The impact of consultation on length of stay in tertiary care emergency departments

A time-motion study on impact of spatial separation for empiric airborne precautions in emergency department length of stay

AIMS

To evaluate the impact of spatial separation on patient flow in the emergency department.

DESIGN

This was a retrospective, time-and-motion analysis conducted from 15 to 22 August, 2022 at the emergency department of a tertiary hospital in Kuala Lumpur, Malaysia. During this duration, spatial separation was implemented in critical and semi-critical zones to separate patients with symptoms of respiratory infections into respiratory area, and patients without into non-respiratory area. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

METHODS

Patients triaged to critical and semi-critical zones were included in this study. Timestamps of patient processes in emergency department until patient departure were documented.

RESULTS

The emergency department length-of-stay was longer in respiratory area compared to non-respiratory area; 527 min (381-698) versus 390 min (285-595) in critical zone and 477 min (312-739) versus 393 min (264-595) in semi-critical zone. In critical zone, time intervals of critical flow processes and compliance to hospital benchmarks were similar in both areas. More patients in respiratory area were managed within the arrival-to-contact ≤30 min benchmark and more patients in non-respiratory area had emergency department length-of-stay ≤8 h.

CONCLUSIONS

The implementation of spatial separation in infection control should address decision-to-departure delays to minimise emergency department length of stay.

IMPACT

The study evaluated the impact of spatial separation on patient flow in the emergency department. Emergency department length-of-stay was significantly prolonged in the respiratory area. Hospital administrators and policymakers can optimise infection control protocols measures in emergency departments, balancing infection control measures with efficient patient care delivery.

REPORTING METHOD

STROBE guidelines.

NO PATIENT OR PUBLIC CONTRIBUTION

None.

TRIAL AND PROTOCOL REGISTRATION

The study obtained ethics approval from the institution's Medical Ethics Committee (MREC ID NO: 20221113-11727).

STATISTICAL ANALYSIS

The author has checked and make sure our submission has conformed to the Journal's statistical guideline. There is a statistician on the author team (Noor Azhar).

Evaluating the Impact of Emergency Department Length of Stay in a Military Training Hospital Following the Implementation of a Standardized Paging System

Emergency department (ED) lengths of stay (LOS) may be unnecessarily extended by inefficient consulting processes. Delays in initiating consultations, returning calls, consultant evaluation of patients, and communication of recommendations can contribute to potentially avoidable increases in LOS. Prolonged ED LOS has been shown to increase patient morbidity and mortality and to decrease patient satisfaction. We created a standardized procedure for ED-initiated consultations, with the goal of reducing the time to initial consultant callback, time to admission, and total ED LOS. Following our intervention, time to consultant callback was decreased; however, there was no reduction in total ED LOS for admitted patients.

Emergency Department Length of Stay for Older Adults With Dementia

STUDY OBJECTIVE

The emergency department (ED) poses unique challenges and risks to persons living with dementia. A longer ED length of stay is associated with the risk of death, delirium, and medication errors. We sought to determine whether ED length of stay differed by dementia status and trends in ED length of stay for persons living with dementia from 2014 to 2018 and whether persons living with dementia were at a higher risk for prolonged ED length of stay (defined as a length of stay > 90th percentile).

METHODS

In this observational study, we used data from the Healthcare Cost and Utilization Project State Emergency Department Database from Massachusetts, Arkansas, Arizona, and Florida. We included ED visits resulting in discharge for adults aged ≥65 years from 2014 to 2018. We used inverse probability weighting to create comparable groups of visits on the basis of dementia status. We used generalized linear models to estimate the mean difference in ED length of stay on the basis of dementia status and logistic regression to determine the odds of prolonged ED length of stay.

RESULTS

We included 1,039,497 ED visits (mean age: 83.5 years; 64% women; 78% White, 12% Hispanic). Compared with visits by persons without dementia, ED length of stay was 3.1 hours longer (95% confidence interval [CI] 3.0 to 3.3 hours) for persons living with dementia. Among the visits resulting in transfer, ED length of stay was on average 4.1 hours longer (95% CI 3.6 to 4.5 hours) for persons living with dementia. Visits by persons living with dementia were more likely to have a prolonged length of stay (risk difference 4.1%, 95% CI 3.9 to 4.4).

CONCLUSION

ED visits were more than 3 hours longer for persons living with versus without dementia. Initiatives focused on optimizing ED care for persons living with dementia are needed.

Comparison of Outpatient Department-Referred and Self-Referred Patients in the Emergency Department

BACKGROUND

Patients present to emergency departments (EDs) from a variety of backgrounds, which may help inform decision making.

OBJECTIVE

This study investigated the clinical characteristics and outcomes of outpatient department (OPD)-referred patients and self-referred patients in the ED.

METHODS

We selected nontrauma ED adult patients from a tertiary teaching hospital in Taiwan between August 1, 2020, and October 31, 2020. The acuity levels were determined by dichotomizing the triage classification scores. After propensity score matching, we compared the hospitalization, mortality, and length of ED stay of OPD-referred and self-referred patients. We categorized the patients into "emergency" or "urgent" subgroups according to their triage information and then analyzed the effects of different severity levels. Statistical significance was set at p < 0.05.

RESULTS

A total of 564 OPD-referred and 11,959 self-referred patients were included. After propensity score matching, the OPD-referred patients (n = 564), compared with self-referred patients (n = 564), had a higher admission rate (49.8% vs. 28.9%; p < 0.001; odds ratio [OR] 2.44). Among the emergency subgroup patients, there was no significant difference between OPD-referred patients (n = 131) and self-referred patients (n = 138) regarding the admission rate (p = 0.257) or the mortality rate (p = 0.253). Among the urgent subgroup patients, OPD-referred patients (n = 433), compared with self-referred patients (n = 426), had a significantly higher admission rate (46.0% vs. 20.2%; p < 0.001; OR 3.36), but not mortality rate (2.1% vs. 0.5%; p = 0.064). Regarding the length of ED stay, OPD-referred and self-referred patients had a significant difference only in the "urgent and discharged" subgroup (5.8 vs. 2.3 h; p < 0.001).

CONCLUSIONS

OPD-referred ED patients might have more severe and complex conditions and need comprehensive care management.

Effects of Clinical Frailty Scale Score on Adverse Outcomes and Length of Emergency Department Stay Before Intensive Care Unit Admission

BACKGROUND

Older adults living with frailty who require treatment in hospitals are increasingly seen in emergency departments (EDs).

OBJECTIVE

This study investigated the effects of frailty severity according to the Clinical Frailty Scale (CFS) on adverse outcomes and length of stay in the ED before intensive care unit (ICU) admission.

METHODS

We conducted this prospective observational study with patients 65 years or older and admitted to the ICU from March 1, 2021 to December 31, 2022. We divided the patients into four groups according to their CFS scores. We determined the effects of frailty severity on length of ED stay and clinical outcomes using logistic regression analysis.

RESULTS

Of the 920 patients included in the study, 25.4% were nonfrail, 26.2% had mild frailty, 25.9% had moderate frailty, and 22.5% had severe frailty. In the regression analysis, compared with those who were nonfrail, the length of ED stay was significantly longer for those with moderate frailty (odds ratio [OR] 2.13; 95% confidence interval [CI] 1.63-2.90) or severe frailty (OR 3.32; 95% CI 1.92-3.87), but the result was not significant for those with mild frailty (OR 1.65; 95% CI 1.21-2.45). ICU mortality was significantly higher among patients with mild, moderate, or severe frailty than among those who were nonfrail.

CONCLUSIONS

We found CFS score to be a predictor of length of ED stay and adverse outcomes. Accordingly, CFS evaluation can provide an idea of the length of ED stay and the likelihood of adverse outcomes.

How Can Specialist Advice Influence the Neuroimaging Practice for Childhood Headache in Emergency Department?

Differentiating between primary and secondary headaches can be challenging, especially in the emergency department (ED). Since symptoms alone are inadequate criteria for distinguishing between primary and secondary headaches, many children with headaches undergo neuroimaging investigations, such as brain CT and MRI. In various studies, the frequency of neuroimaging utilization is influenced by several factors, including teaching status, ownership, metropolitan area, insurance status, and ethnicity of patients. However, only a few studies have considered the role of specialist consultations in ordering neuroimaging studies on childhood headaches. We report the contributions of different specialists to the evaluation of children with headaches admitted to the ED and their influence on neuroimaging decisions. We retrospectively reviewed the medical reports of paediatric patients who presented with headaches to the paediatric ED of the Ospedale Maggiore Policlinico of Milano between January 2017 and January 2022. Overall, 890 children with headaches were evaluated (mean age: 10.0 years; range: 1 to 17 years). All patients were examined by the ED paediatricians, while specialist consultations were required for 261 patients, including 240 neurological (92.0%), 46 ophthalmological (17.6%), and 20 otorhinolaryngological (7.7%) consultations. Overall, 173 neuroimaging examinations were required, of which 51.4 and 48.6% were ordered by paediatricians and neurologists, respectively. In particular, paediatricians required 61.4% of brain CT scans, and neurologists required 92.0% of brain MRI scans. In conclusion, paediatricians were responsible for the management of most children with headaches admitted to the ED, while specialist consultations were required only in about a third of the cases. Although there was no significant difference in the number of neuroimaging studies ordered by specialists, brain CT scans were most often used by paediatricians, and MRI scans by neurologists.

Anecdotes Drive Attitudes, Data Drives Decisions: Optimizing the Emergency Department Workup Prior to Surgical Consultations

PURPOSE

Emergency department (ED) wait times and ED length of stay (LOS) have a significant impact on patient morbidity and mortality and patient satisfaction. Consultation-to-decision time can contribute to increased wait times and LOS in the ED. Up to 40% of patients presenting to the ED require consultation from subspecialty services. We hypothesize that in surgical patients, completion of workup prior to consultation will decrease consultation-to-decision time, ED wait times, and LOS in the ED.

METHODS

A retrospective review was conducted at a single site including all overnight general surgery consultations from the ED over 2-months. Data collected included wait times, LOS, and workup completed prior to consultation. Summary statistics were calculated and bivariate tests were performed using t-tests for continuous variables.

RESULTS

Time to final surgical plan and LOS in ED were evaluated for 137 patients comparing "complete" and "incomplete" workups at time of consultation. It was considered a "complete" workup if labs and imaging were resulted prior to time of consult. If any baseline tests were not ordered prior to time of consult, it was considered an "incomplete" workup. Analysis demonstrated an average time of 4.9 and 2.5 hours for consultation-to-decision time for "incomplete" and "complete" workups respectively (p < 0.0001). For LOS in ED, there was an average of 11.4 and 7.9 hours for "incomplete" and "complete" workups respectively (p < 0.0001).

CONCLUSIONS

There is a significant difference in consultation-to-decision time and LOS in the ED when consultation is performed following a complete versus incomplete workup for surgical patients independent of inherent wait times for testing to result and the need for additional testing requested from consulting services. Developing strategies to optimize workups from the ED prior to surgical consultation, including the development of care pathways, could significantly decrease patient wait times and LOS in the ED.

Interventions to improve consultations in the emergency department: A systematic review

OBJECTIVES

Emergency department (ED) consultations with specialists are necessary for safe and effective patient care. Delays in the ED consultation process, however, have been shown to increase ED length of stay (LOS) and contribute to ED crowding. This review aims to describe and evaluate the effectiveness of interventions to improve the ED consultation process.

METHODS

Eight primary literature databases and the gray literature were searched to identify comparative studies assessing ED-based interventions to improve the specialist consultation process. Two independent reviewers identified eligible studies, assessed study quality, and extracted data. Individual or pooled meta-analysis for continuous outcomes were calculated as mean differences (MDs) with 95% confidence intervals (CIs) using a random-effects model was conducted.

RESULTS

Thirty-five unique comparative intervention studies were included. While the interventions varied, four common components/themes were identified including interventions to improve consultant responsiveness (n = 11), improve access to consultants in the ED (n = 9), expedite ED consultations (n = 8), and bypass ED consultations (n = 7). Studies on interventions to improve consult responsiveness consistently reported a decrease in consult response times in the intervention group with percent changes between 10% and 71%. Studies implementing interventions to improve consult responsiveness (MD -2.55, 95% CI -4.88 to -0.22) and interventions to bypass ED consultations (MD -0.99, 95% CI -1.43 to -0.56) consistently reported a decrease in ED LOS; however, heterogeneity was high (I²  = 99%). Evidence on whether any of the interventions were effective at reducing the proportion of patients consulted or subsequently admitted varied.

CONCLUSIONS

The various interventions impacting the consultation process were predominately successful in reducing ED LOS, with evidence suggesting that interventions improving consult responsiveness and improving access to consultants in the ED also improve consult response times. Health care providers looking to implement interventions to improve the ED consultation process should identify key areas in their setting that could be targeted.

Effect of specialist consultation on emergency department revisits among patients with uncomplicated recent-onset atrial fibrillation or flutter

OBJECTIVES

To examine the association between specialist consultation and risk of 30-day ED revisit in emergency department (ED) patients with recent-onset uncomplicated atrial fibrillation or flutter (AF/AFL).

METHODS

As a secondary analysis of a previously published trial, clinical experts identified predictors of consultation including age and sex, ED sinus conversion, thromboembolic risk, heart rate, rate control medication use, coronary artery disease and anti-platelet use, and chronic obstructive pulmonary disease. These were included in a propensity-matched hierarchical Bayesian model accounting for hospital site as a random effect, with 30-day ED revisit as the primary outcome. We also measured ED length of stay for consulted and non-consulted patients.

RESULTS

We analyzed data from 11 sites for 829 ED patients with AF/AFL, of whom 364 (44%) had specialist consultation. A total of 128 patients (15.4%) had an ED revisit, 78 (16.8%) from the no consult group and 50 (13.7%) from the consult group. Consultation rates ranged from 8.8 to 71% between sites. Median length of stay was 591 min (interquartile range [IQR] 359-1024) for consulted patients and 300 min (IQR 212-409) for patients without consultation. After propensity-matching, consulted patients had a 0.6% (IQR - 4 to 3%) lower risk of 30-day revisits than non-consulted patients (probability of lower risk 55%).

CONCLUSIONS

In ED patients with uncomplicated AF/AFL, there was substantial between-site variation in specialist consultations; such consultation was unlikely to influence revisits within 30 days while ED length of stay was nearly double. ED specialist consultations may not be necessary for uncomplicated patients.

Predicting Patient Length of Stay in Australian Emergency Departments Using Data Mining

Length of Stay (LOS) is an important performance metric in Australian Emergency Departments (EDs). Recent evidence suggests that an LOS in excess of 4 h may be associated with increased mortality, but despite this, the average LOS continues to remain greater than 4 h in many EDs. Previous studies have found that Data Mining (DM) can be used to help hospitals to manage this metric and there is continued research into identifying factors that cause delays in ED LOS. Despite this, there is still a lack of specific research into how DM could use these factors to manage ED LOS. This study adds to the emerging literature and offers evidence that it is possible to predict delays in ED LOS to offer Clinical Decision Support (CDS) by using DM. Sixteen potentially relevant factors that impact ED LOS were identified through a literature survey and subsequently used as predictors to create six Data Mining Models (DMMs). An extract based on the Victorian Emergency Minimum Dataset (VEMD) was used to obtain relevant patient details and the DMMs were implemented using the Weka Software. The DMMs implemented in this study were successful in identifying the factors that were most likely to cause ED LOS > 4 h and also identify their correlation. These DMMs can be used by hospitals, not only to identify risk factors in their EDs that could lead to ED LOS > 4 h, but also to monitor these factors over time.

Modelling Granular Process Flow Information to Reduce Bottlenecks in the Emergency Department

Increasing demand and changing case-mix have resulted in bottlenecks and longer waiting times in emergency departments (ED). However, many process improvement efforts addressing the bottlenecks have limitations, as they lack accurate models of the real system as input accounting for operational complexities. To understand the limitation, this research modelled granular procedural information, to analyse processes in a Level-1 ED of a 1200-bed teaching hospital in the UK. Semi-structured interviews with 21 clinicians and direct observations provided the necessary information. Results identified Majors as the most crowded area, hence, a systems modelling technique, role activity diagram, was used to derive highly granular process maps illustrating care in Majors which were further validated by 6 additional clinicians. Bottlenecks observed in Majors included awaiting specialist input, tests outside the ED, awaiting transportation, bed search, and inpatient handover. Process mapping revealed opportunities for using precedence information to reduce repeat tests; informed alerting; and provisioning for operational complexity into ED processes as steps to potentially alleviate bottlenecks. Another result is that this is the first study to map care processes in Majors, the area within the ED that treats complex patients whose care journeys are susceptible to variations. Findings have implications on the development of improvement approaches for managing bottlenecks.

Not All Testers are Admitters: An Analysis of Emergency Physician Resource Utilization and Consultation Rates

BACKGROUND

Variability exists in emergency physician (EP) resource utilization as measured by ordering practices, rate of consultation, and propensity to admit patients.

OBJECTIVE

To validate and expand upon previous data showing that resource utilization as measured by EP ordering patterns is positively correlated with admission rates.

METHODS

This is a retrospective study of routinely gathered operational data from the ED of an urban academic tertiary care hospital. We collected individual EP data on advanced imaging, consultation, and admission rates per patient encounter. To investigate whether there might be distinct groups of practice patterns relating these 3 resources, we used a Gaussian mixture model, a classification method used to determine the likelihood of distinct subgroups within a larger population.

RESULTS

Our Gaussian mixture model revealed 3 distinct groups of EPs based on their ordering practices. The largest group is characterized by a homogenous pattern of neither high or low resource utilization (n = 37, 27% female, median years' experience: 6 [interquartile ratio {IQR} 3-18]; rates of advanced imaging, 38.9%; consultation, 45.1%; and admission 39.3%), with a modest group of low-resource users (n = 15, 60% female, median years' experience: 6 [IQR 5-14]; rates of advanced imaging, 37%; consultation, 42.6%; and admission 37.3%), and far fewer members of a high-resource use group (n = 6, 0% female, median years' experience: 6 [IQR 4-16]; rates of advanced imaging, 42.2%; consultation, 45.8%; and admission 40.6%). This variation suggests that not "all testers are admitters," but that there exist wider practice variations among EPs.

CONCLUSIONS

At our academic tertiary center, 3 distinct subgroups of EP ordering practices exist based on consultation rates, advanced imaging use, and propensity to admit a patient. These data validate previous work showing that resource utilization and admission rates are related, while demonstrating that more nuanced patterns of EP ordering practices exist. Further investigation is needed to understand the impact of EP characteristics and behavior on throughput and quality of care. © 2022 Elsevier Inc.

Dermatology consultation requests from a university hospital's pediatric and adult emergency departments: A 5-year retrospective analysis

BACKGROUND

Unnecessary dermatology consultation requests from emergency departments (EDs) are a common occurrence worldwide.

AIM

This study aimed to analyze the demographic and clinical characteristics of patients consulted to the dermatology department for dermatologic disorders by a university hospital's pediatric ED (PED) and adult ED (AED).

MATERIALS AND METHODS

The electronic medical records of 2316 dermatology consultation requests from the PED and AED during a 5-year period were retrospectively reviewed. Patient demographic and clinical characteristics, dermatological diagnoses, and time of day of dermatology consultation requests from the PED and AED were retrospectively analyzed.

RESULTS

The electronic medical records of 1845 consultation requests with complete data were included in the study. There were 969 (52.5%) consultation requests from the PED and 876 (47.5%) from the AED. Mean time from onset of dermatological symptoms to ED presentation was 31.6 d. Herpes zoster infections (18.5%), adverse cutaneous drug reactions (8.1%), and urticaria with angioedema (7.9%) were the most common skin disorders resulting in consultation requests from the AED, versus non-specific viral infections (9.2%), insect bites (8.3%), and atopic dermatitis (8.2%) from the PED. In all, 11.5% of ED patients that received dermatology department consultation required hospitalization due to dermatologic disorders.

CONCLUSION

As patients commonly present to EDs with non-urgent dermatological diseases, ED physicians should receive training on common dermatological diseases so as to decrease the number of unnecessary dermatology consultation requests.

The effect of the COVID-19 pandemic on dermatology consultation requests from adult and paediatric emergency departments

AIM

This study aimed to determine the characteristics of dermatology consultation requests from the adult and paediatric emergency departments (EDs) of a university hospital during 8 months of the COVID-19 pandemic in 2020 and to compare them with the same 8 months of 2019.

MATERIALS AND METHODS

Electronic medical records of dermatology consultation requests from adult and paediatric EDs between 15 March 2019 and 15 November 2019, and between 15 March 2020 and 15 November 2020 were retrospectively reviewed.

RESULTS

The study included 495 consecutive dermatology consultation requests. In total, 283 (57%) consultation requests occurred in 2019, vs 212 (43%) between in 2020 during the COVID-19 pandemic. The number of consultation requests per day was significantly lower in 2020 (0.9 ± 0.1 per day) than in 2019 (1.15 ± 0.1 per day; P = .002), and was significantly lower in March, April and May 2020, as compared with March, April, and May 2019 (P = .004, P = .001, and P = .001, respectively). The median time from onset of dermatological symptoms to ED presentation was significantly longer in 2020 than in 2019 (4 days in 2019 vs 7 days in 2020; P < .001). Dermatological emergencies in 2019 and 2020 constituted 6.7% of all emergency presentations, with no significant difference between the 2 years (7.1% of all ED presentations in 2019, vs 6.1% in 2020; P = .795).

CONCLUSION

COVID-19 restrictions and fear of COVID-19 infection might have discouraged patients from presenting to EDs because of skin problems; however, the easing of COVID-19 restrictions might lead to an increase in ED presentations, including non-urgent dermatological disorders. In order to reduce unnecessary use of EDs and prevent ED overcrowding, the general public should be educated about what constitutes a dermatological emergency.

Analysis of Plastic Surgery Consultations in a High-Volume Paediatric Emergency Department: A Quality Improvement Initiative

Introduction

Consult services influence emergency department (ED) workflow. Prolonged ED length of stay (LOS) correlates with ED overcrowding and as a consequence decreased quality of care and satisfaction of health team professionals. To improve management of paediatric ED patients requiring plastic and reconstructive surgery (PRS) expertise, current processes were analyzed.

Methods

Patient characteristics and metrics of PRS consultations in our paediatric ED were collected over a 3-month period. Data analysis was followed by feedback education intervention to ED and PRS staff. Data collection was then resumed and results were compared to the pre-intervention period.

Results

One hundred ninety-eight PRS consultations were reviewed, mean patient age was 6.3 years. Most common (52%) diagnoses were burns and hand trauma; 81% of PRS referrals were deemed appropriate; 25% of PRS consults were requested after hour with no differences in patient characteristics compared to regular hours; 60% of consultations involved interventions in the ED. Time between ED registration and PRS consultation request (116.5 minutes), quality of procedural sedation (52% rated inadequate), and overall ED LOS (289.2 minutes) were identified as main areas of concern and addressed during feedback education intervention. Emergency department LOS and quality of sedation did not improve in the post-intervention period.

Conclusion

The study provides detailed insights in the characteristics of PRS consultation in the paediatric ED population. Despite high referral appropriateness and education feedback intervention, significant inefficiencies were identified that call for further collaborative efforts to optimize quality of care for paediatric ED patients and improve satisfaction of involved healthcare professionals.

Factors associated with emergency department length of stay of internal medicine patients

Emergency Department (ED) Length Of Stay (ED-LOS) is associated with quality of care, patient safety and treatment outcome. The aim of this study is to identify factors associated with ED-LOS of internal medicine patients and provide recommendations to shorten ED-LOS. A retrospective cohort study was conducted in a single center in the Netherlands. Anonymised data of 7,380 ED attendances from January 2016 to January 2018 were analyzed. Data included time of ED arrival and departure, sex, age, source of referral, triage category, first or consecutive visit and number of radiological examinations. Univariate analyses were used. Mean ED-LOS was 220 minutes. Factors which significantly prolonged ED-LOS were older age, source of referral, triage category, need for admission, first visit, number of radiological examinations, presentation in winter or spring and time of arrival (day and evening). Several patient and circumstantial factors are associated with ED-LOS. To shorten ED-LOS, we recommend to anticipate need for admission for older patients who arrive by ambulance and to create time slots in the radiology program and to restructure the morning report.

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.

Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative

INTRODUCTION

Emergency department (ED) wait time is an important health system quality indicator. Prolonged consult to decision time (CTDT), the time it takes to reach a disposition decision after receiving a specialty consultation request, can contribute to increased overall length of stay in the ED.

OBJECTIVE

To identify delays in the consultation process for general internal medicine (GIM) and trial interventions to reduce CTDT.

METHODS

The study was conducted at a large tertiary teaching hospital with GIM inpatient wards at two campuses. Four interventions were trialed over sequential Plan-Do-Study-Act cycles: (1) process mapping, (2) resident education sessions, (3) audit and feedback of CTDT, and (4) adding a swing shift during peak consult volume.

MEASUREMENTS

The primary outcome measures were mean CTDT for patients admitted to GIM and the proportion of admitted patients with CTDT of less than 3 hours.

RESULTS

Mean CTDT decreased from 4.61 hours before intervention to 4.18 hours after intervention (p < .0001). The proportion of GIM patients with CTDT less than 3 hours increased from 25% to 33% (p < .0001).

CONCLUSIONS

The interventions trialed led to a sustained reduction in CTDT over a 12-month period and demonstrated the effectiveness of education in influencing physician performance.

Neurology consults in emergency departments: Opportunities to streamline care

OBJECTIVE

To use the variations in neurology consultations requested by emergency department (ED) physicians to identify opportunities to implement multidisciplinary interventions in an effort to reduce ED overcrowding.

METHODS

We retrospectively analyzed ED visits across 3 urban hospitals to determine the top 10 most common chief complaints leading to neurology consultation. For each complaint, we evaluated the likelihood of consultation, admission rate, admitting services, and provider-to-provider variability of consultation.

RESULTS

Of 145,331 ED encounters analyzed, 3,087 (2.2%) involved a neurology consult, most commonly with chief complaints of acute-onset neurologic deficit, subacute neurologic deficit, or altered mental status. ED providers varied most in their consultation for acute-onset neurologic deficit, dizziness, and headache. Neurology consultation was associated with a 2.3-hour-longer length of stay (LOS) (95% CI: 1.6-3.1). Headache in particular has an average of 6.7-hour-longer ED LOS associated with consultation, followed by weakness or extremity weakness (4.4 hours) and numbness (4.1 hours). The largest estimated cumulative difference (number of patients with the specific consultation multiplied by estimated difference in LOS) belongs to headache, altered mental status, and seizures.

CONCLUSION

A systematic approach to identify variability in neurology consultation utilization and its effect on ED LOS helps pinpoint the conditions most likely to benefit from protocolized pathways.

Using emergency physicians’ abilities to predict patient admission to decrease admission delay time

Background

In many EDs, emergency physicians (EPs) do not have admitting privileges and must wait for consultants to further assess and admit patients. This delays bed requests and increases ED crowding. We measured EPs’ abilities to predict patient admission prior to consultation and estimated the potential ED stretcher time saved if EPs requested a bed with consultation.

Methods

We conducted a prospective cohort study in an academic centre in Canada between October 2017 and February 2018 using a convenience sample of ED patient encounters requiring consultation. We excluded patients under 18 years or those clearly likely to be admitted (traumas, strokes, S-T elevation myocardial infarctions and Canadian Triage and Acuity Scale of 1). EPs predicted patient admission just before consultation. Potential ED stretcher time saved was estimated for correctly predicted admissions assuming bed requests were initiated with consultation and a constant time to inpatient bed.

Results

Characteristics of 454 patients were: mean age 60.1 years, 48.5% male, 46.9% evening presentation, 69.4% admitted and median time to bed request of 3.5 hours (IQR 2.0–5.3 hours). Overall, EPs prediction sensitivity, specificity, positive predictive value and negative predictive value were 90.5% (95% CI 86.7% to 93.5%), 84.2% (95% CI 77.0% to 89.8%), 92.8% (95% CI 89.8% to 95.0%) and 79.6% (95% CI 73.4% to 84.7%). Approximately 922.1 hours of ED stretcher time could have been saved during the 5-month study period if EPs initiated a bed request with consultation.

Conclusion

Crowding is a reality for EDs worldwide, and many systems could benefit from EP-initiated hospital admissions to decrease the amount of time admitted patients wait in the ED.

Admission Decisions Made by Emergency Physicians Can Reduce the Emergency Department Length of Stay for Medical Patients

Background

Emergency department (ED) overcrowding is a worldwide problem that poses a threat to patient safety by causing treatment delays and increasing mortality. Consultations are common and important in the emergency medicine profession and are associated with longer ED length of stay (LOS). The purpose of this study was to evaluate the impact of admission decisions by emergency physicians without consultations on the ED LOS and other quality indicators.

Methods

The study was a retrospective observational study comparing the ED LOS of patients admitted to the internal medicine (IM) department before and after the policy change regarding admission decisions that was implemented in October 2016. During and after the policy change, emergency physicians decided how to arrange for and treat medical patients by processing their admission and providing follow-up care without consultations. The ED LOS and other indicators of patients admitted to the IM department were compared between the study period (January to June 2017) and the control period (January to June 2016).

Results

The median ED LOS of patients admitted to the IM department decreased from 673 (IQR: 347-1,369) minutes in the control period to 237 (IQR: 166-364) minutes in the study period. There were no significant differences in the interdepartmental transfer rate or in-hospital mortality between the two periods.

Conclusions

The admission decisions regarding medical patients made by emergency physicians without specialty consultations reduced the ED LOS without a significant negative effect on mortality or hospital LOS.

Using data mining to predict emergency department length of stay greater than 4 hours: Derivation and single-site validation of a decision tree algorithm

OBJECTIVES

Health services have an imperative to reduce prolonged patient length of stay (LOS) in ED. Our objective is to develop and validate an accurate prediction model for patient LOS in ED greater than 4 hours using a data mining technique.

METHODS

Data were collected from a regional Australian public hospital for all ED presentations between 1 January 2016 and 31 December 2017. A decision tree algorithm was built to predict patients with an ED LOS >4 hours. A total of 33 attributes were analysed. The performance of the final model was internally validated. Clinically relevant patterns from the model were analysed.

RESULTS

The accuracy of the model was 85%. We identified that patients at our site who were at high risk of ED LOS >4 hours were those who were waiting in ED for a medical consultation, or those who were waiting for a urology, surgical, orthopaedic or paediatric consultation if the request for consultation occurred more than 2 hours after the patient was first seen by an ED doctor.

CONCLUSION

This model performed very well in predicting ED LOS >4 hours for each individual patient and demonstrated a number of clinically relevant patterns. Identifying patterns that influence ED LOS is important for health managers in order to develop and implement interventions targeted at those clinical scenarios. Future work should look at the utility of displaying individual patient risk of ED LOS >4 hours using this model in real-time at the point-of-care.

Disparities in Timing of Trauma Consultation: A Trauma Registry Analysis of Patient and Injury Factors

BACKGROUND

Efficient trauma systems rely on field and emergency department (ED) personnel to triage patients to the appropriate level of care. Undertriage puts patients at risk, whereas overtriage results in system strain. Although much research has focused on prehospital triage, little is known about trauma triage processes within the ED. We investigated the timing of trauma consultation in the ED of a level I trauma center. We hypothesized that patient characteristics and injury type would be associated with time to consultation, with women, Black patients, older patients, and those with head and torso injuries experiencing longer time to consult.

MATERIALS AND METHODS

Patients aged ≥18 y referred to the trauma service via consultation were recruited retrospectively. Bivariable and multivariable negative binomial regressions were used to assess the association between patient and injury characteristics and time to consult. We used multivariable logistic regression adjusted for patient and injury characteristics to assess for association between time to consult and mortality and length of stay.

RESULTS

Among 588 adult consult patients, median time to consult was 177 min (interquartile range 106-265). In multivariable analysis, Black patients had longer time to consult (incidence rate ratio [IRR] 1.33, 95% confidence interval [CI] 1.10, 1.60) as did women (IRR 1.15, 95% CI 1.02, 1.29). Head injury was associated with shorter time to consult (IRR 0.81, 95% CI 0.71, 0.92). Time to consult was not associated with mortality or length of stay.

CONCLUSIONS

Patient demographics and injury characteristics influenced the timing of trauma consultation. More robust criteria for equitable evaluation of patients are needed to eliminate disparities, prevent delays, and streamline care.

Analysis of Emergency Health Care Workforce and Service Readiness for a Mass Casualty Event in the Republic of Ireland

Objective

Ultimately, a country’s capacity for a large-scale major emergency response will be directly related to the competence of its health care provider (HCP) workforce and communication between emergency responders and hospitals. The purpose of this study was to assess HCP preparedness and service readiness for a major emergency involving mass casualties (mass casualty event or MCE) in Ireland.

Methods

A cross-sectional study using a 53-item survey was administered to a purposive sample of emergency responders and HCPs in the Republic of Ireland. Data collection was achieved using the Qualtrics® Research Suite. Descriptive statistics and appropriate tests of comparison between professional disciplines were conducted using Stata 13.

Results

A total of 385 respondents, registered nurses (43.4%), paramedics (37.9%), medical doctors (10.1%), and administrators/managers (8.6%), participated in the study. In general, a level of knowledge of MCEs and knowledge of clinical response activities and self-assessed clinical competence varied drastically across many aspects of the survey. Knowledge and confidence also varied across professional disciplines (P&lt;0.05) with nurses, in general, reporting the least knowledge and/or confidence.

Conclusions

The results demonstrate that serious deficits exist in HCP knowledge, skills, and self-perceived abilities to participate in a large-scale MCE. Results also suggest a poor knowledge base of existing major emergency response plans. (Disaster Med Public Health Preparedness. 2019;13:243–255)

Emergency department boarding: a descriptive analysis and measurement of impact on outcomes

OBJECTIVES

Delays in transfer of admitted patients boarded in the emergency department (ED) to an inpatient bed is a major driver of ED overcrowding. We sought to identify explanatory factors behind ED boarding as well as the impact of boarding on total inpatient length of stay (IP LOS) and inpatient mortality.

METHODS

We conducted a retrospective single-centre observational study during the period between January 1 and December 31, 2015 at a very high volume community hospital. All patients admitted from the ED to Medicine, Pediatrics, Surgery, and Critical Care were identified. The mean ED LOS and boarding time as well as patient-specific and institutional factors that were independently associated with prolonged ED LOS (≥24 hours) and prolonged boarding time (≥12 hours) were identified. Mean inpatient length of stay (IP LOS) and the odds of inpatient mortality were calculated for those patients with prolonged ED wait times.

RESULTS

There were 13,872 unique admissions during the study period. Patients admitted to the Medicine service exhibited significantly higher ED wait times than other services. Within Medicine patients, there was a statistically significant greater odds of prolonged ED wait times for patients who were older, had a greater comorbidity burden, and required more specialized inpatient care. Medicine patients with prolonged boarding times also experienced a mean of 0.9 days longer IP LOS even after adjusting for confounders.

CONCLUSION

Within our cohort, older, sicker patients and those patients requiring more resource-intensive inpatient care had the longest ED wait times. These prolonged wait times are associated with significantly increased IP LOS.

Comparison of secure messaging application (WhatsApp) and standard telephone usage for consultations on Length of Stay in the ED. A prospective randomized controlled study

OBJECTIVE

Consultation, the process of an Emergency Physician seeking an opinion from other specialties, occurs frequently in the Emergency Department (ED). The aim of this study was to determine the effect of secure messaging application (WhatsApp) usage for medical consultations on Emergency Department Length of Stay (ED LOS) and consult time.

METHODS

We conducted a prospective, randomized controlled trial in the ED using allocation concealment over three months. Consultations requested in the ED were allocated into two groups: consultations requested via the secure messaging application and consultations requested by telephone as verbal.

RESULTS

A total of 439 consultations requested in the ED were assessed for eligibility and 345 were included in the final analysis: 173 consultations were conducted using secure messaging application and 172 consultations were conducted using standard telephone communications. The median ED LOS was 240 minutes (IQR:230-270, 95% CI:240 to 255.2) for patients in the secure messaging application group and 277 minutes (IQR:270-287.8, 95% CI:277 to 279) for patients in the telephone group. The median total ED LOS was significantly lower among consults conducted using Secure messaging application relative to consults conducted by telephone (median dif: -30, 95%CI:-37to-25, p<0.0001). The median consult time was 158 minutes (IQR:133 to 177.25, 95% CI:150 to 169) for patients in the Secure messaging application group and 170 minutes (IQR:165 to 188.5, 95% CI:170-171) for patients in the Telephone group (median dif: -12, 95%CI:-19 to-7,p<0.0001). Consultations completed without ED arrival was 61.8% in the secure messaging group and 33.1% in the Telephone group (dif: 28.7, 95% CI:48.3 to 66, p<0.001).

CONCLUSIONS

Use of secure messaging application for consultations in the ED reduces the total ED LOS and consultation time. Consultation with secure messaging application eliminated more than half of in-person ED consultation visits.

Predicting Length of Stay among Patients Discharged from the Emergency Department-Using an Accelerated Failure Time Model

Background

Emergency department (ED) crowding continues to be an important health care issue in modern countries. Among the many crucial quality indicators for monitoring the throughput process, a patient’s length of stay (LOS) is considered the most important one since it is both the cause and the result of ED crowding. The aim of this study is to identify and quantify the influence of different patient-related or diagnostic activities-related factors on the ED LOS of discharged patients.

Methods

This is a retrospective electronic data analysis. All patients who were discharged from the ED of a tertiary teaching hospital in 2013 were included. A multivariate accelerated failure time model was used to analyze the influence of the collected covariates on patient LOS.

Results

A total of 106,206 patients were included for analysis with an overall medium ED LOS of 1.46 (interquartile range = 2.03) hours. Among them, 96% were discharged by a physician, 3.5% discharged against medical advice, 0.5% left without notice, and only 0.02% left without being seen by a physician. In the multivariate analysis, increased age (>80 vs <20, time ratio (TR) = 1.408, p<0.0001), higher acuity level (triage level I vs. level V, TR = 1.343, p<0.0001), transferred patients (TR = 1.350, p<0.0001), X-rays obtained (TR = 1.181, p<0.0001), CT scans obtained (TR = 1.515, p<0.0001), laboratory tests (TR = 2.654, p<0.0001), consultation provided (TR = 1.631, p<0.0001), observation provided (TR = 8.435, p<0.0001), critical condition declared (TR = 1.205, p<0.0001), day-shift arrival (TR = 1.223, p<0.0001), and an increased ED daily census (TR = 1.057, p<0.0001) lengthened the ED LOS with various effect sizes. On the other hand, male sex (TR = 0.982, p = 0.002), weekend arrival (TR = 0.928, p<0.0001), and adult non-trauma patients (compared with pediatric non-trauma, TR = 0.687, p<0.0001) were associated with shortened ED LOS. A prediction diagram was made accordingly and compared with the actual LOS.

Conclusions

The influential factors on the ED LOS in discharged patients were identified and quantified in the current study. The model’s predicted ED LOS may provide useful information for physicians or patients to better anticipate an individual’s LOS and to help the administrative level plan its staffing policy.

The relationship between in-hospital location and outcomes of care in patients diagnosed with dementia and/or delirium diagnoses: analysis of patient journey

Background

The discrepancy between the number of admissions and the allocation of hospital beds means that many patients admitted to hospital can be placed in units or wards other than that which specialise in the patient’s primary health issue (home-ward). These patients are called ‘outlier’ patients. Risk factors and health system outcomes of hospital care for ‘outlier’ patients diagnosed with dementia and/or delirium are unknown. Therefore, the aim of this research was to examine patient journeys of people with dementia and/or delirium diagnoses, to identify risk factors for ‘inlier’ or ‘outlier’ status and patient or health system outcomes (consequences) of this status.

Methods

A retrospective, descriptive study compared patients who had dementia and/or delirium according to the proportion of time spent on the home ward i.e. ‘inliers’ or ‘outliers’. Data from the patient journey database at Flinders Medical Centre (FMC), a public hospital in South Australia from 2007 and 2014 were extracted and analysed. The analysis was carried out on the patient journeys of people with a dementia and/or delirium diagnosis.

Results

When 6367 inpatient journeys with dementia and/or delirium within FMC were examined, the Emergency Department (ED) Length of Stay (LOS) after being admitted as inpatient was prolonged for ‘outlier’ patients compared to ‘inlier’ patients (OR: 1.068, 95% CI: 1.057–1.079, p = 0.000). However, the inpatient LOS for’outlier’ patients was only marginally shorter than that of the ‘inlier’ patients (OR: 0.998, 95% CI: 0.998–0.998, p = 0.000). The chances of dying within 48 h of admission increased for ‘outlier’ patients (OR: 1.973, 95% CI: 1.158–3.359, p = 0.012) and their Charlson co-morbidity Index was higher (OR: 1.059, 95% CI: 1.021–1.10, p = 0.002). Completion of discharge summaries within 2 days post-discharge for ‘outlier’ patients was compromised (OR: 1.754, 95% CI: 1.492–2.061, p = 0.000).Additionally, ‘outlier’ patients were more likely to be discharged to another hospital for other care types not offered at FMC (OR: 1.931, 95% CI: 1.559–2.391, p = 0.000).

Conclusion

An examination of the patient journeys at FMC has determined that the health system outcomes for patients with dementia and/or delirium who are admitted outside of their home-ward are affected by in-hospital location despite the homogenous nature of the study population.

Impact of clinical pharmacist intervention on length of stay in an acute admission unit: a cluster randomised study

Objectives

Physicians in acute admission units (AAUs) are obliged to obtain medication history and perform medication reconciliation, which is time consuming and often incomplete. Studies show that clinical pharmacists (CPs) can obtain accurate medication histories, but so far no studies have investigated the effect of this on time measures. Therefore, the objective of the present study was to investigate the effect of a CP intervention on length of stay (LOS) in an AAU.

Methods

The study was designed as a prospective, cluster randomised study. Weekdays were randomised to control or intervention. CP intervention consisted of obtaining medication history and performing medication reconciliation and review. The primary outcome was LOS in the AAU. Secondary outcomes were other time-related measures-for example, physicians' self-reported time spent on medication topics. Finally, the number of documented medications per patient was established.

Results

232 and 216 patients, respectively, were included on control (n=63) and intervention (n=63) days. The mean LOS was 342 (95% CI 323 to 362) min in the intervention group and 339 (95% CI 322 to 357) min in the control group, which was not statistically significantly different. Physicians spent on average 4.3 (95% CI 3.7 to 5.0) min in the intervention group and 7.5 (95% CI 6.6 to 8.5) min in the control group, corresponding to an overall reduction of 43.0% (95% CI 30.9% to 53.0%, p<0.001). The number of documented medications per patient was 10.0 (intervention group) and 8.8 (control group).

Conclusions

This study indicates that LOS in the AAU was not affected by CP intervention; however, physicians reported a significant reduction in time spent on medication topics.

Trial registration number

Clinical Trial Gov: 1-16-02-379-13.

An Analysis of WhatsApp Usage for Communication Between Consulting and Emergency Physicians

The aim of this study was to evaluate WhatsApp messenger usage for communication between consulting and emergency physicians. A retrospective, observational study was conducted in the emergency department (ED) of a tertiary care university hospital between January 2014 and June 2014. A total of 614 consultations requested by using the WhatsApp application were evaluated, and 519 eligible consultations were included in the study. The WhatsApp messages that were transferred to consultant physicians consisted of 510 (98.3%) photographic images, 517 (99.6%) text messages, 59 (11.3%) videos, and 10 (1.9%) voice messages. Consultation was most frequently requested from the orthopedics clinic (n = 160, 30.8%). The majority of requested consultations were terminated only by evaluation via WhatsApp messages. (n = 311, 59.9%). Most of the consulting physicians were outside of the hospital or were mobile at the time of the consultation (n = 292, 56.3%). The outside consultation request rate was significantly higher for night shifts than for day shifts (p = .004), and the majority of outside consultation request were concluded by only WhatsApp application (p < .001). WhatsApp is useful a communication tool between physicians, especially for ED consultants who are outside the hospital, because of the ability to transfer large amounts of clinical and radiological data during a short period of time.

Analyzing Factors Affecting Emergency Department Length of Stay-Using a Competing Risk-accelerated Failure Time Model

Emergency department (ED) length of stay (LOS) is associated with ED crowding and related complications. Previous studies either analyzed single patient disposition groups or combined different endpoints as a whole. The aim of this study is to evaluate different effects of relevant factors affecting ED LOS among different patient disposition groups.This is a retrospective electronic data analysis. The ED LOS and relevant covariates of all patients between January 2013 and December 2013 were collected. A competing risk accelerated failure time model was used to compute endpoint type-specific time ratios (TRs) for ED LOS.A total of 149,472 patients was included for analysis with an overall medium ED LOS of 2.15 [interquartile range (IQR) = 6.51] hours. The medium LOS for discharged, admission, and mortality patients was 1.46 (IQR = 2.07), 11.3 (IQR = 33.2), and 7.53 (IQR = 28.0) hours, respectively. In multivariate analysis, age (TR = 1.012, P < 0.0001], higher acuity (triage level I vs level V, TR = 2.371, P < 0.0001), pediatric nontrauma (compared with adult nontrauma, TR = 3.084, P < 0.0001), transferred patients (TR = 2.712, P < 0.0001), and day shift arrival (compared with night shift, TR = 1.451, P < 0.0001) were associated with prolonged ED LOS in the discharged patient group. However, opposite results were noted for higher acuity (triage level I vs level V, TR = 0.532, P < 0.0001), pediatric nontrauma (TR = 0.375, P < 0.0001), transferred patients (TR = 0.852, P < 0.0001), and day shift arrival (TR = 0.88, P < 0.0001) in the admission patient group.Common influential factors such as age, patient entity, triage acuity level, or arrival time may have varying effects on different disposition groups of patients. These findings and the suggested model could be used for EDs to develop individually tailored approaches to minimize ED LOS and further improve ED crowding status.

Appropriateness, Reasons and Independent Predictors of Consultations in the Emergency Department (ED) of a Dutch Tertiary Care Center: A Prospective Cohort Study

OBJECTIVE

Consultations occur frequently in the emergency department (ED) of tertiary care centres and pose a threat for patient safety as they contribute to ED lengths of stay (LOS) and overcrowding. The aim of this study was to investigate reasons and appropriateness of consultations, and the relative impact of specialty and patient characteristics on the probability of a consultation, because this could help to improve efficiency of ED patient care.

METHODS

This prospective cohort study included ED patients presenting to a Dutch tertiary care centre in a setting where ED physicians mostly treat self-referred and undifferentiated patients and other specialists treat referred patients. Consultations were defined as appropriate if the reason of consultation corresponded with the final advice, conclusion or policy of the consulted specialty. Multivariable logistic regression analysis was used to assess the relative contribution of specialty and patient characteristics on consultation.

RESULTS

In the 344 (24% (95% CI 22 to 26%)) of the 1434 inclusions another specialty was consulted, resulting in a 55% increase of ED LOS. ED physicians more often consulted another specialty with a corrected odds ratio (OR) of 5.6 (4.0 to 7.8), mostly because consultations were mandatory in case of hospitalization or outpatient follow-up. Limited expertise of ED physicians was the reason for consultation in 7% (5 to 9%). The appropriateness of consultations was 84% (81 to 88%), similar between ED physicians and other specialists (P = 0.949). The patient characteristics age, comorbidity, and triage category and complaint predicted consultation.

CONCLUSION

In a Dutch tertiary care centre another specialty was consulted in 24% of the patients, mostly for an appropriate reason, and rarely because of lack of expertise. The impact of consultations on ED LOS could be reduced if mandatory consultations are abolished and predictors of a consultation are used to facilitate timely consultation.

Emergency Department Rotational Patient Assignment

STUDY OBJECTIVE

We compare emergency department (ED) operational metrics obtained in the first year of a rotational patient assignment system (in which patients are assigned to physicians automatically according to an algorithm) with those obtained in the last year of a traditional physician self-assignment system (in which physicians assigned themselves to patients at physician discretion).

METHODS

This was a pre-post retrospective study of patients at a single ED with no financial incentives for physician productivity. Metrics of interest were length of stay; arrival-to-provider time; rates of left before being seen, left subsequent to being seen, early returns (within 72 hours), and early returns with admission; and complaint ratio.

RESULTS

We analyzed 23,514 visits in the last year of physician self-assignment and 24,112 visits in the first year of rotational patient assignment. Rotational patient assignment was associated with the following improvements (percentage change): median length of stay 232 to 207 minutes (11%), median arrival to provider time 39 to 22 minutes (44%), left before being seen 0.73% to 0.36% (51%), and complaint ratio 9.0/1,000 to 5.4/1,000 (40%). There were no changes in left subsequent to being seen, early returns, or early returns with admission.

CONCLUSION

In a single facility, the transition from physician self-assignment to rotational patient assignment was associated with improvement in a broad array of ED operational metrics. Rotational patient assignment may be a useful strategy in ED front-end process redesign.

The level of agreement regarding patient disposition between emergency physicians and consultants in the emergency department

Background

Consultation is a common and important aspect of emergency medicine practice. We examined the frequency of consultations, the level of agreement and factors of disagreement with regard to the disposition of patients who visited two emergency departments (EDs) of tertiary care hospitals in Japan.

Findings

We analyzed 3,503 consecutive patients who visited two EDs in Japan during a 3-month period. The initial diagnosis in the ED, the presence of consultation, and the patient disposition following the ED visit were recorded. At least one consultation was requested in 34.7% of the patients (1,215/3,503), and 88% of these patients were admitted to the hospital (1,063/1,215). Consultants and emergency physicians (EPs) agreed on patient disposition 95% of the time (1,153/1,215), with κ = 0.76 (95% CI 0.70-0.82). Opinions about disposition were discordant in 5% of the patients consulted upon. In 63% of those cases, patients were not diagnosed in the ED.

Conclusion

Consultants and EPs agreed on patient disposition in most cases. In more than half of the cases in which disagreements arose between EPs and consultants, the EPs were not able to reach an initial diagnosis. Further studies are needed to examine the association between disagreements in disposition and adverse outcomes.