Use of emergency observation and assessment wards: a systematic literature review

Emergency short stay area improves access and flow in a rural hospital

OBJECTIVES

Shoalhaven District Memorial Hospital is a rural (MM3) 150-bed hospital in Nowra, New South Wales, whose ED has evolved to a FACEM-led model of care (MOC). It has never had an emergency short stay area (ESSA). The objective of the present study was to pilot an ESSA and determine whether this MOC would increase the operational performance of the ED.

METHODS

An ESSA was designed and delivered by emergency medicine medical, nursing and allied health practitioners. The study period was July-December 2021, with a seasonally matched retrospective cohort of records extracted for comparison (July-December 2020). Both took place within the context of the ongoing COVID-19 pandemic. The primary outcome measured was percentage of admitted patients meeting Emergency Treatment Performance (ETP). Secondary outcomes included discharge ETP, overall ED and inpatient length of stay (LOS), mortality and representation rates.

RESULTS

The admission ETP for patients after the implementation of the ESSA significantly increased, from 13.9% to 31.6% (χ2  = 288, P < 0.001). Discharge ETP significantly declined. There was no effect improvement on overall ETP. There was no change to mortality or representation rates. Average admission LOS decreased.

CONCLUSIONS

The introduction of the ESSA significantly improved the ETP of admitted patients. Ongoing refinement of the ESSA admission processes, as well as the lifting of certain COVID-19 restrictions, could show even greater improvements in this and other areas. Ongoing research in this field is necessary, as well as a more detailed cost-benefit analysis.

Exploration of clinicians’ decision-making regarding transfer of patient care from the emergency department to a medical assessment unit: A qualitative study

Background

Hospitals face immense pressures in balancing patient throughput. Medical assessment units have emerged as a commonplace response to improve the flow of medical patients presenting to the emergency department requiring hospital admission and to ease overcrowding in the emergency department. The aim of this study was to understand factors influencing the decision-making behaviour of key stakeholders involved in the transfer of care of medical patients from one service to the other in a large, tertiary teaching hospital in Queensland, Australia.

Methods

We used a qualitative approach drawing on data from focus groups with key informant health and professional staff involved in the transfer of care. A theoretically-informed, semi-structured focus group guide was used to facilitate discussion and explore factors impacting on decisions made to transfer care of patients from the emergency department to the medical assessment unit. Thematic analysis was undertaken to look for patterns in the data.

Results

Two focus groups were conducted with a total of 15 participants. Four main themes were identified: (1) we have a process—we just don’t use it; (2) I can do it, but can they; (3) if only we could skype them; and (4) why can’t they just go up. Patient flow relies on efficiency in two processes—the transfer of care and the physical re-location of the patient from one service to the other. The findings suggest that factors other than clinical reasoning are at play in influencing decision-making behaviour.

Conclusions

Acknowledgement of the interaction within and between professional and health staff (human factors) with the organisational imperatives, policies, and process (system factors) may be critical to improve efficiencies in the service and minimise the introduction of workarounds that might compromise patient safety.

Small bowel obstruction managed without hospital admission: A safe way to reduce both cost and time in the hospital?

BACKGROUND

Small bowel obstruction management has evolved to incorporate the Gastrografin challenge. We expanded its use to the emergency department observation unit, potentially avoiding hospital admission for highly select small bowel obstruction patients. We hypothesized that the emergency department observation unit small bowel obstruction protocol would reduce admissions, costs, and the total time spent in the hospital without compromising outcomes.

METHODS

We reviewed patients who presented with small bowel obstruction from January 2015 to December 2018. Patients deemed to require urgent surgical intervention were admitted directly and excluded. The emergency department observation unit small bowel obstruction guidelines were introduced in November 2016. Patients were divided into pre and postintervention groups based on this date. The postintervention group was further subclassified to examine the emergency department observation unit patients. Cost analysis for each patient was performed looking at number of charges, direct costs, indirect cost, and total costs during their admission.

RESULTS

In total, 125 patients were included (mean age 69 ± 14.3 years). The preintervention group (n = 62) and postintervention group (n = 63) had no significant difference in demographics. The postintervention group had a 51% (36.7 hours, P < .001) reduction in median duration of stay and a total cost reduction of 49% (P < .001). The emergency department observation unit subgroup (n = 46) median length of stay was 23.6 hours. The readmission rate was 16% preintervention compared to 8% in the postintervention group (P = .18).

CONCLUSION

Management of highly selected small bowel obstruction patients with the emergency department observation unit small bowel obstruction protocol was associated with decreased length of stay and total cost, without an increase in complications, surgical intervention, or readmissions.

Realist analysis of streaming interventions in emergency departments

Background

Several of the many emergency department (ED) interventions intended to address the complex problem of (over)crowding are based on the principle of streaming: directing different groups of patients to different processes of care. Although the theoretical basis of streaming is robust, evidence on the effectiveness of these interventions remains inconclusive.

Methods

This qualitative research, grounded in the population-capacity-process model, sought to determine how, why and under what conditions streaming interventions may be effective. Data came from a broader study exploring patient flow strategies across Western Canada through in-depth interviews with managers at all levels. We undertook realist analysis of interview data from the 98 participants who discussed relevant interventions (fast-track/minor treatment areas, rapid assessment zones, diverse short-stay units), focusing on their explanations of initiatives’ perceived outcomes.

Results

Essential features of streaming interventions included separation of designated populations (population), provision of dedicated space and resources (capacity) and rapid cycle time (process). These features supported key mechanisms of impact: patients wait only for services they need; patient variability is reduced; lag time between steps is eliminated; and provider attitude change promotes prompt discharge. Conversely, reported failures usually involved neglect of one of these dimensions during intervention design and/or implementation. Participants also identified important contextual barriers to success, notably lack of outflow sites and demand outstripping capacity. Nonetheless, failure was more commonly attributed to intervention flaws than to context factors.

Conclusions

While streaming interventions have the potential to reduce crowding, a theory-based intervention relies on its implementers’ adherence to the theory. Streaming interventions cannot be expected to yield the desired results if operationalised in a manner incongruent with the theory on which they are supposedly based.

Effectiveness of clinical criteria in directing patient flow from the emergency department to a medical assessment unit in Queensland, Australia: a retrospective chart review of hospital administrative data

Background

Medical Assessment Units (MAUs) have become a popular model of acute medical care to improve patient flow through timely clinical assessment and patient management. The purpose of this study was to determine the effectiveness of a consensus-derived set of clinical criteria for patient streaming from the Emergency Department (ED) to a 15-bed MAU within the highly capacity-constrained environment of a large quaternary hospital in Queensland, Australia.

Methods

Clinically coded data routinely submitted for inter-hospital benchmarking purposes was used to identify the cohort of medical admission patients presenting to the ED in February 2016 (summer) and June 2016 (winter). A retrospective review of patient medical records for this cohort was then conducted to extract MAU admission data, de-identified patient demographic data, and clinical criteria. The primary outcome was the proportion of admissions that adhered to the MAU admission criteria.

Results

Of the total of 540 included patients, 386 (71 %) patients were deemed to meet the MAU eligibility admission criteria. Among patients with MAU indications, 66 % were correctly transferred (95 % CI: 61 to 71) to the MAU; this estimated sensitivity was statistically significant when compared with random allocation (p-value < 0.001). Transfer outcomes for patients with contraindications were subject to higher uncertainty, with a high proportion of these patients incorrectly transferred to the MAU (73 % transferred; 95 % CI: 50 to 89 %; p-value = 0.052).

Conclusions

Based on clinical criteria, approximately two-thirds of patients were appropriately transferred to the MAU; however, a larger proportion of patients were inappropriately transferred to the MAU. While clinical criteria and judgement are generally established as the process in making decisions to transfer patients to a limited-capacity MAU, our findings suggest that other contextual factors such as bed availability, time of day, and staffing mix, including discipline profile of decision-making staff during ordinary hours and after hours, may influence decisions in directing patient flow. Further research is needed to better understand the interplay of other determinants of clinician decision making behaviour to inform strategies for improving more efficient use of MAUs, and the impact this has on clinical outcomes, length of stay, and patient flow measures in MAUs.

The Effect of an Observation Unit on Pediatric Minor Head Injury

OBJECTIVE

The aim of this study was to evaluate the effect of an observation unit (OU) in an emergency department on reducing unnecessary use of computed tomography (CT) for minor blunt head trauma.

METHODS

This study was a retrospective before-and-after study of pediatric patients 18 years or younger with minor blunt head trauma. Patients with a Glasgow Coma Scale score of 14 or 15 who presented to the emergency department were included in the analysis. The rates of head CT use in the period before and after the institution of the OU were compared.

RESULTS

In total, 4706 patients were analyzed (2344 from the period before and 2362 from period after OU institution). The median age of the patients was 3 years, and 64% were male in each period. The rates of CT use were 5.7% (95% confidence interval [CI], 4.8%-6.7%) in the period before and 4.0% (95% CI, 3.3%-4.9%) in the period after OU institution (P = 0.01). The relative risk reduction was 0.70 (95% CI, 0.54-0.91).

CONCLUSIONS

The rate of CT use decreased by 30% as a result of OU institution. The OU was an effective means of avoiding an unnecessary head CT for pediatric minor head injuries.

Evaluating Safety and Efficacy of Follow-up for Patients With Abdominal Pain Using Video Consultation (SAVED Study): Randomized Controlled Trial

BACKGROUND

The benefits of telemedicine include cost savings and decentralized care. Video consultation is one form that enables early detection of deteriorating patients and promotion of self-efficacy in patients who are well but anxious. Abdominal pain is a common symptom presented by patients in emergency departments. These patients could benefit from video consultation, as it enables remote follow-up of patients who do not require admission and facilitates early discharge of patients from overcrowded hospitals.

OBJECTIVE

The study aimed to evaluate the safety and efficacy of the use of digital telereview in patients presenting with undifferentiated acute abdominal pain.

METHODS

The SAVED study was a prospective randomized controlled trial in which follow-up using existing telephone-based telereview (control) was compared with digital telereview (intervention). Patients with undifferentiated acute abdominal pain discharged from the emergency department observation ward were studied based on intention-to-treat. The control arm received routine, provider-scheduled telereview with missed reviews actively coordinated and rescheduled by emergency department staff. The intervention arm received access to a platform for digital telereview (asynchronous and synchronous format) that enabled patient-led appointment rescheduling. Patients were followed-up for 2 weeks for outcomes of service utilization, efficacy (compliance with their disposition plan), and safety (re-presentation for the same condition).

RESULTS

A total of 70 patients participated, with patients randomly assigned to each arm (1:1 ratio). Patients were a mean age of 40.0 (SD 13.8; range 22-71) years, predominantly female (47/70, 67%), and predominantly of Chinese ethnicity (39/70, 56%). The telereview service was used by 32 patients in the control arm (32/35, 91%) and 18 patients in the intervention arm (18/35, 51%). Most patients in control (33/35, 94%; 95% CI 79.5%-99.0%) and intervention (34/35, 97%; 95% CI 83.4%-99.9%) arms were compliant with their final disposition. There was a low rate of re-presentation at 72 hours and 2 weeks for both control (72 hours: 2/35, 6%; 95% CI 1.0%-20.5%; 2 weeks: 2/35, 6%, 95% CI 1.0%-20.5%) and intervention (72 hours: 2/35, 6%; 95% CI 1.0%-20.5%; 2 weeks: 3/35, 9%, 95% CI 2.2%-24.2%) arms. There were no significant differences in safety (P>.99) and efficacy (P>.99) between the two groups.

CONCLUSIONS

The application of digital telereview for the follow-up of patients with abdominal pain may be safe and effective. Future studies are needed to evaluate its cost-effectiveness and usefulness for broader clinical application.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN28468556; http://www.isrctn.com/ISRCTN28468556.

Clinical experience in management of bloodstream infection in emergency medical ward: A preliminary report

Background:

Bloodstream infection is a life-threatening clinical condition posing significant morbidities and mortalities. An “Emergency Critical Care Management Program” has been implemented in the Emergency Medicine Ward at North Lantau Hospital as a pilot critical care service model in the local emergency medicine wards. Patients with blood stream infection are recruited in the program and managed under pre-defined guideline.

Objectives:

We report our experience in managing patients with blood stream infection in the Emergency Medicine Ward and analyzed their clinical outcomes.

Methods:

This was a retrospective cohort study including a total of 64 patients with blood stream infection admitted to the Emergency Medicine Ward from 1 March 2015 and 31 March 2018. Patients’ characteristics, microbiology, and risk factors associated with adverse outcomes including in-hospital mortality were analyzed.

Results:

The most common organism isolated from blood cultures was Escherichia coli (56%). Eight patients were transferred to the tertiary hospital. The overall in-hospital mortality was 7.8% (5/64). From the univariate analysis, advanced age (p < 0.001), higher Sequential Organ Failure Assessment score and quick Sequential Organ Failure Assessment score (p < 0.001), higher Charlson Comorbidity Index (p = 0.003), more organ dysfunction (p < 0.001), pre-existing medical history of chronic liver disease (p = 0.001), dysfunction in respiratory system (p = 0.032), cardiovascular system (p = 0.044) and the central nervous system (p < 0.001), presence of septic shock (p = 0.004), and need for higher level of organ support from the use of inotropes (p < 0.001) and mechanical ventilation (p = 0.024) were associated with in-hospital mortality. In the subgroup analysis, the in-hospital mortality rate for the patients with Sequential Organ Failure Assessment score less than 6 was 1.56% (1/64). Among the five in-hospital mortality cases, four of them were managed in the Emergency Medicine Ward under the End-of-Life Care Program. Decision for withholding and withdrawing life-sustaining therapy was made with the patients’ families.

Conclusion:

This preliminary report demonstrated that with careful patient selection, adoption of guidelines, and availability of expertise, critical care service can be safely implemented in the emergency medicine ward.

Epidemiological Study on the Status of Nutrition-Support Therapies by Emergency Physicians in China

Objectives

This study aimed to investigate the current status of nutrition-support therapies by emergency physicians in China and to provide an evidence-based case to improve the regulation of enteral and parenteral nutrition-support therapies.

Methods

Physicians from the Emergency Branch of the China Geriatrics Society were enrolled in the present survey. A questionnaire related to nutrition-support therapy, including the time, location, ways, indications, complications, and nutrition-support training for physicians was answered.

Results

527 questionnaires were collected from over 300 hospitals in 25 provinces of China. The time to initiation of emergency nutrition support was often delayed. Furthermore, the treatment intensity and standardized training of physicians are weaknesses concerning nutrition support. Treatment standardization has been significantly improved, including blood glucose monitoring, precaution and management of complications, and the use of immunomodulators.

Conclusions

Emergency physicians should pay attention to early identifying and providing nutrition support to those patients who need it. Finally, standardized training should be developed for emergency nutrition-support therapy.

Converting acute inpatient take to outpatient take with fast-track assessment in internal medicine wards - a before-after study

Background

With an extensive rise in the number of acute patients and increases in both admissions and readmissions, hospitals are at times overcrowded and under immense pressure and this may challenge patient safety. This study evaluated an innovative strategy converting acute internal medicine inpatient take to an outpatient take. Here, acute patients, following referral, underwent fast-track assessment to the needed level of medical care as outpatients, directly in internal medicine wards.

Method

The two internal medicine wards at Diagnostic Centre, Silkeborg, Denmark, changed their take of acute patients 1st of March 2017. The intervention consisted of acute medical patients being received in medical examination chairs, going through accelerated evaluation as outpatients with assessment within one hour for either admission or another form of treatment. A before-and-after study design was used to evaluate changes in activity. All referred patients for 10 months following implementation of the intervention were compared with patients referred in corresponding months the previous year.

Results

A total of 5339 contacts (3632 patients) who underwent acute medical assessment (2633 contacts before and 2706 after) were included. Median hospital length-of-stay decreased from 32.6 h to 22.3 h, and the proportion of referred acute patients admitted decreased with 36.3% points from 94.5 to 58.2%. The median length-of-admission time for the admitted patients increased as expected after the intervention. The risk of being admitted, being readmitted as well as having a hospital length-of-time longer than 24 h, 72 h or 7 days, respectively, were significantly lower during the after-period in comparison to the before-period. Adverse effects, unplanned re-contacts, total contacts to general practice and mortality did not change after the intervention.

Conclusion

Assessing referred acute patients in medical examination chairs as outpatients directly in internal medicine wards and promoting an accelerated trajectory, reduced inpatient admissions and total length-of-stay considerably. This strategy seems effective in everyday acute medical patients and has the potential to ease the increasing pressure on the acute take for wards receiving acute medical patients.

Impact of the SIGN head injury guidelines and NHS 4-hour emergency target on hospital admissions for head injury in Scotland: an interrupted times series

OBJECTIVES

Head injury is a common reason for emergency department (ED) attendance. Around 1% of patients have life-threatening injuries, while 80% of patients are discharged. National guidelines (Scottish Intercollegiate Guidelines Network (SIGN)) were introduced in Scotland with the aim of achieving early identification of those with acute intracranial lesions yet safely reducing hospital admissions.This study aims to assess the impact of these guidelines and any effect the national 4-hour ED performance target had on hospital admissions for head injury.

SETTING

All Scottish hospitals between April 1998 and March 2016.

PARTICIPANTS

Patients admitted to hospital for head injury or traumatic brain injury (TBI) diagnosed by CT imaging identified using administrative Scottish Information Services Division data. There are 275 hospitals in Scotland. In 2015/2016, there were 571 221 emergency hospital admissions in Scotland.

INTERVENTIONS

The SIGN head injury guidelines introduced in 2000 and 2009. The 4-hour ED target introduced in 2004.

OUTCOMES

The monthly rate of hospital admissions for head injury and traumatic brain injury.

STUDY DESIGN

An interrupted time series analysis.

RESULTS

The first guideline was associated with a reduction in monthly admissions of 0.14 (95% CI 0.09 to 4.83) per 100 000 population. The 4-hour target was associated with a monthly increase in admissions of 0.13 (95% CI 0.06 to 0.20) per 100 000 population. The second guideline reduced monthly admissions by 0.09 (95% CI-0.13 to -0.05) per 100 000 population. These effects varied between age groups.The guidelines were associated with increased admissions for patients with injuries identified by CT imaging-guideline 1: 0.06 (95% CI 0.004 to 0.12); guideline 2: 0.05 (95% CI 0.04 to 0.06) per 100 000 population.

CONCLUSION

Increased CT imaging of head injured patients recommended by SIGN guidelines reduced hospital admissions. The 4-hour ED target and the increased identification of TBI by CT imaging acted to undermine this effect.

Factors associated with prolonged length of stay in the psychiatric emergency service

OBJECTIVE

Dedicated regional psychiatric emergency services (PES) were proposed as a better care model for psychiatric emergencies and a possible solution to boarding of psychiatric patients in the emergency department. However, there are limited data on factors associated with prolonged length of stay (LOS) in the PES. The objective of this study was finding factors associated with prolonged LOS in the PES and moving towards a solution to this problem.

METHODS

The study sample comprised 200 PES visits randomly chosen from January 2011 to December 2015 in a psychiatric hospital in Taiwan. Relevant data were collected comprehensively through the health information system and by reviewing medical records. The primary outcome was LOS longer than 24 hours while LOS longer than 48 hours was used as the secondary outcome.

RESULTS

Mean LOS was 17.6±23.2 hours, with 53 (26.5%) visits lasting more than 24 hours and 15 (7.5%) visits lasting more than 48 hours. After adjusting for related confounders, LOS longer than 24 hours was associated with use of restraints in the PES (adjusted odds ratio (aOR) = 3.13, 95% CI = 1.59-6.15) and history of illicit substance use (aOR = 2.46, 95% CI = 1.11-5.44). LOS longer than 48 hours was associated with use of restraints in the PES (aOR = 4.11, 95% CI = 1.2-14.14), history of illicit substance use (aOR = 6.16, 95% CI = 1.37-27.62) and first time visit to the hospital (aOR = 8.54, 95% CI = 2.03-35.96). Neither outcome was associated with transfer to an inpatient unit.

CONCLUSION

Prolonged LOS was common in the study sample. Discharged patients had an equally high rate of prolonged LOS as admitted patients. Therefore measures should be taken to facilitate timely discharge. Use of restraints and history of illicit substance use were common among patients with prolonged LOS.

Hospital ambulatory medicine: A leading strategy for Internal Medicine in Europe

Addressing the current collision course between growing healthcare demands, rising costs and limited resources is an extremely complex challenge for most healthcare systems worldwide. Given the consensus that this critical reality is unsustainable from staff, consumer, and financial perspectives, our aim was to describe the official position and approach of the Working Group on Professional Issues and Quality of Care of the European Federation of Internal Medicine (EFIM), for encouraging internists to lead a thorough reengineering of hospital operational procedures by the implementation of innovative hospital ambulatory care strategies. Among these, we include outpatient and ambulatory care strategies, quick diagnostic units, hospital-at-home, observation units and daycare hospitals. Moving from traditional 'bed-based' inpatient care to hospital ambulatory medicine may optimize patient flow, relieve pressure on hospital bed availability by avoiding hospital admissions and shortening unnecessary hospital stays, reduce hospital-acquired complications, increase the capacity of hospitals with minor structural investments, increase efficiency, and offer patients a broader, more appropriate and more satisfactory spectrum of delivery options.

Development of a paediatric short-stay observation and assessment unit

In recent years children's emergency admissions have risen by 18%. In 2011 a team at a city district general hospital in England recognised that children were being admitted to the general children's ward and often only staying for short periods of time. After a review of the service a plan was put forward for the development of a paediatric short-stay observation and assessment unit. The unit has led to a reduction in ward admissions and offered opportunities for children's nurses to extend their roles in assessment and treatment. This article explores the planning, delivery and audit of this unit and offers an exemplar for other trusts considering a similar change to service delivery.

External validation of the Rapid Assessment Prioritisation and Referral Tool for multidisciplinary teams in medical assessment and planning units

OBJECTIVE

The Rapid Assessment Prioritisation and Referral Tool (RAPaRT) was developed for identifying appropriate referrals to allied members of the multidisciplinary team in hospital medical assessment and planning units (MAPUs). This study examined the performance of the RAPaRT for identifying appropriate referrals as well as predicting requirement for admission to hospital and length of stay.

METHODS

A prospective cohort study was conducted. The RAPaRT, inclusive of seven mandatory items, was completed by nurses for 195 patients presenting to a hospital ED and assessed in a MAPU external to the instrument development site. Members of the multidisciplinary team (dietetics, occupational therapy, physiotherapy, social work and speech pathology) assessed participants to determine whether a referral to their profession was warranted and this was compared to RAPaRT responses.

RESULTS

All health professionals reviewed n = 175/195 (90%) participants, with n = 117/195 (60%) considered appropriate for referral to an allied health professional. At least one positive response to the RAPaRT items was recorded for n = 123 (63%) participants. Patterns of sensitivity and specificity for each item, and the instrument as a whole were consistent with the development study. The RAPaRT also predicted which patients required admission to an acute hospital ward (odds ratio = 1.22; 95% CI 1.01, 1.47) and their length of stay in hospital (coefficient = 0.18; 95% CI 0.14, 0.22).

CONCLUSION

Findings supported the external validation of the RAPaRT. In addition, this investigation made a novel contribution in demonstrating that positive RAPaRT responses were associated with requirement for admission to an acute hospital ward and length of stay.

Short-stay admissions at an inner city hospital: a cross-sectional analysis

OBJECTIVE

To investigate factors predictive of short hospital admissions and appropriate placement to inpatient versus clinical decision units (CDUs).

METHOD

This is a retrospective analysis of attendance and discharge data from an inner-city ED in England for December 2013. The primary outcome was admission for less than 48 hours either to an inpatient unit or CDU. Variables included: age, gender, ethnicity, deprivation score, arrival date and time, arrival method, admission outcome and discharge diagnosis. Analysis was performed by cross-tabulation followed by binary logistic regression in three models using the outcome measures above and seeking to identify factors associated with short-stay admission.

RESULTS

There were 2119 (24%) admissions during the study period and 458 were admitted for less than 24 hours. Those who were admitted in the middle of the week or with ambulatory care sensitive conditions (ACSCs) were significantly more likely to experience short-stays. Older patients and those who arrived by ambulance were significantly more likely to have a longer hospital stay. There was no association of length of inpatient stay with being admitted in the last 10 min of a 4 hours ED stay.

CONCLUSION

Only a few factors were independently predictive of short stays. Patients with ACSCs were more likely to have short stays, regardless of whether they were admitted to CDU or an inpatient ward. This may be a group of patients that could be targeted for dedicated outpatient management pathways or CDU if they need admission.

An Overview of an Emergency Department Short Stay Ward in Hong Kong

Objectives

To describe the structure and service pattern of a short stay ward (SSW) named as Emergency Observation and Pre-admission Ward (EOPW) in Hong Kong. The effectiveness of the EOPW was to be examined.

Methods

This was a retrospective observational cohort study. The facilities, staffing and operation of the EOPW were described. Consecutive patients admitted to the EOPW in the year 2006 were retrieved from the hospital computer database. Admission diagnoses, length of stay (LOS) and destination of disposal were the main outcome variables measured. The ICD coded admission diagnoses were categorised into 24 diagnosis-related groups. Different diagnosis-related groups were compared with respect to the selected efficacy cutoff points of LOS less than 24 hours and hospital admission rate less than 30% respectively.

Results

The service of the 30-bed short stay ward as started in year 2003 was a pilot project in Hong Kong. In year 2006, 10,111 patients were admitted and the mean age was 54.2 years. The five commonest diagnosis-related groups were psychiatric disease, chest pain, dizziness, musculoskeletal pain and poisoning. The overall hospital admission rate and the mean LOS were 26.8% and 23.4 hours respectively and were below the efficacy cutoff points. Musculoskeletal pain, chronic obstructive pulmonary disease and acute urinary retention were the three diagnostic groups with both LOS and hospital admission rate above the efficacy cutoff points.

Conclusion

This first SSW in Hong Kong was demonstrated to be effective according to the analysis result of the 2006 data. SSW has become an integral part of emergency medicine and provided an alternative way of effective management in contrast to traditional inpatient management for various selected disease conditions.

Outcomes after observation stays among older adult Medicare beneficiaries in the USA: retrospective cohort study

Objective To characterize rates and trends over time of emergency department treatment-and-discharge stays, repeat observation stays, inpatient stays, any hospital revisit, and death within 30 days of discharge from observation stays.Design Retrospective cohort study.Setting 4750 hospitals in the USA.Participants Nationally representative sample of Medicare fee for service beneficiaries aged 65 or over discharged after 363 037 index observation stays, 2 540 000 index emergency department treatment-and-discharge stays, and 2 667 525 index inpatient stays from 2006-11.Main outcome measures Rates of emergency department treatment-and-discharge stays, observation stays, inpatient stays, any hospital revisit, and death within 30 days of discharge from index observation stays. Rates were compared with corresponding outcomes within 30 days of discharge from both index emergency department treatment-and-discharge stays and index inpatient stays.Results Among 363 037 index observation stays resulting in discharge from 2006-11, 30 day rates of emergency department treatment-and-discharge stays were 8.4%, repeat observation stays were 2.9%, inpatient stays were 11.2%, any hospital revisit was 20.1%, and death was 1.8%. Of all revisits, 49.7% were for inpatient stays. Revisit rates for emergency department treatment-and-discharge stays, repeat observation stays, and any hospital revisit increased from 2006-11 (P<0.001 for trend), while 30 day rates of inpatient stays (P=0.054 for trend) and 30 day mortality (P=0.091 for trend) were both unchanged. Averaged over the study period, 30 day rates of any hospital revisit were similar after discharge from index emergency department treatment-and-discharge stays (19.9%) and index observation stays (20.1%), as was 30 day mortality (1.8% for both). Rates of any hospital revisit (21.8%) and death (5.2%) were highest after discharge from index inpatient stays.Conclusions Hospital revisits are common after discharge from observation stays, frequently result in inpatient hospitalizations, and have increased over time among Medicare beneficiaries. As revisit rates are similar after emergency department and observation stays, strategies shown to enhance emergency department transitional care may be reasonable starting points to improve post-observation outcomes.

What is the evidence for the management of patients along the pathway from the emergency department to acute admission to reduce unplanned attendance and admission? An evidence synthesis

Background

Globally, the rate of emergency hospital admissions is increasing. However, little evidence exists to inform the development of interventions to reduce unplanned Emergency Department (ED) attendances and hospital admissions. The objective of this evidence synthesis was to review the evidence for interventions, conducted during the patient’s journey through the ED or acute care setting, to manage people with an exacerbation of a medical condition to reduce unplanned emergency hospital attendance and admissions.

Methods

A rapid evidence synthesis, using a systematic literature search, was undertaken in the electronic data bases of MEDLINE, EMBASE, CINAHL, the Cochrane Library and Web of Science, for the years 2000–2014. Evidence included in this review was restricted to Randomised Controlled Trials (RCTs) and observational studies (with a control arm) reported in peer-reviewed journals. Studies evaluating interventions for patients with an acute exacerbation of a medical condition in the ED or acute care setting which reported at least one outcome related to ED attendance or unplanned admission were included.

Results

Thirty papers met our inclusion criteria: 19 intervention studies (14 RCTs) and 11 controlled observational studies. Sixteen studies were set in the ED and 14 were conducted in an acute setting. Two studies (one RCT), set in the ED were effective in reducing ED attendance and hospital admission. Both of these interventions were initiated in the ED and included a post-discharge community component. Paradoxically 3 ED initiated interventions showed an increase in ED re-attendance. Six studies (1 RCT) set in acute care settings were effective in reducing: hospital admission, ED re-attendance or re-admission (two in an observation ward, one in an ED assessment unit and three in which the intervention was conducted within 72 h of admission).

Conclusions

There is no clear evidence that specific interventions along the patient journey from ED arrival to 72 h after admission benefit ED re-attendance or readmission. Interventions targeted at high-risk patients, particularly the elderly, may reduce ED utilization and warrant future research. Some interventions showing effectiveness in reducing unplanned ED attendances and admissions are delivered by appropriately trained personnel in an environment that allows sufficient time to assess and manage patients.

Acute medical units: The way to go? A literature review

BACKGROUND

Acute healthcare chains in the Netherlands are increasingly under pressure because of rising emergency department (ED) admissions, relative bed shortages and government policy changes. In order to improve acute patient flow and quality of care through hospitals, an acute medical unit (AMU) might be a solution, as demonstrated in the UK. However, limited information is available concerning AMUs in the Netherlands. Therefore, the aims of this study were to METHODS: A systematic literature search was performed searching 3 electronic databases: PubMed, Cochrane and EMBASE. All 106 hospitals in the Netherlands were contacted, inquiring about the status of an ED, the AMU or future plans to start one.

RESULTS

The literature search resulted in 31 studies that met inclusion criteria. In general, these studies reported significant benefits on number of admissions, hospital length of stay (LOS), mortality, other wards and readmissions. Among the Dutch hospitals with an ED, 33 out of 93 implemented an AMU or similar ward, these are however organized heterogeneously. Following current trends, more AMUs are expected to be realized in the future.

CONCLUSION

In order to improve the current strain on the Dutch acute healthcare system, an AMU could potentially provide benefits. However, uniform guideline is warranted to optimize and compare quality of care throughout the Netherlands.

Cohort study on emergency general surgery patients and an observation unit

BACKGROUND

Medium-sized, non-trauma hospitals experience many of the same difficulties as tertiary centres do when it comes to managing emergency general surgery patients. However, acute surgical units are not a financially viable option in these hospitals. To improve the care of emergency general surgery patients at one such hospital, a Rapid Assessment Medical Surgical (RAMS) unit was developed to decrease the time to review and increase the efficiency in caring for these patients.

METHODS

To assess the unit's effect, a prospective analysis was completed of the patients who came through the RAMS unit over a 6-month period and compared with a retrospective analysis of patients presenting in the same 6-month period the year prior to the unit's instigation.

RESULTS

The RAMS unit was effective in providing an avenue for faster review by the surgical team. This resulted in patients leaving the emergency department faster, decreased the number of patients that breached emergency department time-targets and increased the number of patients discharged after a period of observation or basic treatments.

CONCLUSION

General surgery patients were managed more efficiently with the RAMS unit in place. However, a full cost analysis is required to determine if such units are cost-effective.

Point-of-care universal screening for meticillin-resistant Staphylococcus aureus: a cluster-randomized cross-over trial

BACKGROUND

Meticillin-resistant Staphylococcus aureus (MRSA) is frequently endemic in healthcare settings and may be transmitted by person-to-person spread. Asymptomatic MRSA carriers are potential, unsuspected sources for transmission and some of them may be identified by admission screening.

AIM

To assess whether rapid point-of-care screening (POCS) for MRSA at hospital admission may be associated with a reduction in MRSA acquisition rates when compared with slower laboratory-based methods.

METHODS

A cluster-randomized cross-over trial was conducted in four admission wards of an acute London tertiary care hospital. Polymerase chain reaction-based POCS screening was compared with conventional culture screening. Patients were screened on ward admission and discharge, and the MRSA acquisition rate on the admission wards was calculated as the primary outcome measure.

RESULTS

In all, 10,017 patients were included; 4978 in the control arm, 5039 in the POCS arm. The MRSA carriage rate on admission was 1.7%. POCS reduced the median reporting time from 40.4 to 3.7 h (P < 0.001). MRSA was acquired on the admission wards by 23 (0.46%) patients in the control arm and by 24 (0.48%) in the intervention arm, acquisition rates of 5.39 and 4.60 per 1000 days respectively. After taking account of predefined confounding factors, the adjusted incidence rate ratio (IRR) for change in trend for MRSA acquisition was 0.961 (95% confidence interval: 0.766-1.206). The adjusted IRR for step change for MRSA acquisition was 0.98 (0.304-3.162).

CONCLUSION

POCS produces a significantly faster result but has no effect on MRSA acquisition on admission wards compared with culture screening. Where compliance with infection prevention and control is high and MRSA carriage is low, POCS has no additional impact on MRSA acquisition rates over the first one to four days of admission compared with conventional culture screening.

Effect of a Multi-Diagnosis Observation Unit on Emergency Department Length of Stay and Inpatient Admission Rate at Two Canadian Hospitals

BACKGROUND

Observation units (OUs) have been shown to reduce emergency department (ED) lengths of stay (LOS) and admissions. Most published studies have been on OUs managing single complaints.

OBJECTIVE

Our aim was to determine whether an OU reduces ED LOS and hospital admission rates for adults with a variety of presenting complaints.

METHODS

We comparatively evaluated two hospitals in British Columbia, Canada (hereafter ED A and ED B) using a pre-post design. Data were extracted from administrative databases. The post-OU cohort included all adults presenting 6 months after OU implementation. The pre-OU cohort included all adults presenting in the same 6-month period 1 year before OU implementation.

RESULTS

There were 109,625 patient visits during the study period. Of the 56,832 visits during the post-OU period (27,512 to ED A and 29,318 to ED B), 1.9% were managed in the OU in ED A and 1.4% in ED B. Implementation was associated with an increase in the median ED LOS at ED A (179.0 min pre vs. 192.0 min post [+13.0 min]; p < 0.001; mean difference -12.5 min, 95% confidence interval [CI] -15.2 to -9.9 min), but no change at ED B (182.0 min pre vs. 182.0 min post; p = 0.55; mean difference +2.0 min, 95% CI -0.7 to +4.7 min). Implementation significantly decreased the hospital admission rate for ED A (17.8% pre to 17.0% post [-0.8%], 95% CI -0.18% to 0.15%; p < 0.05) and did not significantly change the hospital admission rate at ED B (18.9% pre to 18.3% post [-0.6%], 95% CI -1.19% to -0.09%; p = 0.09).

CONCLUSIONS

A multi-diagnosis OU can reduce hospital admission rate in a site-specific manner. In contrast to previous studies, we did not find that an OU reduced ED LOS. Further research is needed to determine whether OUs can reduce ED overcrowding.

Changing paediatric emergency department model of care is associated with improvements in the National Emergency Access Target and a decrease in inpatient admissions

OBJECTIVE

To assess the impact on patient flow as noted by the National Emergency Access Target (NEAT), with the introduction of a new Paediatric ED (PEM ED) model of care.

METHODS

This longitudinal observational study was conducted at the Logan Hospital, a 344 bed public hospital in metropolitan Brisbane, which opened a physically separate, dedicated PEM ED on 14 October 2014, incorporating approximately 30% more staff, limited changes in processes and no changes in governance. De-identified data of the entire clientele from the ED Information System were compared 365 days before and after the opening of the PEM ED.

RESULTS

Although the number of children presenting to ED increased by 23% (pre 18 142, post 22 391), the median length of stay decreased substantially from 152 min to 138 min, resulting in a 7.75% rise in presentations that met the NEAT target (pre 77.41%, post 85.16%; P < 0.0001). Admission to the ED Short Stay Unit rose by 16.48% (pre 5.38%, post 21.86%; P < 0.0001), whereas final disposition to the inpatient paediatric unit fell by 2.30% (pre 11.43, post 9.13%; P < 0.0001). The clinical presentations were similar pre and post across age, sex, ethnicity, referral and arrival mode, Australasian Triage Scale category, presenting problem and discharge diagnosis.

CONCLUSION

NEAT times improved after changing the PEM ED model of care. Further studies may assist identifying which of the specific features within the new model are most effective for improving patient flow.

Pelvic inflammatory disease: improving awareness, prevention, and treatment

Purpose

Pelvic inflammatory disease (PID) is a common disorder of the reproductive tract that is frequently misdiagnosed and inadequately treated. PID and its complications, such as infertility, ectopic pregnancy, and chronic pelvic pain, are preventable by screening asymptomatic patients for sexually transmitted infections (STIs) and promptly treating individuals with STIs and PID.

Recent findings

The rates of adverse outcomes in women with PID are high and disproportionately affect young minority women. There are key opportunities for prevention including improving provider adherence with national screening guidelines for STIs and PID treatment recommendations and patient medication adherence. Nearly half of all eligible women are not screened for STIs according to national quality standards, which may increase the risk of both acute and subclinical PID. Moreover, in clinical practice, providers poorly adhere to the Centers for Disease Control and Prevention recommendations for treatment of PID. Additionally, patients with PID struggle to adhere to the current management strategies in the outpatient setting.

Conclusion

Novel evidence-based clinical and public health interventions to further reduce the rates of PID and to improve outcomes for affected women are warranted. We propose potential cost-effective approaches that could be employed in real-world settings.

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Background

In 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.

Objective

The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.

Data sources

MEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.

Methods

We have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.

Results

The review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.

Limitations

Although there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.

Conclusions

The evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.

Funding

The National Institute for Health Research Health Services and Delivery Research Programme.

Establishing and implementing best practice to reduce unplanned admissions in those aged 85 years and over through system change [Establishing System Change for Admissions of People 85+ (ESCAPE 85+)]: a mixed-methods case study approach

Background

In England, between 2007/8 and 2009/10, the rate of unplanned hospital admissions of people aged 85 years and above rose from 48 to 52 per 100. There was substantial variation, with some areas showing a much faster rate of increase and others showing a decline.

Objectives

To identify system characteristics associated with higher and lower increases in unplanned admission rates in those aged 85 years and over; to develop recommendations to inform providers and commissioners; and to investigate the challenges of starting to implement these recommendations.

Design

Mixed-methods study using routinely collected data, in-depth interviews and focus groups. Data were analysed using the framework approach, with themes following McKinsey’s 7S model. Recommendations derived from our findings were refined and prioritised through respondent validation and consultation with the project steering group. The process of beginning to implement these recommendations was examined in one ‘implementation site’.

Participants

Six study sites were selected based on admission data for patients aged 85 years and above from primary care trusts: three where rates of increase were among the most rapid and three where they had slowed down or declined. Each ‘improving’ or ‘deteriorating’ site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services, and adult social care. At each site, representatives from these organisations at strategic and operational levels, as well as representatives of patient groups, were interviewed to understand how policies had been developed and implemented. A total of 142 respondents were interviewed.

Results

Between 2007/8 and 2009/10, average admission rates for people aged 85 years and over rose by 5.5% annually in deteriorating sites and fell by 1% annually in improving sites. During the period under examination, the population aged 85 years and over in deteriorating sites increased by 3.4%, compared with 1.3% in improving sites. In deteriorating sites, there were problems with general practitioner access, pressures on emergency departments and a lack of community-based alternatives to admission. However, the most striking difference between improving and deteriorating sites was not the presence or absence of specific services, but the extent to which integration within and between types of service had been achieved. There were also overwhelming differences in leadership, culture and strategic development at the system level. The final list of recommendations emphasises the importance of issues such as maximising integration of services, strategic leadership and adopting a system-wide approach to reconfiguration.

Conclusions

Rising admission rates for older people were seen in places where several parts of the system were under strain. Places which had stemmed the rising tide of admissions had done so through strong, stable leadership, a shared vision and strategy, and common values across the system.

Future work

Research on individual components of care for older people needs to take account of their impact on the system as a whole. Areas where more evidence is needed include the impact of improving access and continuity in primary care, the optimal capacity for intermediate care and how the frail elderly can best be managed in emergency departments.

Study registration

UK Clinical Reasearch Network 12960.

Funding details

The National Institute for Health Research Health Services and Delivery Research programme.

Barriers and facilitators to the implementation of Ontario's emergency department clinical decision unit pilot program: a qualitative study

Objective:

In Ontario, clinical decision units (CDUs) were implemented as a pilot project in 2008 by the Ministry of Health and Long-Term Care as part of its strategy to reduce emergency department (ED) waiting times. Our objective was to describe general characteristics of the program at each of the participating sites and to examine barriers and facilitators to integrating CDUs into practice.

Methods:

On-site small-group interviews were conducted in two phases with ED and hospital staff at participating sites, first at 8 to 12 weeks and again at 12 months postimplementation. Interview data were analyzed using the framework approach. Unstructured field notes and CDU clinical care protocols and documentation were also reviewed.

Results:

The qualitative analysis identified 10 key themes related to integrating CDUs into EDs: shift in clinical and operational practice; administrative aspects of implementation; team building and stakeholder involvement; use of clinical care protocols; physical or virtual model of care; responsive ancillary services; involvement of specialist services; coordination with hospital and community supports; appropriate use of the CDU; and ongoing evaluation and monitoring. Each theme represents an important insight from the perspective of clinical and administrative staff at participating sites.

Conclusion:

The implementation of CDUs is a complex process, with no single preferred clinical care or operational model. This study identifies a number of key considerations relevant to the future implementation of CDUs.

Impact of observation status on hospital use for patients with cancer

PURPOSE

For patients with cancer, the impact of observation status on hospital and patient outcomes is not well understood. Our objective was to assess the impact that an observation unit had on hospital use for patients with cancer who presented to the Urgent Care Center at a comprehensive cancer center.

METHODS

We assessed the proportion of Urgent Care Center visits that resulted in an admission to the hospital at a comprehensive cancer center, before (July 9, 2012-December 31, 2012) versus after (July 9, 2013-December 31, 2013) implementation of the observation unit. We also assessed differences in length of stay and stratified the data by presenting complaint.

RESULTS

During each 6-month study interval, there were more than 10,000 patient visits to the Urgent Care Center, representing approximately 6,000 unique patients. Fewer visits resulted in an inpatient admission postimplementation (47%) compared with preimplementation (50%). The duration of hospital stay for admitted patients was higher in the post period (median 108 hours) than in the pre period (median 96 hours). Alternatively, the proportion of hospital admissions with a length of stay less than 24 hours was lower in the post period (pre: 7%; post: 5%). Lower admission rates postimplementation were observed for patients who presented with fluid and electrolyte disorders, nausea and vomiting, syncope, and chest pain.

CONCLUSION

We observed reductions in hospital use for patients with cancer related to an observation unit in a comprehensive cancer center. Adoption of this approach for this patient population has the potential to reduce hospital use, which is of interest to hospitals, payers, and patients.

Age and admission times as predictive factors for failure of admissions to discharge-stream short-stay units

OBJECTIVE

Discharge-stream emergency short-stay units (ESSU) improve ED and hospital efficiency. Age of patients and time of hospital presentations have been shown to correlate with increasing complexity of care. We aim to determine whether an age and time cut-off could be derived to subsequently improve short-stay unit success rates.

METHODS

We conducted a retrospective audit on 6703 (5522 inclusions) patients admitted to our discharge-stream short-stay unit. Patients were classified as appropriate or inappropriate admissions, and deemed successful if discharged out of the unit within 24 h; and failures if they needed inpatient admission into the hospital. We calculated short-stay unit length of stay for patients in each of these groups. A 15% failure rate was deemed as acceptable key performance indicator (KPI) for our unit.

RESULTS

There were 197 out of 4621 (4.3%, 95% CI 3.7-4.9%) patients up to the age of 70 who failed admission to ESSU compared with 67 out of 901 (7.4%, 95% CI 5.9-9.3%, P < 0.01) of patients over the age of 70, reflecting an increased failure rate in geriatric population. When grouped according to times of admission to the ESSU (in-office 06.00-22.00 hours vs out-of-office 22.00-06.00 hours) no significant difference rates in discharge failure (4.7% vs 5.2%, P = 0.46) were noted.

CONCLUSION

Patients >70 years of age have higher rates of failure after admission to discharge-stream ESSU. Although in appropriately selected discharge-stream patients, no age group or time-band of presentation was associated with increased failure rate beyond the stipulated KPI.

Implementation of an acute surgical admission ward

Background

The aim of the study was to assess the impact of an acute surgical admission ward on admission and discharge processes.

Methods

This prospective cohort study was conducted in a university tertiary referral centre. All acute surgical patients were clustered in the acute surgical unit (ASU) in February and March 2012, and discharged or transferred to specialized departments within 48 h. The primary outcome was length of hospital stay (LOS). Secondary outcomes were impact on emergency department waiting times, discharge home within 48 h, incorrect ward admissions, readmissions and mortality. Outcomes of the study group were compared with those of a historical reference group admitted during the same interval the year before.

Results

Some 249 patients were admitted to the ASU during the study interval. The reference group consisted of 211 patients. The total LOS decreased significantly from a median of 4·0 to 2·0 days (P = 0·004). The percentage of patients who were discharged within 48 h increased from 30·3 to 43·4 per cent (P = 0·004). The rate of incorrect ward admission decreased from 9·5 to 0 per cent. Emergency department waiting time, readmission rate and 30-day mortality did not change.

Conclusion

Introduction of an acute surgical unit-shortened length of hospital stay without comprising readmission and mortality rates.

The emergency department prediction of disposition (EPOD) study

BACKGROUND

Emergency departments (ED) continue to evolve models of care and streaming as interventions to tackle the effects of access block and overcrowding. Tertiary ED may be able to design patient-flow based on predicted dispositions in the department. Segregating discharge-stream patients may help develop patient-flows within the department, which is less affected by availability of beds in a hospital. We aim to determine if triage nurses and ED doctors can predict disposition outcomes early in the patient journey and thus lead to successful streaming of patients in the ED.

METHODS

During this study, triage nurses and ED doctors anonymously predicted disposition outcomes for patients presenting to triage after their brief assessments. Patient disposition at the 24-h post ED presentation was considered as the actual outcome and compared against predicted outcomes.

RESULTS

Triage nurses were able to predict actual discharges of 445 patients out of 490 patients with a positive predictive value (PPV) of 90.8% (95% CI 87.8-93.2%). ED registrars were able to predict actual discharges of 85 patients out of 93 patients with PPV of 91.4% (95% CI 83.3-95.9%). ED consultants were able to predict actual discharges of 111 patients out of 118 patients with PPV 94.1% (95% CI 87.7-97.4%). PPVs for admission among ED consultants, ED registrars and Triage nurses were 59.7%, 54.4% and 48.5% respectively.

CONCLUSIONS

Triage nurses, ED consultants and ED registrars are able to predict a patient's discharge disposition at triage with high levels of confidence. Triage nurses, ED consultants, and ED registrars can predict patients who are likely to be admitted with equal ability. This data may be used to develop specific admission and discharge streams based on early decision-making in EDs by triage nurses, ED registrars or ED consultants.

A general medical short-stay unit is not more efficient than a traditional model of care

OBJECTIVES

To assess the efficiency of a short-stay unit (SSU) for undifferentiated medical patients and evaluate its effect on the overall efficiency of a general medicine department.

DESIGN, SETTING AND PATIENTS

Retrospective study of all general medical patients admitted to the SSU at Flinders Medical Centre, South Australia, during its 5 years of operation (2005-2009), compared with 4 years before its institution and 2 years after its closure.

MAIN OUTCOME MEASURES

Relative stay index (RSI); inhospital mortality; readmissions within 7 and 28 days.

RESULTS

23 790 general medical patients were admitted overall, and 10 764 of these (45.2%) were admitted to the SSU. The RSI for the SSU during its years of operation was 0.79, compared with 1.34 for the long-stay unit. The overall RSI for the department did not improve during those years and was not significantly different to the periods before or after.

CONCLUSIONS

We found no evidence that an SSU for undifferentiated medical patients creates bed capacity. It does, however, appear to be safe.

Hospital, patient, and local health system characteristics associated with the prevalence and duration of observation care

OBJECTIVE

To examine the association between hospital, patient, and local health system characteristics and the likelihood, prevalence, and duration of observation care among fee-for-service Medicare beneficiaries.

DATA SOURCES

The 100 percent Medicare inpatient and outpatient claims and enrollment files for 2009, supplemented with 2007 American Hospital Association Survey and 2009 Area Resource File data.

STUDY DESIGN

Using a lagged cross-sectional design, we model the likelihood of a hospital providing any observation care using logistic regression and the conditional prevalence and duration of observation care using linear regression, among 3,692 general hospitals in the United States.

PRINCIPLE FINDINGS

Critical access hospitals (CAHs) have 97 percent lower odds of providing observation care compared to other hospitals, and they conditionally provide three fewer observation stays per 1,000 visits. The provision of observation care is negatively associated with the proportion of racial minority patients, but positively associated with average patient age, proportion of outpatient visits occurring in the emergency room, and diagnostic case mix. Duration is between 1.5 and 2.8 hours shorter at government-owned, for-profit hospitals, and CAHs compared to other nonprofit hospitals.

CONCLUSIONS

Variation in observation care depends primarily on hospital characteristics, patient characteristics, and geographic measures. By contrast, local health system characteristics are not a factor.

Key operational characteristics in emergency department observation units: a comparative study between sites in the United States and Asia

Background

To improve efficiency, emergency departments (EDs) use dedicated observation units (OUs) to manage patients who are unable to be discharged home, yet do not clearly require inpatient hospitalization. However, operational metrics and their ideal targets have not been created for this setting and patient population. Variation in these metrics across different countries has not previously been reported. This study aims to define and compare key operational characteristics between three ED OUs in the United States (US) and three ED OUs in Asia.

Methods

This is a descriptive study of six tertiary-care hospitals, all of which are level 1 trauma centers and have OUs managed by ED staff. We collected data via various methods, including a standardized survey, direct observation, and interviews with unit leadership, and compared these data across continents.

Results

We define multiple key operational characteristics to compare between sites, including OU length of stay (LOS), OU discharge rate, and bed turnover rate. OU LOS in the US and Asian sites averaged 12.9 hours (95% CI, 8.3 to 17.5) and 20.5 hours (95% CI, -49.4 to 90.4), respectively (P = 0.39). OU discharge rates in the US and Asia averaged 84.3% (95% CI, 81.5 to 87.2) and 88.7% (95% CI, 81.5 to 95.8), respectively (P = 0.11), and the bed turnover rates in the US and Asian sites averaged 1.6 patients/bed/day (95% CI, -0.1 to 3.3) and 0.9 patient/bed/day (95% CI, -0.6 to 2.4), respectively (P = 0.27).

Conclusions

Prior research has shown that the OU is a resource that can mitigate many of problems in the ED and hospital, while simultaneously improving patient care and satisfaction. We describe key operational characteristics that are relevant to all OUs, regardless of geography or healthcare system to monitor and maximize efficiency. Although measures of LOS and bed turnover varied widely between US and Asian sites, we did not find a statistically significant difference. Use of these metrics may enable hospitals to establish or revise an ED OU and reduce OU LOS, increase bed turnover, and discharge rates while simultaneously improving patient satisfaction and quality of care.

Effectiveness of Emergency Medicine Wards in reducing length of stay and overcrowding in emergency departments

OBJECTIVE

This study aims to evaluate the effectiveness of an Emergency Medicine Ward (EMW) in reducing the length of stay (LOS) in the emergency department, length of hospitalization, emergency medical admission rate, and the hospital bed occupancy rate.

METHODS

This study is a cross-sectional, observational study with a retrospective, quantitative record review conducted at the EMW of a regional acute hospital in Hong Kong from January 2009 to June 2009.

RESULTS

During the study, a retrospective audit was conducted on 1834 patient records. The five main groups of patients admitted into EMW suffered from cardiac disease (26.5%), pneumonia (19.6%), dizziness (16.2%), Chronic Obstructive Pulmonary Disease (12.3%), and gastroenteritis (7.9%). The mean LOS in the EMW was 1.27 days (SD=0.59). The average emergency medical admission rate within the six-month period was significantly reduced relative to that before the EMW became operational (January 2008 to June 2008). Clinically, the medical in-patient bed occupancy was significantly reduced by 6.2%. The average LOS during in-patient hospitalization after the EMW was established decreased to 4.13 days from the previous length of 5.16 days.

CONCLUSIONS

EMWs effectively reduce both the LOS during in-patient hospitalization and the avoidable medical admission rate.

Can all cause readmission policy improve quality or lower expenditures? A historical perspective on current initiatives

All-cause readmission to inpatient care is of wide policy interest in the United States and a number of other countries (Centers for Medicare and Medicaid Services, in the United Kingdom by the National Centre for Health Outcomes Development, and in Australia by the Australian Institute of Health and Welfare). Contemporary policy efforts, including high powered incentives embedded in the current US Hospital Readmission Reduction Program, and the organizationally complex interventions derived in anticipation of this policy, have been touted based on potential cost savings. Strong incentives and resulting interventions may not enjoy the support of a strong theoretical model or the empirical research base that are typical of strong incentive schemes. We examine the historical broad literature on the issue, lay out a 'full' conceptual organizational model of patient transitions as they relate to the hospital, and discuss the strengths and weaknesses of previous and proposed policies. We use this to set out a research and policy agenda on this critical issue rather than attempt to conduct a comprehensive structured literature review. We assert that researchers and policy makers should consider more fundamental societal issues related to health, social support and health literacy if progress is going to be made in reducing readmissions.

The impact of EHR and HIE on reducing avoidable admissions: controlling main differential diagnoses

BACKGROUND

Many medical organizations have invested heavily in electronic health record (EHR) and health information exchange (HIE) information systems (IS) to improve medical decision-making and increase efficiency. Despite the potential interoperability advantages of such IS, physicians do not always immediately consult electronic health information, and this decision may result in decreased level of quality of care as well as unnecessary costs. This study sought to reveal the effect of EHR IS use on the physicians' admission decisions. It was hypothesizing the using EHR IS will result in more accurate and informed admission decisions, which will manifest through reduction in single-day admissions and in readmissions within seven days.

METHODS

This study used a track log-file analysis of a database containing 281,750 emergency department (ED) referrals in seven main hospitals in Israel. Log-files were generated by the system and provide an objective and unbiased measure of system usage, Thus allowing us to evaluate the contribution of an EHR IS, as well as an HIE network, to decision-makers (physicians). This is done by investigating whether EHR IS lead to improved medical outcomes in the EDs, which are known for their tight time constraints and overcrowding. The impact of EHR IS and HIE network was evaluated by comparing decisions on patients classified by five main differential diagnoses (DDs), made with or without viewing the patients' medical history via the EHR IS.

RESULTS

The results indicate a negative relationship between viewing medical history via EHR systems and the number of possibly redundant admissions. Among the DDs, we found information viewed most impactful for gastroenteritis, abdominal pain, and urinary tract infection in reducing readmissions within seven days, and for gastroenteritis, abdominal pain, and chest pain in reducing the single-day admissions' rate. Both indices are key quality measures in the health system. In addition, we found that interoperability (using external information provided online by health suppliers) contributed more to this reduction than local files, which are available only in the specific hospital. Thus, reducing the rate of redundant admissions by using external information produced larger odds ratios (of the β coefficients; e.g. viewing external information on patients resulted in negative associations of 27.2% regarding readmissions within seven days, and 13% for single-day admissions as compared with viewing local information on patients respectively).

CONCLUSIONS

Viewing medical history via an EHR IS and using HIE network led to a reduction in the number of seven day readmissions and single-day admissions for all patients. Using external medical history may imply a more thorough patient examination that can help eliminate unnecessary admissions. Nevertheless, in most instances physicians did not view medical history at all, probably due to the limited resources available, combined with the stress of rapid turnover in ED units.

Factors associated with prolonged stay in a pediatric emergency observation unit of an urban tertiary children's hospital in China

OBJECTIVES

This study aimed to examine the factors associated with increased length of stay (LOS > 24 hours) in the pediatric emergency observation unit (OU) of an urban tertiary children's hospital in China.

METHODS

This study was a retrospective cohort study. We retrieved and examined all the records of patients (age, 0-16 years) who were admitted to the OU (n = 10,852) during July 1, 2008, to June 30, 2009. The primary outcome was LOS and prolonged stay (LOS > 24 hours). We also performed a sensitivity analysis by using LOS of 3 days or greater and LOS of 6 days or greater as dependent variables in logistic regression and compared with LOS of greater than 24 hours regression to examine the robustness of the associations.

RESULTS

The overall mean (SD) LOS was 24.0 (24.4) hours; 31.3% had LOS of greater than 24 hours, of which the mean (SD) LOS was 50.2 (28.6) hours. The following factors were associated with LOS of greater than 24 hours: age, 28 days to 3 months (odds ratio, [OR], 1.87; 95% confidence interval, 1.36-2.59) and older than 3 months to 12 months (OR, 1.83; 95% CI, 1.35-2.50) compared with age 0 to 28 days; neurologic diseases (OR, 1.50; 95% CI, 1.31-1.72), infectious diseases (OR, 2.00; 95% CI, 1.61-2.49), and visits for non-respiratory-related signs and symptoms (OR, 2.00; 95% CI, 1.61-2.49); acuity level of emergent (OR, 1.79; 95% CI, 1.57-2.04); procedures (OR, 7.09; 95% CI, 4.16-12.10); emergency transfusions (OR, 1.33; 95% CI, 1.01-1.75); staffed by residents (OR, 1.12; 95% CI, 1.01-1.24); and patients living in low-annual gross domestic product districts (OR, 1.14; 95% CI, 1.01-1.29). Arrival at evening (OR, 0.54; 95% CI, 0.49-0.60) and overnight (OR, 0.43; 95% CI, 0.38-0.49) were less likely to have LOS of greater than 24 hours than arrival during day shifts.

CONCLUSIONS

We identified some risk factors for prolonged stay in an OU. These factors are the starting points in understanding issues related to prolonged stay and are needed to assess efficiency and quality of care in pediatric emergency department and OU. Our results have provided information basis for making improvements in the system and may be important considerations for similar institutions, which encounter similar challenges.

Design and application of an information system for the emergency observation room in a Chinese hospital

The emergency observation room (EOR) in a Chinese hospital provides medium-term observation and treatment, as well holding patients who will be admitted to the wards. The operational pattern of the EOR lies between those of the outpatient and inpatient services. We developed a novel information system for the EOR to meet the specific requirements for issuing medication, which includes both order sheets and prescriptions, and tested it in a Grade 3 and Class A hospital. The system reduced the frequency of cashier interactions and the time taken for patients to access their medications, and also reduced the workloads of doctors and other staff members.

Emergency department observation units: A clinical and financial benefit for hospitals

INTRODUCTION

There are nearly 120 million visits to emergency departments each year, one for every three people in the United States. Fifty percent of all hospital admissions come from this group, a marked change from the mid-1990s when the emergency department was a source of only a third of admissions. As the population increases and ages, the growth rate for emergency department visits and the resulting admissions will exceed historical trends creating a surge in demand for inpatient beds.

BACKGROUND

Current health care reform efforts are highlighting deficiencies in access, cost, and quality of care in the United States. The need for more inpatient capacity brings attention to short-stay admissions and whether they are necessary. Emergency department observation units provide a suitable alternate venue for many such patients at lower cost without adversely affecting access or quality.

METHODS

This article serves as a literature synthesis in support of observation units, with special emphasis on the clinical and financial aspects of their use. The observation medicine literature was reviewed using PubMed, and selected sources were used to summarize the current state of practice. In addition, the authors introduce a novel conceptual framework around measures of observation unit efficiency.

FINDINGS AND PRACTICE IMPLICATIONS

Observation units provide high-quality and efficient care to patients with common complaints seen in the emergency department. More frequent use of observation can increase patient safety and satisfaction while decreasing unnecessary inpatient admissions and improving fiscal performance for both emergency departments and the hospitals in which they operate. For institutions with the volume to justify the fixed costs of operating an observation unit, the dominant strategy for all stakeholders is to create one.