Rochester, New York: a decade of emergency department overcrowding

Considering non-hospital data in clinical informatics use cases, a review of the National Emergency Medical Services Information System (NEMSIS)

Background

The National Emergency Medical Services (EMS) Information System (NEMSIS) Technical Assistance Center (TAC) collects and curates EMS activation level records for the United States. Originated as an outcomes assessment and service comparison tool, NEMSIS may have other high value clinical and public health uses.

Methods

This study acquired a 100% activation level public dataset for 2019 from NEMSIS TAC and assessed item response quantities. Subsumption of NEMSIS terms within other controlled clinical vocabularies was also considered.

Results

None of the assessed terminologies (LOINC, ICD10-CM, SNOMED-CT) could describe meaningful volumes of NEMSIS item response codes. The 2019 activation year dataset included 36,525 non-date/time or calculated distinct item responses for 43 activation descriptive items. Said item responses yielded 2,101,844,053 activation distinct non-blank responses. Several NEMSIS item responses had high clinical and public health value.

Conclusions

NEMSIS can support multiple public health use cases in addition to EMS outcomes assessment. A comprehensive custom value set is appropriate to integrate NEMSIS item response codes into controlled terminologies, FHIR or hospital Electronic Health Record applications.

Design Strategies to Improve Emergency Departments' Performance During Mass Casualty Incidents: A Survey of Caregivers

OBJECTIVES

To identify effective facility design strategies to improve the performance of healthcare providers and patient flow during mass casualty incidents (MCIs) in emergency departments.

BACKGROUND

Emergency departments (EDs) are the first line of medical care in MCIs. While operational surge management plans are well described in literature, physical design strategies to improve performance and patient flow during disasters are discussed scarcely.

METHOD

An online questionnaire was sent to EDs' caregivers nationwide asking them to rate the effectiveness of nine physical design strategies, discussed in the literature, to improve caregivers' performance and patient flow during MCIs. Assessed strategies were about providing expandable departments and care areas, alternate care facilities for the least sick to maximize care areas for critical patients, care areas from nonemergency units, increased number of decontamination units, dedicated isolation units, within-hospital and close emergency operation centers, and within-hospital media areas.

RESULTS

All suggested strategies were rated as effective. The most effective and agreed-upon solution was identified as maximizing the care area for critical patients by establishing an alternate care facility with separate entrance and exit doors from the emergency department for the least critical patients. The least effective and agreed-upon strategy was identified as locating a media unit within the hospital outside of the ED.

CONCLUSIONS

Caregivers who work in EDs consider design strategies to be effective in surge management during disasters. Designers can consider implementing identified strategies in designing new emergency departments or expansion and renovation projects.

Performance Analysis of Emergency Room Episodes Through Process Mining

The performance analysis of Emergency Room episodes is aimed at providing decision makers with knowledge that allows them to decrease waiting times, reduce patient congestion, and improve the quality of care provided. In this case study, Process Mining is used to determine which activities, sub-processes, interactions, and characteristics of episodes explain why some episodes have a longer duration. The employed method and the results obtained are described in detail to serve as a guide for future performance analysis in this domain. It was discovered that the main cause of the increment in the episode duration is the occurrence of a loop between the Examination and Treatment sub-processes. It was also found out that as the episode severity increases, the number of repetitions of the Examination-Treatment loop increases as well. Moreover, the episodes in which this loop is more common are those that lead to Hospitalization as discharge destination. These findings might help to reduce the occurrence of this loop, in turn lowering the episode duration and, consequently, providing faster attention to more patients.

Assessment of Inadequate Use of Pediatric Emergency Medical Transport Services: The Pediatric Emergency and Ambulance Critical Evaluation (PEACE) Study

Aim: To provide data on the inadequate use of emergency medical transports services (EMTS) in children and underlying contributing factors. Methods: This was a prospective single-center cohort study (01/2017-12/2017) performed at the Saarland University Children's Hospital, Homburg, Germany. Patients ≤20 years of age transported by EMTS for suspected acute illness/trauma were included and proportion of inadequate/adequate EMTS use, underlying contributing factors, and additional costs were analyzed. Results: Three hundred seventy-nine patients (mean age: 9.0 ± 6.3 years; 55.7% male, 44.3% female) were included in this study. The three most common reasons for EMTS use were: central nervous system (30.6%), respiratory system affection (14.0%), and traumas (13.2%). ETMS use was categorized as inadequate depending on physician's experience: senior physician (58.8%), pediatrician (54.9%), resident (52.7%). All three physicians considered 127 (33.5%) cases to be medically indicated for transportation by EMTS, and 177 (46.7%) to be medically not indicated. The following parameters were significantly associated with inadequate EMTS use: non-acute onset of symptoms (OR 2.5), parental perception as non-life-threatening (OR 1.7), and subsequent out-patient treatment (OR 4.0). Conversely, transport by an emergency physician (OR 3.5) and first time parental EMTS call (OR 1.7) were associated with adequate use of EMTS. Moreover, a significant relation existed between maternal, respectively, paternal educational status and inadequate EMTS use (each p = 0.01). Using multiple logistic regression analysis, non-acute onset of symptoms (OR 2.2) was associated with inadequate use of EMTS while first time parental EMTS call (OR 1.8), transport by an emergency physician (OR 3.3), and need for in-patient treatment (OR 4.0) were associated with adequate use of EMTS. Conclusion: A substantial number of pediatric EMTS is medically not indicated. Possibly, specific measures including multifaceted educational efforts may be helpful in reducing unnecessary EMTS use.

A review on ambulance offload delay literature

Ambulance offload delay (AOD) occurs when care of incoming ambulance patients cannot be transferred immediately from paramedics to staff in a hospital emergency department (ED). This is typically due to emergency department congestion. This problem has become a significant concern for many health care providers and has attracted the attention of many researchers and practitioners. This article reviews literature which addresses the ambulance offload delay problem. The review is organized by the following topics: improved understanding and assessment of the problem, analysis of the root causes and impacts of the problem, and development and evaluation of interventions. The review found that many researchers have investigated areas of emergency department crowding and ambulance diversion; however, research focused solely on the ambulance offload delay problem is limited. Of the 137 articles reviewed, 28 articles were identified which studied the causes of ambulance offload delay, 14 articles studied its effects, and 89 articles studied proposed solutions (of which, 58 articles studied ambulance diversion and 31 articles studied other interventions). A common theme found throughout the reviewed articles was that this problem includes clinical, operational, and administrative perspectives, and therefore must be addressed in a system-wide manner to be mitigated. The most common intervention type was ambulance diversion. Yet, it yields controversial results. A number of recommendations are made with respect to future research in this area. These include conducting system-wide mitigation intervention, addressing root causes of ED crowding and access block, and providing more operations research models to evaluate AOD mitigation interventions prior implementations. In addition, measurements of AOD should be improved to assess the size and magnitude of this problem more accurately.

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.

Increased door to admission time is associated with prolonged throughput for ED patients discharged home

BACKGROUND

Emergency Department (ED) service evaluations are typically based on surveys of discharged patients. Physicians/administrators benefit from data that quantifies system-based factors that adversely impact the experience of those who represent the survey cohort.

OBJECTIVE

While investigators have established that admitted patient boarding impacts overall ED throughput times, we sought to specifically quantify the relationship between throughput times for patients admitted (EDLOS) versus discharged home from the ED (DCLOS).

METHODS

We performed a prospective analysis of consecutive patient encounters at an inner-city ED. Variables collected: median daily DCLOS for ED patients, ED daily census, left without being seen (LWBS), median door to doctor, median room to doctor, and daily number admitted. Admitted patients divided into 2 groups based on daily median EDLOS for admits (<6 hours, ≥6 hours). Continuous variables analyzed by t-tests. Multivariate regression utilized to identify independent effects of the co-variants on median daily DCLOS.

RESULTS

We analyzed 24,127 patient visits. ED patient DCLOS was longer for patients seen on days with prolonged EDLOS (193.7 minutes, 95%CI 186.7-200.7 vs. 152.8, 144.9-160.5, P< .0001). Variables that were associated with increased daily median EDLOS for admits included: daily admits (P= 0.01), room to doctor time (P< .01), number of patients that left without being seen (P< .01). When controlling for the covariate daily census, differences in DCLOS remained significant for the ≥6 hours group (189.4 minutes, 95%CI 184.1-194.7 vs. 164.8, 155.7-173.9 (P< .0001).

CONCLUSION

Prolonged ED stays for admitted patients were associated with prolonged throughput times for patients discharged home from the ED.

'Delayed discharges and boarders': a 2-year study of the relationship between patients experiencing delayed discharges from an acute hospital and boarding of admitted patients in a crowded ED

OBJECTIVE

Many believe that hospital crowding manifesting in the ED with the boarding of admitted patients is a result of significant numbers of acute hospital beds being occupied by patients awaiting discharge to nursing homes, step-down facilities or home with or without additional support. This observational study was performed to establish the actual relationship between boarders in the ED and patients experiencing delayed discharge.

METHODS

Data relating to the number of patients in the ED and their points in their patient pathway were entered into a logbook on a daily basis by the most senior doctor on duty. 630 days of observations of patients boarded in the ED were compared with the number of inpatients with delayed discharges, obtained from the hospital information system, to see if large numbers of inpatients with delayed discharges are associated with crowding in the ED.

RESULTS

Two years of data showed an annual ED census of more than 47 000, with a daily mean ED admission rate of 29.85 patients and a daily mean ED boarding figure of 29 patients. A mean of 15.4% of the 823 hospital beds was occupied by patients with delayed discharges, and the hospital ran at, or near, full capacity (99%-105%) all the time. Results obtained highlighted a statistically significant relationship between delayed discharges in the hospital and ED crowding as a result of boarders (p value<0.001, with a regression coefficient of 0.16, 95% CI 0.12 to 0.20). The study also showed that the number of boarders was related to the number of ED admissions in the preceding 24 hours (p=0.036, with a regression coefficient of 0.14, 95% CI 0.05 to 0.28).

CONCLUSIONS

Delayed hospital discharges significantly contribute to crowding in the ED. Healthcare systems should target timely discharge of inpatients experiencing delayed discharge in an urgent and efficient manner to improve timely access to acute hospital beds for patients requiring emergency admission.

New Intervention Model of Regional Transfer Network System to Alleviate Crowding of Regional Emergency Medical Center

Emergency department (ED) crowding is a serious problem in most tertiary hospitals in Korea. Although several intervention models have been established to alleviate ED crowding, they are limited to a single hospital-based approach. This study was conducted to determine whether the new regional intervention model could alleviate ED crowding in a regional emergency medical center. This study was designed as a "before and after study" and included patients who visited the tertiary hospital ED from November 2011 to October 2013. One tertiary hospital and 32 secondary hospitals were included in the study. A transfer coordinator conducted inter-hospital transfers from a tertiary hospital to a secondary hospital for suitable patients. A total of 1,607 and 2,591 patients transferred from a tertiary hospital before and after the study, respectively (P < 0.001). We found that the median ED length of stay (LOS) decreased significantly from 3.68 hours (interquartile range [IQR], 1.85 to 9.73) to 3.20 hours (IQR, 1.62 to 8.33) in the patient group after implementation of the Regional Transfer Network System (RTNS) (P < 0.001). The results of multivariate analysis showed a negative association between implementation of the RTNS and ED LOS (beta coefficient -0.743; 95% confidence interval -0.914 to -0.572; P < 0.001). In conclusion, the ED LOS in the tertiary hospital decreased after implementation of the RTNS.

Factors Contributing to Inappropriate Visits of Frequent Attenders and Their Economic Effects at an Emergency Department in Singapore

OBJECTIVES

This study aimed to determine which factors contribute to frequent visits at the emergency department (ED) and what proportion were inappropriate in comparison with nonfrequent visits.

METHODS

This study was a retrospective, case-control study comparing a random sample of frequent attenders and nonfrequent attenders, with details of their ED visits recorded over a 12-month duration. Frequent attenders were defined as patients with four or more visits during the study period.

RESULTS

In comparison with nonfrequent attenders (median age = 45.0 years, interquartile range [IQR] = 28.0 to 61.0 years), frequent attenders were older (median = 57.5 years, IQR = 34.0 to 74.8 years; p = 0.0003). They were also found to have more comorbidities, where 53.3% of frequent attenders had three or more chronic illnesses compared to 14% of nonfrequent attenders (p < 0.0001), and were often triaged to higher priority (more severe) classes (frequent 52.2% vs. nonfrequent 37.6%, p = 0.0004). Social issues such as bad debts (12.7%), heavy drinking (3.3%), and substance abuse (2.7%) were very low in frequent attenders compared to Western studies. Frequent attenders had a similar rate of appropriate visits to the ED as nonfrequent attenders (55.2% vs. 48.1%, p = 0.0892), but were more often triaged to P1 priority triage class (6.7% vs. 3.2%, p = 0.0014) and were more often admitted for further management compared to nonfrequent attenders (47.5% vs. 29.6%, p < 0.001). The majority of frequent attender visits were appropriate (55.2%), and of these, 81.1% resulted in admission. For the same number of patients, total visits made by frequent attenders ($174,247.60) cost four times as much as for nonfrequent attenders ($40,912.40). This represents a significant economic burden on the health care system.

CONCLUSIONS

ED frequent attenders in Singapore were associated with higher age and presence of multiple comorbidities rather than with social causes of ED use. Even in integrated health systems, repeat ED visits are frequent and expensive, despite minimal social causes of acute care. EDs in aging populations must anticipate the influx of vulnerable, elderly patients and have in place interventional programs to care for them.

Understanding hospital and emergency department congestion: an examination of inpatient admission trends and bed resources

Objective:

Patients in the emergency department (ED) who have been admitted to hospital (inpatient “boarders”) are associated with ED overcrowding. They are also a symptom of a hospital-wide imbalance between demand and supply of resources. We analyzed the trends of inpatient admissions, ED boarding volumes, lengths of stay and bed resources of 3 major admitting services at our teaching institution.

Methods:

We used hospital databases from Jan. 1, 2004, to Dec. 31, 2007, to analyze ED visits that resulted in admission to hospital.

Results:

During the study period, 21 986 ED patients were admitted to hospital. The percentage of cancer-related admissions to the oncology admitting service decreased from 48% in 2004 to 24% in 2007, and admissions to general internal medicine (GIM) increased nearly 2-fold, from 28% in 2004 to 54% in 2007. In addition, GIM admitted about 10% more myocardial infarction and heart failure patients than did cardiology. General internal medicine constituted the majority of ED boarders and had a median boarding length of stay of approximately 15 hours. Inpatient beds on oncology and cardiology services remained static.

Conclusion:

Without bed capacity to admit more patients, our specialty services relied on GIM to serve as a safety net. At the same time, GIM was cited as a main source of ED congestion as their patients occupied more ED beds for longer periods than any other admitting service. The data presented in this study has helped effect positive change within our institution. Other hospitals running at or near capacity and faced with similar ED congestion may apply the methods we used in this study to analyze the cause and nature of their situation.

Can a universal influenza immunization program reduce emergency department volume?

Objectives:

In 2000 the Ontario Minister of Health and Long-Term Care announced a universal influenza immunization program for Ontario, Canada. The 2 objectives of this $38-million program were to decrease seasonal impact of influenza on emergency department (ED) visits and to decrease the number and severity of influenza cases. This paper examines the correlation between population influenza rates and ED visits in 5 tertiary care hospitals in Ontario over a 5-year period (1996–2001).

Methods:

In this retrospective, observational study, we determined the total number of ED visits during the study period, by month, at 5 tertiary care hospitals in 3 Ontario cities Kingston, London and Ottawa). Detailed ED diagnoses were captured for Kingston, and provincial and national population-based influenza rates were obtained from Health Canada for the 5-year study period. Correlation and regression analyses were used to determine the relationship of influenza rates and ED volumes. “Influenza season” is defined in this study as November 1st to March 31st of each year.

Results:

There was no significant correlation between influenza rates and ED volumes, with Pearson correlation coefficients (r) of 0.22 (p= 0.72), 0.33 (p= 0.59) and 0.27 (p= 0.66) at the Kingston, London and Ottawa study sites, respectively. Data from the Kingston hospitals showed that, during influenza season, acute respiratory diagnoses accounted for only 4.4% of ED visits and influenza for only 0.34% of visits. Multiple linear regression analysis showed that the ED diagnosis of influenza was not significantly related to ED volume. During the influenza season after the universal immunization campaign, ED visits increased at all sites.

Conclusion:

Based on this study, a universal influenza immunization campaign is unlikely to affect ED volume.

Improving diagnostic accuracy using EHR in emergency departments: A simulation-based study

It is widely believed that Electronic Health Records (EHR) improve medical decision-making by enabling medical staff to access medical information stored in the system. It remains unclear, however, whether EHR indeed fulfills this claim under the severe time constraints of Emergency Departments (EDs). We assessed whether accessing EHR in an ED actually improves decision-making by clinicians. A simulated ED environment was created at the Israel Center for Medical Simulation (MSR). Four different actors were trained to simulate four specific complaints and behavior and 'consulted' 26 volunteer ED physicians. Each physician treated half of the cases (randomly) with access to EHR, and their medical decisions were compared to those where the physicians had no access to EHR. Comparison of diagnostic accuracy with and without access showed that accessing the EHR led to an increase in the quality of the clinical decisions. Physicians accessing EHR were more highly informed and thus made more accurate decisions. The percentage of correct diagnoses was higher and these physicians were more confident in their diagnoses and made their decisions faster.

Ambulance Diversion: Ethical Dilema and Necessary Evil

Ambulance diversion presents a dilemma pitting the ethical principles of patient autonomy and beneficence against the principles of justice and nonmaleficence. The guiding priority in requesting ambulance diversion is to maintain the safety of all patients in the emergency department as well as those waiting to be seen. Policies and procedures can be developed that maintain the best possible outcome for patients transported by ambulance during periods of diversion. More importantly, the discussion must focus on addressing the operational inefficiencies within our health systems that lead to conditions such as patient boarding, high waiting room congestion, and ambulance diversion. Addressing these inefficiencies has a greater potential impact on ambulance diversion than simply banning or restricting the practice for practical or ethical considerations.

Effects of emergency department expansion on emergency department patient flow

OBJECTIVES

Emergency department (ED) crowding is an increasing problem associated with adverse patient outcomes. ED expansion is one method advocated to reduce ED crowding. The objective of this analysis was to determine the effect of ED expansion on measures of ED crowding.

METHODS

This was a retrospective study using administrative data from two 11-month periods before and after the expansion of an ED from 33 to 53 adult beds in an academic medical center. ED volume, staffing, and hospital admission and occupancy data were obtained either from the electronic health record (EHR) or from administrative records. The primary outcome was the rate of patients who left without being treated (LWBT), and the secondary outcome was total ED boarding time for admitted patients. A multivariable robust linear regression model was used to determine whether ED expansion was associated with the outcome measures.

RESULTS

The mean (±SD) daily adult volume was 128 (±14) patients before expansion and 145 (±17) patients after. The percentage of patients who LWBT was unchanged: 9.0% before expansion versus 8.3% after expansion (difference = 0.6%, 95% confidence interval [CI] = -0.16% to 1.4%). Total ED boarding time increased from 160 to 180 hours/day (difference = 20 hours, 95% CI = 8 to 32 hours). After daily ED volume, low-acuity area volume, daily wait time, daily boarding hours, and nurse staffing were adjusted for, the percentage of patients who LWBT was not independently associated with ED expansion (p = 0.053). After ED admissions, ED intensive care unit (ICU) admissions, elective surgical admissions, hospital occupancy rate, ICU occupancy rate, and number of operational ICU beds were adjusted for, the increase in ED boarding hours was independently associated with the ED expansion (p = 0.005).

CONCLUSIONS

An increase in ED bed capacity was associated with no significant change in the percentage of patients who LWBT, but had an unintended consequence of an increase in ED boarding hours. ED expansion alone does not appear to be an adequate solution to ED crowding.

Hospital factors impact variation in emergency department length of stay more than physician factors

INTRODUCTION

To analyze the correlation between the many different emergency department (ED) treatment metric intervals and determine if the metrics directly impacted by the physician correlate to the "door to room" interval in an ED (interval determined by ED bed availability). Our null hypothesis was that the cause of the variation in delay to receiving a room was multifactorial and does not correlate to any one metric interval.

METHODS

We collected daily interval averages from the ED information system, Meditech©. Patient flow metrics were collected on a 24-hour basis. We analyzed the relationship between the time intervals that make up an ED visit and the "arrival to room" interval using simple correlation (Pearson Correlation coefficients). Summary statistics of industry standard metrics were also done by dividing the intervals into 2 groups, based on the average ED length of stay (LOS) from the National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary.

RESULTS

Simple correlation analysis showed that the doctor-to-discharge time interval had no correlation to the interval of "door to room (waiting room time)", correlation coefficient (CC) (CC=0.000, p=0.96). "Room to doctor" had a low correlation to "door to room" CC=0.143, while "decision to admitted patients departing the ED time" had a moderate correlation of 0.29 (p <0.001). "New arrivals" (daily patient census) had a strong correlation to longer "door to room" times, 0.657, p<0.001. The "door to discharge" times had a very strong correlation CC=0.804 (p<0.001), to the extended "door to room" time.

CONCLUSION

Physician-dependent intervals had minimal correlation to the variation in arrival to room time. The "door to room" interval was a significant component to the variation in "door to discharge" i.e. LOS. The hospital-influenced "admit decision to hospital bed" i.e. hospital inpatient capacity, interval had a correlation to delayed "door to room" time. The other major factor affecting department bed availability was the "total patients per day." The correlation to the increasing "door to room" time also reflects the effect of availability of ED resources (beds) on the patient evaluation time. The time that it took for a patient to receive a room appeared more dependent on the system resources, for example, beds in the ED, as well as in the hospital, than on the physician.

Emergency medical dispatch codes association with emergency department outcomes

BACKGROUND

Emergency medical dispatch systems are used to help categorize and prioritize emergency medical services (EMS) resources for requests for assistance.

OBJECTIVE

We examined whether a subset of Medical Priority Dispatch System (MPDS) codes could predict patient outcomes (emergency department [ED] discharge versus hospital admission/ED death).

METHODS

This retrospective observational cohort study analyzed requests for EMS through a single public safety answering point (PSAP) serving a mixed urban, suburban, and rural community over one year. Probabilistic matching was used to link subjects. Descriptive statistics, 95% confidence intervals (CIs), and logistic regression were calculated for the 107 codes and code groupings (9E vs. 9E1, 9E2, etc.) that were used 50 or more times during the study period.

RESULTS

Ninety percent of PSAP records were matched to EMS records and 84% of EMS records were matched to ED data, resulting in 26,846 subjects with complete records. The average age of the cohort was 46.2 years (standard deviation [SD] 24.8); 54% were female. Of the transported patients, 70% were discharged from the ED, with nine dispatch codes demonstrating a 90% or greater predictive power. Three code groupings had more than 60% predictive power for admission/death. Subjects aged 65 years and older were found to be at increased risk for admission/death in 33 dispatch codes (odds ratio [OR] 2.0 [95% confidence interval 1.3-3.0] to 19.6 [5.3-72.6]).

CONCLUSIONS

A small subset (8% of codes; 7% by call volume) of MPDS codes were associated with greater than 90% predictive ability for ED discharge. Older adults are at increased risk for admission/death in a separate subset of MPDS codes, suggesting that age criteria may be useful to identify higher-acuity patients within the MPDS code. These findings could assist in prehospital/hospital resource management; however, future studies are needed to validate these findings for other EMS systems and to investigate possible strategies for improvements of emergency response systems.

The Environment of Inpatient Healthcare Delivery and Its Influence on the Outcome of Care

Aim:

This paper addresses issues arising in the literature regarding the environmental design of inpatient healthcare settings and their impact on care.

Background:

Environmental design in healthcare settings is an important feature of the holistic delivery of healthcare. The environmental influence of the delivery of care is manifested by such things as lighting, proximity to bedside, technology, family involvement, and space. The need to respond rapidly in places such as emergency and intensive care can override space needs for family support. In some settings with aging buildings, the available space is no longer appropriate to the needs—for example, the need for privacy in emergency departments. Many aspects of care have changed over the last three decades and the environment of care appears not to have been adapted to contemporary healthcare requirements nor involved consumers in ascertaining environmental requirements. The issues found in the literature are addressed under five themes: the design of physical space, family needs, privacy considerations, the impact of technology, and patient safety.

Conclusion:

There is a need for greater input into the design of healthcare spaces from those who use them, to incorporate dignified and expedient care delivery in the care of the person and to meet the needs of family.

Patterns and factors associated with intensive use of ED services: implications for allocating resources

AIM

This study aims to better understand the patterns and factors associated with the use of emergency department (ED) services on high-volume and intensive (defined by high volume and high-patient severity) days to improve resource allocation and reduce ED overcrowding.

METHODS

This study created a new index of "intensive use" based on the volume and severity of illness and a 3-part categorization (normal volume, high volume, intensive use) to measure stress in the ED environment. This retrospective, cross-sectional study collected data from hospital clinical and financial records of all patients seen in 2001 at an urban academic hospital ED.

RESULTS

Multiple logistic regression models identified factors associated with high volume and intensive use. Factors associated with intensive days included being in a motor vehicle crash; having a gun or stab wound; arriving during the months of January, April, May, or August; and arriving during the days of Monday, Tuesday, or Wednesday. Factors associated with high-volume days included falling from 0 to 10 ft; being in a motor vehicle crash; arriving during the months of January, April, May, or August; and arriving during the days of Monday, Tuesday, or Wednesday.

CONCLUSION

These findings offer inputs for reallocating resources and altering staffing models to more efficiently provide high-quality ED services and prevent overcrowding.

Predicting emergency department volume using forecasting methods to create a "surge response" for noncrisis events

OBJECTIVES

This study investigated whether emergency department (ED) variables could be used in mathematical models to predict a future surge in ED volume based on recent levels of use of physician capacity. The models may be used to guide decisions related to on-call staffing in non-crisis-related surges of patient volume.

METHODS

A retrospective analysis was conducted using information spanning July 2009 through June 2010 from a large urban teaching hospital with a Level I trauma center. A comparison of significance was used to assess the impact of multiple patient-specific variables on the state of the ED. Physician capacity was modeled based on historical physician treatment capacity and productivity. Binary logistic regression analysis was used to determine the probability that the available physician capacity would be sufficient to treat all patients forecasted to arrive in the next time period. The prediction horizons used were 15 minutes, 30 minutes, 1 hour, 2 hours, 4 hours, 8 hours, and 12 hours. Five consecutive months of patient data from July 2010 through November 2010, similar to the data used to generate the models, was used to validate the models. Positive predictive values, Type I and Type II errors, and real-time accuracy in predicting noncrisis surge events were used to evaluate the forecast accuracy of the models.

RESULTS

The ratio of new patients requiring treatment over total physician capacity (termed the care utilization ratio [CUR]) was deemed a robust predictor of the state of the ED (with a CUR greater than 1 indicating that the physician capacity would not be sufficient to treat all patients forecasted to arrive). Prediction intervals of 30 minutes, 8 hours, and 12 hours performed best of all models analyzed, with deviances of 1.000, 0.951, and 0.864, respectively. A 95% significance was used to validate the models against the July 2010 through November 2010 data set. Positive predictive values ranged from 0.738 to 0.872, true positives ranged from 74% to 94%, and true negatives ranged from 70% to 90% depending on the threshold used to determine the state of the ED with the 30-minute prediction model.

CONCLUSIONS

The CUR is a new and robust indicator of an ED system's performance. The study was able to model the tradeoff of longer time to response versus shorter but more accurate predictions, by investigating different prediction intervals. Current practice would have been improved by using the proposed models and would have identified the surge in patient volume earlier on noncrisis days.

Evaluation of a flexible acute admission unit: effects on transfers to other hospitals and patient throughput times

INTRODUCTION

To prevent overcrowding of the emergency department, a flexible acute admission unit (FAAU) was created, consisting of 15 inpatient regular beds located in different departments. We expected the FAAU to result in fewer transfers to other hospitals and in a lower length of stay (LOS) of patients needing hospital admission.

METHODS

A before-and-after interventional study was performed in a level 1 trauma center in the Netherlands. Number of transfers and LOS of admitted ED patients in a 4-month period in 2008 (control period) and a 4-month period in 2009 (intervention period) were analyzed.

RESULTS

Of 1,619 regular admission patients, 768 were admitted in the control period and 851 in the intervention period. The number of transfers decreased from 80 (10.42%) to 54 (6.35%) (P = .0037). The mean ED LOS of both the non-admitted patients and the admitted patients needing special care significantly increased (105 minutes vs 117 minutes [P = .022] and 176 minutes vs 191 minutes [P < .001], respectively). However, the mean LOS of FAAU-admissible patients was unaltered (226 minutes vs 225 minutes, P = .865).

CONCLUSIONS

The FAAU reduced the number of transfers of admitted patients to other hospitals. The increase in LOS for special care patients and non-admitted patients was not observed for regular, FAAU-admissible patients. Flexible bed management might be useful in preventing overcrowding.

Association between ambulance diversion and survival among patients with acute myocardial infarction

CONTEXT

Ambulance diversion, a practice in which emergency departments (EDs) are temporarily closed to ambulance traffic, might be problematic for patients experiencing time-sensitive conditions, such as acute myocardial infarction (AMI). However, there is little empirical evidence to show whether diversion is associated with worse patient outcomes.

OBJECTIVE

To analyze whether temporary ED closure on the day a patient experiences AMI, as measured by ambulance diversion hours of the nearest ED, is associated with increased mortality rates among patients with AMI. DESIGN, STUDY, AND PARTICIPANTS: A case-crossover design of 13,860 Medicare patients with AMI from 508 zip codes within 4 California counties (Los Angeles, San Francisco, San Mateo, and Santa Clara) whose admission date was between 2000 and 2005. Data included 100% Medicare claims data that covered admissions between 2000 and 2005, linked with date of death until 2006, and daily ambulance diversion logs from the same 4 counties. Among the hospital universe, 149 EDs were identified as the nearest ED to these patients.

MAIN OUTCOME MEASURES

The percentage of patients with AMI who died within 7 days, 30 days, 90 days, 9 months, and 1 year from admission (when their nearest ED was not on diversion and when that same ED was exposed to <6, 6 to <12, and ≥12 hours of diversion out of 24 hours on the day of admission).

RESULTS

Between 2000 and 2006, the mean (SD) daily diversion duration was 7.9 (6.1) hours. Based on analysis of 11,625 patients admitted to the ED between 2000 and 2005, and whose nearest ED had at least 3 diversion exposure levels (3541, 3357, 2667, and 2060 patients for no exposure, exposure to <6, 6 to <12, and ≥12 hours of diversion, respectively), there were no statistically significant differences in mortality rates between no diversion and exposure to less than 12 hours of diversion. Exposure to 12 or more hours of diversion was associated with higher 30-day mortality vs no diversion status (unadjusted mortality rate, 392 patients [19%] vs 545 patients [15%]; regression adjusted difference, 3.24 percentage points; 95% confidence interval [CI], 0.60-5.88); higher 90-day mortality (537 patients [26%] vs 762 patients [22%]; 2.89 percentage points; 95% CI, 0.13-5.64); higher 9-month mortality (680 patients [33%] vs 980 patients [28%]; 2.93 percentage points; 95% CI, 0.15-5.71); and higher 1-year mortality (731 patients [35%] vs 1034 patients [29%]; 3.04 percentage points; 95% CI, 0.33-5.75).

CONCLUSION

Among Medicare patients with AMI in 4 populous California counties, exposure to at least 12 hours of diversion by the nearest ED was associated with increased 30-day, 90-day, 9-month, and 1-year mortality.

Managing emergency department overcrowding

Emergency department (ED) crowding and ambulance diversion has been an increasingly significant national problem for more than a decade. More than 90% of hospital ED directors reported overcrowding as a problem resulting in patients in hallways, full occupancy of ED beds, and long waits, occurring several times a week. Overcrowding has many other potential detrimental effects including diversion of ambulances, frustration for patients and ED personnel, lesser patient satisfaction, and most importantly, greater risk for poor outcomes. This article gives a basic blueprint for successfully making hospital-wide changes using principles of operational management. It briefly covers the causes, significance, and dangers of overcrowding, and then focuses primarily on specific solutions.

Effect of an independent-capacity protocol on overcrowding in an urban emergency department

OBJECTIVES

The authors hypothesized that a new strategy, termed the independent-capacity protocol (ICP), which was defined as primary stabilization at the emergency department (ED) and utilization of community resources via transfer to local hospitals, would reduce ED overcrowding without requiring additional hospital resources.

METHODS

This is a before-and-after trial that included all patients who visited an urban, tertiary care ED in Korea from July 2006 to June 2008. To improve ED throughput, introduction of the ICP gave emergency physicians (EPs) more responsibility and authority over patient disposition, even when the patients belonged to another specific clinical department. The ICP utilizes the ED as a temporary, nonspecific place that cares for any patient for a limited time period. Within 48 hours, EPs, associated specialists, and transfer coordinators perform secondary assessment and determine patient disposition. If the hospital is full and cannot admit these patients after 48 hours, the EP and transfer coordinators move the patients to other appropriate community facilities. We collected clinical data such as sex, age, diagnosis, and treatment. The main outcomes included ED length of stay (LOS), the numbers of admissions to inpatient wards, and the mortality rate.

RESULTS

A total of 87,309 patients were included. The median number of daily patients was 114 (interquartile range [IQR] = 104 to 124) in the control phase and 124 (IQR = 112 to 135) in the ICP phase. The mean ED LOS decreased from 15.1 hours (95% confidence interval [CI] = 14.8 to 15.3) to 13.4 hours (95% CI = 13.2 to 13.6; p < 0.001). The mean LOS in the emergency ward decreased from 4.5 days (95% CI = 4.4 to 4.6 days) to 3.1 days (95% CI = 3.0 to 3.2 days; p < 0.001). The percentage of transfers from the ED to other hospitals decreased from 3.5% to 2.5% (p < 0.001). However, transfers from the emergency ward to other hospitals increased from 2.9% to 8.2% (p < 0.001). Admissions to inpatient wards from the ED were significantly reduced, and admission from the emergency ward did not change. The ED mortality and hospital mortality rates did not change (p = 0.15 and p = 0.10, respectively).

CONCLUSIONS

After introduction of the ICP, ED LOS decreased without an increase in hospital capacity.

Intervenções para solucionar a superlotação nos serviços de emergência hospitalar: uma revisão sistemática

Esta revisão discute as intervenções voltadas para solucionar o problema da superlotação dos Serviços de Emergência Hospitalar (SEH), como evidência de baixa efetividade organizacional. Em bases de dados eletrônicas de livre acesso e acesso restrito, os descritores buscados foram "superlotação; emergência; medicina; pronto-socorro". O levantamento identificou 66 citações de intervenções, agrupadas em 47 intervenções afins. A maioria dos trabalhos teve como desenho os estudos observacionais que avaliaram os resultados das intervenções antes e depois. As mais citadas: implantação da unidade de observação dos pacientes graves; implantação do serviço de enfermagem dedicado à admissão, alta e transferência do paciente; instituição de protocolos de saturação operacional e implantação da unidade de pronto-atendimento. Na análise das 21 intervenções para solucionar a superlotação nos SEH, que tiveram resultados favoráveis no evento principal - tempo de permanência no SEH -, 15 tinham relação com a melhoria do fluxo no próprio SEH ou nos setores do hospital, interferindo ativa e positivamente no fluxo interno dos pacientes. As intervenções que aumentaram as barreiras de acesso aos SEH, ou que apenas melhoram a estrutura dos SEH não foram efetivas.

The impact of inpatient boarding on ED efficiency: a discrete-event simulation study

In this study, a discrete-event simulation approach was used to model Emergency Department's (ED) patient flow to investigate the effect of inpatient boarding on the ED efficiency in terms of the National Emergency Department Crowding Scale (NEDOCS) score and the rate of patients who leave without being seen (LWBS). The decision variable in this model was the boarder-released-ratio defined as the ratio of admitted patients whose boarding time is zero to all admitted patients. Our analysis shows that the Overcrowded(+) (a NEDOCS score over 100) ratio decreased from 88.4% to 50.4%, and the rate of LWBS patients decreased from 10.8% to 8.4% when the boarder-released-ratio changed from 0% to 100%. These results show that inpatient boarding significantly impacts both the NEDOCS score and the rate of LWBS patient and this analysis provides a quantification of the impact of boarding on emergency department patient crowding.

Appropriateness of diagnosis and orientation of 996 consecutive patients admitted in an emergency department with flow-based organization

BACKGROUND

Recent data, focused on the inability to transfer emergency patients to inpatient beds, has shown this to be the single most important factor contributing to overcrowding. Our Emergency Department (ED) was reorganized in the year 2000 based on the optimization of patients' flow. In this model, the emergency team had to refer patients to units fitting best to their condition with minimal delays.

OBJECTIVES

To evaluate adequacy of both diagnosis between emergency room and hospitalization wards and patients' orientation in the context of an early discharge from the ED.

METHODS

We collected data from 996 consecutive nontrauma patients for whom an admission was decided. Duration of stay in the ED and all related parameters were studied. Patients were categorized according to the adequacy of the diagnosis proposed at ED discharge as compared with the final diagnosis at hospital discharge. The patients' orientation appropriateness was also assessed.

RESULTS

Despite a median duration of time of 6 h (21 min-54 h) diagnostics made by the emergency physicians and the patients' orientation were considered as adequate in most of the cases (66 and 96%, respectively). Fast track developed with medical intensive care and cardiology intensive care allowed referral of patients requiring these specific units within 2.2 h (27 min-17 h) and 2 h (41 min-8 h), respectively. The ED length of stay was highly influenced by the admission location and by the patient's age.

CONCLUSION

A short time of stay in the ED is compatible with both a good diagnosis and a good orientation of ED patients requiring admission for specialized care.

A summative evaluation of an EMS partnership aimed at reducing ED length of stay

INTRODUCTION

Freestanding emergency departments are full-service emergency departments with no attached inpatient facility. ED congestion and patient dissatisfaction may occur as patients requiring admission are waiting for ambulance arrival and transfer. A partnership between a freestanding emergency department and a private ambulance company was developed in order to reduce ambulance response times and ultimately ED length of stay. The aim of this manuscript was to describe the Partnership in Care program and evaluate the program's effectiveness.

METHODS

The study used a pre-post/post-test summative evaluation design. A retrospective chart review was done for all patients discharged from the freestanding emergency department by the partnered ambulance company during the pre-test period, April 2004 to June 2004, and the post-test period, April 2005 to June 2005. Data variables included time of triage, time ambulance requested, time ambulance arrived, and discharge time. Institutional Review Board approval was obtained.

RESULTS

There were 507 patients transported at discharge by the ambulance company. There was a 5-minute increase for mean ED length of stay although not significant. Mean ambulance response time was significantly reduced by 8 minutes.

DISCUSSION

The program did not achieve the primary goal of reducing ED length of stay, however the private EMS workers provided countless hours of patient care to the freestanding ED patients without charge to the freestanding emergency department for the EMS providers' time.

The effect of physician triage on emergency department length of stay

BACKGROUND

Emergency Department (ED) overcrowding is a serious public health issue, but few solutions exist.

OBJECTIVES

We sought to determine the impact of physician triage on ED length of stay for discharged and admitted patients, left-without-being-seen (LWBS) rates, and ambulance diversion.

METHODS

This was a pre-post study performed using retrospective data at an urban, academic tertiary care, Level I trauma center. On July 11, 2005, physician triage was initiated from 1:00 p.m. to 9:00 p.m., 7 days a week. An additional physician was placed in triage so that the ED diagnostic evaluation and treatment could be started in waiting room patients. Using the hospital information system, we obtained individual patient data, ED and waiting room statistics, and diversion status data from a 9-week pre-physician triage (May 11, 2005 to July 10, 2005) and a 9-week physician triage (July 11, 2005 to September 9, 2005) period.

RESULTS

We observed that overall ED length of stay decreased by 11 min, but this decrease was entirely attributed to non-admitted patients. No difference in ED length of stay was observed in admitted patients. LWBS rates decreased from 4.5% to 2.5%. Total time spent on ambulance diversion decreased from 5.6 days per month to 3.2 days per month.

CONCLUSION

Physician triage was associated with a decrease in LWBS rates, and time spent on ambulance diversion. However, its effect on ED LOS was modest in non-admitted ED patients and negligible in admitted patients.

A novel diversion protocol dramatically reduces diversion hours

INTRODUCTION

Ambulance diversion is a problem in many communities. When patients are diverted prompt and appropriate medical care may be delayed.

OBJECTIVE

Compare diversion hours and drop-off times before and after a dramatic change in diversion policy restricting each hospital to 1 hour out of every 8.

METHODS

This study was a retrospective study in a county of 600,000 people and 10 hospitals from September 2004 to February 2006. A countywide diversion protocol was implemented in March 2005 that limited diversion hours to 1 hour out of every 8 (maximum of 90 h/mo). No other changes were implemented during the study period. Pretrial (9/04-2/05), interim (3/05-8/05), and posttrial (9/05-2/06) periods were compared. The main outcome measures were ambulance diversion hours and emergency medical service (EMS) drop-off times. Results were compared using analysis of variance and a Tukey post hoc analysis. P < .05 was considered significant.

RESULTS

There was no significant difference in the number of monthly transports comparing the posttrial vs pretrial periods; however, a significant decrease in monthly ambulance diversion hours (difference, 251 hours; 95% CI, 136-368) and significant increase in additional time that EMS crews required to transport patients (drop-off times) (difference, 178 hours; 95% CI, 74-283) were observed. Posttrial diversion hours decreased to 18% of the pretrial values (from 305 to 54).

CONCLUSION

This novel ambulance diversion protocol dramatically reduced diversion hours at the cost of increasing EMS drop-off times in a large community.

Improving service quality by understanding emergency department flow: a White Paper and position statement prepared for the American Academy of Emergency Medicine

Emergency Department (ED) crowding is a common problem in the United States and around the world. Process reengineering methods can be used to understand factors that contribute to crowding and provide tools to help alleviate crowding by improving service quality and patient flow. In this article, we describe the ED as a service business and then discuss specific methods to improve the ED quality and flow. Methods discussed include demand management, critical pathways, process-mapping, Emergency Severity Index triage, bedside registration, Lean and Six Sigma management methods, statistical forecasting, queuing systems, discrete event simulation modeling and balanced scorecards. The purpose of this review is to serve as a background for emergency physicians and managers interested in applying process reengineering methods to improving ED flow, reducing waiting times, and maximizing patient satisfaction. Finally, we present a position statement on behalf of the American Academy of Emergency Medicine addressing these issues.

Systematic review of emergency department crowding: causes, effects, and solutions

Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. We conducted a comprehensive PubMed search to identify articles that (1) studied causes, effects, or solutions of ED crowding; (2) described data collection and analysis methodology; (3) occurred in a general ED setting; and (4) focused on everyday crowding. Two independent reviewers identified the relevant articles by consensus. We applied a 5-level quality assessment tool to grade the methodology of each study. From 4,271 abstracts and 188 full-text articles, the reviewers identified 93 articles meeting the inclusion criteria. A total of 33 articles studied causes, 27 articles studied effects, and 40 articles studied solutions of ED crowding. Commonly studied causes of crowding included nonurgent visits, "frequent-flyer" patients, influenza season, inadequate staffing, inpatient boarding, and hospital bed shortages. Commonly studied effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and financial effect. Commonly studied solutions of crowding included additional personnel, observation units, hospital bed access, nonurgent referrals, ambulance diversion, destination control, crowding measures, and queuing theory. The results illustrated the complex, multifaceted characteristics of the ED crowding problem. Additional high-quality studies may provide valuable contributions toward better understanding and alleviating the daily crisis. This structured overview of the literature may help to identify future directions for the crowding research agenda.

Likelihood of reroute during ambulance diversion periods in central Maryland

OBJECTIVES

To determine the proportion of patients rerouted during ambulance diversion periods and factors associated with reroute.

METHODS

A retrospective cohort design was used to examine reroute practices of prehospital providers in central Maryland in 2000. Ambulance transport and diversion data were merged to identify transports that occurred during diversion periods. The proportion of patients rerouted when the closest hospital was on diversion was determined. Generalized estimating equation modeling identified patient, transport, and hospital factors that influenced the likelihood of reroute.

RESULTS

Central Maryland hospitals were on diversion 25% of the time in 2000, although it varied by hospital (range of 1-34%). There were 128,165 transports during the study period, of which 18,633 occurred when the closest hospital was on diversion. Of these, only 23% were rerouted. More than half of all transports during a diversion period (53%) occurred when multiple neighboring hospitals were also on diversion. The factors that influenced the likelihood of reroute the most were hospital-related factors. Large volume hospitals and hospitals that spent more time on diversion were less likely to have transports rerouted to them.

CONCLUSIONS

Rerouted transports more frequently go to lower volume, less busy hospitals. However, only a small proportion of patients were rerouted. Prehospital providers have limited options because often when one hospital is on diversion, other nearby hospitals are as well. Although ambulance diversion may be an important signal of hospital distress, in this region it infrequently resulted in its intended outcome, rerouting patients to less crowded facilities.