 to July 2012. Patients who were younger than 18 years of age, who were dead on arrival and whose triage information was not available were excluded. TRACT was implemented in August 2010, and the Emergency Severity Index (ESI) was used for triage. Primary and secondary outcomes were ED mortality and ED LOS. Multivariate logistic regression models for ED mortality and multivariable general linear models on the ED LOS were used to compare the before- and after-intervention periods.

RESULTS

For the 155 563 visits over study period, the ED mortality rate was 0.2%, and the ED LOS was 4.6 h (median). The adjusted odds ratios (95% confidence intervals [CIs]) of the TRACT protocol on ED mortality were 0.69 (0.54-0.88) for total patients, 0.42 (0.30-0.59) for ESI 1, 1.04 (0.66-1.65) for ESI 2 and 1.45 (0.76-2.75) for ESI 3 group. The adjusted coefficients (95% CIs) of the TRACT on the ED LOS were -88.1 (-96.9 ∼ -79.2) min for all patients, -44.9 (-72.0 ∼ -17.9) min for ESI level 2 and -104.3 (-114.7 ∼ -94.0) min for ESI level 3.

CONCLUSIONS

The TRACT protocol decreased the ED mortality in ESI 1 group and reduced the ED LOS in ESI levels 2 and 3 groups.

Overcrowding of accident & emergency units: is it a growing concern in Nigeria?

BACKGROUND

The inability of the Nigeria's Accident and Emergency Departments (AED) to meet current demands is growing among the public and health care professionals. The data supporting perceptions of insufficient capacity are limited. Therefore, this study was intended to determine the prevalence, causes, and effects of overcrowding AEDs in Nigeria.

MATERIALS AND METHODS

This was a cross sectional, descriptive study carried out among AED staff of 3 referral teaching hospitals in Nigeria, using a pre-tested and validated structured questionnaire.

RESULTS

The analysis of the 267 AED staff revealed 20-56 years (36.40+5.1 mean) age range. One hundred and twenty eight (47.9%) were males, 139 (52.1%) females. Two hundred and fifty nine (97%) agreed that an AED should have a bed capacity of 21-30. Agreement to AED overcrowding in Nigeria was quite considerable. The frequency of AED overcrowding per week was 4-7 times. The average bed occupancy level was 3.25. Agreed common causes of prolonged AED admissions were to be a high volume of critically ill patients, Delayed transfer of patients to the wards, delay in theatre operation, delay in radiological investigations and exceptionally high proportion of patients requiring admission in AED. Also, long pre-review waiting time and haematological delays were more causes. The average waiting time for victims to be seen was 29.7 minutes.

CONCLUSION

There are many causes of AED overcrowding in this environment. However, improving AED bed management, better organized and diligent discharge planning, and reducing access block should be a priority to reduce AED overcrowding.

Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department

Introduction

The adverse effects of delayed admission to the intensive care unit (ICU) have been recognized in previous studies. However, the definitions of delayed admission vary across studies. This study proposed a model to define ‘delayed admission’, and explored the effect of ICU waiting time on patients’ outcome.

Methods

This retrospective cohort study included nontraumatic adult patients on mechanical ventilation in the emergency department (ED), from July 2009 to June 2010. The primary outcomes measures were 21-ventilator-day mortality and prolonged hospital stays (over 30 days). Models of Cox regression and logistic regression were used for multivariate analysis. The non-delayed ICU waiting was defined as a period in which the time effect on mortality was not statistically significant in a Cox regression model. To identify a suitable cutoff point between ‘delayed’ and ‘non-delayed’ subsets from the overall data were made based on ICU waiting time and the hazard ratio of ICU waiting hour in each subset was iteratively calculated. The cutoff time was then used to evaluate the impact of delayed ICU admission on mortality and prolonged length of hospital stay.

Results

The final analysis included 1,242 patients. The time effect on mortality emerged after 4 hours, thus we deduced ICU waiting time in the ED of >4 hours as delayed. By logistic regression analysis, delayed ICU admission affected the outcomes of 21-ventilator-day mortality and prolonged hospital stay, with an odds ratio of 1.41 (95% confidence interval, 1.05 to 1.89) and 1.56 (95% confidence interval, 1.07 to 2.27) respectively.

Conclusions

For patients on mechanical ventilation in the ED, delayed ICU admission is associated with higher probability of mortality and additional resource expenditure. A benchmark waiting time of no more than 4 hours for ICU admission is recommended.

Time series modelling and forecasting of emergency department overcrowding

Efficient management of patient flow (demand) in emergency departments (EDs) has become an urgent issue for many hospital administrations. Today, more and more attention is being paid to hospital management systems to optimally manage patient flow and to improve management strategies, efficiency and safety in such establishments. To this end, EDs require significant human and material resources, but unfortunately these are limited. Within such a framework, the ability to accurately forecast demand in emergency departments has considerable implications for hospitals to improve resource allocation and strategic planning. The aim of this study was to develop models for forecasting daily attendances at the hospital emergency department in Lille, France. The study demonstrates how time-series analysis can be used to forecast, at least in the short term, demand for emergency services in a hospital emergency department. The forecasts were based on daily patient attendances at the paediatric emergency department in Lille regional hospital centre, France, from January 2012 to December 2012. An autoregressive integrated moving average (ARIMA) method was applied separately to each of the two GEMSA categories and total patient attendances. Time-series analysis was shown to provide a useful, readily available tool for forecasting emergency department demand.

Mobile and web-based education: delivering emergency department discharge and aftercare instructions

Prior research has identified deficiencies in the standard process of providing instructions for care at discharge from the emergency department (ED). Patients typically receive a brief verbal instruction, along with preformatted written discharge documents. Studies have found that understanding and retention of such information by families are very poor, leading to nonadherence in follow-up care, unnecessary return visit to the ED, and poor health outcomes. The combination of systems factors (information content, delivery methods, and timing) and patient factors (health literacy, language proficiency, and cultural factors) contributes to the challenge of providing successful discharge communication. Internet and mobile devices provide a novel opportunity to better engage families in this process.Mobile health can address both system- and patient-level challenges. By incorporating images, animation, and full Web-based video content, more comprehensible content that is better suited for patients with lower health literacy and today's visual learners can be created. Information can also be delivered both synchronously and asynchronously, enabling the health care providers to deliver health education to the patients electronically to their home, where health care occurs. Furthermore, the providers can track information access by patients, customize content to the individual patients, and reach other caregivers who may not be present during the ED visit. Further research is needed to develop the systems and best practices for incorporating mobile health in the ED setting.

Emergency department crowding in The Netherlands: managers' experiences

Background

In The Netherlands, the state of emergency department (ED) crowding is unknown. Anecdotal evidence suggests that current ED patients experience a longer length of stay (LOS) compared to some years ago, which is indicative of ED crowding. However, no multicenter studies have been performed to quantify LOS and assess crowding at Dutch EDs. We performed this study to describe the current state of emergency departments in The Netherlands regarding patients’ length of stay and ED nurse managers’ experiences of crowding.

Methods

A survey was sent to all 94 ED nurse managers in The Netherlands with questions regarding the type of facility, annual ED census, and patients’ LOS. Additional questions included whether crowding was ever a problem at the particular ED, how often it occurred, which time periods had the worst episodes of crowding, and what measures the particular ED had undertaken to improve patient flow.

Results

Surveys were collected from 63 EDs (67%). Mean annual ED visits were 24,936 (SD ± 9,840); mean LOS for discharged patients was 119 (SD ± 40) min and mean LOS for admitted patients 146 (SD ± 49) min. Consultation delays, laboratory and radiology delays, and hospital bed shortages for patients needing admission were the most cited reasons for crowding. Admitted patients had a longer LOS because of delays in obtaining inpatient beds. Thirty-nine of 57 respondents (68%) reported that crowding occurred several times a week or even daily, mostly between 12:00 and 20:00. Measures taken by hospitals to manage crowding included placing patients in hallways and using fasttrack with treatment of patients by trained nurse practitioners.

Conclusions

Despite a relatively short LOS, frequent crowding appears to be a nationwide problem according to Dutch ED nurse managers, with 68% of them reporting that crowding occurred several times a week or even daily. Consultations delays, laboratory and radiology delays, and hospital bed shortage for patients needing admission were believed to be the most important factors contributing to ED crowding.

Primary care spatial density and nonurgent emergency department utilization: a new methodology for evaluating access to care

OBJECTIVE

To determine the spatial and demographic characteristics of pediatric patients who make nonurgent visits (NUVs) to an urban pediatric emergency department (ED). We hypothesized that the rate of NUVs would be inversely associated with the spatial density of primary care providers (PCPs).

METHODS

A retrospective, cross-sectional analysis was conducted for all visits to Washington, DC's principal pediatric ED between 2003 and 2006. NUVs were defined by a unique algorithm combining resource allocation, ambulatory-sensitive diagnoses, and billing data. Multivariate linear regression analysis was used to determine the association of PCP density and demographic variables on the spatial rate of NUVs.

RESULTS

Over the 4-year period, 35.1% (52,110) of the 148,314 ED visits by Washington, DC, residents were nonurgent. NUVs were most associated with neighborhood median household income <$40,000 and low spatial density of PCPs. For every 1-unit increase in PCP density, the spatial rate of NUVs decreased by 9%. The odds of a visit being nonurgent were significantly higher for African Americans and Hispanics than for whites (odds ratio [OR] 2.4, 95% confidence interval [CI] 2.19-2.64; and OR 2.6, 95% CI 2.36-2.86, respectively), for patients using public insurance versus private (OR 1.46, 95% CI 1.42-1.50), and for patients age <5 years (OR 2.66, 95% CI 2.60-2.72).

CONCLUSIONS

Low spatial density of primary care is strongly associated with nonurgent ED utilization. Improving spatial distribution of primary care may decrease ED misuse and improve access to the medical home.

The impact of ED boarding time, severity of illness, and discharge destination on outcomes of critically ill ED patients

This aim of this study was to determine the association between emergency department (ED) boarding time, severity of illness, and outcomes for critically ill patients. This was a prospective cohort study of ED patients who met criteria for admission to the intensive care unit (ICU). Patients were divided into 2 groups: those who spent less than 6 hr in the ED prior to transfer, and those who spent 6 hr or more. The groups were compared on the basis of severity of illness, Glasgow Coma Scale score, presence of fever, admission time, and hospital survival. Factors associated with increased mortality included patients who spent 6 hr or longer in the ED, had a fever, were admitted in the evening or night, or were indirect ICU admissions. Length of time spent in the ED prior to transfer to inpatient care is one of several factors associated with increased mortality in critical care patients who were intubated in the ED.

The impact of psychiatric patient boarding in emergency departments

Objectives. Studies have demonstrated the adverse effects of emergency department (ED) boarding. This study examines the impact of resource utilization, throughput, and financial impact for psychiatric patients awaiting inpatient placement. Methods. The authors retrospectively studied all psychiatric and non-psychiatric adult admissions in an Academic Medical Center ED (>68,000 adult visits) from January 2007-2008. The main outcomes were ED length of stay (LOS) and associated reimbursement. Results. 1,438 patients were consulted to psychiatry with 505 (35.1%) requiring inpatient psychiatric care management. The mean psychiatric patient age was 42.5 years (SD 13.1 years), with 2.7 times more women than men. ED LOS was significantly longer for psychiatric admissions (1089 min, CI (1039-1140) versus 340 min, CI (304-375); P < 0.001) when compared to non-psychiatric admissions. The financial impact of psychiatric boarding accounted for a direct loss of ($1,198) compared to non-psychiatric admissions. Factoring the loss of bed turnover for waiting patients and opportunity cost due to loss of those patients, psychiatric patient boarding cost the department $2,264 per patient. Conclusions. Psychiatric patients awaiting inpatient placement remain in the ED 3.2 times longer than non-psychiatric patients, preventing 2.2 bed turnovers (additional patients) per psychiatric patient, and decreasing financial revenue.

Emergency department crowding is associated with decreased quality of care for children with acute asthma

STUDY OBJECTIVE

We seek to determine which dimensions of quality of care are most influenced by emergency department (ED) crowding for patients with acute asthma exacerbations.

METHODS

This cross-sectional study with retrospective data collection included patients aged 2 to 21 years treated for acute asthma during November 2007 to October 2008 at a children's hospital ED. We studied 3 processes of care-asthma score, β-agonist, and corticosteroid administration-and 9 quality measures representing 3 quality dimensions: timeliness (1-hour receipt of each process), effectiveness (receipt/nonreceipt of each process), and equity (language, identified primary care provider, and insurance). Primary independent variables were 2 crowding measures: ED occupancy and number waiting to see an attending-level physician. Models were adjusted for age, language, insurance, primary care access, triage level, ambulance arrival, oximetry, smoke exposure, and time of day. For timeliness and effectiveness quality measures, we calculated the adjusted risk of each quality measure at 5 percentiles of crowding for each crowding measure and assessed the significance of the adjusted relative interquartile risk ratios. For equity measures, we tested their role as moderators of the crowding-quality models.

RESULTS

The asthma population included 927 patients. Timeliness and effectiveness quality measures showed an inverse, dose-related association with crowding, an effect not moderated by equity measures. Patients were 52% to 74% less likely to receive timely care and were 9% to 14% less likely to receive effective care when each crowding measure was at the 75th rather than at the 25th percentile (P<.05).

CONCLUSION

ED crowding is associated with decreased timeliness and effectiveness-but not equity-of care for children with acute asthma.

Effect of a rapid assessment program on total length of stay in a pediatric emergency department

OBJECTIVES

Wait times and length of stay (LOS) measure efficiency of care in pediatric emergency departments (PEDs). Our hospital introduced a rapid assessment program (RAP) wherein patients will be seen by a physician within 29 minutes of arrival to the PED. Our primary objective was to evaluate the impact of this RAP on total LOS and compare it with the pre-RAP period. The secondary objective was to compare door-to-physician times and admission frequencies.

METHODS

We conducted an observational study of randomly selected visits before (in 2004) and after (in 2005) RAP in a PED. Data were acquired retrospectively from charts. We compared total LOS (time from arrival at triage to discharge), boarding time (time from the decision to admit to transfer to inpatient bed), door-to-physician time (arrival at triage to first evaluation by physician), and admission frequencies.

RESULTS

Data from 990 visits (in 2004) and 1010 visits (in 2005) indicated similar age, sex, seasonal distribution, and weekday distribution. The total median LOS decreased by 37 minutes with RAP (103 [interquartile range {IQR}, 57-187] minutes in 2005 vs 140 [IQR, 78-234] minutes in 2004, P < 0.001) but only among lower triage categories. Median door-to-physician time decreased by 20 minutes with RAP (15 [IQR, 7-29] minutes in 2005 vs 35 [IQR, 18-72] minutes in 2004, P < 0.001) among lower triage categories. The LOS was reduced both in admitted and discharged patients with no difference in the boarding times or admission frequencies.

CONCLUSIONS

In our PED, a RAP reduced the total LOS of patients with lower acuity of illness.

ED overcrowding is associated with an increased frequency of medication errors

OBJECTIVES

Despite the growing problems of emergency department (ED) crowding, the potential impact on the frequency of medication errors occurring in the ED is uncertain. Using a metric to measure ED crowding in real time (the Emergency Department Work Index, or EDWIN, score), we sought to prospectively measure the correlation between the degree of crowding and the frequency of medication errors occurring in our ED as detected by our ED pharmacists.

METHODS

We performed a prospective, observational study in a large, community hospital ED of all patients whose medication orders were evaluated by our ED pharmacists for a 3-month period. Our ED pharmacists review the orders of all patients in the ED critical care section and the Chest Pain unit, and all admitted patients boarding in the ED. We measured the Spearman correlation between average daily EDWIN score and number of medication errors detected and determined the score's predictive performance with receiver operating characteristic (ROC) curves.

RESULTS

A total of 283 medication errors were identified by the ED pharmacists over the study period. Errors included giving medications at incorrect doses, frequencies, durations, or routes and giving contraindicated medications. Error frequency showed a positive correlation with daily average EDWIN score (Spearman's rho = 0.33; P = .001). The area under the ROC curve was 0.67 (95% confidence interval, 0.56-0.78) with failure defined as greater than 1 medication error per day.

CONCLUSIONS

We identified an increased frequency of medication errors in our ED with increased crowding as measured with a real-time modified EDWIN score.

Emergency department reliance: a discriminatory measure of frequent emergency department users

OBJECTIVE

High emergency department (ED) use has previously been defined as a person's having a large number of ED visits, implying that all frequent users are the same. ED reliance (EDR), the percentage of all health care visits that occur in the ED, considers ED use in relation to primary care use and, thus, may discriminate among high-ED-user populations. Our objective was to determine whether EDR, as a complementary use measure, could differentiate frequent users secondary to increased need for care from those with access issues.

METHODS

We conducted an analysis of prospectively collected data from the Medical Expenditure Panel Survey from 2000-2001 and 2001-2002. Frequent ED users were defined as having >or=2 ED visits, and EDR was dichotomized as high (>0.33) or low (<or=0.33). Odds of being a frequent user or having high EDR were analyzed by using logistic regression.

RESULTS

A total of 8823 children were included. Within frequent-ED-use populations, young children and children with special health care needs were less likely (odds ratio: 0.55 and 0.72, respectively) to have high EDR, whereas those with lower education, low income, and public insurance and those of black race were more likely to have high EDR.

CONCLUSIONS

EDR is a readily available measure in large administrative databases that discriminates among frequent-user populations, differentiating increased need for ED services from lack of access to quality primary care.

Forecasting emergency department crowding: an external, multicenter evaluation

STUDY OBJECTIVE

We apply a previously described tool to forecast emergency department (ED) crowding at multiple institutions and assess its generalizability for predicting the near-future waiting count, occupancy level, and boarding count.

METHODS

The ForecastED tool was validated with historical data from 5 institutions external to the development site. A sliding-window design separated the data for parameter estimation and forecast validation. Observations were sampled at consecutive 10-minute intervals during 12 months (n=52,560) at 4 sites and 10 months (n=44,064) at the fifth. Three outcome measures-the waiting count, occupancy level, and boarding count-were forecast 2, 4, 6, and 8 hours beyond each observation, and forecasts were compared with observed data at corresponding times. The reliability and calibration were measured following previously described methods. After linear calibration, the forecasting accuracy was measured with the median absolute error.

RESULTS

The tool was successfully used for 5 different sites. Its forecasts were more reliable, better calibrated, and more accurate at 2 hours than at 8 hours. The reliability and calibration of the tool were similar between the original development site and external sites; the boarding count was an exception, which was less reliable at 4 of 5 sites. Some variability in accuracy existed among institutions; when forecasting 4 hours into the future, the median absolute error of the waiting count ranged between 0.6 and 3.1 patients, the median absolute error of the occupancy level ranged between 9.0% and 14.5% of beds, and the median absolute error of the boarding count ranged between 0.9 and 2.8 patients.

CONCLUSION

The ForecastED tool generated potentially useful forecasts of input and throughput measures of ED crowding at 5 external sites, without modifying the underlying assumptions. Noting the limitation that this was not a real-time validation, ongoing research will focus on integrating the tool with ED information systems.

Emergency department patient flow: the influence of hospital census variables on emergency department length of stay

OBJECTIVES

The objective was to evaluate the association between hospital census variables and emergency department (ED) length of stay (LOS). This may give insights into future strategies to relieve ED crowding.

METHODS

This multicenter cohort study captured ED LOS and disposition for all ED patients in five hospitals during five 1-week study periods. A stepwise multiple regression analysis was used to examine associations between ED LOS and various hospital census parameters.

RESULTS

Data were analyzed on 27,325 patients on 161 study days. A significant positive relationship was demonstrated between median ED LOS and intensive care unit (ICU) census, cardiac telemetry census, and the percentage of ED patients admitted each day. There was no relationship in this cohort between ED LOS and ED volume, total hospital occupancy rate, or the number of scheduled cardiac or surgical procedures.

CONCLUSIONS

In multiple hospital settings, ED LOS is correlated with the number of admissions and census of the higher acuity nursing units, more so than the number of ED patients each day, particularly in larger hospitals with busier EDs. Streamlining ED admissions and improving availability of inpatient critical care beds may reduce ED LOS.

Overcrowding is associated with delays in percutaneous coronary intervention for acute myocardial infarction

BACKGROUND

Recently developed crowding measures, such as the Emergency Department (ED) Work Index (EDWIN) score, provide a quantifiable measurement of overcrowding in the ED.

AIMS

We sought to determine the association between overcrowding, measured with the EDWIN score, and the time required to initiate percutaneous coronary intervention (PCI) for patients presenting to the ED with acute myocardial infarction (AMI).

METHODS

We retrospectively reviewed the performance improvement (PI) data on all patients presenting to the ED over a 2-month period with chest pain and whose subsequent ECG showed AMI requiring PCI. We recorded the time from patient presentation to the (1) time to first ECG, (2) time to patient arrival in the catheterization laboratory, and (3) time to catheter balloon inflation. We calculated EDWIN scores using data archived from our electronic tracking board and compared the proportion of patients who achieved our established ED goal times between patients presenting during low crowding (EDWIN < 1.5) and high crowding (EDWIN > or = 1.5) conditions.

RESULTS

Seventeen patients underwent emergent PCI in the study period. Patients presenting to the ED during periods of low crowding had shorter times to balloon inflation (median of 84 min, IQR 80 to 93 min) than patients presenting to the ED during periods of high crowding (median of 107 min, IQR 94 to 122 min), P = 0.008. Times to first ECG and to arrival in the catheterization laboratory were not significantly different between patients presenting during low and high crowding conditions.

CONCLUSION

Overcrowding appears to be associated with a decreased likelihood of timely treatment for acute AMI in our ED.

Caregiver adherence to follow-up after an emergency department visit for common pediatric illnesses: Impact on future ED use

BACKGROUND

Access to primary care is often a problem for children living in urban areas and the rate of emergency department (ED) use can be high. For acute childhood illnesses, primary care follow-up is often recommended to prevent subsequent ED visits.

METHODS

We conducted an observational study of 455 children with common childhood illnesses, between 6 weeks and 8 years of age, presenting to 1 of 3 EDs, and discharged to the community. ED physicians recommended that the child visit their primary care physician within 1 to 4 days of discharge (ie, "short-term" follow-up). Caregivers were surveyed during the ED index visit and after discharge to assess primary care follow-up adherence. We collected data on child and caregiver characteristics, type and severity of illness at the ED index visit, and ED return visits in the 2-month period after the ED index visit.

RESULTS

A total of 45.3% of caregivers adhered to short-term primary care follow-up. Short-term follow-up adherence was associated with greater ED use for the same illness over the subsequent 2 months (odds ratio = 2.97; 95% confidence interval, 1.31-6.72). Subsequent ED use was greatest for children with short-term primary care follow-up and: (1) prior ED use, (2) single caregivers, (3) mild severity illnesses at the ED index visit, or (4) younger children. ED use after the initial visit did not vary by type of illness or site.

CONCLUSIONS

There was no evidence that primary care follow-up soon after an ED visit was associated with a lower rate of subsequent ED use for common pediatric illnesses.