Effect on emergency department efficiency of an accelerated diagnostic pathway for the evaluation of chest pain

Emergency department performance assessment using administrative data: A managerial framework

Administrative data play an important role in performance monitoring of healthcare providers. Nonetheless, little attention has been given so far to the emergency department (ED) evaluation. In addition, most of existing research focuses on a single core ED function, such as treatment or triage, thus providing a limited picture of performance. The goal of this study is to harness the value of routinely produced records proposing a framework for multidimensional performance evaluation of EDs able to support internal decision stakeholders in managing operations. Starting with the overview of administrative data, and the definition of the desired framework's characteristics from the perspective of decision stakeholders, a review of the academic literature on ED performance measures and indicators is conducted. A performance measurement framework is designed using 224 ED performance metrics (measures and indicators) satisfying established selection criteria. Real-world feedback on the framework is obtained through expert interviews. Metrics in the proposed ED performance measurement framework are arranged along three dimensions: performance (quality of care, time-efficiency, throughput), analysis unit (physician, disease etc.), and time-period (quarter, year, etc.). The framework has been judged as "clear and intuitive", "useful for planning", able to "reveal inefficiencies in care process" and "transform existing data into decision support information" by the key ED decision stakeholders of a teaching hospital. Administrative data can be a new cornerstone for health care operation management. A framework of ED-specific indicators based on administrative data enables multi-dimensional performance assessment in a timely and cost-effective manner, an essential requirement for nowadays resource-constrained hospitals. Moreover, such a framework can support different stakeholders' decision making as it allows the creation of a customized metrics sets for performance analysis with the desired granularity.

Point-of-Care Testing for the Emergency Department Patient: Quantity and Quality of the Available Evidence

CONTEXT.—

Point-of-care test (POCT) instruments produce lab results with rapid turnaround times. Based on that fact, emergency department (ED) POCT requests are predicated on the belief that rapid test turnaround times lead to improved care, typically a decreased ED length of stay (LOS).

OBJECTIVE.—

To compile the available peer-reviewed data regarding use of POCT in the ED with an emphasis on ED-LOS.

DATA SOURCES.—

An English-language PubMed search using the following free text terms: ("EMERGENCY" AND "POINT OF CARE") NOT ULTRASOUND as well as "RAPID INFECTIOUS DISEASE TESTING." In addition, the PubMed "similar articles" functionality was used to identify related articles that were not identified on the initial search.

CONCLUSIONS.—

Seventy-four references were identified that studied POCT ED use to determine if they resulted in significant changes in ED processes, especially ED-LOS. They were divided into 3 groups: viral-influenza (n = 24), viral-respiratory not otherwise specified (n = 8), and nonviral (n = 42). The nonviral group was further divided into the following groups: chemistry, cardiac, bacterial/strep, C-reactive protein, D-dimer, drugs of abuse, lactate, and pregnancy. Across all groups there was a trend toward a significantly decreased ED-LOS; however, a number of studies showed no change, and a third group was not assessed for ED-LOS. For POCT to improve ED-LOS it has to be integrated into existing ED processes such that a rapid test result will allow the patient to have a shorter LOS, whether it is to discharge or admission.

The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: a multisite prospective longitudinal nested cohort study

BACKGROUND

Health reforms in service improvement have included the use of nurse practitioners. In rural emergency departments, nurse practitioners work to the full scope of their expanded role across all patient acuities including those presenting with undifferentiated chest pain. Currently, there is a paucity of evidence regarding the effectiveness of emergency nurse practitioner service in rural emergency departments. Inquiry into the safety and quality of the service, particularly regarding the management of complex conditions is a priority to ensure that this service improvement model meets health care needs of rural communities.

METHODS

This study used a prospective, longitudinal nested cohort study of rural emergency departments in Queensland, Australia. Sixty-one consecutive adult patients with chest pain who presented between November 2014 and February 2016 were recruited into the study cohort. A nested cohort of 41 participants with suspected or confirmed acute coronary syndrome were identified. The primary outcome was adherence to guidelines and diagnostic accuracy of electrocardiograph interpretation for the nested cohort. Secondary outcomes included service indicators of waiting times, diagnostic accuracy as measured by unplanned representation rates, satisfaction with care, quality-of-life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care.

RESULTS

The median waiting time was 8.0 min (IQR 20) and length-of-stay was 100.0 min (IQR 64). Participants were 2.4 times more likely to have an unplanned representation if managed by the standard service model. The majority of participants (91.5%) were highly satisfied with the care that they received, which was maintained at 30-day follow-up measurement. In the evaluation of quality of life and functional status, summary scores for the SF-12 were comparable with previous studies. No differences were demonstrated between service models.

CONCLUSIONS

There was a high level of adherence to clinical guidelines for the emergency nurse practitioner service model and a concomitant high level of diagnostic accuracy. Nurse practitioner service demonstrated comparable effectiveness to that of the standard care model in the evaluation of the service indicators and patient reported outcomes. These findings provide a foundation for the beginning evaluation of rural emergency nurse practitioner service in the delivery of safe and effective beyond the setting of minor injury and illness presentations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616000823471 (Retrospectively registered).

Retrospective observational study of patients who present to Australian rural emergency departments with undifferentiated chest pain

OBJECTIVE

To identify the demographic and clinical characteristics of patients who present to Australian rural emergency departments (EDs) with chest pain.

DESIGN

Retrospective, observational study.

SETTING

Rural EDs in Queensland, Australia.

PARTICIPANTS

Three hundred thirty-seven consecutive adult patients with undifferentiated chest pain who presented between 1 September 2013 and 30 November 2013.

MAIN OUTCOME MEASURES

Service indicators, discharge diagnoses and disposition.

RESULTS

Presentations for undifferentiated chest pain represented 3.5% of all patient presentations during the sampling period. The mean age of patients was 48 years and 54% were male. Overall, 92% of patients left the ED within the 4-hour NEAT target. The majority of presentations were related to cardiac concerns (39%), followed by non-cardiac chest pain (17%), musculoskeletal (15%) and respiratory (10%) conditions. More than half of these patients were discharged at the completion of the ED service (52.8%), 40.6% were admitted, 3.3% left at own risk, 2.4% did not wait and less than 1% of patients required transfer to another hospital directly from the ED.

CONCLUSIONS

This study has provided information on the characteristics and processes of care for patients presenting to Australian rural EDs with undifferentiated chest pain that will inform service planning and further research to evaluate the effectiveness of care for these patients.

Outcome at 30 days for low-risk chest pain patients assessed using an accelerated diagnostic pathway in the emergency department

OBJECTIVES

Primary: to determine incidence of 30 day major adverse cardiac events (MACE) in patients discharged from the ED following assessment using an accelerated diagnostic pathway (ADP). Secondary: to determine incidence of 30 day MACE for all ADP patients.

METHODS

Monash Health ED patients thought at low risk for acute myocardial infarction (AMI) or hospital admission are assessed using an ADP, based on arrival and 90 min point-of-care (POC) cardiac troponin I and myoglobin concentration. Other patients are assessed using a traditional pathway of arrival and 6 h central lab cardiac troponin I. Choice of pathway is based on the clinical judgement of the attending ED doctor. To investigate the safety of the ADP component, an observational study of all ADP patients presenting from 6 June 2013 to 30 September 2013 was conducted. After 30 days, occurrence of MACE was determined by examination of hospital records or telephone contact with patients who had not returned.

RESULTS

Of 1547 eligible patients, 1384 (89.5%) were followed up. Of the 1143 discharged patients with follow-up information, 30 day MACE occurred in one (0.09%, 95% CI 0.002-0.5). Of all 1547 patients, 60 patients had a MACE detected: 56 AMI during the initial attendance, four AMI post-discharge (one from ED, three after hospital admission). In total, of the 1328 patients who did not have AMI during the target admission and were followed up, 30 day post-discharge MACE occurred in four patients (0.3%, 95% CI 0.08-0.8).

CONCLUSION

The ADP supports safe, early discharge of low-risk chest pain patients from the ED.

Effectiveness of an emergency nurse practitioner service for adults presenting to rural hospitals with chest pain: protocol for a multicentre, longitudinal nested cohort study

INTRODUCTION

Chest pain is common in emergency department (ED) patients and represents a considerable burden for rural health services. Health services reforms to improve access to care need appropriately skilled and supported clinicians in the delivery of safe and effective care, including the use of emergency nurse practitioners (ENPs). Despite increasing use of ENPs, little is known about the safety and quality of the service in the rural ED context. The aims of this study are (1) to examine the safety and quality of the ENP service model in the provision of care in the rural environment and (2) to evaluate the effectiveness of the service in the management of patients presenting with undifferentiated chest pain.

METHODS AND ANALYSIS

This is the protocol for a prospective longitudinal nested cohort study to compare the effectiveness of ENP service with that of standard care. Adults presenting to three rural EDs in Queensland, Australia with a primary presenting complaint of atraumatic chest pain will be eligible for enrolment. We will measure (1) clinician's use of evidence-based guidelines (2) diagnostic accuracy of ECG interpretation for the management of patients with suspected or confirmed ACS (3) service indicators of waiting times, length-of-stay and did-not-wait rates and (4) clinician's diagnostic accuracy as measured by rates of unplanned representation within 7 days (5) satisfaction with care, (6) quality-of-life and (7) functional status. To assess these outcomes we will use a combination of measures collected from routinely collected data, medical record review and questionnaires (with 30-day follow-up).

ETHICS AND DISSEMINATION

Queensland Health Human Research Ethics Committee (HREC) has approved this protocol. The results will be published in peer-reviewed scientific journals and presented at one or more scientific conferences.

Leading and managing an emergency department-A personal view

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.