Access block and ED overcrowding

Project to improve the management of the head injury patients presenting to the emergency department

INTRODUCTION

At Sandwell General Hospital, there was no risk stratification tool or pathway for head injury (HI) patients presenting to the emergency department (ED). This resulted in significant delays in the assessment of HI patients, compromising patient safety and quality of care.

AIMS

To employ quality improvement methodology to design an effective adult HI pathway that: ensured >90% of high-risk HI patients being assessed by ED clinicians within 15 min of arrival, reduce CT turnaround times, and aiming to keep the final decision making <4 hours.

METHODS

SWOT analysis was performed; driver diagrams were used to set out the aims and objectives. Plan-Do-Study-Act cycle was used to facilitate the change and monitor the outcomes. Process map was designed to identify the areas for improvement. A new HI pathway was introduced, imaging and transporting the patients was modified, and early decisions were made to meet the standards.

RESULTS

Data were collected and monitored following the interventions. The new pathway improved the proportion of patients assessed by the ED doctors within 15 min from 31% to 63%. The average time to CT head scan was decreased from 69 min to 53 min. Average CT scan reporting time also improved from 98 min to 71 min. Overall, the average time to decision for admission or discharge decreased from 6 hours 48 min to 4 hours 24 min.

CONCLUSIONS

Following implementation of the new HI pathway, an improvement in the patient safety and quality of care was noted. High-risk HI patients were picked up earlier, assessed quicker and had CT head scans performed sooner. Decision time for admission/discharge was improved. The HI pathway continues to be used and will be reviewed and re-audited between 3 and 6 months to ensure the sustained improvement.

Comparing Emergency Nursing Measures Before and During COVID-19: A Retrospective Study of Assessment, Triage, and Workflow

Background

The COVID-19 pandemic significantly impacted emergency department (ED) operations and patient care. Understanding its effects on nursing processes, triage accuracy, and wait times is pivotal for optimizing outcomes.

Objectives

This study aimed to analyze the differences in nursing processes, triage accuracy, and wait times before and during the COVID-19 pandemic.

Design

A retrospective cohort study.

Methods

The study analyzed 224 electronic medical records from a single ED, with 120 records from the pre-pandemic period (January 2019-February 2020) and 104 records from the pandemic period (March 2020-March 2021). Dependent variables included missed nursing care per validated scales, triage accuracy per Emergency Severity Index, and wait times for nursing triage and physician examination. Independent factors encompassed sociodemographic, clinical characteristics, and organization dynamics.

Results

Sociodemographic and clinical profiles were comparable between periods. Triage accuracy remained high except for older patients. Nursing triage wait times differed little, yet physician examination and urgent case waits decreased amidst the pandemic. Nursing documentation completeness, such as recording patient status and mental state, augmented during this crisis period.

Conclusion

This evaluation identified differences in triage accuracy, wait times, and documentation completeness before and during the COVID-19 pandemic period at a single institution. Patient age and clinical status influenced some metrics. Lessons from comparing precrisis benchmarks to intra-pandemic nursing performance may guide pandemic preparedness strategies. Further research is warranted to optimize emergency processes and outcomes during public health emergencies, as well as examine strategies through multicenter investigations comparing prepandemic to intra-pandemic performance to provide broader insights into challenges and inform efforts to bolster emergency care through future crises.

Hospital utilisation in Australia, 1993-2020, with a focus on use by people over 75 years of age: a review of AIHW data

OBJECTIVES

To assess Australian hospital utilisation, 1993-2020, with a focus on use by people aged 75 years or more.

DESIGN

Review of Australian Institute of Health and Welfare (AIHW) hospital utilisation data.

SETTING, PARTICIPANTS

Tertiary data from all Australian public and private hospitals for the financial years 1993-94 to 2019-20.

MAIN OUTCOME MEASURES

Numbers and population-based rates of hospital separations and bed utilisation (bed-days) (all and multiple day admissions) and mean hospital length of day (multiple day admissions), overall and by age group (under 65 years, 65-74 years, 75 years or more).

RESULTS

Between 1993-94 and 2019-20, the Australian population grew by 44%; the number of people aged 75 years or more increased from 4.6% to 6.9% of the population. The annual number of hospital separations increased from 4.61 million to 11.33 million (146% increase); the annual hospital separation rate increased from 261 to 435 per 1000 people (66% increase), most markedly for people aged 75 years or more (from 745 to 1441 per 1000 people; 94% increase). Total bed utilisation increased from 21.0 million to 29.9 million bed-days (42% increase), but the bed utilisation rate did not change markedly (1993-94, 1192 bed-days per 1000 people; 2019-20, 1179 bed-days per 1000 people), primarily because the mean hospital length of stay for multiple day admissions declined from 6.6 days to 5.4 days; for people aged 75 years or more it declined from 12.2 to 7.1 days. However, declines in stay length have slowed markedly since 2017-18. Total bed utilisation was 16.8% lower than projected from 1993-94 rates, and was 37.3% lower for people aged 75 years or more.

CONCLUSION

Hospital bed utilisation rates declined although admission rates increased during 1993-94 to 2019-20; the proportion of beds occupied by people aged 75 years or more increased slightly during this period. Containing hospital costs by limiting bed availability and reducing length of stay may no longer be a viable strategy.

Operational Status of Isolation Rooms in Emergency Departments and Patient Concentration in Higher-Level Emergency Departments in Daegu Metropolitan City and Neighboring Provinces, South Korea, during the COVID-19 Pandemic

BACKGROUND

In a pandemic situation such as the one of the COVID-19 pandemic, nosocomial transmissions attempted to be prevented by initially classifying them in triage. Therefore, emergency departments (EDs) installed isolation rooms at their entrance. Additionally, a system for pre-emptive quarantine at the triage stage was established nationwide for patients with COVID-19-related symptoms.

METHODS

Data were retrospectively collected from 28,609 patients who visited the regional emergency medical center of Yeungnam University Hospital in Daegu Metropolitan City in 2021. The study population was divided into experimental and control groups comprising patients with and without COVID-19-related symptoms, respectively. The difference in the percentage of patients visiting from outside the city was investigated between the two groups. The critically ill patient (CP) ratio was analyzed in the experimental group to verify the appropriateness of visiting a higher-level ED and was further divided into sub-regions to determine their reason for visiting an ED beyond their residential region.

RESULTS

Most lower-level EDs did not have isolation rooms. About 20.1% and 17.3% of patients in the experimental and control groups visited a higher-level ED with an isolation room beyond their residential region, respectively. The absence of an isolation room in the ED in their residential region was one reason for traveling beyond their residential region, with an odds ratio of 4.44 (95% confidence interval: 0.53-8.35).

CONCLUSION

In the process of implementing the "pre-emptive quarantine" system, it was revealed that the cooperation of the lower-level EDs was not effective during the implementation of the "pre-emptive quarantine" system. Consequently, a higher number of patients with COVID-19-related symptoms had to locate an ED with an isolation room and travel a longer distance than general patients. The participation of more EDs is required.

The effects of an emergency department length-of-stay management system on severely ill patients' treatment outcomes

PURPOSE

This study aimed to compare the length of stay (LOS) and treatment outcomes based on the application and achievement of a newly developed emergency department (ED) LOS management system for severely ill patients.

METHODS

Data were retrospectively collected from electronic medical records (EMRs) for the system evaluation and research purpose. The study subjects are severely ill patients whose diagnosis codes are designated by the Ministry of Health and Welfare and who visited the ED of a tertiary hospital from January to December 2019. The control group (Group 1) refers to those who have neither applied nor achieved the goal (5 hours or less) of the ED LOS management system even after it was applied, and the experimental group (Group 2) refers to those who have achieved the 5-hour goal after applying the system.

RESULTS

A total of 2034 severely ill patients applied the ED LOS management system. Group 1 included 837 patients and Group 2 included 1197 patients. Thirty days in-hospital mortality corresponded to 10.6% in Group 1 and 6.6% in Group 2 (χ2 = 10.58, p = .001). The total duration of hospitalization was 14.66 ± 18.26 days in Group 1 and 10.19 ± 16.00 days in Group 2 (t = 9.03, p < .001). Six hundred forty-two patients (76.6%) in Group 1 were discharged to their home (normal discharge) and 979 patients (81.7%) were discharged to their home in Group 2, but the discharge-as-death rate was 14.1% in Group 1 and 7.5% in Group 2 (χ2 = 29.80, p < .001).

CONCLUSION

With the application and attainment of the ED LOS management system for severely ill patients, we have concluded the new system produced a lower LOS in the ED, 30 days in-hospital mortality, length of the hospitalization, mortality rate, and a higher rate of normal discharge.

Length of stay and its associated factors among adult patients who visit Emergency Department of University Hospital, Eastern Ethiopia

Objectives

This study was aimed to assess the length of stay and its associated factors among adult patients who visited Emergency Department of Hiwot Fana Specialized University Hospital, Eastern Ethiopia.

Method

A hospital-based cross-sectional study was conducted among 400 adult patients who visit the Emergency Department. Systematic random sampling technique and an interviewer-administered data collection method was used. Data analyses were done using STATA version 16. Bivariable and multivariable logistic regression analysis was used to control the potential confounders. The analysis outputs were presented using an odds ratio with a corresponding 95% confidence interval (CI). Independent variables were defined as statistically significant at p-values <0.05 in the final model.

Result

A total of 169 [42.25% (95% CI: 37.5%-47.0%)] patients stayed longer than 24 h in the Emergency Department. We identified factors significantly associated with length of stay in ED include: patients treated at orange triage type (adjusted odds ratio (AOR) = 0.267; 95% CI: 0.13-0.53), laboratory request (AOR: 3.05; 95% CI: 1.49-6.23), radiological requests (AOR: 1.80; 95% CI: 1.05-3.07), and diagnosed with medical condition (AOR: 2.27; 95% CI: 1.21-4.26).

Conclusion

A significant number of patients stay longer in the Emergency Department. Evaluation of the clinical diagnosis, diagnostic investigations, and organizational factors is essential to reduce the length of stay in the Emergency Department.

A Qualitative Study of Factors Influencing Unsafe Work Behaviors Among Environmental Service Workers: Perspectives of Workers, and Safety Managers: The Case of Government Hospitals in Addis Ababa, Ethiopia

BACKGROUND

Environmental Service (EVS) is a term that refers to cleaning in healthcare facilities. EVS personnel are exposed to a variety of hazards, including physical, chemical, ergonomic, cognitive, and biological hazards that contribute to the development of diseases and disabilities. Recognizing the conditions that promote unsafe behavior is the first step in reducing such hazards. The purpose of this study was to (a) investigate the attitudes and perceptions of safety among employees and safety managers in Addis Ababa hospitals, and (b) figure out what factors inhibit healthy work behaviors.

METHODS

The data for this study was gathered using 2 qualitative data gathering methods: key informant interviews and individual in-depth interviews. About 25 personnel from 3 Coronavirus treatment hospitals were interviewed to understand more about the factors that make safe behavior challenging. The interviews were recorded, transcribed, and then translated into English. Open Code 4.02 was used for thematic analysis.

RESULTS

Poor safety management and supervision, a hazardous working environment, and employee perceptions, skills, and training levels were all identified as key factors in the preponderance of unsafe work behaviors among environmental service workers.

CONCLUSIONS

Different types of personal and environmental factors were reported to affect safe work behavior among environmental service personnel. Individual responsibility is vital in reducing or eliminating these risk factors for unsafe behaviors, but management's involvement in providing resources for safe work behavior is critical.

Portrait of the Emergency Department at Orotta National Referral and Teaching Hospital in Asmara, Eritrea: A Prospective Observational Study

Background

Provision of high-quality emergency care for acute, life-threatening illnesses can significantly reduce DALY and mortality in sub-Saharan Africa. Here, we present data on the profile of an Emergency Department (ED) in the largest referral hospital in Eritrea and potential gaps for intervention.

Patients and Methods

This was a prospective single-center observational study of 1093 patients who presented to the ED between September and October of 2020. Data were collected using a questionnaire from the patients’ interview, observation and medical record review. The data were summarized using descriptive statistics and where applicable logistic regressions were performed.

Results

The median age was 45.0 years among the patients. In terms of acuity, 741 (68.5%), 283 (26.2%), 48 (4.4%), 10 (0.9%) patients were triaged as green, yellow, red, and black, respectively. In addition, the number of self-referred patients was 857 (79.1%) and among all the visitors, 376 (34.9%) used Ambulance service. The median ± IQR for ED length of stay (LOS) was 2.7 (1.4–10.0) Hours. Further, 154 (14.4%) patients stayed in the ED for >24 hours. The hospitalization rate was 146 (14.7%). In the multivariate analysis, higher likelihood of prolonged ED LOS was observed in: medical department patients (aOR = 3.53, 95% CI = 2.03–6.14); patients referred from primary health-care centers (aOR = 2.63, 95% CI = 1.10–6.30) and hospital (aOR = 3.70, 95% CI = 2.15–6.37). Prolonged ED LOS was also associated with prior emergency visit (aOR = 1.96, 95% CI = 1.13–3.40); consultation (aOR = 12.27, 95% CI = 6.98–21.56); the need for inpatient admission (aOR = 2.34, 95% CI = 1.38–3.96); and the need for investigation and treatment (aOR = 2.03, 95% CI = 1.07–3.85).

Conclusion

Improvements regarding ED specialist personnel, inpatient ward capacity, availability of investigations throughout the day and night shifts, amendments in referral system, strengthening ED and critical care capacity in zonal referral hospitals, and access to quality care among the non-communicable disease patients may ameliorate most of the bottlenecks observed in this set-up.

Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions

It is certain and established that overcrowding represents one of the main problems that has been affecting global health and the functioning of the healthcare system in the last decades, and this is especially true for the emergency department (ED). Since 1980, overcrowding has been identified as one of the main factors limiting correct, timely, and efficient hospital care. The more recent COVID-19 pandemic contributed to the accentuation of this phenomenon, which was already well known and of international interest. Considering what would appear to be a trivial definition of overcrowding, it may seem simple for the reader to hypothesize solutions for what seems to be one of the most avoidable problems affecting the hospital system. However, proposing solutions to overcrowding, as well as their implementation, cannot be separated from a correct and precise definition of the issue, which must consider the main causes and aggravating factors. In light of the need of finding solutions that can put an end to hospital overcrowding, this review aims, through a review of the literature, to summarize the triggering factors, as well as the possible solutions that can be proposed.

A novel reflective practice intervention improves quality of care in the emergency department

INTRODUCTION

Most interventions to improve clinical outcomes in the emergency department (ED) are based on structural changes. This study embraced a different strategy and examined the impact of a reflective practice intervention (RPI) on ED quality of care.

METHODS

A pre-post-intervention quasi-experimental nested design was conducted between January 2017 and June 2018 in an Israeli public tertiary academic ED. Nighty-six ED teams (triage and staff nurses and a physician) were included pre and post RPI. Data were collected pre and post RPI at patient-triage nurse encounters using triage-accuracy questionnaires. Time to decision, length-of-stay, and hospitalization and mortality rates were retrieved from the medical charts of 1920 patients (20 per team).

RESULTS

Accurate triage was significantly higher post than pre intervention (4.84 ± 1.45 vs. 3.87 ± 1.48; range 1-7; p < .001), whereas time to decision (253.30 ± 246.75 vs. 304.64 ± 249.14 min), hospitalization rates (n = 291, 30.3% vs. n = 374, 39.0%; p < .001), and hospital length-of-stay (5.73 ± 6.72 vs. 6.69 ± 6.20; p = .04) significantly decreased.

CONCLUSIONS

By adapting organizational reflective practice principles to the ED dynamic environment, the RPI was associated with a significant improvement in ED quality-of-care measures.

Review article: Emergency department crowding measures associations with quality of care: A systematic review

ED crowding has been reported to reduce the quality of care. There are many proposed crowding metrics, but the metric most strongly associated with care quality remains unknown. The present study aims to determine the crowding metric with the strongest links with processes and outcomes of care linked to the Institute of Medicine quality domains. Systematic searches in healthcare databases were conducted using terms for 'crowding', 'metrics' and 'performance', supplemented by grey literature and citation searches. The level of evidence for each association was assessed using an explicit tool. The body of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. Evidence was synthesised using harvest plots. Titles and abstracts of 2052 studies were screened, 452 selected for full-text review and 183 included. Inter-observer agreement was moderate κ = 0.54 (95% confidence interval 0.50-0.59). Two thirds were from urban tertiary hospitals in North America (65%), Australasia (13%), Europe (12%) and Asia (8%). One third provided Level 3 or higher evidence. Metrics were based on occupancy (38%), time (31%), workload (19%) or combinations (9%). Data were synthesised from 25 607 375 patients, 2368 staff, 9089 hospitals and 101 177 sampling times. Almost all crowding metrics were patient-centred and reflect timeliness and efficiency. ED length of stay, boarding time and total occupancy had the strongest association with safety and effectiveness of care. ED length of stay was also associated with equity. The certainty of evidence for associations between crowding measures varied across domains of quality, from very low to moderate certainty.

Injuries and frequent use of emergency department services: a systematic review

OBJECTIVE

To review all studies having examined the association between patients with physical injuries and frequent emergency department (ED) attendance or return visits.

DESIGN

Systematic review.

DATA SOURCE

Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO databases were searched up to and including July 2019.

ELIGIBILITY CRITERIA

English and French language publications reporting on frequent use of ED services (frequent attendance and return visits), evaluating injured patients and using regression analysis.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened the search results, and assessed methodological quality using the Joanna Briggs Institute tool for prevalence studies. Results were collated and summarised using a narrative synthesis. A sensitivity analysis was performed to evaluate the repercussions of removing a study that did not meet the quality criteria.

RESULTS

Of the 2184 studies yielded by this search, 1957 remained after the removal of duplicates. Seventy-eight studies underwent full-text screening leaving nine that met the eligibility criteria and were included in this study: five retrospective cohort studies; two prospective cohort studies; one cross-sectional study; and one case-control study. Different types of injuries were represented, including fractures, trauma and physical injuries related to falls, domestic violence or accidents. Sample sizes ranged from 200 to 1 259 809. Six studies included a geriatric population while three addressed a younger population. Of the four studies evaluating the relationship between injuries and frequent ED use, three reported an association. Additionally, of the five studies in which the dependent variable was return ED visits, three articles identified a positive association with injuries.

CONCLUSIONS

Physical injuries appear to be associated with frequent use of ED services (frequent ED attendance as well as return ED visits). Further research into factors including relevant youth-related covariates such as substance abuse and different types of traumas should be undertaken to bridge the gap in understanding this association.

Lost bed capacity in emergency departments: A descriptive analysis and data visualisation exploration

OBJECTIVE

To map utilisation of bed resources within an ED over time, in order to determine the proportions of patient stay spent receiving emergency care versus non-emergent care. To produce visualisations that effectively convey this bed utilisation.

METHODS

This was a retrospective cohort study using routinely collected administrative data, derived from the ED electronic health record (FirstNet; Cerner, North Kansas City, MO, USA), on all patients presenting to a single tertiary-level ED during a 1-month period and who were triaged to an acute area bed in order to undergo their emergency care. Resuscitation, subacute, fast track and paediatric area patients were excluded from analysis as firstly, in our institution the acute area processing appears to contribute most to barriers to patient flow and secondly, using acute area patients allowed us to approximate standardisation of acuity. Lost bed capacity (LBC) was defined as the time spent in an ED bed after an emergency clinician indicated that they were ready to depart the ED, as recorded in the electronic medical record.

RESULTS

The overall proportion of time spent in an ED bed after completion of emergency care was 38.5% (interquartile range 21.8-47.2%). This time differed significantly between 'discharged' (1 min), 'admitted-ward' (72 min) and 'admitted-critical care' (110 min) groups. This was clearly revealed in our novel LBC heatmaps.

CONCLUSIONS

A considerable proportion of ED length of stay is because of patients remaining in an ED bed after their emergency care is concluded. Absolute time is much greater for admitted patients than for discharged patients, and therefore efforts to reduce LBC are likely to reduce overall ED length of stay. LBC heatmaps may provide an intuitively useful, potentially automated tool to understand these problems.

Length of Stay in the Emergency Department and Its Associated Factors at Jimma Medical Center, Southwest Ethiopia

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.

Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care

Background: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients’ characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient’s clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients’ management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusions: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.

Trends in Hospitalization of Patients with Potentially Serious Diseases Evaluated at a Quick Diagnosis Clinic

Although quick diagnosis units (QDU) have become a cost-effective alternative to inpatient admission for diagnosis of potentially serious diseases, the rate of return hospitalizations among evaluated patients is unknown. This study examined the temporal trends in admissions of QDU patients through 15 years. Adult patients referred to QDU from 2004 to 2019 who were hospitalized between the first and last visit in the unit were eligible. Decisions about admissions were mainly based on the Appropriateness Evaluation Protocol and required independent validation by experienced clinicians using a customized tool. The final analysis included 825 patients. Patient characteristics and major reasons for admission were compared each year and linear trends were analyzed. Admission rates decreased from 7.2% in 2004–2005 to 4.3% in 2018–2019 (p < 0.0001). While a significant increasing trend was observed in the rate of admissions due to cancer-related complications (from 39.5% in 2004–2005 to 61.7% in 2018–2019; p < 0.0001), those due to anemia-related complications and scheduled invasive procedures experienced a significant downward trend. A likely explanation for these declining trends was the relocation of the unit to a new daycare center in 2013–2014 with recovery rooms and armchairs for IV treatments. The facts of this study could help in the provision of anticipatory guidance for the optimal management of patients at risk of clinical complications.

Role of a Brief Intensive Observation Area with a Dedicated Team of Doctors in the Management of Acute Heart Failure Patients: A Retrospective Observational Study

Background and objectives: Acute heart failure (AHF) is one of the main causes of hospitalization in Western countries. Usually, patients cannot be admitted directly to the wards (access block) and stay in the emergency room. Holding units are clinical decision units, or observation units, within the ED that are able to alleviate access block and to contribute to a reduction in hospitalization. Observation units have also been shown to play a role in specific clinical conditions, like the acute exacerbation of heart failure. This study aimed to analyze the impact of a brief intensive observation (OBI) area on the management of acute heart failure (AHF) patients. The OBI is a holding unit dedicated to the stabilization of unstable patients with a team of dedicated physicians. Materials and Methods: We conducted a retrospective and single-centered observational study with retrospective collection of the data of all patients who presented to our emergency department with AHF during 2017. We evaluated and compared two cohorts of patients, those treated in the OBI and those who were not, in terms of the reduction in color codes at discharge, mortality rate within the emergency room (ER), hospitalization rate, rate of transfer to less intensive facilities, and readmission rate at 7, 14, and 30 days after discharge. Results: We enrolled 920 patients from 1^st January to 31^st December. Of these, 61% were transferred to the OBI for stabilization. No statistically significant difference between the OBI and non-OBI populations in terms of age and gender was observed. OBI patients had worse clinical conditions on arrival. The patients treated in the OBI had longer process times, which would be expected, to allow patient stabilization. The stabilization rate in the OBI was higher, since presumably OBI admission protected patients from “worse condition” at discharge. Conclusions: Data from our study show that a dedicated area of the ER, such as the OBI, has progressively allowed a change in the treatment path of the patient, where the aim is no longer to admit the patient for processing but to treat the patient first and then, if necessary, admit or refer. This has resulted in very good feedback on patient stabilization and has resulted in a better management of beds, reduced admission rates, and reduced use of high intensity care beds.

Lost capacity in emergency departments and its economic implications: A simulation study and economic analysis

OBJECTIVE

To determine the effect of lost bed capacity (LBC) on the overall capacity of an ED, and to estimate the costs attributable to excess stay in the ED beyond that required for actual emergency care.

METHODS

This was a retrospective simulation and health economic evaluation, using data from a single-centre tertiary level ED. Data from all patients who presented to the ED during a 1-month period and triaged to receive an acute bed in order to undergo their emergency care were included. The main outcomes measured were the change in overall ED length of stay, and costs attributable to LBC, in both discharged and admitted patients.

RESULTS

Overall daily median ED length of stay decreased by 182 min (95% confidence interval 165-198; P < 0.01) in the simulated cohort when LBC was removed. Within the admitted cohort, the median cost attributable to LBC was AUD$202.99 (95% confidence interval $186.50-$216.70) per patient. We estimate the cost of an ED bed to be AUD$164.59 per hour.

CONCLUSIONS

A substantial amount of ED length of stay is due to patients remaining in the ED for time after their emergency care is concluded. This likely represents a substantial overall monetary cost to the Australian healthcare system.

Liu S, A. Camargo C, Aburawi E, Moeckel M, Slagman A, Christ M, Singer A, Tazarourte K, Rathlev NK, A. Grossman S, Bellou A. Association between boarding in the emergency department and in-hospital mortality: A systematic review

IMPORTANCE

Boarding in the emergency department (ED) is a critical indicator of quality of care for hospitals. It is defined as the time between the admission decision and departure from the ED. As a result of boarding, patients stay in the ED until inpatient beds are available; moreover, boarding is associated with various adverse events.

STUDY OBJECTIVE

The objective of our systematic review was to determine whether ED boarding (EDB) time is associated with in-hospital mortality (IHM).

METHODS

A systematic search was conducted in academic databases to identify relevant studies. Medline, PubMed, Scopus, Embase, Cochrane, Web of Science, Cochrane, CINAHL and PsychInfo were searched. We included all peer-reviewed published studies from all previous years until November 2018. Studies performed in the ED and focused on the association between EDB and IHM as the primary objective were included. Extracted data included study characteristics, prognostic factors, outcomes, and IHM. A search update in PubMed was performed in May 2019 to ensure the inclusion of recent studies before publishing.

RESULTS

From the initial 4,321 references found through the systematic search, the manual screening of reference lists and the updated search in PubMed, a total of 12 studies were identified as eligible for a descriptive analysis. Overall, six studies found an association between EDB and IHM, while five studies showed no association. The last remaining study included both ICU and non-ICU subgroups and showed conflicting results, with a positive association for non-ICU patients but no association for ICU patients. Overall, a tendency toward an association between EDB and IHM using the pool random effect was observed.

CONCLUSION

Our systematic review did not find a strong evidence for the association between ED boarding and IHM but there is a tendency toward this association. Further well-controlled, international multicenter studies are needed to demonstrate whether this association exists and whether there is a specific EDB time cut-off that results in increased IHM.

Quantifying patient satisfaction with process metrics using a weighted bundle approach

Background

Current patient satisfaction assessment results are delayed and obtained from select patient surveys. As a result, these assessments may not represent the experience of the entire patient population. This study developed a method to measure and evaluate all patients' experiences while they are within the care episode and link it to processes within the organisation.

Methods

Using the Six Sigma methodology, sites assembled diverse teams to categorise and analyse negative experience comments from patients to understand the drivers of dissatisfaction. These customer expectations lead to the development of the four components in the Patient Experience Bundle (PEB): communication, environment, basic needs/comfort and logistics. Individual process elements were ranked to create a numerical relationship between service and the needs expressed by the voice of the customer. Sites created surveys incorporating questions that focused on the bundle elements and measured daily bundle compliance. Graphical analysis and hypothesis testing enabled sites to determine key drivers of patient dissatisfaction within the bundle elements. Improvement strategies were developed and implemented to address the key drivers of patient dissatisfaction.

Results

After implementing process improvements focused on issues identified by the PEB, bundle compliance improved from an average of 51% to an average of 82.5% and Press Ganey Likelihood to Recommend (PG LTR) scores improved from an average of 64.73% to an average 74.64%. The data demonstrated that the trends in improving PEB are followed by meaningful changes in PG LTR scores.

Conclusion

This work is built on the identification of common elements of care that impact patient satisfaction and detailed mathematical analysis of the relationship between factors. Using the bundle concept, these improvement efforts maintain highly reliable processes to drive outcomes and provide real-time feedback on patient experience.

Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: a qualitative social dynamic perspective

Background

The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project.

Methods

The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015–2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis.

Results

Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels.

Conclusion

Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff’s experiences.

Medications that reduce emergency hospital admissions: an overview of systematic reviews and prioritisation of treatments

BACKGROUND

Rates of emergency hospitalisations are increasing in many countries, leading to disruption in the quality of care and increases in cost. Therefore, identifying strategies to reduce emergency admission rates is a key priority. There have been large-scale evidence reviews to address this issue; however, there have been no reviews of medication therapies, which have the potential to reduce the use of emergency health-care services. The objectives of this study were to review systematically the evidence to identify medications that affect emergency hospital admissions and prioritise therapies for quality measurement and improvement.

METHODS

This was a systematic review of systematic reviews. We searched MEDLINE, PubMed, the Cochrane Database of Systematic Reviews & Database of Abstracts of Reviews of Effects, Google Scholar and the websites of ten major funding agencies and health charities, using broad search criteria. We included systematic reviews of randomised controlled trials that examined the effect of any medication on emergency hospital admissions among adults. We assessed the quality of reviews using AMSTAR. To prioritise therapies, we assessed the quality of trial evidence underpinning meta-analysed effect estimates and cross-referenced the evidence with clinical guidelines.

RESULTS

We identified 140 systematic reviews, which included 1968 unique randomised controlled trials and 925,364 patients. Reviews contained 100 medications tested in 47 populations. We identified high-to moderate-quality evidence for 28 medications that reduced admissions. Of these medications, 11 were supported by clinical guidelines in the United States, the United Kingdom and Europe. These 11 therapies were for patients with heart failure (angiotensin-converting-enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor antagonists and digoxin), stable coronary artery disease (intensive statin therapy), asthma exacerbations (early inhaled corticosteroids in the emergency department and anticholinergics), chronic obstructive pulmonary disease (long-acting muscarinic antagonists and long-acting beta-2 adrenoceptor agonists) and schizophrenia (second-generation antipsychotics and depot/maintenance antipsychotics).

CONCLUSIONS

We identified 11 medications supported by strong evidence and clinical guidelines that could be considered in quality monitoring and improvement strategies to help reduce emergency hospital admission rates. The findings are relevant to health systems with a large burden of chronic disease and those managing increasing pressures on acute health-care services.

Consensus-based clinical research priorities for emergency nursing in Australia

INTRODUCTION

Research is vital to responding to contemporary challenges of providing safe, high quality emergency nursing care, yet the research priorities for emergency nursing practice in Australia are unknown. This study aimed to establish research priorities for emergency nursing in Australia.

METHODS

A two-stage descriptive, exploratory study was conducted. First, research themes were identified through a survey of 232 emergency nurses the Delphi Technique (2 rounds) was used to rank and prioritise the research themes.

RESULTS

There were five research themes with a CVI≥0.90: (i) recognising and responding to deteriorating ED patients; (ii) effect of access block on clinical care of admitted ICU patients; (iii) effects of ED overcrowding on clinical care; (iv) scope of practice of specialist emergency nurses; and (v) effect of access block on clinical care of admitted ward patients. These are reflected in four broad research priority areas: professional issues, patient safety, emergency care of vulnerable populations, and healthcare system issues.

CONCLUSION

Future research should focus on these priority areas in partnership with other emergency disciplines to enable safe, high quality emergency care, and, to inform the practice of emergency nursing in Australia.

Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine

Background

The main objective of this methodological manuscript was to illustrate the role of using qualitative research in emergency settings. We outline rigorous criteria applied to a qualitative study assessing perceptions and experiences of staff working in Australian emergency departments.

Methods

We used an integrated mixed-methodology framework to identify different perspectives and experiences of emergency department staff during the implementation of a time target government policy. The qualitative study comprised interviews from 119 participants across 16 hospitals. The interviews were conducted in 2015–2016 and the data were managed using NVivo version 11. We conducted the analysis in three stages, namely: conceptual framework, comparison and contrast and hypothesis development. We concluded with the implementation of the four-dimension criteria (credibility, dependability, confirmability and transferability) to assess the robustness of the study,

Results

We adapted four-dimension criteria to assess the rigour of a large-scale qualitative research in the emergency department context. The criteria comprised strategies such as building the research team; preparing data collection guidelines; defining and obtaining adequate participation; reaching data saturation and ensuring high levels of consistency and inter-coder agreement.

Conclusion

Based on the findings, the proposed framework satisfied the four-dimension criteria and generated potential qualitative research applications to emergency medicine research. We have added a methodological contribution to the ongoing debate about rigour in qualitative research which we hope will guide future studies in this topic in emergency care research. It also provided recommendations for conducting future mixed-methods studies. Future papers on this series will use the results from qualitative data and the empirical findings from longitudinal data linkage to further identify factors associated with ED performance; they will be reported separately.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2915-2) contains supplementary material, which is available to authorized users.

The importance of population differences: Influence of individual characteristics on the Australian public's preferences for emergency care

A better understanding of the public's preferences and what factors influence them is required if they are to be used to drive decision-making in health. This is particularly the case for service areas undergoing continual reform such as emergency and primary care. Accordingly, this study sought to determine if attitudes, socio-demographic characteristics and healthcare experiences influence the public's intentions to access care and their preferences for hypothetical emergency care alternatives. A discrete choice experiment was used to elicit the preferences of Australian adults (n=1529). Mixed logit regression analyses revealed the influence of a range of individual characteristics on preferences and service uptake choices across three different presenting scenarios. Age was associated with service uptake choices in all contexts, whilst the impact of other sociodemographics, health experience and attitudinal factors varied by context. The improvements in explanatory power observed from including these factors in the models highlight the need to further clarify their influence with larger populations and other presenting contexts, and to identify other determinants of preference heterogeneity. The results suggest social marketing programs undertaken as part of demand management efforts need to be better targeted if decision-makers are seeking to increase community acceptance of emerging service models and alternatives. Other implications for health policy, service planning and research, including for workforce planning and the possible introduction of a system of co-payments are discussed.

Uniting emergency and inpatient clinicians across the ED-inpatient interface: The last frontier?

Unwell patients in the ED requiring inpatient admission must negotiate the interface between the ED and inpatient wards. Despite its importance and scale, this ED-inpatient interface (EDii) is poorly characterised. The aim of this paper is to clearly define the EDii and to describe its importance to (i) the patient: delays to admission and errors in communication across the EDii can increase adverse outcomes; (ii) the hospital: poor EDii function reduces hospital efficiency and effectiveness; and (iii) the healthcare system: half of all hospital inpatient admissions occur via the EDii and so EDii affects system-wide performance. The EDii can be defined as the dynamic, transitional phase of patient care in which responsibility for, and delivery of care, is shared between ED and inpatient hospital services. The EDii is characterised by a complex interplay of patient, hospital and system factors. A clear definition of the EDii and an understanding of its importance will assist future research and interventions to improve patient outcomes.

Towards a best measure of emergency department crowding: Lessons from current Australasian practice

OBJECTIVE

Despite extensive literature, how crowding in EDs should be measured is still debated. The present study aimed to describe crowding metrics used in Australasia, what they were used for, the perceived extent and frequency of crowding and the challenges faced when trying to measure crowding.

METHODS

A survey of ED clinical directors was undertaken between December 2014 and July 2015. Free-text responses were categorised and thematically coded. Quantitative data were analysed descriptively and with logistic regression.

RESULTS

There were 113 of 145 responses (78%). Crowding was considered a major problem by 84 of 113 (74%) and not rare by 88 of 111 participants (79%). These constructs were correlated; G = -0.851, P < 0.001. Levels 1-3 EDs were less likely to report crowding as a major problem than Level 4 EDs; odds ratio 0.15 (0.03-0.69), P = 0.02. Sixteen current metrics were identified and categorised into 'time', 'occupancy' and 'workload' metrics. These categories of metric were used differently, and multiple metrics had more uses than single metrics. Previously described complex crowding metrics were infrequently recognised (<20%). Common challenges to measuring crowding were lack of an agreed metric (40%) and lack of buy-in by inpatient teams or hospital management (35%).

CONCLUSION

ED crowding remains a common and important problem in Australasia. Crowding is multifaceted, so a single metric might not capture all important elements of crowding or be relevant to all stakeholders. However, a metric like Access Block, which encompasses elements of time, occupancy and workload and is relevant to stakeholders outside the ED, might hold the most promise.

Improving Emergency Department radiology transportation time: a successful implementation of lean methodology

Background

Emergency Department overcrowding has become a global problem and a growing safety and quality concern. Radiology and laboratory turnaround time, ED boarding and increased ED visits are some of the factors that contribute to ED overcrowding. Lean methods have been used in the ED to address multiple flow challenges from improving door-to-doctor time to reducing length of stay. The objective of this study is to determine the effectiveness of using Lean management methods on improving Emergency Department transportation times for plain radiography.

Methods

We performed a before and after study at an academic urban Emergency Department with 49,000 annual visits after implementing a Lean driven intervention. The primary outcome was mean radiology transportation turnaround time (TAT). Secondary outcomes included overall study turnaround time from order processing to preliminary report time as well as ED length of stay. All ED patients undergoing plain radiography 6 months pre-intervention were compared to all ED patients undergoing plain radiography 6 months post-intervention after a 1 month washout period.

Results

Post intervention there was a statistically significant decrease in the mean transportation TAT (mean ± SD: 9.87 min ± 15.05 versus 22.89 min ± 22.05, respectively, p-value <0.0001). In addition, it was found that 71.6% of patients in the post-intervention had transportation TAT ≤ 10 min, as compared to 32.3% in the pre-intervention period, p-value <0.0001, with narrower interquartile ranges in the post-intervention period. Similarly, the “study processing to preliminary report time” and the length of stay were lower in the post-intervention as compared to the pre-intervention, (52.50 min ± 35.43 versus 54.04 min ± 34.72, p-value = 0.02 and 3.65 h ± 5.17 versus 4.57 h ± 10.43, p < 0.0001, respectively), in spite of an increase in the time it took to elease a preliminary report in the post-intervention period.

Conclusion

Using Lean change management techniques can be effective in reducing transportation time to plain radiography in the Emergency Department as well as improving process reliability.

A Systematic Review of the Impact of Healthcare Reforms on Access to Emergency Department and Elective Surgery Services: 1994-2014

This systematic review sought to identify whether health care reforms led to improvement in the emergency department (ED) length of stay (LOS) and elective surgery (ES) access in Australia, Canada, New Zealand, and the United Kingdom. The review was registered in the PROSPERO database (CRD42015016343), and nine databases were searched for peer-reviewed, English-language reports published between 1994 and 2014. We also searched relevant "grey" literature and websites. Included studies were checked for cited and citing papers. Primary studies corresponding to national and provincial ED and ES reforms in the four countries were considered. Only studies from Australia and the United Kingdom were eventually included, as no studies from the other two countries met the inclusion criteria. The reviewers involved in the study extracted the data independently using standardized forms. Studies were assessed for quality, and a narrative synthesis approach was taken to analyze the extracted data. The introduction of health care reforms in the form of time-based ED and ES targets led to improvement in ED LOS and ES access. However, the introduction of targets resulted in unintended consequences, such as increased pressure on clinicians and, in certain instances, manipulation of performance data.

Describing the categories of people that contribute to an Emergency Centre crowd at Khayelitsha hospital, Western Cape, South Africa

INTRODUCTION

Emergency Centre (EC) crowding has globally been recognised to adversely affect patients, staff and visitors. Anecdotally, local ECs are perceived to be fairly crowded, however, not much is known about the size of this crowd and what constitutes it. Although more reliable, resource restrictions render more detailed flow studies less achievable. This study describes the EC crowd at Khayelitsha hospital in Cape Town, South Africa as the number and different categories of people, at predefined times during the day over a four-week period.

METHODS

A prospective, cross-sectional design was used. Headcounts were made by predefined groups at 09h00, 14h00, and 21h00 every day for four weeks. Predefined groups included doctors, nurses, visitors, patients, and other allied health staff. Summary statistics were used to describe the data. Precision was described using the 95% confidence interval.

RESULTS

A total of 16,353 people were counted during the study period. On average, 6370 (39%) of the groups were staff, 5231 (32%) were patients and 4752 (29%) were visitors. Of the staff, 586 (3.6%) were EC doctors, 733 (4.4%) were non-EC doctors, 1488 (9%) were EC nurses, and 445 (3%) were non-EC nurses. Although patient numbers in the EC remained constant, visitors and non-EC staff varied significantly with visitors peaking in the afternoon and non-EC staff drastically reducing in the evening. The EC was consistently crowded - average occupancy: 130%.

CONCLUSION

Staff levels fluctuated predictably, reducing at night and over weekends, while patient levels remained constant. Non-EC doctors more than doubled during the day on week shifts, in significantly more numbers than EC doctors, suggesting that many of the patients in the EC were likely to be admissions boarding in the EC. Visitor numbers were substantial during visiting hours and further aggravated crowding. Resource-light studies involving flow are important to explore crowding in low- and middle income settings.

Factors associated with failure of emergency wait-time targets for high acuity discharges and intensive care unit admissions

Objective

Ontario established emergency department length-of-stay (EDLOS) targets but has difficulty achieving them. We sought to determine predictors of target time failure for discharged high acuity patients and intensive care unit (ICU) admissions.

Methods

This was a retrospective, observational study of 2012 Sunnybrook Hospital emergency department data. The main outcome measure was failing to meet government EDLOS targets for high acuity discharges and ICU emergency admissions. The secondary outcome measures examined factors for low acuity discharges and all admissions, as well as a run chart for 2015 – 2016 ICU admissions. Multiple logistic regression models were created for admissions, ICU admissions, and low and high acuity discharges. Predictor variables were at the patient level from emergency department registries.

Results

For discharged high acuity patients, factors predicting EDLOS target failure were having physician initial assessment duration (PIAD)>2 hours (OR 5.63 [5.22-6.06]), consultation request (OR 10.23 [9.38-11.14]), magnetic resonance imaging (MRI) (OR 19.33 [12.94-28.87]), computed tomography (CT) (OR 4.24 [3.92-4.59]), and ultrasound (US) (OR 3.47 [3.13-3.83]). For ICU admissions, factors predicting EDLOS target failure were bed request duration (BRD)>6 hours (OR 364.27 [43.20-3071.30]) and access block (AB)>1 hour (OR 217.27 [30.62-1541.63]). For discharged low acuity patients, factors predicting failure for the 4-hour target were PIAD>2 hours (OR 15.80 [13.35-18.71]), consultation (OR 20.98 [14.10-31.22]), MRI (OR 31.68 [6.03-166.54]), CT (OR 16.48 [10.07-26.98]), and troponin I (OR 13.37 [6.30-28.37]).

Conclusion

Sunnybrook factors predicting failure of targets for high acuity discharges and ICU admissions were hospital-controlled. Hospitals should individualize their approach to shortening EDLOS by analysing its patient population and resource demands.

The impact of walk-in centres and GP co-operatives on emergency department presentations: A systematic review of the literature

BACKGROUND

Internationally, non-urgent presentations are increasing the pressure on Emergency Department (ED) staff and resources. This systematic review aims to identify the impact of alternative emergency care pathways on ED presentations - specifically GP cooperatives and walk-in clinics.

METHODS

Based on a structured PICO enquiry with either walk-in clinic or GP cooperative as the intervention, a search was made for peer-reviewed publications in English, between 2000 and 2014. Medline plus, OVID, PubMed, and Google Scholar were searched. The Critical Appraisal Skills Program (CASP) guidelines were used to assess study quality and data was extracted using an adapted JBI Qualitative Assessment and Review Instrument (QARI). Subsequent reporting followed the PRISMA guideline.

RESULTS

Eleven high quality quantitative studies met the inclusion criteria. Walk-in clinics do have the potential to reduce non-urgent emergency department presentations, however evidence of this effect is low. GP cooperatives offer an alternative care stream for patients presenting to the ED and do significantly reduce local ED attendances. Community members need to be made aware of these options in order to make informed treatment choices.

CONCLUSION

GP cooperatives in particular do have the potential to reduce ED workload. Further research is required to uncover recent trends and patient outcomes for walk-in clinics and GP cooperatives.

Why do children present to emergency departments? Exploring motivators and measures of presentation appropriateness for children presenting to a paediatric emergency department

AIM

To compare the parental motivators and referring general practitioner's (GP's) reasons for advising emergency department (ED) attendance with the assessment of ED medical staff. To compare ED clinician opinion with other published methods that have attempted to define 'primary care suitable' presentations to the ED.

METHODS

A prospective observational study and series of surveys regarding the attendance of children presenting to a single tertiary paediatric ED. Surveys were distributed to the treating ED clinician, the child's parent/guardian, and the referring GP. Results between the three groups were analysed and compared.

RESULTS

There were a total of 1069 presentations during the study period. Six hundred (58.4%, 95% CI 55.3-61.4%) presentations were judged as 'ED appropriate' by the treating ED clinician. When compared with methods used to retrospectively judge whether ED patients are considered 'primary care suitable', ED clinicians disagree between 22.4 and 38.8% of the time. For patients who presented directly to ED, 85.6% did so for a medical reason, whilst 32.1% did so for a GP access reason. Being referred by a GP improved the ED clinicians' opinion of the appropriateness of the presentation (49.2 vs. 73.9%, P < 0.05).

CONCLUSIONS

We caution that many strategies attempting to 'solve' the issue of increasing ED attendances by paediatric patients have been driven by opinion, and a better understanding of the motivators that drive this behaviour is needed. We believe the solution to increasing utilisation of EDs by children must be a balanced approach that addresses community expectations and appropriately resources EDs.

Two Hour Evaluation and Referral Model for Shorter Turnaround Times in the emergency department

OBJECTIVE

The objective of this study was to assess the implementation of a novel ED model of care, which combines clinical streaming, team-based assessment and early senior consultation to reduce length of stay.

METHODS

A pre-post-intervention study was used to compare ED performance following an extensive clinical redesign programme. Clinical teams and work sequences were reconfigured to promote the role of the staff specialist, with a focus on earlier decisions regarding disposition. Primary outcome measures were ED length of stay and National Emergency Access Target (NEAT) compliance. Secondary outcomes included referral and workup times, wait times by triage category, ambulance offload times, ward discharges and unit transfers within 24 h of admission, representation within 48 h, and Medical Emergency Response Team (MERT) calls within 24 h of admission.

RESULTS

Two seasonally matched 26 week intervals were compared with adjustment for demographics, triage category and arrival by ambulance. Overall, there was an 18.4% rise in NEAT performance (95% confidence interval (CI): 17.7-19.1) while ED length of stay decreased by a total of 86.8 min (95% CI: 83.6-90.1). Time series analysis did not suggest any preexisting trends to explain these results. The average time to referral decreased by 74.7 min (95% CI: 69.8-79.6) and waiting times decreased across all triage categories. Rates of MERT activation and unplanned representation were unchanged.

CONCLUSION

A facilitated team leader role for senior doctors can help to reduce length of stay by via early disposition, without significant risks to the patient.

Implementation evaluation and refinement of an intervention to improve blunt chest injury management-A mixed-methods study

Aims and objectives

To investigate uptake of a Chest Injury Protocol (ChIP), examine factors influencing its implementation and identify interventions for promoting its use.

Background

Failure to treat blunt chest injuries in a timely manner with sufficient analgesia, physiotherapy and respiratory support, can lead to complications such as pneumonia and respiratory failure and/or death.

Design

This is a mixed‐methods implementation evaluation study.

Methods

Two methods were used: (i) identification and review of the characteristics of all patients eligible for the ChIP protocol, and (ii) survey of hospital staff opinions mapped to the Theoretical Domains Framework (TDF) to identify barriers and facilitators to implementation. The characteristics and treatment received between the groups were compared using the chi‐square test or Fischer's exact test for proportions, and the Mann–Whitney U‐test for continuous data. Quantitative survey data were analysed using descriptive statistics. Qualitative data were coded in NVivo 10 using a coding guide based on the TDF and Behaviour Change Wheel (BCW). Identification of interventions to change target behaviours was sourced from the Behaviour Change Technique Taxonomy Version 1 in consultation with stakeholders.

Results

Only 68.4% of eligible patients received ChIP. Fifteen facilitators and 10 barriers were identified to influence the implementation of ChIP in the clinical setting. These themes were mapped to 10 of the 14 TDF domains and corresponded with all nine intervention functions in the BCW. Seven of these intervention functions were selected to address the target behaviours and a multi‐faceted relaunch of the revised protocol developed. Following re‐launch, uptake increased to 91%.

Conclusions

This study demonstrated how the BCW may be used to revise and improve a clinical protocol in the ED context.

Relevance to clinical practice

Newly implemented clinical protocols should incorporate clinician behaviour change assessment, strategy and interventions. Enhancing the self‐efficacy of emergency nurses when performing assessments has the potential to improve patient outcomes and should be included in implementation strategy.

Cross-sectional study of emergency department presentation triage categories at Goondiwindi Hospital and their effect on the treatment of acute emergencies

OBJECTIVE

The objective of this study was to investigate the number and proportion of non-acute presentations to a district hospital emergency department in Goondiwindi, a rural Queensland town, both in the treatment of emergency cases and potential barriers patients have in seeing a medical practitioner in the general practice setting.

DESIGN

Occasions of service to Goondiwindi Hospital were collated from administrative records according to Australasian Triage Scale categories and analysed by Student's t-test for monthly variations in triage category presentations.

SETTING

Outpatient clinic (emergency department of a public district hospital).

PARTICIPANTS

All patients presenting to Goondiwindi Hospital Emergency Department from 1 January 2013 to 30 June 2013.

MAIN OUTCOME MEASURE

Proportion of high and low triage category presentations in Goondiwindi Hospital during the study period.

RESULTS

Triage category 4 and 5 presentations comprised 35.9% (mean = 225 per month) and 44.4% (mean = 278 per month), respectively, of all occasions of service at the Goondiwindi Hospital Emergency Department during this 6 month period. Life-threatening presentations (Triage Category 1 and 2) comprised <5% of all occasions of service at Goondiwindi Hospital. There were statistically insignificant differences between total occasions of service by month of presentation.

CONCLUSIONS

Although patients of all acuities presented to Goondiwindi Hospital, low-acuity presentations were more common than reported at larger hospitals. Frequent interruptions impairing attention to more urgent tasks were noted at Goondiwindi Hospital, causing delayed treatment of sick patients. Educating the local community in the appropriate use of public health services would help direct more attention to the most ill seeking medical care at rural emergency departments such as Goondiwindi Hospital.

Accuracy of rapid disposition by emergency clinicians

Objectives Rapid disposition protocols are increasingly being considered for implementation in emergency departments (EDs). Among patients presenting to an adult tertiary referral hospital, this study aimed to compare prediction accuracy of a rapid disposition decision at the conclusion of history and examination, compared with disposition following standard assessment. Methods Prospective observational data were collected for 1 month between October and November 2012. Emergency clinicians (including physicians, registrars, hospital medical officers, interns and nurse practitioners) filled out a questionnaire within 5 min of obtaining a history and clinical examination for eligible patients. Predicted patient disposition (representing ‘rapid disposition’) was compared with final disposition (determined by ‘standard assessment’). Results There were 301 patient episodes included in the study. Predicted disposition was correct in 249 (82.7%, 95% confidence interval (CI) 78.0–86.8) cases. Accuracy of predicting discharge to home appeared highest among emergency physicians at 95.8% (95% CI 78.9–99.9). Overall accuracy at predicting admission was 79.7% (95% CI 67.2–89.0). The remaining 20.3% (95% CI 11.0–32.8) were not admitted following standard assessment. Conclusion Rapid disposition by ED clinicians can predict patient destination accurately but was associated with a potential increase in admission rates. Any model of care using rapid disposition decision making should involve establishment of inpatient systems for further assessment, and a culture of timely inpatient team transfer of patients to the most appropriate treating team for ongoing patient management. What is known about the topic? In response to the National Emergency Access Targets, there has been widespread adoption of rapid-disposition-themed care models across Australia. Although there is emerging data that clinicians can predict disposition accurately, this data is currently limited. What does this paper add? Results of this study support the previously limited evidence that ED practitioners can accurately predict disposition early in the patient journey through ED, and that accuracy is similar across clinician groups. In addition to overall prediction accuracy, admission, discharge and treating team predictions were separately measured. These additional outcomes lend insight into safety and performance aspects relating to a rapid disposition model of care. What are the implications for practitioners? This study offers practical insights that could aid safe and efficient implementation of a rapid disposition model of care.

Impact of process improvements on measures of emergency department efficiency

OBJECTIVE

To study the operational impact of process improvements on emergency department (ED) patient flow. The changes did not require any increase in resources or expenditures.

METHODS

This was a 36-month pre- and post-intervention study to evaluate the effect of implementing process improvements at a community ED from January 2010 to December 2012. The intervention comprised streamlining triage by having patients accepted into internal waiting areas immediately after triage. Within the ED, parallel processes unfolded, and there was no restriction on when registration occurred or which health care provider a patient saw first. Flexible nursing ratios allowed nursing staff to redeploy and move to areas of highest demand. Last, demand-based physician scheduling was implemented. The main outcome was length of stay (LOS). Secondary outcomes included time to physician initial assessment (PIA), left-without-being-seen (LWBS) rates, and left-against-medical-advice (LAMA) rates. Segmented regression of interrupted time series analysis was performed to quantify the impact of the intervention, and whether it was sustained.

RESULTS

Patients totalling 251,899 attended the ED during the study period. Daily patient volumes increased 17.3% during the post-intervention period. Post-intervention, mean LOS decreased by 0.64 hours (p<0.005). LOS for non-admitted Canadian Triage and Acuity Scale 2 (-0.58 hours, p<0.005), 3 (-0.75 hours, p<0.005), and 4 (-0.32 hours, p<0.005) patients also decreased. There were reductions in PIA (43.81 minutes, p<0.005), LWBS (35.2%, p<0.005), and LAMA (61.9%, p<0.005).

CONCLUSION

A combination of process improvements in the ED was associated with clinically significant reductions in LOS, PIA, LWBS, and LAMA for non-resuscitative patients.

A Realist Case Study of a Regional Hospital's Response to Improve Emergency Department Access in the Context of Australian Health Care Reforms

Introduction:

Major health-care reforms have extended across all Australian public hospitals in recent years. Improving emergency department (ED) access has been a focus of these reforms.

Objective:

This study evaluates how the national reforms have led to improvement in ED access in a regional hospital in remote Australia.

Methods:

Assessing a complex scenario such as national reforms and the challenges faced by the regional hospital to implement these reforms requires in-depth analysis. A realist evaluation theory-based approach was employed, allowing investigation of what, how, why, and for whom change occurred. A case study mixed methods design was adopted within the realist framework to answer these questions about change.

Results and Conclusion:

The study identified moderate improvement in ED access as a result of the reforms (investment in infrastructure and workforce and the introduction of ED targets). Clinical leadership and support from management were essential for the improvement. Without ongoing investment and clinical redesign activities, however, sustainability of the improvement may prove difficult.

Cost-effectiveness of 'Program We Care' for patients with chronic obstructive pulmonary disease: A case-control study

OBJECTIVES

To evaluate the effectiveness of a discharge program for patients with chronic obstructive pulmonary disease (COPD) patients on discharge from an emergency medical ward on discharge home rate, hospital length of stay (LOS), inpatient admission rate and cost.

BACKGROUND

Frequent visits to the emergency department (ED) and subsequent hospital admission are common among patients with COPD, which adds a burden to ED and hospital care. A discharge program was implemented in an ED emergency medical ward. The program consisted of multidisciplinary care, discharge planning, discharge health education on disease management, and continued support from the community nursing services.

METHODS

A retrospective case-control study was used. Data were retrieved and compared between 478 COPD program cases and 478 COPD non-program cases.

RESULTS

No significant difference was found in age, gender, and triage category, LOS in ED, and readmission rate between the program and non-program groups. The program group demonstrated a significantly higher discharge home rate from the ED (33.89% vs. 20.08%) and fewer medical admissions (40.59% vs. 55.02%) compared with the non-program group, resulting in lower total medical costs after the program was implemented.

CONCLUSION

The program provides insight on the strategic planning for discharge care in a short stay unit of emergency department.

PERC rule to exclude the diagnosis of pulmonary embolism in emergency low-risk patients: study protocol for the PROPER randomized controlled study

BACKGROUND

The diagnosis of Pulmonary Embolism (PE) in the emergency department (ED) is crucial. As emergency physicians fear missing this potential life-threatening condition, PE tends to be over-investigated, exposing patients to unnecessary risks and uncertain benefit in terms of outcome. The Pulmonary Embolism Rule-out Criteria (PERC) is an eight-item block of clinical criteria that can identify patients who can safely be discharged from the ED without further investigation for PE. The endorsement of this rule could markedly reduce the number of irradiative imaging studies, ED length of stay, and rate of adverse events resulting from both diagnostic and therapeutic interventions. Several retrospective and prospective studies have shown the safety and benefits of the PERC rule for PE diagnosis in low-risk patients, but the validity of this rule is still controversial. We hypothesize that in European patients with a low gestalt clinical probability and who are PERC-negative, PE can be safely ruled out and the patient discharged without further testing.

METHODS/DESIGN

This is a controlled, cluster randomized trial, in 15 centers in France. Each center will be randomized for the sequence of intervention periods: a 6-month intervention period (PERC-based strategy) followed by a 6-month control period (usual care), or in reverse order, with 2 months of "wash-out" between the 2 periods. Adult patients presenting to the ED with a suspicion of PE and a low pre test probability estimated by clinical gestalt will be eligible. The primary outcome is the percentage of failure resulting from the diagnostic strategy, defined as diagnosed venous thromboembolic events at 3-month follow-up, among patients for whom PE has been initially ruled out.

DISCUSSION

The PERC rule has the potential to decrease the number of irradiative imaging studies in the ED, and is reported to be safe. However, no randomized study has ever validated the safety of PERC. Furthermore, some studies have challenged the safety of a PERC-based strategy to rule-out PE, especially in Europe where the prevalence of PE diagnosed in the ED is high. The PROPER study should provide high-quality evidence to settle this issue. If it confirms the safety of the PERC rule, physicians will be able to reduce the number of investigations, associated subsequent adverse events, costs, and ED length of stay for patients with a low clinical probability of PE.

TRIAL REGISTRATION

NCT02375919 .

Cost-effectiveness of a physician-nurse supplementary triage assessment team at an academic tertiary care emergency department

OBJECTIVE

The purpose of this study was to evaluate the cost-effectiveness of physician-nurse supplementary triage assistance team (MDRNSTAT) from a hospital and patient perspective.

METHODS

This was a cost-effectiveness evaluation of a cluster randomized control trial comparing the MDRNSTAT with nurse-only triage in the emergency department (ED) between the hours of 0800 and 1500. Cost was MDRNSTAT salary. Revenue was from Ontario's Pay-for-Results and patient volume-case mix payment programs. The incremental cost-effectiveness ratio was based on MDRNSTAT cost and three consequence assessments: 1) per additional patient-seen; 2) per physician initial assessment (PIA) hour saved; and 3) per ED length of stay (EDLOS) hour saved. Patient opportunity cost was determined. Patient satisfaction was quantified by a cost-benefit ratio. A sensitivity analysis extrapolating MDRNSTAT to different working hours, salary, and willingness-to-pay data was performed.

RESULTS

The added cost of the MDRNSTAT was $3,597.27 [$1,729.47 to ∞] per additional patient-seen, $75.37 [$67.99 to $105.30] per PIA hour saved, and $112.99 [$74.68 to $251.43] per EDLOS hour saved. From the hospital perspective, the cost-benefit ratio was 38.6 [19.0 to ∞] and net present value of -$447,996 [-$435,646 to -$459,900]. For patients, the cost-benefit ratio for satisfaction was 2.8 [2.3 to 4.6]. If MDRNSTAT performance were consistently implemented from noon to midnight, it would be more cost-effective.

CONCLUSIONS

The MDRNSTAT is not a cost-effective daytime strategy but appears to be more feasible during time periods with higher patient volume, such as late morning to evening.