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Bandiera G, Ovens H, Revue E. One size does not fit all: the complexities of addressing flow in contemporary EDs. CAN J EMERG MED 2023; 25:185-186. [PMID: 36877437 DOI: 10.1007/s43678-023-00468-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Affiliation(s)
- Glen Bandiera
- Temerty Faculty of Medicine, University of Toronto, Unity Health Toronto, Toronto, ON, Canada.
| | - Howard Ovens
- Sinai Health, Sinai Health Foundation, University of Toronto, Toronto, ON, Canada
| | - Eric Revue
- Chair of the Prehospital Section of EUSEM, SAMU of Paris, Lariboisière Hospital, AP-HP, Paris, France
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Walker K, Honan B, Haustead D, Mountain D, Gangathimmaiah V, Forero R, Mitchell R, Martini E, Tesch G, Bissett I, Jones P. Review article: Have emergency department time-based targets influenced patient care? A systematic review of qualitative literature. Emerg Med Australas 2021; 33:202-213. [PMID: 33622021 DOI: 10.1111/1742-6723.13747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 12/01/2022]
Abstract
Time-based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time-based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time-based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets.
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Affiliation(s)
- Katie Walker
- Emergency Department, Cabrini Institute, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bridget Honan
- Central Australian Retrieval Service, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Daniel Haustead
- Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David Mountain
- Emergency Department, Sir Charles Gardner Hospital, Perth, Western Australia, Australia
| | - Vinay Gangathimmaiah
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Roberto Forero
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Rob Mitchell
- Emergency Department, Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Greg Tesch
- Nephrology Department, Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Ian Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Peter Jones
- School of Medicine, The University of Auckland, Auckland, New Zealand
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Xu D, Yin Y, Hou L, Zhou H. A special acute care surgery model for dealing with dilemmas involved in emergency department in China. Sci Rep 2021; 11:1723. [PMID: 33462376 PMCID: PMC7813847 DOI: 10.1038/s41598-021-81347-9] [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: 06/24/2020] [Accepted: 12/30/2020] [Indexed: 12/26/2022] Open
Abstract
There was a fast growth in the number and the formation of emergency department (ED) visits in China during the twenty-first century. As a result, engaging special medical model will be essential to decompressing the ED visits. To do this, it will be important to understand which specific aspects to focus interventions on for the greatest impact. To characterize the emergency surgery patients who were seen and discharged from ED. Retrospective cohort study of hospitalized emergency surgery patients currently under the care from specialists presenting to an urban, university affiliated hospital between 01 January 2018 and 1 January 2019. This study will highlight some of the controversies and challenges and key lessons learned. During the study period there were 231,229 ED visits; 4100 of these patients were admitted for Acute care surgery (ACS) service. Multivariate analysis identified age ≧ 65 (p = 0.023; odds ratio, OR = 2.66), ACS model (p = 0.000, OR = 0.18), ICU stay (p = 0.000, OR = 118.73) as factors associated with in-hospital mortality. There was a increase in length of stay between young and elderly postoperative patients when stratifying patients by age (11.67 ± 9.48 vs 13.95 ± 9.11 p < 0.05). ED overcrowding is not just an ED problem. ED overcrowding is a systems problem requiring a systematic facility-wide multidisciplinary response. Continuous and high-quality surveillance data across China are needed to estimate the acute care surgery model which used to deal with ED overcrowding.
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Affiliation(s)
- Dequan Xu
- Department of Emergency Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, People's Republic of China
| | - Yue Yin
- Department of Thyroid Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, People's Republic of China
| | - Limin Hou
- Department of Emergency Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, People's Republic of China.
| | - Haoxin Zhou
- Department of Emergency Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, People's Republic of China
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4
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What would Osler do? CAN J EMERG MED 2019; 21:567-568. [DOI: 10.1017/cem.2019.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Prang KH, Canaway R, Bismark M, Dunt D, Kelaher M. The impact of Australian healthcare reforms on emergency department time-based process outcomes: An interrupted time series study. PLoS One 2018; 13:e0209043. [PMID: 30540856 PMCID: PMC6291126 DOI: 10.1371/journal.pone.0209043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/27/2018] [Indexed: 12/01/2022] Open
Abstract
Background In 2011, the Australian government introduced national healthcare reforms aimed at increasing the timeliness and quality of hospital care. The healthcare reforms included, but were not limited to, emergency department (ED) time-based targets, financial incentives, and public performance reporting of hospital data. We sought to evaluate the impact of the national healthcare reforms on ED time-based process outcomes. Methods A quasi-experimental study of ED presentations from 2006 to 2016 in the state of Victoria, Australia. Uncontrolled, interrupted time-series analyses were used to evaluate, by hospital peer groups, the effect of national healthcare reforms on: patient wait times for treatment; treatment within recommended time; and patient departure within four hours of arrival in ED. Results There were small improvements in ED time-based process outcomes following the introduction of the national healthcare reforms. These occurred in most hospital peer groups immediately and over the longer term, across the various triage categories. The largest improvements occurred in small hospitals and smallest improvements in medium sized hospitals. ED time-based targets, now abolished by the Australian government, were not achieved in any hospital peer groups. Conclusions Our findings suggest that national healthcare reforms had the potential to prompt fundamental changes in ED processes leading to significant improvements in ED performances across most hospital peer groups but were generally unable to reach the ED targets imposed nationally. ED performances also varied by hospital peer groups. Attention to ED time-based process outcomes within hospital peer groups may provide insights into hospital practices that could improve the quality and efficiency of ED care.
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Affiliation(s)
- Khic-Houy Prang
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rachel Canaway
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marie Bismark
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Dunt
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Margaret Kelaher
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- * E-mail:
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Steer S, Bhalla MC, Zalewski J, Frey J, Nguyen V, Mencl F. Use of Radio Frequency Identification to Establish Emergency Medical Service Offload Times. PREHOSP EMERG CARE 2015; 20:254-9. [PMID: 26382887 DOI: 10.3109/10903127.2015.1076093] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Emergency medical services (EMS) crews often wait for emergency department (ED) beds to become available to offload their patients. Presently there is no national benchmark for EMS turnaround or offload times, or method for objectively and reliably measuring this. This study introduces a novel method for monitoring offload times and identifying variance. We performed a descriptive, observational study in a large urban community teaching hospital. We affixed radio frequency identification (RFID) tags (Confidex Survivor™, Confidex, Inc., Glen Ellyn, IL) to 65 cots from 19 different EMS agencies and placed a reader (CaptureTech Weatherproof RFID Interpreter, Barcoding Inc., Baltimore, Maryland) in the ED ambulance entrance, allowing for passive recording of traffic. We recorded data for 16 weeks starting December 2009. Offload times were calculated for each visit and analyzed using STATA to show variations in individual and cumulative offload times based on the time of day and day of the week. Results are presented as median times, confidence intervals (CIs), and interquartile ranges (IQRs). We collected data on 2,512 visits. Five hundred and ninety-two were excluded because of incomplete data, leaving 1,920 (76%) complete visits. Average offload time was 13.2 minutes. Median time was 10.7 minutes (IQR 8.1 minutes to 15.4 minutes). A total of 43% of the patients (833/1,920, 95% CI 0.41-0.46) were offloaded in less than 10 minutes, while 27% (513/1,920, 95% CI 0.25-0.29) took greater than 15 minutes. Median times were longest on Mondays (11.5 minutes) and shortest on Wednesdays (10.3 minutes). Longest daily median offload time occurred between 1600 and 1700 (13.5 minutes), whereas the shortest median time was between 0800 and 0900 (9.3 minutes). Cumulative time spent waiting beyond 15 minutes totaled 72.5 hours over the study period. RFID monitoring is a simple and effective means of monitoring EMS traffic and wait times. At our institution, most squads are able to offload their patients within 15 minutes, with many in less than 10 minutes. Variations in wait times are seen and are a topic for future study.
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Vermeulen MJ, Guttmann A, Stukel TA, Kachra A, Sivilotti MLA, Rowe BH, Dreyer J, Bell R, Schull M. Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-differences analysis. BMJ Qual Saf 2015; 25:489-98. [PMID: 26271919 PMCID: PMC4941160 DOI: 10.1136/bmjqs-2015-004189] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/15/2015] [Indexed: 12/18/2022]
Abstract
Background We sought to determine whether patients seen in hospitals who had reduced overall emergency department (ED) length of stay (LOS) in the 2 years following the introduction of the Ontario Emergency Room Wait Time Strategy were more likely to experience improvements in other measures of ED quality of care for three important conditions. Methods Retrospective medical record review using difference-in-differences analysis to compare changes in performance on quality indicators over the 3-year period between 11 Ontario hospitals where the median ED LOS had improved from fiscal year 2008 to 2010 and 13 matched sites where ED LOS was unchanged or worsened. Patients with acute myocardial infarction (AMI), asthma and paediatric and adult upper limb fractures in these hospitals in 2008 and 2010 were evaluated with respect to 18 quality indicators reflecting timeliness and safety/effectiveness of care in the ED. In a secondary analysis, we examined shift-level ED crowding at the time of the patient visit and performance on the quality indicators. Results Median ED LOS improved by up to 26% (63 min) from 2008 to 2010 in the improved hospitals, and worsened by up to 47% (91 min) in the unimproved sites. We abstracted 4319 and 4498 charts from improved and unimproved hospitals, respectively. Improvement in a hospital's overall median ED LOS from 2008 to 2010 was not associated with a change in any of the other ED quality indicators over the same time period. In our secondary analysis, shift-level crowding was associated only with indicators that reflected timeliness of care. During less crowded shifts, patients with AMI were more likely to be reperfused within target intervals (rate ratio 1.59, 95% CI 1.03 to 2.45), patients with asthma more often received timely administration of steroids (rate ratio 1.88, 95% CI 1.59 to 2.24) and beta-agonists (rate ratio 1.47, 95% CI 1.25 to 1.74), and adult (but not paediatric) patients with fracture were more likely to receive analgesia or splinting within an hour (rate ratio 1.66, 95% CI 1.22 to 2.26). Conclusions These results suggest that a policy approach that targets only reductions in ED LOS is not associated with broader improvements in selected quality measures. At the same time, there is no evidence that efforts to address crowding have a detrimental effect on quality of care.
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Affiliation(s)
| | - Astrid Guttmann
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Therese A Stukel
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ashif Kachra
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan Dreyer
- Division of Emergency Medicine, University of Western Ontario, London, Ontario, Canada
| | - Robert Bell
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael Schull
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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Rotteau L, Webster F, Salkeld E, Hellings C, Guttmann A, Vermeulen MJ, Bell RS, Zwarenstein M, Rowe BH, Nigam A, Schull MJ. Ontario's emergency department process improvement program: the experience of implementation. Acad Emerg Med 2015; 22:720-9. [PMID: 25996451 PMCID: PMC5032978 DOI: 10.1111/acem.12688] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/21/2015] [Accepted: 01/28/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In recent years, Lean manufacturing principles have been applied to health care quality improvement efforts to improve wait times. In Ontario, an emergency department (ED) process improvement program based on Lean principles was introduced by the Ministry of Health and Long-Term Care as part of a strategy to reduce ED length of stay (LOS) and to improve patient flow. This article aims to describe the hospital-based teams' experiences during the ED process improvement program implementation and the teams' perceptions of the key factors that influenced the program's success or failure. METHODS A qualitative evaluation was conducted based on semistructured interviews with hospital implementation team members, such as team leads, medical leads, and executive sponsors, at 10 purposively selected hospitals in Ontario, Canada. Sites were selected based, in part, on their changes in median ED LOS following the implementation period. A thematic framework approach as used for interviews, and a standard thematic coding framework was developed. RESULTS Twenty-four interviews were coded and analyzed. The results are organized according to participants' experience and are grouped into four themes that were identified as significantly affecting the implementation experience: local contextual factors, relationship between improvement team and support players, staff engagement, and success and sustainability. The results demonstrate the importance of the context of implementation, establishing strong relationships and communication strategies, and preparing for implementation and sustainability prior to the start of the project. CONCLUSIONS Several key factors were identified as important to the success of the program, such as preparing for implementation, ensuring strong executive support, creation of implementation teams based on the tasks and outcomes of the initiative, and using multiple communication strategies throughout the implementation process. Explicit incorporation of these factors into the development and implementation of future similar interventions in health care settings could be useful.
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Affiliation(s)
- Leahora Rotteau
- The Centre for Quality Improvement and Patient Safety University of Toronto Toronto Ontario Canada
| | - Fiona Webster
- The Department of Family and Community Medicine University of Toronto Toronto Ontario Canada
| | - Erin Salkeld
- The Institute for Clinical Evaluative Sciences Toronto Ontario Canada
| | - Chelsea Hellings
- The Institute for Clinical Evaluative Sciences Toronto Ontario Canada
| | - Astrid Guttmann
- The Institute for Health Policy, Management and Evaluation University of Toronto Toronto Ontario Canada
- The Department of Paediatrics Division of Paediatric and Emergency Medicine Hospital for Sick Children University of Toronto Toronto Ontario Canada
- The Institute for Clinical Evaluative Sciences Toronto Ontario Canada
| | | | - Robert S. Bell
- The Department of Surgery University of Toronto Toronto Ontario Canada
| | - Merrick Zwarenstein
- The Institute for Clinical Evaluative Sciences Toronto Ontario Canada
- The Centre for Studies in Family Medicine Schulich School of Medicine and Dentistry Western University London Ontario Canada
| | - Brian H. Rowe
- The Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
| | - Amit Nigam
- Cass Business School City University London UK
| | - Michael J. Schull
- The Institute for Health Policy, Management and Evaluation University of Toronto Toronto Ontario Canada
- The Department of Medicine Division of Emergency Medicine University of Toronto Toronto Ontario Canada
- The Institute for Clinical Evaluative Sciences Toronto Ontario Canada
- The Trauma, Emergency and Critical Care Program Sunnybrook Health Sciences Centre Toronto Ontario Canada
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Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study. CAN J EMERG MED 2015; 17:253-62. [DOI: 10.1017/cem.2014.39] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroductionEmergency department (ED) crowding is associated with adverse outcomes. Several jurisdictions have established benchmarks and targets for length-of-stay (LOS) to reduce crowding. An evaluation has been conducted on whether performance on Ontario’s ED LOS benchmarks is associated with reduced risk of death or hospitalization.MethodsA retrospective cohort study of discharged ED patients was conducted using population-based administrative data from Ontario (April 2008 to February 2012). For each ED visit, the proportion of patients seen during the same shift that met ED LOS benchmarks was determined. Performance was categorized as <80%, 80% to <90%, 90% to <95%, and 95%–100% of same-shift ED patients meeting the benchmark. Logistic regression models analysed the association between performance on ED LOS benchmarks and 7-day death or hospitalization, controlled for patient and ED characteristics and stratified by patient acuity.ResultsFrom 122 EDs, 2,295,256 high-acuity and 1,626,629 low-acuity visits resulting in discharge were included. Deaths and hospitalizations within 7 days totalled 1,429 (0.062%) and 49,771 (2.2%) among high-acuity, and 220 (0.014%) and 9,005 (0.55%) among low-acuity patients, respectively. Adverse outcomes generally increased among patients seen during shifts when a lower proportion of ED patients met ED LOS benchmarks. The adjusted odds ratios (and 95% confidence intervals) among high- and low-acuity patients seen on shifts when <80% met ED benchmarks (compared with ≥95%) were, respectively, 1.32 (1.05–1.67) and 1.84 (1.21–2.81) for death, and 1.13 (1.08–1.17) and 1.40 (1.31–1.49) for hospitalization.ConclusionsBetter performance on Ontario’s ED LOS benchmarks for each shift is associated with a 10%–45% relative reduction in the odds of death or admission 7 days after ED discharge.
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10
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Carrier E, Khaldun J, Hsia RY. Association between emergency department length of stay and rates of admission to inpatient and observation services. JAMA Intern Med 2014; 174:1843-6. [PMID: 25222625 PMCID: PMC4235758 DOI: 10.1001/jamainternmed.2014.3467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Emily Carrier
- Mathematica Policy Research, Princeton, New Jersey2now with the Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Joneigh Khaldun
- Department of Emergency Medicine, University of Maryland, College Park
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco
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11
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Quinn GR, Le E, Soni K, Berger G, Mak YE, Pierce R. "Not so fast!" the complexity of attempting to decrease door-to-floor time for emergency department admissions. Jt Comm J Qual Patient Saf 2014; 40:30-8. [PMID: 24640455 DOI: 10.1016/s1553-7250(14)40004-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Successful quality improvement is fundamental to high-performing health care systems, but becomes increasingly difficult as systems become more complex. Previous attempts at the University of California, San Francisco (UCSF) Medical Center to reduce door-to-floor (D2F) time -the time required to move an ill patient through the emergency department (ED) to an appropriate inpatient bed-had not resulted in meaningful improvement. An analysis of why attempts at decreasing D2F times in the ED had failed, with attention to contextual factors, yields recommendations on how to decrease D2F time. METHODS A team of 11 internal medicine residents, in partnership with the Patient Flow Executive Steering Committee, performed a literature review, process mapping, and analysis of the admissions process. The team conducted interviews with medical center staff across disciplines, members of high-performing patient care units, and leaders of peer institutions who had undertaken similar efforts. FINDINGS AND RECOMMENDATIONS Each of the following three domains-(1) Improving Work Flow, (2) Changing Culture, and (3) Understanding Incentives-is independently an important source of resistance and opportunity. However, the improvement work and understanding of complexity science suggest that all three domains must be addressed simultaneously to effect meaningful change. Recommendations include eliminating redundant and frustrating processes; encouraging multidisciplinary collaboration; fostering trust between departments; providing feedback on individual performance; enhancing provider buy-in; and, ultimately, uniting staff behind a common goal. CONCLUSION By conceptualizing the hospital as a complex adaptive system, multiple interrelated groups can be encouraged to work together and accomplish a common goal.
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Schuur JD, Hsia RY, Burstin H, Schull MJ, Pines JM. Quality Measurement In The Emergency Department: Past And Future. Health Aff (Millwood) 2013; 32:2129-38. [DOI: 10.1377/hlthaff.2013.0730] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jeremiah D. Schuur
- Jeremiah D. Schuur is an attending physician; chief of the Division of Health Policy Translation; and director of quality, patient safety, and performance improvement, all in the Department of Emergency Medicine, Brigham and Women’s Hospital, in Boston, Massachusetts. He is also an assistant professor of emergency medicine at Harvard Medical School
| | - Renee Y. Hsia
- Renee Y. Hsia is an associate professor in the Department of Emergency Medicine at the University of California, San Francisco
| | - Helen Burstin
- Helen Burstin is senior vice president for performance measures at the National Quality Forum, in Washington, D.C
| | - Michael J. Schull
- Michael J. Schull is the president and CEO of the Institute for Clinical Evaluative Sciences in Toronto, Ontario, and a professor in the Division of Emergency Medicine, Department of Medicine, at the University of Toronto
| | - Jesse M. Pines
- Jesse M. Pines is director of the Office for Clinical Practice Innovation, School of Medicine and Health Sciences, and a professor of emergency medicine and health policy at the George Washington University, in Washington, D.C
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13
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Seow E. Leading and managing an emergency department-A personal view. J Acute Med 2013; 3:61-66. [PMID: 38620258 PMCID: PMC7147188 DOI: 10.1016/j.jacme.2013.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 06/07/2013] [Indexed: 11/28/2022]
Abstract
The emergency department (ED) is a "unique operation, optimized to exist at the edge of chaos". It is the responsibility of the leaders and managers of the ED to ensure that their teams work in an environment where they can deliver the best care to their patients. This environment is defined by people, system and place. People are the most important asset of the ED. One of the most important responsibilities of the ED leaders and managers (senior management) is to foster teamwork. They will also have to ensure that communication between team members is optimal and that there is a structure in place for conflict resolution. ED senior management should be aware of their team dynamics and know the "movers and shakers" in their organization. ED systems should be kept simple. One of the core businesses of an ED is contingency planning. ED senior management must plan, prepare, practice, review, analyze, assess and strategize for unexpected events. The ED physical environment has an impact on the flow of care being delivered to her patients. ED senior management must manage change. Change works only if it takes root in the hearts and minds of the organization's people. The quality of the leaders and managers of the ED will determine whether or not, their teams work in an environment where they can deliver the best care to their patients.
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Affiliation(s)
- Eillyne Seow
- Emergency Department, Tan Tock Seng Hospital, Jalan Tan Tock Seng, Singapore
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14
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Cooney DR, Wojcik S, Seth N, Vasisko C, Stimson K. Evaluation of ambulance offload delay at a university hospital emergency department. Int J Emerg Med 2013; 6:15. [PMID: 23663387 PMCID: PMC3663714 DOI: 10.1186/1865-1380-6-15] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 03/28/2013] [Indexed: 11/10/2022] Open
Abstract
Background Ambulance offload delay (AOD) has been recognized by the National Association of EMS Physicians (NAEMSP) as an important quality marker. AOD is the time between arrival of a patient by EMS and the time that the EMS crew has given report and moved the patient off of the EMS stretcher, allowing the EMS crew to begin the process of returning to service. The AOD represents a potential delay in patient care and a delay in the availability of an EMS crew and their ambulance for response to emergencies. This pilot study was designed to assess the AOD at a university hospital utilizing direct observation by trained research assistants. Findings A convenience sample of 483 patients was observed during a 12-month period. Data were analyzed to determine the AOD overall and for four groups of National Emergency Department Overcrowding Scale (NEDOCS) score ranges. The AOD ranged from 0 min to 157 min with a median of 11 min. When data were grouped by NEDOCS score, there was a statistically significant difference in median AOD between the groups (p < 0.001), indicating the relationship between ED crowding and AOD. Conclusion The median AOD was considered significant and raised concerns related to patient care and EMS system resource availability. The NEDOCS score had a positive correlation with AOD and should be further investigated as a potential marker for determining diversion status or for destination decision-making by EMS personnel.
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Affiliation(s)
- Derek R Cooney
- EMS Medicine Fellowship, Department of Emergency Medicine, SUNY Upstate Medical University, 550 East Genesee / EMSTAT Center, Syracuse, NY, 13202, USA.
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Pines JM, McCarthy ML. Executive summary: interventions to improve quality in the crowded emergency department. Acad Emerg Med 2011; 18:1229-33. [PMID: 22168183 DOI: 10.1111/j.1553-2712.2011.01228.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Emergency department (ED) crowding is a major public health problem in the United States, with increasing numbers of ED visits, longer lengths of stay in the ED, and the common practice of ED boarding. In the next several years, several measures of ED crowding will be assessed and reported on government websites. In addition, with the implementation of the Affordable Care Act (ACA), millions more Americans will have health care insurance, many of whom will choose the ED for their care. In June 2011, a consensus conference was conducted in Boston, Massachusetts, by the journal Academic Emergency Medicine entitled "Interventions to Assure Quality in the Crowded Emergency Department." The overall goal of the conference was to develop a series of research agendas to identify promising interventions to safeguard the quality of emergency care during crowded periods and to reduce ED crowding altogether through systemwide solutions. This was achieved through three objectives: 1) a review of interventions that have been implemented to reduce crowding and summarize the evidence of their effectiveness on the delivery of emergency care; 2) to identify strategies within or outside of the health care setting (i.e., policy, engineering, operations management, system design) that may help reduce crowding or improve the quality of emergency care provided during episodes of ED crowding; and 3) to identify the most appropriate design and analytic techniques for rigorously evaluating ED interventions designed to reduce crowding or improve the quality of emergency care provided during episodes of ED crowding. This article describes the background and rationale for the conference and highlights some of the discussions that occurred on the day of the conference. A series of manuscripts on the details of the conference is presented in this issue of Academic Emergency Medicine.
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