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Nothelle S, Slade E, Zhou J, Magidson PD, Chotrani T, Prichett L, Amjad H, Szanton S, Boyd CM, Wolff JL. Emergency Department Length of Stay for Older Adults With Dementia. Ann Emerg Med 2024; 83:446-456. [PMID: 38069967 PMCID: PMC11032237 DOI: 10.1016/j.annemergmed.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/11/2023] [Accepted: 09/28/2023] [Indexed: 01/11/2024]
Abstract
STUDY OBJECTIVE The emergency department (ED) poses unique challenges and risks to persons living with dementia. A longer ED length of stay is associated with the risk of death, delirium, and medication errors. We sought to determine whether ED length of stay differed by dementia status and trends in ED length of stay for persons living with dementia from 2014 to 2018 and whether persons living with dementia were at a higher risk for prolonged ED length of stay (defined as a length of stay > 90th percentile). METHODS In this observational study, we used data from the Healthcare Cost and Utilization Project State Emergency Department Database from Massachusetts, Arkansas, Arizona, and Florida. We included ED visits resulting in discharge for adults aged ≥65 years from 2014 to 2018. We used inverse probability weighting to create comparable groups of visits on the basis of dementia status. We used generalized linear models to estimate the mean difference in ED length of stay on the basis of dementia status and logistic regression to determine the odds of prolonged ED length of stay. RESULTS We included 1,039,497 ED visits (mean age: 83.5 years; 64% women; 78% White, 12% Hispanic). Compared with visits by persons without dementia, ED length of stay was 3.1 hours longer (95% confidence interval [CI] 3.0 to 3.3 hours) for persons living with dementia. Among the visits resulting in transfer, ED length of stay was on average 4.1 hours longer (95% CI 3.6 to 4.5 hours) for persons living with dementia. Visits by persons living with dementia were more likely to have a prolonged length of stay (risk difference 4.1%, 95% CI 3.9 to 4.4). CONCLUSION ED visits were more than 3 hours longer for persons living with versus without dementia. Initiatives focused on optimizing ED care for persons living with dementia are needed.
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Affiliation(s)
- Stephanie Nothelle
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Eric Slade
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Junyi Zhou
- Biostatistics Epidemiology and Data Management Core, Johns Hopkins University, Baltimore, Maryland
| | - Phillip D Magidson
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tanya Chotrani
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Laura Prichett
- Biostatistics Epidemiology and Data Management Core, Johns Hopkins University, Baltimore, Maryland
| | - Halima Amjad
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah Szanton
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jennifer L Wolff
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Aljerian N, Alharbi A. Assessing Medical Emergency E-referral Request Acceptance Patterns and Trends: A Comprehensive Analysis of Secondary Data From the Kingdom of Saudi Arabia. Cureus 2024; 16:e53511. [PMID: 38314384 PMCID: PMC10838169 DOI: 10.7759/cureus.53511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 02/06/2024] Open
Abstract
Introduction Patient transfers in emergencies have been linked to reduced mortality rates and enhanced quality of care. The Saudi Medical Appointments and Referrals Centre (SMARC), an e-referral system in the Kingdom of Saudi Arabia (KSA) since 2019, plays a crucial role in ensuring quality and continuity of care. The findings of this study can provide valuable insights into the effectiveness of the e-referral system and identify potential areas for improvement in the management of emergency cases. Objective This study aims to examine e-referral patterns for emergency medical cases throughout all 13 administrative regions of KSA. Concurrently, it estimates the acceptance rate of medical emergency referrals and investigates associated factors among KSA hospitals. Methods This retrospective study utilized secondary data from the SMARC e-referral system, specifically focusing on medical emergency e-referral requests in the entire KSA during 2021. Descriptive univariate analyses were conducted to characterize the referral requests, followed by bivariate analyses to explore associations between factors and referral acceptance. Adjusted multiple logistic regression analyses were then performed to calculate adjusted odds ratios (ORs) and corresponding 95% confidence intervals, controlling for potential confounding variables. Results A total of 29,660 medical emergency referral requests were initiated across all regions of KSA during the study time frame, and, of these, 20,523 (69.19%) were accepted. The average age of patients with a medical emergency referral was 52 years old, and referral requests were higher among Saudis (13,781; 54.18%), males (13,781; 54.18%), and those from the Western region (10,560; 35.60%). Nearly 20,854 (70%) were due to the unavailability of specialized doctors or specialties in facilities. Based on multi-logistic regression, referral request acceptance was high in some factors as follows: compared to the Central region, requests from the Northern, Southern, Eastern, and Western regions had higher acceptance rates at 123%, 64%, 54%, and 46%, respectively. In addition, referral requests that were due to the unavailability of a specialized doctor or medical equipment had higher acceptance rates (19% and 16%), respectively, than those due to the unavailability of a specific specialty. Conclusion This study provides valuable insights into regional variations, sociodemographic factors, and referral reasons within the medical emergency e-referral system in the KSA. By estimating the acceptance rate of medical emergency referrals and investigating associated factors, this analysis confirms the effectiveness of the e-referral system in facilitating access to quality care, particularly for marginalized patients. The study highlights the need for health policy improvements to ensure equitable resource allocation and reduce disparities in healthcare access.
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Affiliation(s)
- Nawfal Aljerian
- Emergency Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Emergency Medicine, Medical Referrals Centre, Ministry of Health, Riyadh, SAU
| | - Abdullah Alharbi
- Family and Community Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
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Alharbi AA, Muhayya M, Alkhudairy R, Alhussain AA, Muaddi MA, Alqassim AY, AlOmar RS, Alabdulaali MK. The pattern of emergency department length of stay in Saudi Arabia: an epidemiological Nationwide analyses of secondary surveillance data. Front Public Health 2023; 11:1265707. [PMID: 38162606 PMCID: PMC10757469 DOI: 10.3389/fpubh.2023.1265707] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 11/09/2023] [Indexed: 01/03/2024] Open
Abstract
Background Emergency department length of stay is a vital performance indicator for quality and efficiency in healthcare. This research aimed to evaluate the length of stay patterns in emergency departments across Saudi Arabia and to identify predictors for extended stays. The study used secondary data from the Ministry of Health's Ada'a program. Methods Using a retrospective approach, the study examined data from the Ada'a program on emergency department length of stay from September 2019 to December 2021. These data covered 1,572,296 emergency department visits from all regions of Saudi Arabia. Variables analyzed included quality indicators, year of visit, shift time, hospital type, and data entry method. The analysis was conducted using multiple linear regression. Results The study found that the median length of stay was 61 min, with significant differences among related predictors. All associations were significant with a value of p of less than 0.001. Compared to 2019, the length of stay was notably shorter by 28.5% in 2020 and by 44.2% in 2021. Evening and night shifts had a shorter length of stay by 5.9 and 7.8%, respectively, compared to the morning shift. Length of stay was lower in winter, summer, and fall compared to spring. Patients in levels I and II of the Canadian Triage and Acuity Scales had longer stays than those in level III, with those in level I reaching an increase of 20.5% in length of stay. Clustered hospitals had a longer length of stay compared to the non-clustered ones. Pediatric hospitals had a 15.3% shorter stay compared to general hospitals. Hospitals with data entered automatically had a 14.0% longer length of stay than those entered manually. Patients admitted to the hospital had a considerably longer length of stay, which was 54.7% longer compared to non-admitted patients. Deceased patients had a 20.5% longer length of stay than patients discharged alive. Conclusion Data at the national level identified several predictors of prolonged emergency department length of stay in Saudi Arabia, including shift time, season, severity level, and hospital type. These results underline the necessity of continuous monitoring and improvement efforts in emergency departments, in line with policy initiatives aiming to enhance patient outcomes in Saudi Arabia.
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Affiliation(s)
- Abdullah A. Alharbi
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | | | | | | | - Mohammed A. Muaddi
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Ahmad Y. Alqassim
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Reem S. AlOmar
- Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Reinfeld S, Gill P, Cáceda R, Batra J. Integrating Psychiatric Services in the Emergency Room to Improve Patient Care by Using Quality Improvement Methods. J Nerv Ment Dis 2023; 211:550-553. [PMID: 37382997 DOI: 10.1097/nmd.0000000000001664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
ABSTRACT Prolonged length of stay in emergency departments (EDs) for patients with a psychiatric chief complaint is a widespread problem. Prolonged stays can lead to adverse outcomes and poor quality of care. We sought to improve quality of care for patients in the medical ED who needed psychiatric care. To identify the areas of weakness, we queried the ED staff via an online survey about the perception of the challenges working with our Comprehensive Psychiatric Emergency Program (CPEP), which is located adjacent to and works closely with the medical ED providing psychiatric consultation. We identified several action steps and used the Plan-Do-Study-Act methodology for implementation. We reported a reduction in time to complete consultations and improved communication between CPEP and the medical ED staff.
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Affiliation(s)
- Samuel Reinfeld
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, New York
| | - Poonamdeep Gill
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, New York
| | | | - Jaskanwar Batra
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, New York
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Adi O, Apoo FN, Fong CP, Ahmad AH, Roslan NL, Khan FA, Fathil S. Inhaled volatile anesthetic gas for severe bronchospasm in the emergency department. Am J Emerg Med 2023; 68:213.e5-213.e9. [PMID: 37120400 DOI: 10.1016/j.ajem.2023.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 05/01/2023] Open
Abstract
Bronchospasm is caused by reversible constriction of the smooth muscles of the bronchial tree. This causes obstruction of the lower airways, which is commonly seen at the emergency department (ED) in patients with acute exacerbation of asthma or chronic obstructive pulmonary disease. Ventilation may be difficult in mechanically intubated patients with severe bronchospasm due to airflow limitation, air trapping, and high airway resistance. The beneficial effects of volatile inhaled anesthetic gas had been reported due to its bronchodilation properties. In this case series, we would like to share our experience delivering inhaled volatile anesthetic gas via a conserving device for three patients with refractory bronchospasm at the ED. Inhaled anesthetic gas is safe, feasible and should be considered as an alternative rescue therapy for ventilated patients with severe lower airway obstruction.
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Affiliation(s)
- Osman Adi
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia.
| | - Farah Nuradhwa Apoo
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Chan Pei Fong
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Azma Haryaty Ahmad
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Nurul Liana Roslan
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Kuala Lumpur, Malaysia
| | | | - Shahridan Fathil
- Department of Anesthesia & Critical Care, Gleneagles Hospital Medini Johor, Johor, Malaysia
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Lee K, Jang K, Kim H, Bae G, Jang CS, Shin JH. Factors Affecting the Length of Stay in the Emergency Department in Psychiatric Emergency Patients in the COVID-19 Pandemic Context. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231167529. [PMID: 37052169 PMCID: PMC10102821 DOI: 10.1177/00469580231167529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
To reduce overcrowding in emergency departments (ED), which is a serious international problem, it is important to reduce the length of ED stay (ED LOS) of emergency patients. In particular, due to the COVID 19 pandemic, psychiatric emergency patients spent much longer in ED. This study was conducted to identify the characteristics of psychiatric emergency patients who visited the ED during the COVID-19 pandemic and to identify factors affecting ED LOS. This retrospective study was conducted on adult patients aged 19 years or older who visited a psychiatric emergency center operated by an ED from 1 May 2020 to 31 April 2021 because of the COVID-19 pandemic. In this study, the average ED LOS of psychiatric emergency patients was 7.8 h. Factors affecting ED LOS for over 12 h were isolation (OR = 2.39, CI = 1.409-4.052), unaccompanied police officers (OR = 2.106, CI = 1.338-3.316), night-time visits (OR = 2.127, CI = 1.357-3.332), use of sedatives (OR = 1.671, CI = 1.030-2.713), and restraints (OR = 1.968, CI = 1.172-4.895). The ED LOS of psychiatric emergency patients is longer than that of general emergency patients, and a long ED LOS causes ED overcrowding. To reduce the ED LOS of psychiatric emergency patients, they must be accompanied by a police officer when visiting the ED, and the treatment process should be reorganized so that a psychiatrist can promptly intervene. Furthermore, it is necessary to reorganize the isolation guidelines and admission criteria for mental emergency patients.
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Affiliation(s)
- Kangbum Lee
- Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | | | - Hyeonjeong Kim
- Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Gitak Bae
- Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Chang Seob Jang
- Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jong Hwan Shin
- Seoul National University Boramae Medical Center, Seoul, Korea
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Loke DE, Farcas AM, Ko JS, Aluce LM, McDonald VR, Shakeri N, Fant AL. Implementation of a standardized pregnancy screening process to address gender disparities in radiology turn-around-time and ED length of stay. CAN J EMERG MED 2022; 24:206-213. [PMID: 35018621 DOI: 10.1007/s43678-021-00227-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/27/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVE The objective of this initiative was to quantify and intervene upon suspected gender disparities in CT turn-around-time and emergency department (ED) length of stay. METHODS This was a single-site before-after quality improvement initiative including patients aged 12-50 who underwent CT chest and/or abdomen/pelvis. The intervention included protocolization of the pregnancy screening process in triage. Primary outcomes included the difference between women of childbearing age and similarly aged men in regards to CT turn-around-time and ED length of stay. Pre- and post-intervention data were analyzed, including an "intensive intervention period" subanalysis. RESULTS CT turn-around-time for women of childbearing age was 19 min longer than for similarly aged men at baseline and did not change significantly post-intervention. ED length of stay was 27 min longer for women of childbearing age compared to similarly aged men at baseline and 7 min longer post-intervention, although this was still a significant difference. During the intensive intervention period, CT turn-around-time for women of childbearing age was 15 min longer than similarly aged men but the difference in ED length of stay of 10 min was no longer significant. CONCLUSIONS There is gender disparity in CT turn-around-time and ED length of stay in our ED, highlighting an important area for improvement to promote equitable care. A quality improvement initiative that aimed to protocolize pregnancy testing in triage did not show sustainable improvement in these outcomes but did result in increased pregnancy testing.
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Affiliation(s)
- Dana E Loke
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 E Ontario St, Suite 200, Chicago, IL, 60611, USA.
| | - Andra M Farcas
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 E Ontario St, Suite 200, Chicago, IL, 60611, USA
| | - Justine S Ko
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 E Ontario St, Suite 200, Chicago, IL, 60611, USA
| | - Laurie M Aluce
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 E Ontario St, Suite 200, Chicago, IL, 60611, USA
| | - Valerie R McDonald
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 E Ontario St, Suite 200, Chicago, IL, 60611, USA
| | - Nahzinine Shakeri
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 E Ontario St, Suite 200, Chicago, IL, 60611, USA
| | - Abra L Fant
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 E Ontario St, Suite 200, Chicago, IL, 60611, USA
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Katayama Y, Kitamura T, Tanaka J, Nakao S, Nitta M, Fujimi S, Kuwagata Y, Shimazu T, Matsuoka T. Factors associated with prolonged hospitalization among patients transported by emergency medical services: A population-based study in Osaka, Japan. Medicine (Baltimore) 2021; 100:e27862. [PMID: 35049188 PMCID: PMC9191281 DOI: 10.1097/md.0000000000027862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/01/2021] [Indexed: 11/25/2022] Open
Abstract
The emergency medical system, one of the essential elements of public health, has been around for more than 50 years. Although many studies have assessed the factors associated with overcrowding and prolonged length of stay in emergency departments, whether the clinical characteristics and background of a patient are associated with prolonged hospitalization among patients transported by ambulance is unknown. The purpose of this study was to reveal factors associated with the continuation of hospitalization at 21 days after hospital admission among patients transported by ambulance using a population-based patient registry in Osaka, Japan.This was a retrospective observational study whose study period was the three years from January 2016 to December 2018. In this study, we included patients who were hospitalized after transportation by ambulance in Osaka, Japan. The main outcome was continuation of hospitalization at 21 days after hospital admission. We calculated the adjusted odds ratios (AOR) and 95% confidence interval (CI) with a multivariable logistic regression model to assess factors associated with the outcome.We included 481,886 patients in this study, of whom 158,551 remained hospitalized at 21 days after hospital admission and 323,335 had been discharged home by 21 days after hospital admission. Factors associated with prolonged hospitalization were elderly (AOR: 1.767 [95% CI: 1.730-1.805]), traffic accident (AOR: 1.231 [95% CI: 1.183-1.282]), no fixed address (AOR: 4.494 [95% CI: 3.632-5.314]), need for nursing care (AOR: 1.420 [95% CI: 1.397-1.443]) and solitary person (AOR: 1.085 [95% CI: 1.050-1.120]).In this study, the elderly, traffic accidents, no fixed address, need for nursing care, and solitary person were associated with prolonged hospitalization of patients transported by ambulance in Japan.
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Affiliation(s)
- Yusuke Katayama
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Division of Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Jun Tanaka
- Osaka Prefectural Government, Osaka, Japan
| | - Shota Nakao
- Rinku General Medical Center, Senshu Trauma and Critical Care Center, Izumisano, Japan
| | - Masahiko Nitta
- Department of Emergency Medicine, Osaka Medical College, Takatsuki, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuya Matsuoka
- Rinku General Medical Center, Senshu Trauma and Critical Care Center, Izumisano, Japan
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Association between Shock Index and Emergency Department Cardiac Arrest. Emerg Med Int 2021; 2021:9138449. [PMID: 34733560 PMCID: PMC8560289 DOI: 10.1155/2021/9138449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/25/2021] [Accepted: 10/16/2021] [Indexed: 11/18/2022] Open
Abstract
Background In the emergency department (ED), early identification of patients at risk of cardiac arrest is paramount, especially in the context of overcrowding. The shock index (SI) is defined as the ratio of heart rate to systolic blood pressure. It is a tool used for predicting the prognosis of critically ill and injured patients. In this study, we have discussed the relationship between SI and cardiac arrest in the ED. Methods Patients who experienced cardiac arrest in the ED were classified into two groups, SI ≥ 0.9 and < 0.9, according to their triage vital signs. The association between SI ≥ 0.9 and in-hospital mortality was analyzed in five different etiologies of cardiac arrest, including hypoxia, cardiac cause, bleeding, sepsis, and other metabolic problems. Results In total, 3,313 patients experienced cardiac arrest in the ED. Among them, 1,909 (57.6%) had a SI of ≥0.9. The incidence of SI ≥ 0.9 in the five etiologies was 43.5% (hypoxia), 58.1% (cardiac cause), 56.1% (bleeding), 58.0% (sepsis), and 65.5% (other metabolic problems). SI was associated with in-hospital mortality (adjusted odds ratio (aOR), 1.6; 95% confidence interval (CI), 1.5–1.8). The aOR (CI) in the five etiologies was 1.3 (1.1–1.6) for hypoxia, 1.8 (1.6–2.1) for cardiac cause, 1.3 (0.98–1.7) for bleeding, 1.3 (1.03–1.6) for sepsis, and 1.9 (1.5–2.1) for other metabolic problems. Conclusion More than half of the patients who experienced cardiac arrest in the ED had a SI ≥ 0.9. The SI was also associated with in-hospital mortality after cardiac arrest in the ED. SI maybe used as a screening tool to identify patients at risk of cardiac arrest in the ED and a predictor of mortality in those experiencing cardiac arrest in the ED.
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Zhang CS, Wang L, Saxe J. Emergency department disposition: Do surgical residents contribute to inefficiency? Am J Surg 2021; 223:555-558. [PMID: 34772480 DOI: 10.1016/j.amjsurg.2021.10.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Residents are often viewed as contributors to Emergency Department (ED) prolongation of length of stay (LOS). To understand this proposition, we performed a study to identify ED patient care intervals and how each contributed to LOS. METHODS We performed a retrospective review of prospectively gathered data on 145 ED surgery consults. Residents prospectively documented patient names, page times, and time of plan. Key ED patient care intervals were then retrospectively extracted from the patient's chart. A time analysis was then performed. RESULTS Average arrival to disposition time was 305 min, and residents averaged 47 min to see and staff consults. The longest intervals were arrival to imaging (75 min) and imaging time (73 min). Average disposition to discharge time was 170 min (36% of LOS). CONCLUSIONS Surgery residents see and staff consults within the norms for care established by the hospital. Imaging time is a bottleneck hindering disposition. Access block also significantly increases ED LOS.
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Affiliation(s)
- Crystal Siyu Zhang
- Ascension St. Vincent Hospital, 2001 W. 86th St, Indianapolis, IN, 46260, USA.
| | - Larry Wang
- Indiana University School of Medicine, 340 W 10th St, Indianapolis, IN, 46202, USA.
| | - Jonathan Saxe
- Ascension St. Vincent Hospital, 2001 W. 86th St, Indianapolis, IN, 46260, USA.
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Lyons TW, Michelson KA, Nigrovic LE, Perron CE, Fine AM. Attending-Provider Handoffs and Pediatric Emergency Department Revisits. Pediatr Emerg Care 2021; 37:e679-e685. [PMID: 31977767 PMCID: PMC10071514 DOI: 10.1097/pec.0000000000001983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine if intradepartment attending-provider transitions of care (handoffs) during a pediatric emergency department (ED) encounter were associated with return ED visits resulting in hospitalization. METHODS We analyzed ED encounters for patients younger than 21 years discharged from a single pediatric ED from January 2013 to February 2017. We classified an encounter as having a handoff when the initial attending and discharging attending differed. Our primary outcome was a revisit within 72 hours resulting in hospitalization. Our secondary outcomes were any revisit within 72 hours and revisits resulting in hospitalization with potential deficiencies in care. We compared outcome rates for ED encounters with and without provider handoffs, both with and without adjustment for demographic, clinical, and visit characteristics. RESULTS Of the 177,350 eligible ED encounters, 1961 (1.1%) had a return visit resulting in hospitalization and 6821 (3.9%) had any return visit. In unadjusted analyses, handoffs were associated with an increased likelihood of a return visit resulting in hospitalization (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.26-1.70) or any return visit (OR, 1.20; 95% CI, 1.10-1.31). However, after adjustment, provider handoffs were not associated with return ED visits resulting in hospitalization (OR, 0.96; 95% CI, 0.81-1.13) or any return ED visits (OR, 1.00; 95% CI, 0.90-1.10). CONCLUSIONS Provider handoffs in a pediatric ED did not increase the risk of return ED visits or return ED visits with deficiencies in care after adjustment for demographic, clinical, and visit factors.
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Affiliation(s)
- Todd W. Lyons
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA and Department of Pediatrics Harvard Medical School, Boston, MA
- Computational Health Informatics Program (CHiP) at Boston Children’s Hospital, Boston, MA
| | - Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA and Department of Pediatrics Harvard Medical School, Boston, MA
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA and Department of Pediatrics Harvard Medical School, Boston, MA
| | - Catherine E. Perron
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA and Department of Pediatrics Harvard Medical School, Boston, MA
| | - Andrew M. Fine
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA and Department of Pediatrics Harvard Medical School, Boston, MA
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Increasing Utilization of Emergency Department Neuroimaging from 2007 to 2017. AJR Am J Roentgenol 2021; 218:165-173. [PMID: 34346786 DOI: 10.2214/ajr.21.25864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: The volume of emergency department (ED) visits and neuroimaging have grown since the start of the century. Little is known about this growth in the commercially insured and Medicare Advantage populations. Objective: To evaluate changing emergency department utilization of neuroimaging from 2007 to 2017 in both commercially insured and Medicare Advantage enrollees. Methods: Using patient-level claims from Optum's De-identified Clinformatics Data Mart database, which annually includes approximately 12 to 14 million commercial and Medicare Advantage health plan enrollees, annual ED utilization of head computed tomography (CT), head magnetic resonance (MR), head CT angiography (CTA), neck CTA, head MR angiography (MRA), neck MRA, and carotid duplex ultrasound (CDUS) were assessed from 2007 through 2017. To account for an aging sample population, utilization rates were adjusted using annual relative proportions of age groups and stratified by patient demographics, payer type, and provider state. Results: Between 2007 and 2017, age-adjusted ED neuroimaging utilization rates per 1000 ED visits increased 72% overall (compound annual growth rate [CAGR] 5%). This overall increase corresponded to an increase of 69% for head CT (CAGR 5%); 67% for head MRI (CAGR 5%); 1100% for head CTA (CAGR 25%); 1300% for neck CTA (CAGR 27%); 36% for head MRA (CAGR 3%); 52% for neck MRA (CAGR 4%); and a decrease of 8% for CDUS (CAGR -1%). The utilization of head CT and CTA of the head and neck per 1000 ED visits continuously increased in those 65 or older by 48% (CAGR 4%) and 1011% (CAGR 24%). Conclusion: Neuroimaging utilization in the ED grew considerably between 2007 and 2017, with growth of head and neck CTA far outpacing other modalities. Unenhanced head CT remains by far the dominant ED neuroimaging examination. Clinical Impact: The rapid growth of head and neck CTA observed in the fee-for-service Medicare population is also observed in the commercially insured and Medicare Advantage populations. The appropriateness of this growth should be monitored as the indications for CTA expand.
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Al-Qahtani MF, Khubrani FY. Exploring Potential Association Between Emergency Department Crowding Status and Patients' Length of Stay at a University Hospital in Saudi Arabia. Open Access Emerg Med 2021; 13:257-263. [PMID: 34188561 PMCID: PMC8235939 DOI: 10.2147/oaem.s305885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
Background Emergency department (ED) crowding has been described as the most serious problem that endangers the reliability of healthcare system worldwide. The aim of this study was to explore the possible relationship of ED crowding status and length of stay in patient received care. In addition, association between LOS and other variables in relation to crowding status has been explored. Methods This is a retrospective cohort analysis study done by using dataset abstracted from Quadra Med Information System of patients visited emergency department of a tertiary university hospital at Eastern Province of Saudi Arabia during the period of January 1st, 2018 to December 30th, 2018. ED occupancy rates were used to define crowding status (as crowding and overcrowding), while the percentage of patient who spent in ED more than 6 hours was used to define the length of stay in ED. Results There were 53,309 crowded and 57,290 overcrowded presentations in ED. The median length ± interquartile range of the length of stay for low-crowded and high-crowded conditions were 211 ± 606 and 242 ± 659 minutes, respectively. There was a significant association between ED crowding status and length of stay (p < 0.05). Conclusion The increased patients' length of stay at ED was associated with crowding status of ED. Therefore, decision-makers at ministry of health should develop and implement measures and interventions to shed light on the causes of crowding, to reduce the crowding at ED, and resolve the problem steamed from such crowding for the purpose of shorten patients' length of stay at ED.
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Affiliation(s)
- Mona Faisal Al-Qahtani
- Department of Public Health, College of Public Health, Imam Abdulrahman Bin Faisal University, Dammam, 31441, Saudi Arabia
| | - Fatimah Yahyia Khubrani
- Quality Control Department, Medical Center, King Fahd University of Petroleum and Mineral, Dhahran, Saudi Arabia
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Davidson T, Mirza F, Baig MM. Impact of socio-economic status and race on emergency hospital admission outcomes: Analysis from hospital admissions between 2001 and 2012. Health Serv Manage Res 2021; 35:127-133. [PMID: 34107791 DOI: 10.1177/09514848211012189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Socio-economic and racial/ethnic disparities in healthcare quality have been the point of huge discussion and debate. There is currently a public debate over healthcare legislation in the United States to eliminate the disparities in healthcare. We reviewed the literature and critically examined standard socio-economic and racial/ethnic measurement approaches. As a result of the literature review, we identified and discussed the limitations in existing quality assessment for identifying and addressing these disparities. The aim of this research was to investigate the difference between health outcomes based on patients' ability to pay and ethnic status during a single emergency admission. We conducted a multifactorial analysis using the 11-year admissions data from a single hospital to test the bias in short-term health outcomes for length of stay and death rate, based on 'payment type' and 'race', for emergency hospital admissions. Inconclusive findings for racial bias in outcomes may be influenced by different insurance and demographic profiles by race. As a result, we found that the Self-Pay (no insurance) category has the shortest statistically significant length of stay. While the differences between Medicare, Private and Government are not significant, Self-Pay was significantly shorter. That 'Whites' have more Medicare (older) patients than 'Blacks' might possibly lead to a longer length of stay and higher death rate for the group.
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Affiliation(s)
- Thomas Davidson
- School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Farhaan Mirza
- School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Mirza M Baig
- School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand
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Rachh P, Pendley AM, Duong PAT, Hanna TN, Heilbrun ME. Decreasing CT Acquisition Time in the Emergency Department through Lean Management Principles. Radiographics 2021; 41:E81-E89. [PMID: 33939543 DOI: 10.1148/rg.2021200107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Emergency departments (EDs) rely on advanced imaging such as CT for diagnosis. Owing to increased ED volumes at the authors' institution, CT image acquisition became a significant bottleneck in ED patient throughput. Methods A multidisciplinary team was formed to solve this complex patient flow issue. Lean management principles were leveraged to identify process gaps and institute changes to achieve workflow improvements, remove process wastes, and improve patient throughput in the ED CT scanner. Process metrics such as percentage of CT examinations completed within 120 minutes and monthly median examination turnaround time (TAT) were tracked on a monthly basis. To measure impact, outcome metrics such as time savings from elimination of wasted steps were developed. Interventions Four projects including development of an ideal staffing model, a patient flow worksheet, revision of the CT patient screening form, and examination prioritization efforts were tested. Just-do-it activities such as revision of the CT angiography protocol ordering tool, optimizing scanner utilization, and improving communication and collaboration between the radiology department and ED were also attempted. Results After a phased rollout of changes over 6 months, the percentage of ordered ED CT examinations completed within 120 minutes increased by 10% (61%-71%); however, this improvement was sustained for only 6 weeks. Elimination of process inefficiencies resulted in a monthly median TAT reduction from 90-109 minutes to 82-106 minutes, and approximately 6 weeks (268 hours) of annualized full-time technologist time was saved. Conclusion Lean management tools can be leveraged to solve complex ED CT patient flow issues and reduce TAT. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Pratik Rachh
- From the Departments of Radiology and Imaging Sciences (P.R., T.N.H., M.E.H.) and Emergency Medicine (A.M.P.), Emory Healthcare, 1364 Clifton Rd NE, Atlanta, GA 30322-1007; and Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah (P.A.T.D.)
| | - Andrew M Pendley
- From the Departments of Radiology and Imaging Sciences (P.R., T.N.H., M.E.H.) and Emergency Medicine (A.M.P.), Emory Healthcare, 1364 Clifton Rd NE, Atlanta, GA 30322-1007; and Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah (P.A.T.D.)
| | - Phuong-Anh T Duong
- From the Departments of Radiology and Imaging Sciences (P.R., T.N.H., M.E.H.) and Emergency Medicine (A.M.P.), Emory Healthcare, 1364 Clifton Rd NE, Atlanta, GA 30322-1007; and Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah (P.A.T.D.)
| | - Tarek N Hanna
- From the Departments of Radiology and Imaging Sciences (P.R., T.N.H., M.E.H.) and Emergency Medicine (A.M.P.), Emory Healthcare, 1364 Clifton Rd NE, Atlanta, GA 30322-1007; and Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah (P.A.T.D.)
| | - Marta E Heilbrun
- From the Departments of Radiology and Imaging Sciences (P.R., T.N.H., M.E.H.) and Emergency Medicine (A.M.P.), Emory Healthcare, 1364 Clifton Rd NE, Atlanta, GA 30322-1007; and Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah (P.A.T.D.)
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Quantifying Dynamic Flow of Emergency Department (ED) Patient Managements: A Multistate Model Approach. Emerg Med Int 2020; 2020:2059379. [PMID: 33354372 PMCID: PMC7737449 DOI: 10.1155/2020/2059379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/14/2020] [Accepted: 11/09/2020] [Indexed: 12/03/2022] Open
Abstract
Background Emergency department (ED) crowding and prolonged lengths of stay continue to be important medical issues. It is difficult to apply traditional methods to analyze multiple streams of the ED patient management process simultaneously. The aim of this study was to develop a statistical model to delineate the dynamic patient flow within the ED and to analyze the effects of relevant factors on different patient movement rates. Methods This study used a retrospective cohort available with electronic medical data. Important time points and relevant covariates of all patients between January and December 2013 were collected. A new five-state Markov model was constructed by an expert panel, including three intermediate states: triage, physician management, and observation room and two final states: admission and discharge. A day was further divided into four six-hour periods to evaluate dynamics of patient movement over time. Results A total of 149,468 patient records were analyzed with a median total length of stay being 2.12 (interquartile range = 6.51) hours. The patient movement rates between states were estimated, and the effects of the age group and triage level on these movements were also measured. Patients with lower acuity go home more quickly (relative rate (RR): 1.891, 95% CI: 1.881–1.900) but have to wait longer for physicians (RR: 0.962, 95% CI: 0.956–0.967) and admission beds (RR: 0.673, 95% CI: 0.666–0.679). While older patients were seen more quickly by physicians (RR: 1.134, 95% CI: 1.131–1.139), they spent more time waiting for the final state (for admission RR: 0.830, 95% CI: 0.821–0.839; for discharge RR: 0.773, 95% CI: 0.769–0.776). Comparing the differences in patient movement rates over a 24-hour day revealed that patients wait longer before seen by physicians during the evening and that they usually move from the ED to admission afternoon. Predictive dynamic illustrations show that six hours after the patients' entry, the probability of still in the ED system ranges from 28% in the evening to 38% in the morning. Conclusions The five-state model well described the dynamic ED patient flow and analyzed the effects of relevant influential factors at different states. The model can be used in similar medical settings or incorporate different important covariates to develop individually tailored approaches for the improvement of efficiency within the health professions.
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Disparities in the Use of Emergency Department Advanced Imaging in Medicare Beneficiaries. AJR Am J Roentgenol 2020; 216:519-525. [PMID: 33356434 DOI: 10.2214/ajr.20.23161] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE. The purpose of our study was to assess potential disparities in the utilization of advanced imaging during emergency department (ED) visits. MATERIALS AND METHODS. This retrospective study was conducting using 5% Research Identifiable Files. All CT and MRI (together defined as "advanced imaging") examinations associated with ED visits in 2015 were identified for continuously enrolled Medicare beneficiaries. Individuals with medical claims 30 days before the index ED event were excluded, and encounters that occurred in hospitals without advanced imaging capabilities were also excluded. Patient characteristics were identified using Medicare files and hospital characteristics using the American Hospital Association Annual Survey of Hospitals. Multivariate logistic regression was used for the analysis. RESULTS. Of 86,976 qualifying ED encounters, 52,833 (60.74%) ED encounters were for female patients; 29.03% (n = 25,245) occurred at rural hospitals and 15.81% (n = 13,750) at critical access hospitals. Race distribution was 83.13% White, 11.05% Black, and 5.82% Other. Compared with ED patients at urban hospitals, those at rural and critical access hospitals were 6.9% less likely (odds ratio [OR] = 0.931, p = 0.015) and 18.0% less likely (OR = 0.820, p < 0.0001), respectively, to undergo advanced imaging. Compared with White patients, Black patients were 31.6% less likely (OR = 0.684, p < 0.0001) to undergo advanced imaging. Relative to their urban counterparts, both White (OR = 0.941, p = 0.05) and Black (OR = 0.808, p = 0.047) rural ED patients were less likely to undergo advanced imaging. CONCLUSION. Among Medicare beneficiaries receiving care in U.S. EDs, significant disparities exist in advanced imaging utilization. Although imaging appropriateness was not investigated, these findings suggest inequity. Further research is necessary to understand why consistent health benefits do not translate into consistent imaging access among risk-adjusted ED patients.
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Ahmed AA, Ibro SA, Melkamu G, Seid SS, Tesfaye T. Length of Stay in the Emergency Department and Its Associated Factors at Jimma Medical Center, Southwest Ethiopia. Open Access Emerg Med 2020; 12:227-235. [PMID: 33116958 PMCID: PMC7553249 DOI: 10.2147/oaem.s254239] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 09/18/2020] [Indexed: 11/23/2022] Open
Abstract
Background Prolonged emergency department stays can adversely affect patient outcomes leading to an increased length of hospital admission and higher mortality. Despite this fact, there are few data describing emergency department length of stay and associated factors in Ethiopia. Objective To assess length of stay in the emergency department and its associated factors among patients visited adult emergency department of Jimma Medical Center, Jimma town, southwest of Ethiopia. Methods Institution-based cross-sectional study was conducted from April 9, 2018 to May 11, 2018. Overall, 422 patients presented during study period were sequentially included in the study. A semi-structured questionnaire was used to collect data through interview, observation and medical record review. The collected data were cleaned, entered to Epi-data 3.1 and exported to SPSS version 21 for binary and multivariable logistic regression analysis. To identify factors associated with outcome variable, candidate variables were fitted to multivariable analysis, and those with P-values <0.05 were considered as significantly associated. Results More than one-third, 162 (38.4%), experienced prolonged length of stay in the emergency department. The odds of prolonged stay were higher among rural area residency (AOR, 3.0; CI, 1.279–7.042), evening presentation (AOR, 4.25; CI, 1.742–10.417), and night-time presentation (AOR, 14.93; CI, 4.22–52.63), and having at least one diagnostic investigation (AOR, 4.48; CI, 1.69–11.88). However, participants who did not experience shift changes of nurses during their stay (AOR, 0.003; CI, 0.001–0.010) had a less prolonged stay. Conclusion A significant proportion of patients experienced a prolonged stay at the emergency department. Age, rural residency, evening and night-time presentation, shift change and having a diagnostic investigation were predictors of prolonged stay. Thus, establishing time-targeted service for patients can reduce the length of stay.
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Affiliation(s)
| | - Shemsedin Amme Ibro
- School of Nursing and Midwifery, Jimma University, Jimma, Oromia Region, Ethiopia
| | - Gemechis Melkamu
- School of Medicine, Jimma University, Jimma, Oromia Region, Ethiopia
| | - Sheka Shemsi Seid
- School of Nursing and Midwifery, Jimma University, Jimma, Oromia Region, Ethiopia
| | - Temamen Tesfaye
- School of Nursing and Midwifery, Jimma University, Jimma, Oromia Region, Ethiopia
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Kurji N, Pracht EE, Langland-Orban B, Pracht K. Added Cost and Time Spent by Patients With History of Abuse in Florida Emergency Departments. VIOLENCE AND VICTIMS 2020; 35:741-750. [PMID: 33060254 DOI: 10.1891/vv-d-19-00105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Interpersonal violence is known to lead to both short- and long-term health effects. Victims of sexual abuse tend to have higher healthcare costs and higher rates of physical and mental health issues than nonvictims. In this study, we investigate whether the comorbidity of mental illness and a personal history of adult physical and sexual abuse (HAPSA) results in higher healthcare costs and length of emergency department (ED) stay among Florida residents. A Negative Binomial and Log-Linear Regression Analysis suggest increased ED visit duration for those with a history of abuse, Hispanics, the uninsured, and those with multiple comorbidities. In addition, increased costs were found to be associated with White race, the uninsured, those with multiple comorbidities, and the facility type (for-profit hospitals).
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Bahl A, Jamali AM, Ramesh G. Impact of Early Urine Specimen Collection on Emergency Department Time to Disposition: A Randomized Controlled Trial. Cureus 2020; 12:e10495. [PMID: 33083194 PMCID: PMC7567408 DOI: 10.7759/cureus.10495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Diagnostic testing in the ED increases the length of stay (LOS). Urinalysis testing is highlighted specifically as a source of delays. We aim to determine whether a triage-initiated urine specimen collection process decreases ED time to disposition (TTD) in ambulatory patients with abdominal pain. Methods This prospective, randomized controlled study was implemented at a Suburban Level One trauma ED with greater than 120,000 annual visits. A convenience sample of patients was recruited. Adult, non-ambulance patients presenting with abdominal pain were eligible. Participants were randomized into experimental and control groups. Patients in the control group provided a urine sample after physician evaluation, if ordered by the provider. Patients in the experimental group were prompted to provide a urine sample in the triage restrooms immediately after screening at the greeter desk. The UA sample was transported to the treatment area and sent to the laboratory after physician evaluation. Results A total of 125 control patients and 124 experimental patients were enrolled. Forty-two patients were excluded because they were unable to provide a urine sample. Patients who had a urinalysis ordered were included in statistical analysis. Final data set included 65 patients in the experimental group and 96 patients in the control group. No significant difference (p=0.5072) in disposition time between subjects in the experimental group (n=65, mean=5:17 [hours:min]) and subjects in the control group (n=96, mean=5:30) was found. Conclusions The triage protocol for urine specimen collection did not significantly reduce ED TTD. Further research in overcrowded EDs with long patient waiting room times may benefit from implementing a triage protocol for urine specimen collection.
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Affiliation(s)
- Amit Bahl
- Emergency Medicine, Beaumont Hospital, Royal Oak, USA
| | - Ameen M Jamali
- Emergency Medicine, Medical Center Health System, Odessa, USA
| | - Gautam Ramesh
- Emergency Medicine, Michigan State University College of Human Medicine, Lansing, USA
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Mitchell OJL, Edelson DP, Abella BS. Predicting cardiac arrest in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:321-326. [PMID: 33000054 PMCID: PMC7493514 DOI: 10.1002/emp2.12015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 12/03/2022] Open
Abstract
In-hospital cardiac arrest remains a leading cause of death: roughly 300,000 in-hospital cardiac arrests occur each year in the United States, ≈10% of which occur in the emergency department. ED-based cardiac arrest may represent a subset of in-hospital cardiac arrest with a higher proportion of reversible etiologies and a higher potential for neurologically intact survival. Patients presenting to the ED have become increasingly complex, have a high burden of critical illness, and face crowded departments with thinly stretched resources. As a result, patients in the ED are vulnerable to unrecognized clinical deterioration that may lead to ED-based cardiac arrest. Efforts to identify patients who may progress to ED-based cardiac arrest have traditionally been approached through identification of critically ill patients at triage and the identification of patients who unexpectedly deteriorate during their stay in the ED. Interventions to facilitate appropriate triage and resource allocation, as well as earlier identification of patients at risk of deterioration in the ED, could potentially allow for both prevention of cardiac arrest and optimization of outcomes from ED-based cardiac arrest. This review will discuss the epidemiology of ED-based cardiac arrest, as well as commonly used approaches to predict ED-based cardiac arrest and highlight areas that require further research to improve outcomes for this population.
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Affiliation(s)
- Oscar J L Mitchell
- Division of Pulmonary, Allergy, and Critical Care Medicine and the Center for Resuscitation Science Hospital of the University of Pennsylvania Philadelphia Pennsylvania
| | - Dana P Edelson
- Department of Medicine University of Chicago Chicago Illinois
| | - Benjamin S Abella
- Department of Emergency Medicine and the Center for Resuscitation Science University of Pennsylvania School of Medicine Philadelphia Pennsylvania
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Rezaianzadeh A, Dastoorpoor M, Sanaei M, Salehnasab C, Mohammadi MJ, Mousavizadeh A. Predictors of length of stay in the coronary care unit in patient with acute coronary syndrome based on data mining methods. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2020. [DOI: 10.1016/j.cegh.2019.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Patel AT, Lee BR, Donegan R, Humiston SG. Length of Stay for Patients With Limited English Proficiency in Pediatric Urgent Care. Clin Pediatr (Phila) 2020; 59:421-428. [PMID: 31994413 DOI: 10.1177/0009922820902439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This retrospective chart review compared the length of stay (LOS) of families with limited English proficiency (LEP) versus English-speaking families seen in 3 pediatric urgent care centers (PUCCs). Visits were included for patients aged 2 months to 17 years seen between January 1, 2016, and December 31, 2016, with 1 of 5 primary diagnoses. For each LEP encounter, we randomly selected 3 English-speaking encounters within the same PUCC and diagnosis class. We compared overall LOS between LEP and English-speaking encounters. Of our entire sample, 184 (1.03%) were LEP encounters, of which 145 (78.8%) preferred Spanish. Comparing the LEP visits to 552 matched English-speaking visits, we found a significant difference in average LOS (LEP 85.5 minutes; English-speaking 76.4 minutes) and in prescriptions provided (P = .005) but not in triaged acuity nor number of medications administered, laboratory or radiological studies, or suction treatments. This study serves as a starting point to better care for patients/families with LEP in PUCCs.
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Shachaf S, Davidovitch N, Halpern P, Mor Z. Utilization profile of emergency department by irregular migrants and hospitalization rates: lessons from a large urban medical center in Tel Aviv, Israel. Int J Equity Health 2020; 19:56. [PMID: 32349751 PMCID: PMC7191790 DOI: 10.1186/s12939-020-1152-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 03/02/2020] [Indexed: 11/17/2022] Open
Abstract
Background Irregular migrants (IMM) are excluded from the National health insurance in most developed countries and may use the emergency department (ED) as a source for medical care. This study aims to compare the use of ED by IM with that of Israeli citizens (IC) in a large urban hospital in Tel Aviv, including socio-demographic characteristics, hospitalization proportion and medical conditions on admission. Methods This cross-sectional study included all IM and IC patients older than 18 years who attended the ED between 2007 and 2011, and compared their socio-demographic characteristics, the administrative details of the visit and clinical variables upon admission. Hospitalization proportion was calculated by dividing the number of patients who were admitted to the hospital ward by the number of all patients who attended the ED. Results IM who attended the ED were younger compared to IC (mean 39 ± 17 versus 52 ± 22 years, respectively), mostly males (1.4 Male/Female ratio) and mainly originated from developing countries. IM were more commonly self-referred, more likely to attend the ED during evening hours and weekends, complained of occupational injuries and frequented the surgical rather the medical ward of the ED compared with IC. IM stayed at the ED for longer periods than IC, yet the proportion of their hospitalization was lower than that of IC (19.4% versus 23.5%, respectively). Conclusion IM stayed in the ED for longer periods and were less likely to be admitted to the hospital wards, suggesting presentation of non-severe medical conditions or possible barriers in ensuring care continuity in the community following discharge. Minimizing the barriers of IM to primary care in the community can reduce unnecessary referrals to the ED. Additionally, hospitals managements should respond to the high-volume of IM by shifting staff to busy hours and improving the communication with IM.
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Affiliation(s)
- S Shachaf
- Department of Health Systems Management, School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, POB 653, 8410501, Beer Sheva, Israel. .,Department of Emergency Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
| | - N Davidovitch
- Department of Health Systems Management, School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, POB 653, 8410501, Beer Sheva, Israel
| | - P Halpern
- Department of Health Systems Management, School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, POB 653, 8410501, Beer Sheva, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Z Mor
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,School of Health Sciences, Ashkelon Academic College, Ashkleon, Israel
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Ortíz-Barrios MA, Alfaro-Saíz JJ. Methodological Approaches to Support Process Improvement in Emergency Departments: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17082664. [PMID: 32294985 PMCID: PMC7216091 DOI: 10.3390/ijerph17082664] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/22/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Abstract
The most commonly used techniques for addressing each Emergency Department (ED) problem (overcrowding, prolonged waiting time, extended length of stay, excessive patient flow time, and high left-without-being-seen (LWBS) rates) were specified to provide healthcare managers and researchers with a useful framework for effectively solving these operational deficiencies. Finally, we identified the existing research tendencies and highlighted opportunities for future work. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to undertake a review including scholarly articles published between April 1993 and October 2019. The selected papers were categorized considering the leading ED problems and publication year. Two hundred and three (203) papers distributed in 120 journals were found to meet the inclusion criteria. Furthermore, computer simulation and lean manufacturing were concluded to be the most prominent approaches for addressing the leading operational problems in EDs. In future interventions, ED administrators and researchers are widely advised to combine Operations Research (OR) methods, quality-based techniques, and data-driven approaches for upgrading the performance of EDs. On a different tack, more interventions are required for tackling overcrowding and high left-without-being-seen rates.
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Affiliation(s)
- Miguel Angel Ortíz-Barrios
- Department of Industrial Management, Agroindustry and Operations, Universidad de la Costa CUC, Barranquilla 081001, Colombia
- Correspondence: ; Tel.: +57-3007239699
| | - Juan-José Alfaro-Saíz
- Research Centre on Production Management and Engineering, Universitat Politècnica de València, 46022 Valencia, Spain;
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Blood sampling during nurse triage reduces patient length of stay in the emergency department: A propensity score-weighted, population-based study. Int Emerg Nurs 2020; 49:100826. [PMID: 32046951 DOI: 10.1016/j.ienj.2019.100826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/12/2019] [Accepted: 11/29/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Increases in patients' length of stay (LOS) in the emergency department (ED) have led to overcrowding. OBJECTIVES In this study, the implementation of blood sampling during triage in lower priority level patients was assessed as a possible means to reduce LOS. METHODS A retrospective study was performed from January 2018 to January 2019. Lower priority level patients who required blood sampling for further diagnosis were considered. Patients who underwent blood sampling during triage evaluation were compared with those who underwent blood sampling after a physician's initial evaluation. RESULTS During the study period, 15,596 patients were enrolled. LOS was shorter in patients who underwent triage blood sampling, presenting a median value of 154 min in comparison with the 172 min recorded in the control group (p < 0.001). Using a propensity score-matching to control the two groups' differences, LOS remained lower in the triage-sampling group (151 vs. 175 min; p < 0.001). In the adjusted multivariate model, triage blood sampling was found to be an independent factor for a decrease in the LOS, with standardized coefficient β = 0.857 (0.822-0.894; p < 0.001). CONCLUSIONS Performing blood sampling during nurse triage can decrease LOS in ED and also reduce ED permanence after a physician's initial evaluation.
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Analysis of factors influencing length of stay in the Emergency Department in public hospital, Yogyakarta, Indonesia. Australas Emerg Care 2019; 22:174-179. [DOI: 10.1016/j.auec.2019.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 11/19/2022]
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Mentzoni I, Bogstrand ST, Faiz KW. Emergency department crowding and length of stay before and after an increased catchment area. BMC Health Serv Res 2019; 19:506. [PMID: 31331341 PMCID: PMC6647148 DOI: 10.1186/s12913-019-4342-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/11/2019] [Indexed: 11/10/2022] Open
Abstract
Background Emergency department (ED) crowding and prolonged length of stay (LOS) are associated with delays in treatment, adverse outcomes and decreased patient satisfaction. Hospital restructuring and mergers are often associated with increased ED crowding. The aim of this study was to explore ED crowding and LOS in Norway’s largest ED before and after an increased catchment area. Methods The catchment area of Akershus University Hospital increased by approximately 150,000 inhabitants in 2011, from 340,000 to 490,000. In this retrospective study, admissions to the ED during a six-year period, from Jan 1st 2010 to Dec 31st 2015 were included and analyzed. Results A total of 179,989 admissions were included (51.0% men). The highest occupancy rate was in the age group 70–79 years. Following the increase in the catchment area, the annual ED admissions increased by 8343 (40.9%) from 2010 to 2011, and peaked in 2013 (34,002). Mean LOS increased from 3:59 h in 2010 to 4:17 in 2012 (highest), and decreased to 3:45 h in 2015 after staff, capacity and organizational measures. In 2010, 37.9% of the ED patients experienced crowding, and this proportion increased to between 52.9–77.6% in 2011–2015. Crowding peaked between 4 and 5 PM. Conclusions LOS increased and crowding was more frequent after a major increase in the hospital’s catchment area in Norway’s largest emergency department. Even after 5 years, the LOS was higher than before the expansion, mainly because of the throughput and output components, which were not properly adapted to the changes in input. Electronic supplementary material The online version of this article (10.1186/s12913-019-4342-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ida Mentzoni
- Emergency Department, Akershus University Hospital, Lørenskog, Norway.,Lovisenberg Diaconal University College, Oslo, Norway
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Section of Drug Abuse Research, Oslo University Hospital, Oslo, Norway.,Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Kashif Waqar Faiz
- Health Services Research Unit, Akershus University Hospital, PO Box 1000, N-1478, Lørenskog, Norway. .,Department of Neurology, Akershus University Hospital, Lørenskog, Norway.
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Mirza AA, Alsakkaf MA, Mohammed AA, Mirza AA, Elmorsy SA. Patterns of emergency department visits during Hajj period: Towards healthcare optimization in view of Saudi Arabia's vision 2030. Pak J Med Sci 2019; 35:647-652. [PMID: 31258569 PMCID: PMC6572959 DOI: 10.12669/pjms.35.3.611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: This study aimed to examine the pattern of emergency department (ED) visits by Hajj patients and determine the urgency of emergency visits at an advanced healthcare center. Methods: A retrospective review of medical records of Hajj patients visiting the ED at King Abdullah Medical City Makkah from September 1 to October 5, 2015 was conducted. Results: We considered 233 visits by 199 Hajj patients. Most diseases were cardiovascular related. Approximately half of the ED visits led to hospital admission, which were largely during the evening and nighttime. Potentially avoidable visits were significantly encountered during the daytime. Average bed occupation time in the ED was similar for both cases: those admitted to inpatient care and discharged from ED. Results from the Canadian Triage and Acuity Scale revealed that most patients were triaged with a score of III (48.4%) followed by a clinically better score of IV (32%); however, scores did not change significantly throughout the Hajj day. Conclusions: During Hajj, a significant proportion of patients who visited the ED at the ultimate healthcare facility were discharged within 24 hours, with a higher rate in the morning-afternoon period. Both admitted and discharged cases required equal levels of care. Therefore, an extension in working days at primary care centers and optimization of advanced healthcare facilities during Hajj is currently warranted.
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Affiliation(s)
- Ahmad A Mirza
- Ahmad A. Mirza, MBBS, Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia. Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed A Alsakkaf
- Mohammed A. Alsakkaf, MBBS, Department of Surgery, Security Forces Hospital Program, Makkah, Saudi Arabia
| | - Amrallah A Mohammed
- Amrallah A. Mohammed, MD, Department of Medical Oncology, Faculty of Medicine, Zagazig University, Zagazig, Egypt. Home Healthcare Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia
| | - Abdulrahim A Mirza
- Abdulrahim A. Mirza, MBBS, Department of Surgery-Urology Section, Ministry of National Guard - Health Affairs, Jeddah, Saudi Arabia
| | - Soha A Elmorsy
- Soha A. Elmorsy, PhD, Department of Pharmacology, Faculty of Medicine, Cairo University, Cairo, Egypt. Department of Epidemiology and Statistics, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia
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de Angelis P, Kaufman EJ, Barie PS, Narayan M, Smith K, Winchell RJ. Disparities in Timing of Trauma Consultation: A Trauma Registry Analysis of Patient and Injury Factors. J Surg Res 2019; 242:357-362. [PMID: 31132627 DOI: 10.1016/j.jss.2019.04.073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 04/10/2019] [Accepted: 04/25/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Efficient trauma systems rely on field and emergency department (ED) personnel to triage patients to the appropriate level of care. Undertriage puts patients at risk, whereas overtriage results in system strain. Although much research has focused on prehospital triage, little is known about trauma triage processes within the ED. We investigated the timing of trauma consultation in the ED of a level I trauma center. We hypothesized that patient characteristics and injury type would be associated with time to consultation, with women, Black patients, older patients, and those with head and torso injuries experiencing longer time to consult. MATERIALS AND METHODS Patients aged ≥18 y referred to the trauma service via consultation were recruited retrospectively. Bivariable and multivariable negative binomial regressions were used to assess the association between patient and injury characteristics and time to consult. We used multivariable logistic regression adjusted for patient and injury characteristics to assess for association between time to consult and mortality and length of stay. RESULTS Among 588 adult consult patients, median time to consult was 177 min (interquartile range 106-265). In multivariable analysis, Black patients had longer time to consult (incidence rate ratio [IRR] 1.33, 95% confidence interval [CI] 1.10, 1.60) as did women (IRR 1.15, 95% CI 1.02, 1.29). Head injury was associated with shorter time to consult (IRR 0.81, 95% CI 0.71, 0.92). Time to consult was not associated with mortality or length of stay. CONCLUSIONS Patient demographics and injury characteristics influenced the timing of trauma consultation. More robust criteria for equitable evaluation of patients are needed to eliminate disparities, prevent delays, and streamline care.
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Affiliation(s)
- Paolo de Angelis
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Elinore J Kaufman
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY.
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Mayur Narayan
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Kira Smith
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Robert J Winchell
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
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Risk Factors for Prolonged Length of Stay of Older Patients in an Academic Emergency Department: A Retrospective Cohort Study. Emerg Med Int 2019; 2019:4937827. [PMID: 31186963 PMCID: PMC6521575 DOI: 10.1155/2019/4937827] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 04/09/2019] [Indexed: 11/18/2022] Open
Abstract
Emergency departments (EDs) are challenged with a growing population of older patients. These patients are at risk for a prolonged length of stay (LOS) at the ED and face more complications and poorer clinical outcomes. We aimed to identify risk factors for a prolonged LOS of older patients at the ED. For this retrospective clinical database study, we analyzed medical records of 2000 patients ≥70 years old presenting at the ED of a large level I trauma center in the Netherlands. LOS above the 75th percentile of LOS at our ED, 293 minutes, was considered prolonged. After bivariate analysis, we identified associations between LOS and patient, organizational, and clinical factors. Associations with a p < 0.05 were inserted in multivariable logistic regression models. We analyzed 1048 men (52%) and 952 women (48%) with a mean age of 78 ± 6.2 years. Risk factors for prolonged LOS of older patients at the ED were follows: higher number (more than one) of consultations (OR [odds ratio] 2.4, CI [confidence interval] 2.0-2.91), or diagnostic interventions (OR 1.5, CI 1.4-1.7); presenting complaints of a neurological (OR 2.2, CI 1.0-4.5) or internal medicine focus (OR 2.6, CI 1.4-4.6); patients with an altered consciousness (OR 3.3, CI 1.6-6.6); treatment by physicians of the departments of surgery (OR 3.4, CI 2.2-5.2), internal medicine (OR 2.6, CI 1.9-3.7), or pulmonology (OR 2.2, CI 1.4-3.6); and urgency category of ≥ U1. Awareness of factors associated with prolonged LOS of older patients presenting at the ED is essential. Physicians should recognize and take these factors into account, in order to improve clinical outcomes of the (strongly increasing) population of older patients at the ED.
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Emergency department care for patients with mental health problems, a longitudinal registry study and a before and after intervention study. Int Emerg Nurs 2019; 44:14-19. [DOI: 10.1016/j.ienj.2019.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 01/16/2019] [Accepted: 02/04/2019] [Indexed: 11/21/2022]
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Alishahi Tabriz A, Trogdon JG, Fried BJ. Association between adopting emergency department crowding interventions and emergency departments' core performance measures. Am J Emerg Med 2019; 38:258-265. [PMID: 31060861 DOI: 10.1016/j.ajem.2019.04.048] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/12/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES To estimate the association between adopting emergency department (ED) crowding interventions and emergency departments' core performance measures. METHODS We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2007 to 2015. The outcome variables are ED length of stay for discharged and admitted patients, boarding time, wait time and percentage of patients who left ED before being seen (LWBS). The independent variables are whether or not a hospital adopted each of the 20 crowding interventions. Controlling for patient-level, hospital level and temporal confounders we analyze and report results using multivariable logit model. RESULTS Between 2007 and 2015, NHAMCS collected data for 269,721 ED visit encounters, representing a nationwide of about 1.18 billion separate ED visits. Of 20 crowding interventions we tested, using adopting bedside registration (OR = 0.89, 95% CI = 0.75-0.98, P < .05), electronic dashboard (OR = 0.86, 95% CI = 0.76-0.98, P < .05), kiosk check-in technology (OR = 0.56, 95% CI = 0.41-0.83, P < .001), physician based triage (OR = 0.86, 95% CI = 0.73-0.99, P < .05) full capacity protocol (OR = 0.91, 95% CI = 0.79-0.99, P < .05) are associated with decrease in the odds of prolonged wait time. Adopting kiosk check-in (OR = 0.55, 95% CI = 0.35-0.85, P < .05) is associated with a decrease in the odds of prolonged boarding time. Using wireless communication devices (OR = 0.77, 95% CI = 0.57-0.97, P < .05), bedside registration (OR = 0.77, 95% CI = 0.64-0.094, P < .05) and pooled nursing (OR = 0.84, 95% CI = 0.72-0.98, P < .05) are associated with decrease in the odds of a patient LWBS. CONCLUSIONS Majority of interventions did not significantly associated with ED' core performance measures.
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Affiliation(s)
- Amir Alishahi Tabriz
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Bruce J Fried
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Alemu GH, Negari KG, Rodamo KM, Hirigo AT. Factors associated with the length of stay in emergency departments in Southern-Ethiopia. BMC Res Notes 2019; 12:239. [PMID: 31023367 PMCID: PMC6482488 DOI: 10.1186/s13104-019-4271-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 04/15/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES This cross-sectional study was conducted on 399 patients at Hawassa University Comprehensive Specialized Hospital from February 15 to March 30/2018 to assess the length of stay (LOS) and its associated factors in emergency departments (EDs). RESULT About 91.5% patients were stayed in the EDs for greater than 24 h in different reasons. Inadequacy of beds in inpatient wards, overcrowding, absence of different laboratory test profiles and delay in radiological services were showed a significant differences in LOS greater than 24 h when compared to LOS ≤ 24 h in EDs (p < 0.05 for all). In addition, admission beds [adjusted odds ratio: 8.7 (95% CI 3.2-23.2)]; overcrowding [adjusted odds ratio: 3.6 (95% CI 1.6-8.3)]; laboratory test profiles [adjusted odds ratio: 5.1 (95% CI 1.9-14.1)], and radiology services [adjusted odds ratio: 3.7 (95% CI 1.5-9.2)] were significantly and positively associated with LOS greater than 24 h in EDs. Further, a significant proportion of patients were stayed for unnecessary extended length of time in EDs due to different factors. Therefore, the commitment of organization is crucial to provide sufficient number of admission beds, to scale-up laboratory test profiles and to decrease radiology service turn-around time in order to improve LOS in EDs.
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Affiliation(s)
- Getahun H/Meskel Alemu
- College of Medicine and Health Science, Comprehensive Specialized Hospital, Hawassa University, P.O. Box 1560, Hawassa, Ethiopia.
| | - Keneni Gutema Negari
- College of Medicine and Health Science, School of Public Health, Hawassa University, Hawassa, Ethiopia
| | - Kaleb Mayisso Rodamo
- College of Medicine and Health Science, School of Public Health, Hawassa University, Hawassa, Ethiopia
| | - Agete Tadewos Hirigo
- College of Medicine and Health Science, School of Medical Laboratory Sciences, Hawassa University, Hawassa, Ethiopia
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Abstract
BACKGROUND In case of acute bacterial meningitis, a decision on the need for intensive care admission should be made within the first hour. The aim of this study was to assess the ability of a point-of-care glucometer to determine abnormal cerebrospinal fluid (CSF) glucose concentration at the bedside that contributes toward bacterial meningitis diagnosis. METHODS We carried out a prospective study and simultaneously measured the glucose concentrations in CSF and blood using a central laboratory and a point-of-care glucometer. We compared CSF/blood glucose ratios obtained at the bedside with a glucometer versus those obtained by the central laboratory. We determined the performance characteristics of the CSF/blood glucose ratio provided by a glucometer to detect bacterial infection in the CSF immediately after CSF sampling. RESULTS We screened 201 CSF collection procedures during the study period and included 172 samples for analysis. Acute bacterial meningitis was diagnosed in 17/172 (9.9%) of CSF samples. The median turnaround time for a point-of-care glucometer analysis was 5 (interquartile range 2-10) min versus 112 (interquartile range 86-154) min for the central laboratory (P<0.0001). The optimal cut-off of the CSF/blood glucose ratio calculated from a bedside glucometer was 0.46, with a sensitivity of 94.1% (95% confidence interval: 71.3-99.9%), a specificity of 91% (95% confidence interval: 85.3-95%), and a positive likelihood ratio of 10. CONCLUSION A glucometer accurately detects an abnormal CSF/blood glucose ratio immediately after the lumbar puncture. This cheap point-of-care method has the potential to speed up the diagnostic process of patients with bacterial meningitis.
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Bazargan M, Smith JL, Cobb S, Barkley L, Wisseh C, Ngula E, Thomas RJ, Assari S. Emergency Department Utilization among Underserved African American Older Adults in South Los Angeles. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16071175. [PMID: 30986915 PMCID: PMC6479964 DOI: 10.3390/ijerph16071175] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/21/2019] [Accepted: 04/01/2019] [Indexed: 12/14/2022]
Abstract
Objectives: Using the Andersen’s Behavioral Model of Health Services Use, we explored social, behavioral, and health factors that are associated with emergency department (ED) utilization among underserved African American (AA) older adults in one of the most economically disadvantaged urban areas in South Los Angeles, California. Methods: This cross-sectional study recruited a convenience sample of 609 non-institutionalized AA older adults (age ≥ 65 years) from South Los Angeles, California. Participants were interviewed for demographic factors, self-rated health, chronic medication conditions (CMCs), pain, depressive symptoms, access to care, and continuity of care. Outcomes included 1 or 2+ ED visits in the last 12 months. Polynomial regression was used for data analysis. Results: Almost 41% of participants were treated at an ED during the last 12 months. In all, 27% of participants attended an ED once and 14% two or more times. Half of those with 6+ chronic conditions reported being treated at an ED once; one quarter at least twice. Factors that predicted no ED visit were male gender (OR = 0.50, 95% CI = 0.29–0.85), higher continuity of medical care (OR = 1.55, 95% CI = 1.04–2.31), individuals with two CMCs or less (OR = 2.61 (1.03–6.59), second tertile of pain severity (OR = 2.80, 95% CI = 1.36–5.73). Factors that predicted only one ED visit were male gender (OR = 0.45, 95% CI = 0.25–0.82), higher continuity of medical care (OR = 1.39, 95% CI = 1.01–2.15) and second tertile of pain severity (OR = 2.42, 95% CI = 1.13–5.19). Conclusions: This study documented that a lack of continuity of care for individuals with multiple chronic conditions leads to a higher rate of ED presentations. The results are significant given that ED visits may contribute to health disparities among AA older adults. Future research should examine whether case management decreases ED utilization among underserved AA older adults with multiple chronic conditions and/or severe pain. To explore the generalizability of these findings, the study should be repeated in other settings.
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Affiliation(s)
- Mohsen Bazargan
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA.
- Department of Family Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA.
| | - James L Smith
- Department of Family Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA.
| | - Sharon Cobb
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA.
- School of Nursing, Charles R. Drew University of Medicine and Science, Los Angeles, CA 90095, USA.
| | - Lisa Barkley
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA.
| | - Cheryl Wisseh
- Department of Pharmacy Practice, West Coast University, Los Angeles, CA 90004, USA.
| | - Emma Ngula
- Department of public health, Charles R. Drew University of Medicine and Science, Los Angeles, CA 90095, USA.
| | - Ricky J Thomas
- Department of Emergency Medicine, UC Davis Medical Center, University of California, Davis, Sacramento, CA 95817, USA.
| | - Shervin Assari
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA 90059, USA.
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The effect of emergency department crowding on lung-protective ventilation utilization for critically ill patients. J Crit Care 2019; 52:40-47. [PMID: 30954692 DOI: 10.1016/j.jcrc.2019.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/16/2019] [Accepted: 03/21/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To measure effects of ED crowding on lung-protective ventilation (LPV) utilization in critically ill ED patients. METHODS This is a retrospective cohort study of adult mechanically ventilated ED patients admitted to the medical intensive care unit (MICU), over a 3.5-year period at a single academic tertiary care hospital. Clinical data, including reason for intubation, severity of illness (MPM0-III), acute respiratory distress syndrome (ARDS) risk score (EDLIPS), and ventilator settings were extracted via electronic query of electronic health record and standardized chart abstraction. Crowding metrics were obtained at 5-min intervals and averaged over the ED stay, stratified by acuity and disposition. Multivariate logistic regression was used to predict likelihood of LPV prior to ED departure. RESULTS Mechanical ventilation was used in 446 patients for a median ED duration of 3.7 h (interquartile ratio, IQR, 2.3, 5.6). Mean MPM0-III score was 32.5 ± 22.7, with high risk for ARDS (EDLIPS ≥5) seen in 373 (82%) patients. Initial and final ED ventilator settings differed in 134 (30.0%) patients, of which only 47 (35.1%) involved tidal volume changes. Higher percentages of active ED patients (workup in-progress) and those requiring eventual admission were associated with lower odds of LPV utilization by ED departure (OR 0.97, 95%CI 0.94-1.00; OR 0.97, 95%CI 0.94-1.00, respectively). In periods of high volume, ventilator adjustments to settings other than the tidal volume were associated with higher odds of LPV utilization. Reason for intubation, MPM0-III, and EDLIPS were not associated with LPV utilization, with no interactions detected in times of crowding. CONCLUSIONS ED patients remain on suboptimal tidal volume settings with infrequent ventilator adjustments during the ED stay. Hospitals should focus on both systemic factors and bedside physician and/or respiratory therapist interventions to increase LPV utilization in times of ED boarding and crowding for all patients.
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Hwang CW, Fitzpatrick DE, Becker TK, Jones JM. Paramedic determination of appropriate emergency department destination. Am J Emerg Med 2019; 37:482-485. [DOI: 10.1016/j.ajem.2018.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 11/29/2022] Open
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Emergency department imaging superusers. Emerg Radiol 2018; 26:161-168. [DOI: 10.1007/s10140-018-1659-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 11/09/2018] [Indexed: 11/27/2022]
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Chaou CH, Chen HH, Tang P, Yen AMF, Wu KH, Hsiao CT, Chiu TF. Traffic Intensity of Patients and Physicians in the Emergency Department: A Queueing Approach for Physician Utilization. J Emerg Med 2018; 55:718-725. [PMID: 30253956 DOI: 10.1016/j.jemermed.2018.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/16/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
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Schieferle Uhlenbrock J, Hudson J, Prewitt J, Thompson JA, Pereira K. Retrospective Chart Review of the Triage Algorithm for Psychiatric Screening (TAPS) for Patients Who Present to Emergency Departments With Psychiatric Chief Complaints. J Emerg Nurs 2018; 44:459-465. [DOI: 10.1016/j.jen.2017.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/04/2017] [Accepted: 12/07/2017] [Indexed: 10/18/2022]
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Hearld KR, Hearld LR, Landry AY, Budhwani H. Evidence that patient-centered medical homes are effective in reducing emergency department admissions for patients with depression. Health Serv Manage Res 2018; 32:26-35. [PMID: 30149725 DOI: 10.1177/0951484818794340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The patient-centered medical home (PCMH) has increasingly been touted as one means of integrating behavioral health and primary care and more holistically caring for patients with chronic disease. With its whole person orientation, the PCMH presents an opportunity to reduce emergency department visits for patients with depression by focusing on the patient and his/her health care needs, facilitating communication among providers and patients, and improving patients' access to care providers across settings. This study examines the relationship between PCMH capacity - defined as the ability to offer a service identified as a component part of the PCMH - and the number of emergency department visits for patients with depression. Health plan claims data, self-report data from physician practices on their PCMH characteristics, and the Area Resource File were analyzed. Results show that overall PCMH capacity is associated with fewer emergency department visits for patients with depression, and interpersonal aspects of the PCMH in particular, were associated with fewer emergency department visits while technical capabilities were not. Interpersonal activities that facilitate care coordination, patient engagement, and connect patients with community resources might be more effective in keeping patients out of the emergency department for unnecessary reasons as compared to technical activities focused on reporting and information management.
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Affiliation(s)
- Kristine R Hearld
- 1 Department of Health Services Administration For Budhwani, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Larry R Hearld
- 1 Department of Health Services Administration For Budhwani, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amy Y Landry
- 1 Department of Health Services Administration For Budhwani, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Henna Budhwani
- 2 Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, USA
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Hsu CC, Chan HY. Factors associated with prolonged length of stay in the psychiatric emergency service. PLoS One 2018; 13:e0202569. [PMID: 30125316 PMCID: PMC6101399 DOI: 10.1371/journal.pone.0202569] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 08/06/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Dedicated regional psychiatric emergency services (PES) were proposed as a better care model for psychiatric emergencies and a possible solution to boarding of psychiatric patients in the emergency department. However, there are limited data on factors associated with prolonged length of stay (LOS) in the PES. The objective of this study was finding factors associated with prolonged LOS in the PES and moving towards a solution to this problem. METHODS The study sample comprised 200 PES visits randomly chosen from January 2011 to December 2015 in a psychiatric hospital in Taiwan. Relevant data were collected comprehensively through the health information system and by reviewing medical records. The primary outcome was LOS longer than 24 hours while LOS longer than 48 hours was used as the secondary outcome. RESULTS Mean LOS was 17.6±23.2 hours, with 53 (26.5%) visits lasting more than 24 hours and 15 (7.5%) visits lasting more than 48 hours. After adjusting for related confounders, LOS longer than 24 hours was associated with use of restraints in the PES (adjusted odds ratio (aOR) = 3.13, 95% CI = 1.59-6.15) and history of illicit substance use (aOR = 2.46, 95% CI = 1.11-5.44). LOS longer than 48 hours was associated with use of restraints in the PES (aOR = 4.11, 95% CI = 1.2-14.14), history of illicit substance use (aOR = 6.16, 95% CI = 1.37-27.62) and first time visit to the hospital (aOR = 8.54, 95% CI = 2.03-35.96). Neither outcome was associated with transfer to an inpatient unit. CONCLUSION Prolonged LOS was common in the study sample. Discharged patients had an equally high rate of prolonged LOS as admitted patients. Therefore measures should be taken to facilitate timely discharge. Use of restraints and history of illicit substance use were common among patients with prolonged LOS.
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Affiliation(s)
- Chun-Chi Hsu
- Department of General Psychiatry, Taoyuan Psychiatric Center, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Hung-Yu Chan
- Department of General Psychiatry, Taoyuan Psychiatric Center, Ministry of Health and Welfare, Taoyuan, Taiwan
- Department of Psychiatry, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail:
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Kraaijvanger N, Rijpsma D, Roovers L, van Leeuwen H, Kaasjager K, van den Brand L, Horstink L, Edwards M. Development and validation of an admission prediction tool for emergency departments in the Netherlands. Emerg Med J 2018; 35:464-470. [DOI: 10.1136/emermed-2017-206673] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 02/22/2018] [Accepted: 03/18/2018] [Indexed: 11/03/2022]
Abstract
ObjectiveEarly prediction of admission has the potential to reduce length of stay in the ED. The aim of this study is to create a computerised tool to predict admission probability.MethodsThe prediction rule was derived from data on all patients who visited the ED of the Rijnstate Hospital over two random weeks. Performing a multivariate logistic regression analysis factors associated with hospitalisation were explored. Using these data, a model was developed to predict admission probability. Prospective validation was performed at Rijnstate Hospital and in two regional hospitals with different baseline admission rates. The model was converted into a computerised tool that reported the admission probability for any patient at the time of triage.ResultsData from 1261 visits were included in the derivation of the rule. Four contributing factors for admission that could be determined at triage were identified: age, triage category, arrival mode and main symptom. Prospective validation showed that this model reliably predicts hospital admission in two community hospitals (area under the curve (AUC) 0.87, 95% CI 0.85 to 0.89) and in an academic hospital (AUC 0.76, 95% CI 0.72 to 0.80). In the community hospitals, using a cut-off of 80% for admission probability resulted in the highest number of true positives (actual admissions) with the greatest specificity (positive predictive value (PPV): 89.6, 95% CI 84.5 to 93.6; negative predictive value (NPV): 70.3, 95% CI 67.6 to 72.9). For the academic hospital, with a higher admission rate, a 90% probability was a better cut-off (PPV: 83.0, 95% CI 73.8 to 90.0; NPV: 59.3, 95% CI 54.2 to 64.2).ConclusionAdmission probability for ED patients can be calculated using a prediction tool. Further research must show whether using this tool can improve patient flow in the ED.
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Park JH, Park JO, Ro YS, Shin SD. Effect of alcohol use on emergency department length of stay among minimally injured patients based on mechanism of injury: multicenter observational study. Clin Exp Emerg Med 2018; 5:7-13. [PMID: 29618187 PMCID: PMC5891740 DOI: 10.15441/ceem.16.180] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/23/2018] [Accepted: 02/01/2018] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to evaluate the effect of alcohol use on emergency department (ED) length of stay (LOS) among minimally injured patients by mechanism of injury. Methods This was a retrospective study of injury surveillance data for injured patients (except poisoning), aged over 18 years, discharged home from the ED, and treated at seven academic EDs in Korea during 2008 to 2012. Patients were divided into alcohol-related and alcohol-unrelated groups based on self-report. We used multivariable quantile regression models for the analysis and adjusted covariates including age, sex, consciousness status, severity of injury, emergency medical service use, the season, day and time of visit, and hospital. To determine if there were different effects of alcohol use across mechanism of injury, all analyses were stratified by each mechanism. Results Among 192,200 patients, 95,807 patients were analyzed. The number of participants in the alcohol-related group was 16,249 (17.0%). In the multivariable quantile regression model, the alcohol-related group had significantly longer ED LOS at the 10th (7 minutes; 95% confidence interval [CI], 6 to 8), 50th (21 minutes; 95% CI, 19 to 23), and 90th (81 minutes; 95% CI, 74 to 87) percentiles when compared to the alcohol-unrelated group. The effect of alcohol use on increased ED LOS was most prominent in motor vehicle injuries. Conclusion We found that alcohol use was associated with increased emergency ED LOS. Furthermore, if we limited our attention to the effect of alcohol use on the number of patients, the burden of alcohol use on the ED would have been underestimated.
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Affiliation(s)
- Jeong Ho Park
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea.,Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ju Ok Park
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea.,Department of Emergency Medicine, Hallym Univertisy Dongtan Sacred Hospital, Hwaseong, Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Sang Do Shin
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea.,Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
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Zhu JM, Singhal A, Hsia RY. Emergency Department Length-Of-Stay For Psychiatric Visits Was Significantly Longer Than For Nonpsychiatric Visits, 2002-11. Health Aff (Millwood) 2018; 35:1698-706. [PMID: 27605653 DOI: 10.1377/hlthaff.2016.0344] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite increases in the use of emergency department (EDs) for mental health care, there are limited data on whether psychiatric patients disproportionately contribute to ED crowding. We conducted a retrospective analysis using a national database of ED visits in the period 2002-11 to describe trends in median and ninetieth-percentile length-of-stay for patients with psychiatric versus nonpsychiatric primary diagnoses. Psychiatric patients who visited the ED were transferred to another facility at six times the rate of nonpsychiatric patients. Median lengths-of-stay were similar for psychiatric and nonpsychiatric patients among those who were admitted to the hospital (264 versus 269 minutes) but significantly different for those who were admitted for observation (355 versus 279 minutes), transferred (312 versus 195 minutes), or discharged (189 versus 144 minutes). Overall, differences in ED length-of-stay between psychiatric and nonpsychiatric patients did not narrow over time. These findings suggest deficiencies in ED capacity for psychiatric care, which may necessitate improvements in both throughput and alternative models of care.
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Affiliation(s)
- Jane M Zhu
- Jane M. Zhu is a National Clinician Scholar in the Division of General Internal Medicine at the Perelman School of Medicine and a fellow at the Leonard Davis Institute of Health Economics, both at the University of Pennsylvania, in Philadelphia
| | - Astha Singhal
- Astha Singhal is an assistant professor of health policy and health services research in the Henry M. Goldman School of Dental Medicine at Boston University, in Massachusetts
| | - Renee Y Hsia
- Renee Y. Hsia is a professor in the Department of Emergency Medicine and at the Philip R. Lee Institute for Health Policy Studies, both at the University of California, San Francisco
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Klein LR, Driver BE, Miner JR, Martel ML, Cole JB. Emergency department length of stay for ethanol intoxication encounters. Am J Emerg Med 2017; 36:1209-1214. [PMID: 29305022 DOI: 10.1016/j.ajem.2017.12.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/04/2017] [Accepted: 12/07/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Emergency Department (ED) encounters for ethanol intoxication are becoming increasingly common. The purpose of this study was to explore factors associated with ED length of stay (LOS) for ethanol intoxication encounters. METHODS This was a multi-center, retrospective, observational study of patients presenting to the ED for ethanol intoxication. Data were abstracted from the electronic medical record. To explore factors associated with ED LOS, we created a mixed-effects generalized linear model. RESULTS We identified 18,664 eligible patients from 6 different EDs during the study period (2012-2016). The median age was 37years, 69% were male, and the median ethanol concentration was 213mg/dL. Median LOS was 348min (range 43-1658). Using a mixed-effects generalized linear model, independent variables associated with a significant increase in ED LOS included use of parenteral sedation (beta=0.30, increase in LOS=34%), laboratory testing (beta=0.21, increase in LOS=23%), as well as the hour of arrival to the ED, such that patients arriving to the ED during evening hours (between 18:00 and midnight) had up to an 86% increase in LOS. Variables not significantly associated with an increase in LOS included age, gender, ethanol concentration, psychiatric disposition, using the ED frequently for ethanol intoxication, CT use, and daily ED volume. CONCLUSION Variables such as diagnostic testing, treatments, and hour of arrival may influence ED LOS in patients with acute ethanol intoxication. Identification and further exploration of these factors may assist in developing hospital and community based improvements to modify LOS in this population.
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Affiliation(s)
- Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN, USA.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN, USA
| | - James R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN, USA
| | - Marc L Martel
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN, USA
| | - Jon B Cole
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN, USA
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Mahmoudian-Dehkordi A, Sadat S. A Generic Simulation Model of the Relative Cost-Effectiveness of ICU Versus Step-Down (IMCU) Expansion. J Intensive Care Med 2017; 35:191-202. [PMID: 29088994 DOI: 10.1177/0885066617737303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many jurisdictions are facing increased demand for intensive care. There are two long-term investment options: intensive care unit (ICU) versus step-down or intermediate care unit (IMCU) capacity expansion. Relative cost-effectiveness of the two investment strategies with regard to patient lives saved has not been studied to date. METHODS We expand a generic system dynamics simulation model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to estimate the long-term effects of expanding ICU versus IMCU beds on patient lives saved under a common assumption of 2.1% annual increase in hospital arrivals. Two alternative policies of expanding ICU by two beds versus introducing a two-bed IMCU are compared over a ten-year simulation period. Russel equation is used to calculate total cost of patients' hospitalization. Using two possible values for the ratio of ICU to IMCU cost per inpatient day and four possible values for the percentage of patients transferred from ICU to IMCU found in the literature, nine scenarios are compared against the baseline scenario of no capacity expansion. RESULTS Expanding ICU capacity by two beds is demonstrated as the most cost-effective scenario with an incremental cost-effectiveness ratio of 3684 (US $) per life saved against the baseline scenario. Sensitivity analyses on the mortality rate of patients in IMCU, direct transfer of IMCU-destined patients to the ward upon completing required IMCU length of stay in the ICU, admission of IMCU patient to ICU, adding two ward beds, and changes in hospital size do not change the superiority of ICU expansion over other scenarios. CONCLUSIONS In terms of operational costs, ICU beds are more cost effective for saving patients than IMCU beds. However, capital costs of setting up ICU versus IMCU beds should be considered for a complete economic analysis.
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Affiliation(s)
- Amin Mahmoudian-Dehkordi
- Lazaridis School of Business and Economics, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Somayeh Sadat
- Health Systems Engineering Program, Faculty of Industrial and Systems Engineering, Tarbiat Modares University, Tehran, Iran
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Angotti LB, Richards JB, Fisher DF, Sankoff JD, Seigel TA, Al Ashry HS, Wilcox SR. Duration of Mechanical Ventilation in the Emergency Department. West J Emerg Med 2017; 18:972-979. [PMID: 28874952 PMCID: PMC5576636 DOI: 10.5811/westjem.2017.5.34099] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/24/2017] [Accepted: 05/26/2017] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Due to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS). METHODS This was a multi-center, prospective, observational study of patients ventilated in the ED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. All consecutive adult patients on invasive mechanical ventilation were eligible for enrollment. We performed a Cox regression to assess for a mortality effect for mechanically ventilated patients with each hour of increasing LOS in the ED and multivariable regression analyses to assess for independently significant contributors to in-hospital mortality. Our primary outcome was in-hospital mortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. We further commented on use of lung protective ventilation and frequency of ventilator changes made in this cohort. RESULTS We enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer total duration of intubation. However, adjusted multivariable regression analysis demonstrated only older age and admission to the neurosciences ICU as independently associated with increased mortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours had changes made to their ventilator. CONCLUSION In a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting.
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Affiliation(s)
- Lauren B Angotti
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina
| | - Jeremy B Richards
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina
| | - Daniel F Fisher
- Massachusetts General Hospital, Respiratory Care Services, Boston, Massachusetts
| | - Jeffrey D Sankoff
- University of Colorado at Denver, School of Medicine, Department of Emergency Medicine, Denver, Colorado
| | - Todd A Seigel
- Kaiser Permanente East Bay, Oakland and Richmond Medical Centers, Department of Emergency Medicine and Critical Care, Oakland, California
| | - Haitham S Al Ashry
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina
| | - Susan R Wilcox
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina.,Medical University of South Carolina, Division of Emergency Medicine, Charleston, South Carolina
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Hang CC, Yang J, Wang S, Li CS, Tang ZR. Evaluation of serum neutrophil gelatinase-associated lipocalin in predicting acute kidney injury in critically ill patients. J Int Med Res 2017; 45:1231-1244. [PMID: 28553762 PMCID: PMC5536404 DOI: 10.1177/0300060517709199] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective This investigation evaluated the real-time point-of-care testing (RT-POCT) of neutrophil gelatinase-associated lipocalin (NGAL) for detecting acute kidney injury (AKI) and prognosis of critically ill patients. Methods A total of 249 critically ill patients in the emergency department (ED), who were diagnosed with acute decompensated heart failure, sepsis or diabetic ketoacidosis were enrolled in this study. All enrolled patients were followed up for 28 days or to death and the mortalities were recorded. Serum creatinine (sCr) and NGAL were measured. Results 40.6% enrolled patients deteriorated to AKI during the observation period. The NGAL level was significantly higher in the AKI versus non-AKI group. The NGAL levels in the non-survivors group at 7-day and 28-day were significantly higher than in the survivors group. NGAL was detected as an independent risk factor of AKI, and 7-day and 28-day morality. The receiver operating characteristic curve of NGAL was calculated for diagnosing AKI; the area under the curve (AUC) was significantly higher than that of 1-day eGFR. Conclusions NGAL is an independent predictor of AKI, and 7-day and 28-day mortality in critically ill ED patients, and can be an early alert for AKI and useful for determining prognosis.
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Affiliation(s)
- Chen-Chen Hang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Jun Yang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Shuo Wang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Chun-Sheng Li
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Zi-Ren Tang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
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