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Ahmed A, Aram KY, Tutun S, Delen D. A study of "left against medical advice" emergency department patients: an optimized explainable artificial intelligence framework. Health Care Manag Sci 2024:10.1007/s10729-024-09684-5. [PMID: 39138745 DOI: 10.1007/s10729-024-09684-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/19/2024] [Indexed: 08/15/2024]
Abstract
The issue of left against medical advice (LAMA) patients is common in today's emergency departments (EDs). This issue represents a medico-legal risk and may result in potential readmission, mortality, or revenue loss. Thus, understanding the factors that cause patients to "leave against medical advice" is vital to mitigate and potentially eliminate these adverse outcomes. This paper proposes a framework for studying the factors that affect LAMA in EDs. The framework integrates machine learning, metaheuristic optimization, and model interpretation techniques. Metaheuristic optimization is used for hyperparameter optimization-one of the main challenges of machine learning model development. Adaptive tabu simulated annealing (ATSA) metaheuristic algorithm is utilized for optimizing the parameters of extreme gradient boosting (XGB). The optimized XGB models are used to predict the LAMA outcomes for patients under treatment in ED. The designed algorithms are trained and tested using four data groups which are created using feature selection. The model with the best predictive performance is then interpreted using the SHaply Additive exPlanations (SHAP) method. The results show that best model has an area under the curve (AUC) and sensitivity of 76% and 82%, respectively. The best model was explained using SHAP method.
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Affiliation(s)
- Abdulaziz Ahmed
- Department of Health Services Administration, School of Health Professions, The University of Alabama at Birmingham, Birmingham, AL, 35233, USA.
- Department of Biomedical Informatics and Data Science, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35233, USA.
| | - Khalid Y Aram
- School of Business & Technology , Emporia State University, Emporia, KS, 66801, USA
| | - Salih Tutun
- WashU Olin Business School, Washington University in St. Louis, St. Louis, MO, 63130, USA
| | - Dursun Delen
- Center for Health Systems Innovation, Department of Management Science and Information Systems, Spears School of Business, Oklahoma State University, Stillwater, OK, 74078, USA
- Department of Industrial Engineering, Faculty of Engineering and Natural Sciences, Istinye University, Sariyer/İstanbul,, 34396, Türkiye
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Janerka C, Leslie GD, Gill FJ. Patient experience of emergency department triage: An integrative review. Int Emerg Nurs 2024; 74:101456. [PMID: 38749231 DOI: 10.1016/j.ienj.2024.101456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 04/07/2024] [Accepted: 04/26/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Emergency department (ED) triage is often patients' first contact with a health service and a critical point for patient experience. This review aimed to understand patient experience of ED triage and the waiting room. METHODS A systematic six-stage approach guided the integrative review. Medline, CINAHL, EmCare, Scopus, ProQuest, Cochrane Library, and JBI database were systematically searched for primary research published between 2000-2022 that reported patient experience of ED triage and/or waiting room. Quality was assessed using established critical appraisal tools. Data were analysed for descriptive statistics and themes using the constant comparison method. RESULTS Twenty-nine articles were included. Studies were mostly observational (n = 17), conducted at a single site (n = 23), and involved low-moderate acuity patients (n = 13). Nine interventions were identified. Five themes emerged: 'the who, what and how of triage', 'the patient as a person', 'to know or not to know', 'the waiting game', and 'to leave or not to leave'. CONCLUSION Wait times, initiation of assessment and treatment, information provision and interactions with triage staff appeared to have the most impact on patient experience, though patients' desires for each varied. A person-centred approach to triage is recommended.
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Affiliation(s)
- Carrie Janerka
- School of Nursing, Curtin University, Western Australia, Australia; Fiona Stanley Hospital, South Metropolitan Health Service, Western Australia, Australia.
| | - Gavin D Leslie
- School of Nursing, Curtin University, Western Australia, Australia
| | - Fenella J Gill
- School of Nursing, Curtin University, Western Australia, Australia; Perth Children's Hospital, Child and Adolescent Health Service, Western Australia, Australia
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Davies F, Ballesteros P, Melniker L, Atkinson P. CJEM Debate Series: #TriageAgain-are current triage methods dangerous?… if we cannot actually treat those triaged as urgent within a safe time frame? CAN J EMERG MED 2024; 26:312-315. [PMID: 38592664 DOI: 10.1007/s43678-024-00681-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/17/2024] [Indexed: 04/10/2024]
Affiliation(s)
- Ffion Davies
- Emergency Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Larry Melniker
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY, USA
| | - Paul Atkinson
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Horizon Health Network, Saint John, NB, Canada.
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McLane P, Bill L, Healy B, Barnabe C, Plume TB, Bird A, Colquhoun A, Holroyd BR, Janvier K, Louis E, Rittenbach K, Curtin KD, Fitzpatrick KM, Mackey L, MacLean D, Rosychuk RJ. Leaving emergency departments without completing treatment among First Nations and non-First Nations patients in Alberta: a mixed-methods study. CMAJ 2024; 196:E510-E523. [PMID: 38649167 PMCID: PMC11045230 DOI: 10.1503/cmaj.231019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Our previous research showed that, in Alberta, Canada, a higher proportion of visits to emergency departments and urgent care centres by First Nations patients ended in the patient leaving without being seen or against medical advice, compared with visits by non-First Nations patients. We sought to analyze whether these differences persisted after controlling for patient demographic and visit characteristics, and to explore reasons for leaving care. METHODS We conducted a mixed-methods study, including a population-based retrospective cohort study for the period of April 2012 to March 2017 using provincial administrative data. We used multivariable logistic regression models to control for demographics, visit characteristics, and facility types. We evaluated models for subgroups of visits with pre-selected illnesses. We also conducted qualitative, in-person sharing circles, a focus group, and 1-on-1 telephone interviews with health directors, emergency care providers, and First Nations patients from 2019 to 2022, during which we reviewed the quantitative results of the cohort study and asked participants to comment on them. We descriptively categorized qualitative data related to reasons that First Nations patients leave care. RESULTS Our quantitative analysis included 11 686 287 emergency department visits, of which 1 099 424 (9.4%) were by First Nations patients. Visits by First Nations patients were more likely to end with them leaving without being seen or against medical advice than those by non-First Nations patients (odds ratio 1.96, 95% confidence interval 1.94-1.98). Factors such as diagnosis, visit acuity, geography, or patient demographics other than First Nations status did not explain this finding. First Nations status was associated with greater odds of leaving without being seen or against medical advice in 9 of 10 disease categories or specific diagnoses. In our qualitative analysis, 64 participants discussed First Nations patients' experiences of racism, stereotyping, communication issues, transportation barriers, long waits, and being made to wait longer than others as reasons for leaving. INTERPRETATION Emergency department visits by First Nations patients were more likely to end with them leaving without being seen or against medical advice than those by non-First Nations patients. As leaving early may delay needed care or interfere with continuity of care, providers and departments should work with local First Nations to develop and adopt strategies to retain First Nations patients in care.
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Affiliation(s)
- Patrick McLane
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.
| | - Lea Bill
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Bonnie Healy
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Cheryl Barnabe
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Tessy Big Plume
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Anne Bird
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Amy Colquhoun
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Brian R Holroyd
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Kris Janvier
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Eunice Louis
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Katherine Rittenbach
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Kimberley D Curtin
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Kayla M Fitzpatrick
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Leslee Mackey
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Davis MacLean
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Rhonda J Rosychuk
- Alberta Health Services, Strategic Clinical Networks (McLane, Holroyd); Departments of Emergency Medicine (McLane, Holroyd, Curtin, Fitzpatrick, Mackey, MacLean), and Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Alberta First Nations Information Governance Centre (Bill), Calgary, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Departments of Community Health Sciences (Barnabe), Medicine (Barnabe, MacLean), and Psychiatry (Rittenbach), University of Calgary, Calgary, Alta; Stoney Nakoda Tsuut'ina Tribal Council (Big Plume), Tsuut'ina, Alta.; Paul First Nation Health Services (Bird), Parkland County, Alta.; Analytics and Performance Reporting (Colquhoun), Alberta Health, Edmonton, Alta.; Kee Tas Kee Now Tribal Council (Janvier), Atikameg, Alta.; Maskwacis Health Services (Louis), Maskwacis Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
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Kappy B, McKinley K, Chamberlain J, Isbey S. Response to "Diverging Trends in Left Without Being Seen Rates During the Pandemic Era: Emergency Department Length of Stay May Be a Key Factor". J Emerg Med 2024; 66:e547-e548. [PMID: 38580417 DOI: 10.1016/j.jemermed.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/23/2023] [Indexed: 04/07/2024]
Affiliation(s)
- Brandon Kappy
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Kenneth McKinley
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Sarah Isbey
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
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6
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Payne K, Risi D, O'Hare A, Binks S, Curtis K. Factors that contribute to patient length of stay in the emergency department: A time in motion observational study. Australas Emerg Care 2023; 26:321-325. [PMID: 37142544 DOI: 10.1016/j.auec.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/02/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVES Increased Emergency Department length of stay impacts access to emergency care and is associated with increased patient morbidity, overcrowding, reduced patient and staff satisfaction. We sought to determine the contributing factors to increased length of stay in our mixed ED. METHODS A real-time observational study was conducted at Wollongong Hospital over a continuous 72-h period. Times of intervention, assessment and treatment were recorded by dedicated emergency medical or nurse observers. The time from triage to each event was calculated and descriptive analyses performed. Free text comments were analysed using inductive content analysis. RESULTS Data were collected on 381 of 389 eligible patients. The largest time delays were experienced by patients who required a CT, specialist review and/or an inpatient bed. Registrars and nurse practitioners were the most efficient in reaching a decision to admit or discharge. The time from triage to specialist review increased with the number requested (148 min for one, 224 min for two and 285 min for three). The longest length of stay was experienced by mental health and paediatric patients. CONCLUSIONS The main delays contributing to ED length of stay were CT imaging and specialist reviews. Overcrowding in ED need targeted, site-specific interventions.
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Affiliation(s)
- Karlie Payne
- Emergency Department, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Dante Risi
- Research Central, Illawarra Shoalhaven Local Health District, NSW, Australia
| | - Anna O'Hare
- Emergency Department, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Simon Binks
- Emergency Department, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Kate Curtis
- Emergency Department, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia; Research Central, Illawarra Shoalhaven Local Health District, NSW, Australia; Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, RC Mills Building, The University of Sydney, NSW 2006, Australia; George Institute for Global Health, King St, Newtown, NSW, Australia.
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7
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Kappy B, McKinley K, Chamberlain J, Badolato GM, Podolsky RH, Bond G, Schultz TR, Isbey S. Leaving Without Being Seen From the Pediatric Emergency Department: A New Baseline. J Emerg Med 2023; 65:e237-e249. [PMID: 37659902 DOI: 10.1016/j.jemermed.2023.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/05/2023] [Accepted: 05/26/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Left without being seen (LWBS) rates are an important quality metric for pediatric emergency departments (EDs), with high-acuity LWBS children representing a patient safety risk. Since July 2021, our ED experienced a surge in LWBS after the most stringent COVID-19 quarantine restrictions ended. OBJECTIVE We assessed changes in LWBS rates and examined associations of system factors and patient characteristics with LWBS. METHODS We performed a retrospective study in a large, urban pediatric ED for all arriving patients, comparing the following three time-periods: before COVID-19 (PRE, January 2018-February 2020), during early COVID-19 (COVID, March 2020-June 2021), and after the emergence of COVID-19 variants and re-emergence of seasonal viruses (POST, July 2021-December 2021). We compared descriptive statistics of daily LWBS rates, patient demographic characteristics, and system characteristics. Negative binomial (system factors) and logistic regression (patient characteristics) models were developed to evaluate the associations between system factors and LWBS, and patient characteristics and LWBS, respectively. RESULTS Mean daily LWBS rates changed from 1.8% PRE to 1.4% COVID to 10.7% during POST. Rates increased across every patient demographic and triage level during POST, despite a decrease in daily ED volume compared with PRE. LWBS rates were significantly associated with patients with an Emergency Severity Index score of 2, mean ED census, and staff productivity within multiple periods. Patient characteristics associated with LWBS included lower assigned triage levels and arrival between 8 pm and 4 am. CONCLUSIONS LWBS rates have shown a large and sustained increase since July 2021, even for high-acuity patients. We identified system factors that may provide opportunities to reduce LWBS. Further work should develop strategies to prevent LWBS in at-risk patients.
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Affiliation(s)
- Brandon Kappy
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia.
| | - Kenneth McKinley
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Gia M Badolato
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Robert H Podolsky
- Division of Biostatistics and Study Methodology, Center for Translational Research, Children's National Hospital, Washington, District of Columbia
| | - Gregory Bond
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Theresa Ryan Schultz
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Sarah Isbey
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
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8
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Darkwa M, Engel K, Findlay Z, Voyer AM, Waddell AE. Using co-design to improve the client waiting experience at an outpatient mental health clinic. BMJ Open Qual 2023; 12:bmjoq-2021-001781. [PMID: 36599501 PMCID: PMC9814997 DOI: 10.1136/bmjoq-2021-001781] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023] Open
Abstract
Prolonged wait times in healthcare are a complex issue that can negatively impact both clients and staff. Longer wait times are often caused by a number of factors such as overly complicated scheduling, inefficient use of resources, extraneous processes, and misalignment of supply and demand. Growing evidence suggests a correlation between wait times and client satisfaction. This relationship, however, is complex. Some research suggests that client satisfaction with wait times may be improved with interventions that enhance the waiting experience and not actual wait times. This project aimed to improve the average daily rating of the client waiting experience by 1 point on a 7-point Likert scale.A quality improvement study was conducted to analyse client satisfaction with wait times and enhance clients' satisfaction while waiting. Quality improvement methods, mainly co-design sessions, were used to co-create and implement an intervention to improve clients' experience with waiting in the clinic.The project resulted in the implementation of a whiteboard intervention in the clinic to inform clients where they are in the queue. The whiteboard also included static data summarising the average wait times from the previous month. Both aspects of the whiteboard were designed to allow patients to better approximate their wait times. Though the quantitative analysis did not reveal a 1-point improvement on a 7-point Likert scale, the feedback from staff and clients was positive. Since implementation, clinic staff and management have developed the intervention into a high-fidelity digital board that is still in use today. Furthermore, the use of the intervention has been extended locally, with additional ambulatory clinics at the hospital planning to use the set-up in their clinic waiting rooms.
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Affiliation(s)
- Maame Darkwa
- Faculty of Laboratory Medicine & Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Katrina Engel
- Faculty of Laboratory Medicine & Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Zoe Findlay
- Faculty of Laboratory Medicine & Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Anne-Marie Voyer
- Faculty of Laboratory Medicine & Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Andrea E Waddell
- Department of Psychiatry, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
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9
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de Bragança RL, Nogueira M, Pinheiro M, Moita RM, Pedrosa A, Viana J, Santos LA. Why do patients leave the Pediatric Emergency Department and what happens to them? Minerva Pediatr (Torino) 2022; 74:752-760. [PMID: 33820403 DOI: 10.23736/s2724-5276.21.05883-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The dropout rate is an important indicator of the quality of emergency services. The authors intend to evaluate factors that influence abandonments in the Pediatric Emergency Department (PED) and to assess outcome and destination of the highest triage leveled patients. METHODS Retrospective analysis of the abandonment cases occurring between 2014 and 2016 in a tertiary hospital, including sociodemographic characterization, temporal factors, triage level, referral from other health services, waiting time and patient attendance. The outcome of the highest triage level was also accessed. RESULTS In the three years analyzed, there were 240171 PED visits, with an abandonment rate of 2.57%. PED abandonment was influenced by higher patient attendance and waiting time, a younger age, and less urgent triage level. Only 1.78% of the urgent or emergent patients (level three or two) abandoned the PED. Of these, 44% sought medical care in the next five days, 41% of which in private institutions, 40% in public hospitals and 19% in primary care. Only 0.81% of those were hospitalized. CONCLUSIONS The majority of patients who leave the PED do not correspond to urgent cases. Health education awareness campaigns, clinical counseling platforms (online or phone services) and the improved accessibility of primary health care may optimize the usage of health resources. The reinforcement of the teams in times of greater affluence may contribute to decrease the rate of abandonment.
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Affiliation(s)
- Raquel L de Bragança
- Service of Pediatrics, Autonomous Unit of Moternal and Child Health, São João University Hospital, Porto, Portugal -
| | - Mayara Nogueira
- Service of Pediatrics, Autonomous Unit of Moternal and Child Health, São João University Hospital, Porto, Portugal
| | - Marta Pinheiro
- Service of Pediatrics, Autonomous Unit of Moternal and Child Health, São João University Hospital, Porto, Portugal
| | - Rita M Moita
- Service of Pediatrics, Autonomous Unit of Moternal and Child Health, São João University Hospital, Porto, Portugal
| | - Afonso Pedrosa
- Unit of Software Development, São João University Hospital, Porto, Portugal
| | - João Viana
- Research Center for Health Technology and Information Systems, Porto, Portugal
| | - Luís A Santos
- Service of Pediatrics, Autonomous Unit of Moternal and Child Health, São João University Hospital, Porto, Portugal
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10
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Zikusooka M, Hanna R, Malaj A, Ertem M, Elci OC. Factors affecting patient satisfaction in refugee health centers in Turkey. PLoS One 2022; 17:e0274316. [PMID: 36112570 PMCID: PMC9480993 DOI: 10.1371/journal.pone.0274316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Turkey hosts an estimated 3.7 million Syrian refugees. Syrian refugees have access to free primary care provided through Refugee Health Centers(RHC). We aimed to determine factors that influence patient satisfaction in refugee health centers. METHODS The study was a cross-sectional quantitative study. A patient survey was administered among 4548 patients attending services in selected 16 provinces in Turkey. A quantitative questionnaire was used to collect information on patient satisfaction and experience in the healthcare facility. Information on "overall satisfaction with health services" was collected on a 5-point Likert scale and dichotomized for analysis. Logistic regression was conducted to identify factors that influenced patient satisfaction. RESULTS We found that 78.2% of the participants were satisfied with the health services they received. Factors related to service quality and communication were significant determinants of patient satisfaction. The strongest predictors of satisfaction were having a sufficient consultation time (AOR: 2.37; 95% CI: 1.76-3.21; p< 0.0001), receiving a comprehensive examination (AOR: 2.01; 95% CI: 1.49-2.70; p < 0.0001) and being treated with respect by the nurse (AOR: 2.08; 95% CI: 1.52-2.85; p< 0.0001). CONCLUSION Providing integrated, culturally and linguistically sensitive health services is important in refugee settings. The quality of service and communication with patients influence patient satisfaction in refugee health centers. As such, improvements in aspects such as consultation time and the quality of physician-patient interaction are recommended for patient satisfaction.
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Affiliation(s)
- Monica Zikusooka
- Refugee Health Programme, WHO Country Office in Turkey, WHO Regional Office for Europe, Turkey
| | - Radysh Hanna
- Refugee Health Programme, WHO Country Office in Turkey, WHO Regional Office for Europe, Turkey
| | - Altin Malaj
- Refugee Health Programme, WHO Country Office in Turkey, WHO Regional Office for Europe, Turkey
| | | | - Omur Cinar Elci
- Refugee Health Programme, WHO Country Office in Turkey, WHO Regional Office for Europe, Turkey
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11
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Bin KJ, Melo AAR, da Rocha JGMF, de Almeida RP, Cobello Junior V, Maia FL, de Faria E, Pereira AJ, Battistella LR, Ono SK. The Impact of Artificial Intelligence on Waiting Time for Medical Care in an Urgent Care Service for COVID-19: Single-Center Prospective Study. JMIR Form Res 2022; 6:e29012. [PMID: 35103611 PMCID: PMC8812142 DOI: 10.2196/29012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/14/2021] [Accepted: 11/22/2021] [Indexed: 11/25/2022] Open
Abstract
Background To demonstrate the value of implementation of an artificial intelligence solution in health care service, a winning project of the Massachusetts Institute of Technology Hacking Medicine Brazil competition was implemented in an urgent care service for health care professionals at Hospital das Clínicas of the Faculdade de Medicina da Universidade de São Paulo during the COVID-19 pandemic. Objective The aim of this study was to determine the impact of implementation of the digital solution in the urgent care service, assessing the reduction of nonvalue-added activities and its effect on the nurses’ time required for screening and the waiting time for patients to receive medical care. Methods This was a single-center, comparative, prospective study designed according to the Public Health England guide “Evaluating Digital Products for Health.” A total of 38,042 visits were analyzed over 18 months to determine the impact of implementing the digital solution. Medical care registration, health screening, and waiting time for medical care were compared before and after implementation of the digital solution. Results The digital solution automated 92% of medical care registrations. The time for health screening increased by approximately 16% during the implementation and in the first 3 months after the implementation. The waiting time for medical care after automation with the digital solution was reduced by approximately 12 minutes compared with that required for visits without automation. The total time savings in the 12 months after implementation was estimated to be 2508 hours. Conclusions The digital solution was able to reduce nonvalue-added activities, without a substantial impact on health screening, and further saved waiting time for medical care in an urgent care service in Brazil during the COVID-19 pandemic.
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Affiliation(s)
- Kaio Jia Bin
- Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | | | - Renata Pivi de Almeida
- Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Vilson Cobello Junior
- Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fernando Liebhart Maia
- Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Elizabeth de Faria
- Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Antonio José Pereira
- Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Suzane Kioko Ono
- Department of Gastroenterology, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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12
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Moskalewicz RL, Pham PK, Liberman DB, Hall JE. Leaving Without Being Seen From a Pediatric Emergency Department: Identifying Caregivers' Perspectives Using Q-methodology. Pediatr Emerg Care 2021; 37:615-620. [PMID: 30985630 DOI: 10.1097/pec.0000000000001792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE National rates of left (or leaving) without being seen (LWBS) in pediatric emergency departments (PED) are higher than general emergency departments. We investigated coexisting perspectives on LWBS. METHODS Q-methodology was implemented through a mixed-methods design. Semistructured interviews elicited a concourse of caregivers' thoughts on waiting in the PED and their consideration of LWBS. Themes from the concourse were identified and framed as statements. Caregivers sorted these statements, which ranged from choosing to stay versus leave the PED before their child is seen by a physician. Sorted data were analyzed through centroid factor analysis. RESULTS Seventy-seven caregivers contributed interview data, from which 31 themes were identified and framed as statements. Thirty-one different caregivers contributed Q-sort data, from which 2 factors were revealed, each representing a unique perspective on LWBS. Most caregivers (26 of 31) shared the following perspective: "I would leave the PED before my child is seen by a doctor if there are no reassessments for my child while we are in the queue, no updates on our queue position, or no explanations for wait time." The remaining caregivers (5 of 31) perceived feelings of uncertainty and helplessness, lack of updates, and competing obligations as primary influences on LWBS. CONCLUSIONS Elements that factor into caregivers' decision to LWBS from a PED include lack of reassessments, lack of updates on queue position, and lack of information about the triage process. Quality improvement interventions for decreasing LWBS rates should account for diverse coexisting perspectives such as these.
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Affiliation(s)
- Risha L Moskalewicz
- From the Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles
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13
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de la Roche MRP, Froats M, Bell A, McDonald L, Bolton C, Devins R, Hall R, Leclerc J, Istead J, Miron M, Badowski M, Steinitz T, King N, Gogna P. Estimation of unregistered patients who left without being seen: At an urban mid-sized Canadian community emergency department. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:114-120. [PMID: 33608364 PMCID: PMC8324120 DOI: 10.46747/cfp.6702114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To determine whether changes to the appearance of an emergency department (ED) waiting room influenced the number of patients who left without being seen (LWBS). DESIGN Retrospective analysis using National Ambulatory Care Reporting System data collected at the time of patient registration. SETTING The ED of Belleville General Hospital, a mid-sized secondary care community hospital in Ontario with a catchment population of 125 000. PARTICIPANTS All unscheduled patients registering at the hospital to be seen in the ED from July 1 to December 31, 2016 (control period), and from July 1 to December 31, 2017 (study period). MAIN OUTCOME MEASURES The volume of patients registering by Canadian Triage and Acuity Scale (CTAS) level to be seen in the ED during the study period compared with the volume of patients registering during the control period, and the number of LWBS during the 2 time periods. RESULTS The average number of patients registered per month was significantly greater in the study period than in the control period (t 10 = -5.53, P < .01). A total increase of 1881 registrations was recorded in the study period, or 10.47% (increase per month ranged from 9.59% to 11.66%). The proportion of patients with less acute triage scores decreased in the study period; however, the differences in CTAS levels between the 2 years was not statistically significant (χ 2 = 1.05, P = .90). The number of LWBS according to CTAS level was lower in all categories in the study period, including those in the less acute levels, decreasing from 60 in CTAS 5 in 2016 to 45 in 2017, and 585 in CTAS 4 in 2016 to 330 in 2017. Overall, the distribution of LWBS by CTAS level was significantly different between the control and study periods (P < .01). CONCLUSION The number of patients registering is influenced by the apparent high or low occupancy of the waiting area at the time of registration.
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Affiliation(s)
| | - Mark Froats
- Active staff members at Quinte Health Care in Belleville, Ont
| | - Allen Bell
- Active staff members at Quinte Health Care in Belleville, Ont
| | - Lois McDonald
- Active staff members at Quinte Health Care in Belleville, Ont
| | - Craig Bolton
- Active staff members at Quinte Health Care in Belleville, Ont
| | - Rob Devins
- Active staff members at Quinte Health Care in Belleville, Ont
| | - Ryan Hall
- Active staff members at Quinte Health Care in Belleville, Ont
| | | | - Jann Istead
- Active staff members at Quinte Health Care in Belleville, Ont
| | - Michele Miron
- Active staff members at Quinte Health Care in Belleville, Ont
| | - Martin Badowski
- Active staff members at Quinte Health Care in Belleville, Ont
| | - Tracy Steinitz
- Active staff members at Quinte Health Care in Belleville, Ont
| | - Nathan King
- Doctoral candidates at Queen's University in Kingston, Ont
| | - Priyanka Gogna
- Doctoral candidates at Queen's University in Kingston, Ont
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Loso JM, Filipp SL, Gurka MJ, Davis MK. Using Queue Theory and Load-Leveling Principles to Identify a Simple Metric for Resource Planning in a Pediatric Emergency Department. Glob Pediatr Health 2021; 8:2333794X20944665. [PMID: 33614834 PMCID: PMC7841236 DOI: 10.1177/2333794x20944665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/15/2020] [Accepted: 06/30/2020] [Indexed: 11/20/2022] Open
Abstract
Increased waiting time in pediatric emergency departments is a well-recognized
and complex problem in a resource-limited US health care system. Efforts to
reduce emergency department wait times include modeling arrival rates, acuity,
process flow, and human resource requirements. The aim of this study was to
investigate queue theory and load-leveling principles to model arrival rates and
to identify a simple metric for assisting with determination of optimal physical
space and human resource requirements. We discovered that pediatric emergency
department arrival rates vary based on time of day, day of the week, and month
of the year in a predictable pattern and that the hourly change in pediatric
emergency department waiting room census may be useful as a simple metric to
identify target times for shifting resources to better match supply and demand
at no additional cost.
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15
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Sheridan MD, Adams KT, Booker E, Krevat SA, Calabrese M, Gomes K, Ratwani RM. Pilot assessment of an on-demand telehealth 'left without being seen' follow-up programme. J Telemed Telecare 2021; 29:304-307. [PMID: 33476220 DOI: 10.1177/1357633x20983159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION On-demand telehealth can have a high rate of patients requesting visits and dropping off without being seen by a provider, especially during the COVID-19 pandemic. METHODS On-demand telehealth requests made to a large healthcare system in the USA between 15 March 2020 and 31 May 2020 were included for analysis with a focus on patients who were defined as left without being seen (LWBS). As part of a pilot program a registered nurse attempted to call LWBS patients within 24 hours of their telehealth request and asked if they were ok, if they sought care for their original visit reason, what that care was, or if they still needed guidance. This information and patient demographics were analyzed. RESULTS During the study period there were 21,610 completed on-demand telehealth visits and 1852 patients for whom there were LWBS attempted follow-ups. Most patients LWBS for a reason that originated from the patient and not associated with the provider or telehealth platform. The mean wait time for LWBS patients was 12.4 min compared to patients waiting 15.1 min before engaging with a provider to complete a visit. Of the 1852 total LWBS patients in the follow-up programme, 819 (44.2%) were successfully contacted with a follow-up phone call. Most of these patients (63.2%) already completed or planned to complete a telehealth visit, 13.6% indicated they no longer needed to see a provider, and 12.8% planned or already completed an in-person visit. Only 2.2% went to an emergency department. DISCUSSION Results suggest patients can effectively self-manage their care needs.
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Affiliation(s)
| | | | | | - Seth A Krevat
- Georgetown University School of Medicine, USA.,MedStar Health National Center for Human Factors in Healthcare, USA
| | - Mary Calabrese
- MedStar Health Simulation, Training and Education Lab, USA
| | - Kylie Gomes
- MedStar Health National Center for Human Factors in Healthcare, USA
| | - Raj M Ratwani
- Georgetown University School of Medicine, USA.,MedStar Health National Center for Human Factors in Healthcare, USA
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Stamy C, Shane DM, Kannedy L, Van Heukelom P, Mohr NM, Tate J, Montross K, Lee S. Economic Evaluation of the Emergency Department After Implementation of an Emergency Psychiatric Assessment, Treatment, and Healing Unit. Acad Emerg Med 2021; 28:82-91. [PMID: 32869891 DOI: 10.1111/acem.14118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/04/2020] [Accepted: 08/21/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit on emergency department (ED) revenue, psychiatric boarding time, and length of stay (LOS). METHODS We conducted a before-and-after economic evaluation of a single academic midwestern ED (60,000 annual visits) for all adult (≥18 years) patients before (December 2017-May 2018) and after (December 2018-May 2019) opening an EmPATH unit. These are outpatient hospital-based programs that provide emergent treatment and stabilization for mental health emergencies from ED patients. The Holt-Winters method was used to forecast pre-EmPATH expected ED levels of patients leaving without being seen, leaving against medical advice, eloping, or being transferred using 3 years of ED visits. ED revenues were calculated by finding the difference of pre-EmPATH expected and post-EmPATH observed values and multiplying by the revenue per visit. ED boarding time and LOS were obtained from the hospital's electronic medical record. RESULTS There were 23,231 and 23,336 ED visits evaluated during the pre- and post-EmPATH unit periods. The ED generated an estimated additional $404,954 in the 6 months and $861,065 annually after the implementation of the EmPATH unit. The median (interquartile range [IQR]) psychiatric boarding time decreased from 212 (119-536) minutes to 152 (86-307) minutes (mean difference = 189 minutes, 95% confidence interval [CI] = 150 to 228 minutes) and median (IQR) LOS decreased from 351 (204-631) minutes to 334 (212-517) minutes (mean difference = 114 minutes, 95% CI = 87 to 143 minutes). CONCLUSION The EmPATH unit had a positive impact on ED revenue and decreased ED boarding time and LOS for psychiatric patients.
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Affiliation(s)
- Chris Stamy
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Dan M. Shane
- the Department of Health Management and PolicyUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Levi Kannedy
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Paul Van Heukelom
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Nicholas M. Mohr
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
- the Division of Critical Care Department of AnesthesiaUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Jodi Tate
- and the Department of Psychiatry University of Iowa Carver College of Medicine Iowa City IAUSA
| | - Kelsey Montross
- and the Department of Psychiatry University of Iowa Carver College of Medicine Iowa City IAUSA
| | - Sangil Lee
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
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Keyes D, Valiuddin H, Mouzaihem H, Stone P, Vidosh J. The Affordable Care Act and emergency department use by low acuity patients in a US hospital. Health Serv Manage Res 2020; 34:128-135. [PMID: 32883130 DOI: 10.1177/0951484820943599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) is one of the biggest healthcare reforms in US history. A key issue is the ACAs effect on low acuity, potentially primary care patients. This study evaluates the effect of the ACA on low acuity patients seen in the emergency department (ED). METHODS This is an age-period-cohort analysis for a community hospital ED in Michigan, from 2009 to 2015. Patients were stratified by age, year seen, emergency severity index (ESI) and insurance status. Data were compared between before and after ACA along with descriptive statistics, Chi-square and Student t-tests. The primary outcome was the change in ED usage by low acuity. Patients > 65 were used as a temporal control. RESULTS 305,350 ED visits were analyzed. ED visits with ESI 4/5 increased from 11.9% to 14.8%. Patients < 19 years increased from 25.5% to 34.3% (p = .0026). Ages 19-25 increased from 16.3% to 19.7% (p = 0.0515). Ages 26-64 increased from 11% to 14.9% (p = 0.0129). Ages > 65 increased from 5.1% to 6.5%. Patients < 65 showed a decreased uninsured rate from 12.30% to 6.28% (p < 0.0001). Comparatively, for age > 65: uninsured rate remained the same 0.46% to 0.49%. CONCLUSION Low acuity ED visits increased with the ACA reform in conjunction with a more insured population.
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Affiliation(s)
- Daniel Keyes
- St Mary Mercy Hospital, Livonia, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Hassan Mouzaihem
- School of Medicine, Wayne State University, Dearborn Heights, MI, USA
| | - Patrick Stone
- R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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18
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Teo AWJ, Rim TH, Wong CW, Tsai ASH, Loh N, Jayabaskar T, Wong TY, Cheung CMG, Yeo IYS. Design, implementation, and evaluation of a nurse-led intravitreal injection programme for retinal diseases in Singapore. Eye (Lond) 2020; 34:2123-2130. [PMID: 32382144 DOI: 10.1038/s41433-020-0920-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/16/2020] [Accepted: 04/21/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND To describe the design, implementation, and evaluation of a nurse-led intravitreal injection (NL-IVT) programme in a Singapore tertiary eye hospital. METHODS Patients requiring anti-vascular endothelial growth factor (VEGF) IVT were recruited. Implementation and evaluation were done in the Singapore National Eye Centre, a tertiary centre. To assess safety, nurse injectors recorded details of procedures performed and complications for an 8-month period from February 2019. To evaluate patient experience, we used a modified patient questionnaire and recorded both patients' waiting time and IVT procedure duration. A retrospective audit of IVTs before and after the introduction of NL-IVT was performed from January 2017 to September 2019. Cost difference between NL-IVT and standard doctor-led (DL) IVT was evaluated. RESULTS A total of 8599 NL-IVTs were performed. No cases of severe complication were detected in the follow-up. A total of 135 patients who received NL-IVT and DL-IVT were surveyed. General satisfaction, interpersonal manner, financial aspect, time spent with injector, and staff competence were higher in NL-IVTs than in DL-IVTs (p < 0.05). There were no differences in terms of technical quality and communication. For 934 patients, waiting time was significantly shorter in NL-IVT (3.6 ± 10.3 min) compared with DL-IVTs (35.3 ± 32.3 min); on average, 19.7 min were saved through NL-IVT (p < 0.01). The cost difference per IVT between NL-IVT and DL-IVT is estimated at 286 SGD (163 GBP). CONCLUSION With a well-designed training programme, NL-IVT is a safe, acceptable, and cost savings procedure. With increasing demand for IVT, NL-IVT provides an alternative model of care for healthcare systems globally.
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Affiliation(s)
- Alvin Wei Jun Teo
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | - Tyler Hyungtaek Rim
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore
| | - Chee Wai Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | | | - Nazurah Loh
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | | | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore
| | - Chui Ming Gemmy Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore
| | - Ian Yew San Yeo
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore. .,Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore.
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19
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Williams A. An exploration of the reasons why people attend but do not wait to be seen in emergency departments. Emerg Nurse 2019; 27:33-41. [PMID: 29943944 DOI: 10.7748/en.2018.e1811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2018] [Indexed: 06/08/2023]
Abstract
AIM The aim of the study was to explore the reasons why people do not always wait to receive treatment after registering in emergency departments (EDs). METHOD Patients who attended the ED at a general hospital in the south of England and left without being seen (LWBS) were recorded between 1 June and 31 August 2016 and 597 patient records were analysed. Six patients participated in semi-structured interviews. Data were manually coded. FINDINGS The most common presenting complaint for people who LWBS was limb problems, however some had potentially more serious conditions such as chest pain. The six interviewees accessed the ED because of a perceived urgent need, and reasons for leaving before being seen included long waiting time, other commitments, non-availability of specialty services, perceiving their problem as less urgent, resolution of condition and discomfort in the waiting area. CONCLUSION People who LWBS may not have trivial health problems, which is a risk for them and hospital trusts. Although many of the people who LWBS did so because of the lengthy waiting time, there may be other factors involved some of which could be prevented.
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Andrews SL, Lewena S, Cheek JA. Rapid Assessment, Planning, Investigations and Discharge: Piloting the introduction of a senior doctor at triage model in an Australian paediatric emergency department. Emerg Med Australas 2019; 32:112-116. [PMID: 31436015 DOI: 10.1111/1742-6723.13382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/16/2019] [Accepted: 07/20/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We implemented a senior doctor at triage (SDT) pilot programme at The Royal Children's Hospital, Melbourne. We examined the impact on ED length of stay, seen on time and fail to wait (FTW) rates. METHODS A SDT model was piloted on Monday and Tuesday afternoons (pilot period) for 10 weeks, and compared with equivalent shifts for the preceding 10 weeks (pre-pilot period). We determined the differences between the proportions of patients seen on time, length of stay in the ED of less than 4 h and FTW rate, as well as the medians of time to clinician and length of stay in ED. RESULTS A total of 2736 patients presented in the pilot period, and 2889 in the pre-pilot. The percentage of patients who were seen on time improved from 52.3% to 68.7% (absolute difference 16.4%, 95% confidence interval [CI] 13.6-19.2%, P < 0.001), the percentage of patients who had an ED length of stay of <4 h improved from 58.2% to 72.0% (absolute difference 13.8%, 95% CI 11.1-16.5%, P < 0.001) and the FTW rate reduced from 12.5% to 7.1% (absolute difference 5.4%, 95% CI 3.8-7.0%, P < 0.001) when the SDT model was operational. CONCLUSION Implementation of a SDT model in a tertiary paediatric ED resulted in an increased proportion of patients being seen on time, having shorter length of stays in the ED and reduced the number of patients who FTW. Further studies are required to determine whether these improvements are sustained over time.
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Affiliation(s)
- Sarah L Andrews
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Stuart Lewena
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - John A Cheek
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Peng LS, Rasid MF, Salim WI. Using modified triage system to improve emergency department efficacy: A successful Lean implementation. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2019. [DOI: 10.1080/20479700.2019.1655216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Leong Shian Peng
- Emergency Department, Hospital Port Dickson, Ministry of Health Malaysia
| | - Mohd Faizal Rasid
- Emergency Department, Hospital Port Dickson, Ministry of Health Malaysia
| | - Wan Immi Salim
- Emergency Department, Hospital Port Dickson, Ministry of Health Malaysia
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Alrasheedi KF, Al-Mohaithef M, Edrees HH, Chandramohan S. The Association Between Wait Times and Patient Satisfaction: Findings From Primary Health Centers in the Kingdom of Saudi Arabia. Health Serv Res Manag Epidemiol 2019; 6:2333392819861246. [PMID: 31312675 PMCID: PMC6614942 DOI: 10.1177/2333392819861246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/12/2019] [Accepted: 06/12/2019] [Indexed: 11/23/2022] Open
Abstract
Background: It is no doubt that longer wait times can affect patient care and patients’ willingness
to seek health-care services. Not only does this disrupt the continuity of treatment and
care, but it also negatively impacts patient outcomes. During the past few years, the
concept of patient satisfaction has become a vital component in assessing the delivery
and efficiency of care. Patient satisfaction is a performance indicator that measures
the extent to which patient is content and satisfied with the level of care provided by
health-care institutions and providers. Therefore, this research examined association
between the wait times and patient satisfaction in selected primary health-care centers
in Al Qassim region in the Kingdom of Saudi Arabia. Methodology: A patient satisfaction questionnaire was administered to 850 patients, which collected
patient perceptions on the delivery of care at health-care centers in Al Qassim City.
Outcome measures included wait times for: registration and payment, seeing the
physician, performing radiation and assays, and dispensing the medications. Results: The response rate was 72.94% (n = 620). The study found that 27.90% of the participants
stated that the wait time to see the physician ranged between 21 and 30 minutes. Overall
patients were mainly dissatisfied for wait times in relation to medication dispensation,
vital signs measurement, dental consultations, and radiological investigation. The study
found a positive association between the patient satisfaction and their education,
marital status, and job. A significant regression equation was established between the
patient satisfaction and age-group and literacy. Conclusion: The study advocated the need for recent technology, sufficient staffing, and
patient-centered friendly methods to reduce wait times.
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Affiliation(s)
- Khaled Falah Alrasheedi
- General Directorate of Health Affairs-Al-Qassim Area, Ministry of Health, Saudi Electronic University, Riyadh, Saudi Arabia
| | - Mohammed Al-Mohaithef
- Department of Public Health, College of Health Sciences, Saudi Electronic University, Riyadh, Kingdom of Saudi Arabia
| | - Hanan H Edrees
- Department of Health Policy and Management, John Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sriram Chandramohan
- Department of Public Health, College of Health Sciences, Saudi Electronic University, Abha Branch, Kingdom of Saudi Arabia
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Alarcon-Ruiz CA, Heredia P, Taype-Rondan A. Association of waiting and consultation time with patient satisfaction: secondary-data analysis of a national survey in Peruvian ambulatory care facilities. BMC Health Serv Res 2019; 19:439. [PMID: 31262280 PMCID: PMC6604432 DOI: 10.1186/s12913-019-4288-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 06/23/2019] [Indexed: 11/17/2022] Open
Abstract
Background Research suggested that waiting time and consultation time are associated with overall patient satisfaction concerning health services. However, there is a lack of information regarding this subject in Latin American countries, where particular aspects of health systems and population characteristics could modify this association. Our aim was to evaluate the association of waiting time and consultation time with patient satisfaction, in Peruvian ambulatory care facilities and propose a cut-off points of waiting and consultation time based on patient satisfaction. Methods Cross-sectional secondary data analysis of the National Survey on User Satisfaction of Health Services (ENSUSALUD-2015), a national-wide survey with a probabilistic sample of 181 Peruvian ambulatory care facilities. Patient satisfaction, waiting time, consultation time, and sociodemographic variables were collected from the ENSUSALUD-2015. All variables were collected by survey directly to patients, from the selected ambulatory care facilities, after their consultation. Complex survey sampling was considered for data analysis. In the association analysis, we grouped the waiting time and consultation time variables, every 10 min, because for it is more relevant and helpful in the statistical and practical interpretation of the results, instead of the every-minute unit. Results The survey was performed in 13,360 participants. Response rate were 99.8 to 100% in the main variables. Waiting time (for every 10 min) was inversely associated with patient satisfaction (aOR: 0.98, 95% CI: 0.97–0.99), although the aOR was lower among those who reported a waiting time ≤ 90 min (aOR: 0.92, 95% CI: 0.89–0.96). Consultation time (for every 10 min) was directly associated with patient satisfaction (aOR: 1.59, 95% CI: 1.26–2.01), although the aOR was higher among those who reported a consultation time ≤ 15 min (aOR: 2.31, 95% CI: 1.66–3.21). Conclusion In Peruvian ambulatory care facilities, both waiting time and consultation time showed an association with overall patient satisfaction, which was stronger in the first 90 min of waiting time and in the first 15 min of consultation time. This should be taken into consideration when designing interventions to improve waiting times and consultation times in ambulatory care facilities from Peru or from similar contexts.
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Affiliation(s)
- Christoper A Alarcon-Ruiz
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru.
| | - Paula Heredia
- Faculty of Medicine, Universidad Ricardo Palma, Lima, Peru
| | - Alvaro Taype-Rondan
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
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Hitti E, Hadid D, Tamim H, Al Hariri M, El Sayed M. Left without being seen in a hybrid point of service collection model emergency department. Am J Emerg Med 2019; 38:497-502. [PMID: 31128935 DOI: 10.1016/j.ajem.2019.05.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE This study identifies reasons and predictors of LWBS and examines outcomes of patients in a model that uses "point-of-service" (POS) collection for low acuity patients. METHODS This was a matched case-control study of all patients who left without being seen from the ED of a tertiary care center in Beirut Lebanon between June 2016 and May 2017. Matching was done for the ESI score, date and time (±2 h). A descriptive analysis and a bivariate analysis were conducted comparing patients who LWBS and those who completed their medical treatment. This was followed by a Logistic regression to identify predictors of LWBS. RESULTS 133 LWBS cases and 133 matched controls were enrolled in the study. Mean age for LWBS patients was (31.69 ± 15.29). The average reported wait time of LWBS patients was reported as 27.48 min (±25.09). Reasons for LWBS were; non-compensable status (66.9%), financial reasons (12.8%), long waiting times (12.8%), and others (8.3%). The majority of LWBS patients (81.2%) sought medical care after leaving the ED, and 8.3% of the LWBS patients represented to the ED after 48 h. Important predictors of LWBS included male gender, lower than undergraduate education level, waiting room time, non-compensable coverage status and fewer ED visits in the past year. CONCLUSION In an ED setting with POS collection for low acuity patients, non-compensable coverage status was the strongest predictor for LWBS. Further studies are needed to assess the outcomes of patients who LWBS in this model of care.
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Affiliation(s)
- Eveline Hitti
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon.
| | - Dima Hadid
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon.
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.
| | - Moustafa Al Hariri
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon.
| | - Mazen El Sayed
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon.
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SAIA M, BUJA A, FUSINATO R, FONZO M, BERTONCELLO C, BALDO V. Uncompleted Emergency Department Care (UEDC): a 5-year population-based study in the Veneto Region, Italy. JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2019; 60:E18-E24. [PMID: 31041406 PMCID: PMC6477553 DOI: 10.15167/2421-4248/jpmh2019.60.1.1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 02/03/2019] [Indexed: 11/16/2022]
Abstract
Introduction Uncompleted visits to emergency departments (UEDC) are a patient safety concern. The purpose of this study was to investigate risk factors for UEDC, describing not only the sociodemographic characteristics of patients who left against medical advice (AMA) and those who left without being seen (LWBS), but also the characteristics of their access to the emergency department (ED) and of the hospital structure. Methods This was a cross sectional study on anonymized administrative data in a population-based ED database. Results A total of 9,147,415 patients attended EDs in the Veneto Region from 2011 to 2015. The UEDC rate was 28.7‰, with a slightly higher rate of AMA than of LWBS (15.3‰ vs 13.4‰). Age, sex, citizenship, and residence were sociodemographic factors associated with UEDC, and so were certain characteristics of access, such as mode of admission, type of referral, emergency level, waiting time before being seen, and type of medical issue (trauma or other). Some characteristics of the hospital structure, such as the type of hospital and the volume of patients managed, could also be associated with UEDC. Conclusion Cases of UEDC, which may involve patients who leave AMA and those who LWBS, differ considerably from other cases managed at the ED. The present findings are important for the purpose of planning and staffing health services. Decision-makers should identify and target the factors associated with UEDC to minimize walkouts from public hospital EDs.
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Affiliation(s)
- M. SAIA
- Veneto Region, Local Health Unit n. 6Padova, Italy
| | - A. BUJA
- Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, Italy
- Alessandra Buja, Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, via Loredan 18, 35131 Padova, Italy - Tel. +39 049 8275387 - E-mail:
| | - R. FUSINATO
- Department of Statistical Sciences, University of Padova, Italy
| | - M. FONZO
- Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, Italy
| | - C. BERTONCELLO
- Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, Italy
| | - V. BALDO
- Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, Italy
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Mataloni F, Colais P, Galassi C, Davoli M, Fusco D. Patients who leave Emergency Department without being seen or during treatment in the Lazio Region (Central Italy): Determinants and short term outcomes. PLoS One 2018; 13:e0208914. [PMID: 30540845 PMCID: PMC6291150 DOI: 10.1371/journal.pone.0208914] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 11/27/2018] [Indexed: 11/19/2022] Open
Abstract
Background and Aims Patients who leave Emergency Department before physician’s visit (LWBS) or during treatment (LDT) represent a useful indicator of the emergency care's quality. The profile of patients LWBS was described: they are generally males, young, with lower urgency triage allocation and longer waiting time. They have a greater risk of ED re-admission compared to discharged patients, but effect on hospitalization and mortality are more controversial. The aims of this study are to identify determinants and adverse short term outcomes for LWBS and LDT patients. Methods This is a retrospective cohort study that include all ED visits of LWBS, LDT and discharged patients in 2015 in the Lazio region, Central Italy. Determinants of LWBS or LDT were selected from gender, age, citizenship, residence area, triage category, chronic comorbidities, number of uncompleted ED visit in the previous year, mode of arrival in ED, time-band, day of the week, waiting time and ED crowding, using a multi-level logistic regression. A multivariate logistic regression was used to test if LWBS or LDT have a greater risk of short term adverse outcome compared to discharged patients. Results The cohort consists in 835,440 visits in ED, 86.8% subjects visited and discharged, 8.9% subjects are LWBS patients and 4.3% LDT. LWBS and LDT patients are mainly young, males, with a less severe triage, with long waiting times in ED. Moreover, ED crowding and leaving ED before physician’s visit in the previous year are risk factors of self-discharging. LWBS and LDT patients have a higher risk of readmission (LWBS: OR = 4.63, 95%CI 4.5–4.7; OR = 2.89, 95%CI 2.8–2.9; LDT: OR = 3.12, 95%CI 3–3.2; OR = 2.25, 95%CI2.2–2.3 for readmissions within 2 and 7 days respectively) and hospitalization (LWBS: OR = 3.65, 95%CI 3.4–3.9; OR = 2.25, 95%CI 2.1–2.4; LDT: OR = 3.96, 95%CI 3.6–4.3; OR = 2.62, 95%CI 2.4–2.8 for hospitalization within 2 and 7 days respectively). Furthermore, we find a mortality excess of risk for LWBS patients compared to the reference group (OR = 2.56, 95%CI1.6–4.2; OR = 1.7, 95%CI 1.3–2.2 within 2 and 7 days respectively). Conclusions Determinants of LWBS confirmed what already known, but LDT patients should be further investigated. There could be adverse health effects for people with LWBS and LDT behaviour. This could be an issue that the Regional Health System should deal with.
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Affiliation(s)
- Francesca Mataloni
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
- * E-mail:
| | - Paola Colais
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Claudia Galassi
- Unit of Clinical Epidemiology, Città della Salute e della Scienza di Torino University Hospital and CPO Piemonte, Torino, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Slemon A. Embracing the wild profusion: A Foucauldian analysis of the impact of healthcare standardization on nursing knowledge and practice. Nurs Philos 2018; 19:e12215. [PMID: 29952072 DOI: 10.1111/nup.12215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/20/2018] [Accepted: 05/28/2018] [Indexed: 01/22/2023]
Abstract
Standardization has emerged as the dominant principle guiding the organization and provision of healthcare, with standards resultantly shaping how nurses conceptualize and deliver patient care. Standardization has been critiqued as homogenizing diverse patient experiences and diminishing nurses' skills and critical thinking; however, there has been limited examination of the philosophical implications of standardization for nursing knowledge and practice. In this manuscript, I draw on Foucault's philosophy of order and categorization to inform an analysis of the consequences of healthcare standardization for the profession of nursing. I utilize three exemplars to illustrate the impact of the primacy of standardized thinking and practices on nurses, patients and families: pain assessments using the 0-10 pain scale; patient triage emergency departments through the Canadian Triage and Acuity Scale; and determination of cause of death within the context of the current opioid crisis. Through each exemplar, I demonstrate that standardization reductively constrains nursing knowledge and the health and healthcare experiences of patients and populations. I argue that the centrality of standardization must be re-envisioned to embrace the complexity of health and more effectively and meaningfully frame nursing knowledge and practice within healthcare systems.
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Affiliation(s)
- Allie Slemon
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
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Triaging the Emergency Department, Not the Patient: United States Emergency Nurses’ Experience of the Triage Process. J Emerg Nurs 2018; 44:258-266. [DOI: 10.1016/j.jen.2017.06.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 06/23/2017] [Accepted: 06/25/2017] [Indexed: 11/20/2022]
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Xie Z, Or C. Associations Between Waiting Times, Service Times, and Patient Satisfaction in an Endocrinology Outpatient Department: A Time Study and Questionnaire Survey. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2017; 54:46958017739527. [PMID: 29161947 PMCID: PMC5798665 DOI: 10.1177/0046958017739527] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The issue of long patient waits has attracted increasing public attention due to the negative effects of waiting on patients' satisfaction with health care. The present study examined the associations between actual waiting time, perceived acceptability of waiting time, actual service time, perceived acceptability of service time, actual visit duration, and the level of patient satisfaction with care. We conducted a cross-sectional time study and questionnaire survey of endocrinology outpatients visiting a major teaching hospital in China. Our results show that actual waiting time was negatively associated with patient satisfaction regarding several aspects of the care they received. Also, patients who were less satisfied with the sociocultural atmosphere and the identity-oriented approach to their care tended to perceive the amounts of time they spent waiting and receiving care as less acceptable. It is not always possible to prevent dissatisfaction with waiting, or to actually reduce waiting times by increasing resources such as increased staffing. However, several improvements in care services can be considered. Our suggestions include providing clearer, more transparent information to keep patients informed about the health care services that they may receive, and the health care professionals who are responsible for those services. We also suggest that care providers are encouraged to continue to show empathy and respect for patients, that patients are provided with private areas where they can talk with health professionals and no one can overhear, and that hospital staff treat the family members or friends who accompany patients in a courteous and friendly way.
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Affiliation(s)
| | - Calvin Or
- 1 The University of Hong Kong, China
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Leiman DA, Mills AM, Shofer FS, Weber AT, Leiman ER, Riff BP, Lewis JD, Mehta SJ. Glasgow Blatchford Score of limited benefit for low-risk urban patients: a mixed methods study. Endosc Int Open 2017; 5:E950-E958. [PMID: 28971143 PMCID: PMC5621904 DOI: 10.1055/s-0043-117880] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 06/26/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Most patients with upper gastrointestinal bleeding (UGIB) are hospitalized. Risk-stratifying UGIB with scoring tools may decrease avoidable admissions, thereby reducing the cost of care. We sought to describe how frequently low-risk UGIB patients present to urban emergency departments (ED) and the proportion who are admitted to examine how incorporating risk scores into decision support might diminish healthcare utilization in this population. PATIENTS AND METHODS This is a retrospective cohort study of ED patients presenting from 2009 - 2013 to three urban hospitals that do not use electronic UGIB decision support. We used ED disposition diagnosis codes (ICD-9) to identify patients followed by manual chart review for verification and additional data collection. Patients with a Glasgow Blatchford Score (GBS) of 0 were classified as low risk. We also surveyed ED physicians at these hospitals to assess their beliefs about UGIB decision support. RESULTS Over the study period, 66 patients (13.2 per year) presented to the ED with low-risk UGIB. Of these, 10 patients (15.2 %) were admitted and none required endoscopic hemostasis. Most survey respondents (55.6 %, n = 20) were aware of UGIB risk scores but a minority (19.4 %, n = 7) used one. CONCLUSIONS Low-risk UGIB patients infrequently present to the ED and only a minority are admitted. Despite advocacy to incorporate decision support into routine clinical care, ED physicians independently identified low risk patients. There is insufficient evidence to suggest the magnitude of this problem is large enough to warrant implementation of decision support for low risk UGIB.
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Affiliation(s)
- David A. Leiman
- Division of Gastroenterology, Duke University of School of Medicine, 2301 Erwin Road, Durham, NC, USA,Corresponding author David A. Leiman, MD, MSHP 200 Trent Drive, Box 3913Durham, NC 27710+1-919-681-8147
| | - Angela M. Mills
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania, United States
| | - Frances S. Shofer
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania, United States
| | - Andrew T. Weber
- Department of Internal Medicine, Geffen School of Medicine at the University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, California, United States
| | - Erin R. Leiman
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Brian P. Riff
- Advanced Endoscopy Center, St. Jude Medical Center, Fullerton, California, United States
| | - James D. Lewis
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Shivan J. Mehta
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
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A Queue-Based Monte Carlo Analysis to Support Decision Making for Implementation of an Emergency Department Fast Track. JOURNAL OF HEALTHCARE ENGINEERING 2017; 2017:6536523. [PMID: 29065634 PMCID: PMC5387845 DOI: 10.1155/2017/6536523] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/24/2016] [Accepted: 01/24/2017] [Indexed: 11/24/2022]
Abstract
Emergency departments (EDs) are seeking ways to utilize existing resources more efficiently as they face rising numbers of patient visits. This study explored the impact on patient wait times and nursing resource demand from the addition of a fast track, or separate unit for low-acuity patients, in the ED using a queue-based Monte Carlo simulation in MATLAB. The model integrated principles of queueing theory and expanded the discrete event simulation to account for time-based arrival rates. Additionally, the ED occupancy and nursing resource demand were modeled and analyzed using the Emergency Severity Index (ESI) levels of patients, rather than the number of beds in the department. Simulation results indicated that the addition of a separate fast track with an additional nurse reduced overall median wait times by 35.8 ± 2.2 percent and reduced average nursing resource demand in the main ED during hours of operation. This novel modeling approach may be easily disseminated and informs hospital decision-makers of the impact of implementing a fast track or similar system on both patient wait times and acuity-based nursing resource demand.
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Hadadi A, Khashayar P, Karbakhsh M, Vasheghani Farahani A. Discharge against medical advice from a Tehran emergency department. Int J Health Care Qual Assur 2017; 29:24-32. [PMID: 26771059 DOI: 10.1108/ijhcqa-03-2015-0030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to identify the main reasons for discharge against medical advice (DAMA) in the emergency department (ED) of a teaching hospital in Tehran, Iran. DESIGN/METHODOLOGY/APPROACH This cross-sectional study was conducted on all the patients who left the ED of a referral teaching hospital against medical advice (AMA) in 2008. A questionnaire was filled out for each patient to determine the reasons behind patient leaving AMA. FINDINGS In total, 12.8 percent of the patients left the hospital AMA. Dissatisfaction with being observed in the ED, having a feeling of recovery and hospital personnel encouraging patients to leave the hospital were the main reasons for leaving the hospital AMA. PRACTICAL IMPLICATIONS Like many other centers, the results showed that poor communication skill and work overload were the main contributing factors to DAMA. The center managed to improve patient satisfaction and thus lowered DAMA rates following this study. Considering the similarities reported in the reports and that of other studies, it could be concluded that policy makers in other centers can also benefit from the results to adopt effective approaches to reduce DAMA rate. ORIGINALITY/VALUE To the knowledge no study has evaluated the rate and the reasons behind DAMA in the Iranian EDs.
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Affiliation(s)
- Azar Hadadi
- Research Development Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
OBJECTIVE To study the operational impact of process improvements on emergency department (ED) patient flow. The changes did not require any increase in resources or expenditures. METHODS This was a 36-month pre- and post-intervention study to evaluate the effect of implementing process improvements at a community ED from January 2010 to December 2012. The intervention comprised streamlining triage by having patients accepted into internal waiting areas immediately after triage. Within the ED, parallel processes unfolded, and there was no restriction on when registration occurred or which health care provider a patient saw first. Flexible nursing ratios allowed nursing staff to redeploy and move to areas of highest demand. Last, demand-based physician scheduling was implemented. The main outcome was length of stay (LOS). Secondary outcomes included time to physician initial assessment (PIA), left-without-being-seen (LWBS) rates, and left-against-medical-advice (LAMA) rates. Segmented regression of interrupted time series analysis was performed to quantify the impact of the intervention, and whether it was sustained. RESULTS Patients totalling 251,899 attended the ED during the study period. Daily patient volumes increased 17.3% during the post-intervention period. Post-intervention, mean LOS decreased by 0.64 hours (p<0.005). LOS for non-admitted Canadian Triage and Acuity Scale 2 (-0.58 hours, p<0.005), 3 (-0.75 hours, p<0.005), and 4 (-0.32 hours, p<0.005) patients also decreased. There were reductions in PIA (43.81 minutes, p<0.005), LWBS (35.2%, p<0.005), and LAMA (61.9%, p<0.005). CONCLUSION A combination of process improvements in the ED was associated with clinically significant reductions in LOS, PIA, LWBS, and LAMA for non-resuscitative patients.
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Vermeulen MJ, Stukel TA, Boozary AS, Guttmann A, Schull MJ. The Effect of Pay for Performance in the Emergency Department on Patient Waiting Times and Quality of Care in Ontario, Canada: A Difference-in-Differences Analysis. Ann Emerg Med 2016. [DOI: 10.1016/j.annemergmed.2015.06.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Moe J, Belsky JB. Comparing patients who leave the ED prematurely, before vs after medical evaluation: a National Hospital Ambulatory Medical Care Survey analysis. Am J Emerg Med 2016; 34:830-3. [PMID: 26935229 DOI: 10.1016/j.ajem.2016.01.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 01/15/2016] [Accepted: 01/19/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Many patients leave the Emergency Department (ED) before beginning or completing medical evaluation. Some of these patients may be at higher medical risk depending on their timing of leaving the ED. OBJECTIVES To compare patient, hospital, and visit characteristics of patients who leave before completing medical care to patients who leave before ED evaluation. METHODS Retrospective cross-sectional analysis of ED visits using the 2009-2011 National Hospital Ambulatory Medical Care Survey. RESULTS A total of 100962 ED visits were documented in the 2009-2011 National Hospital Ambulatory Medical Care Survey, representing a weighted count of 402211907 total ED visits. 2646 (2.62%) resulted in a disposition of left without completing medical care. Of these visits, 1792 (67.7%) left before being seen by a medical provider versus 854 (32.3%) who left after medical provider evaluation but before a final disposition. Patients who left after being assessed by a medical provider were older, had higher acuity visits, were more likely to have visited an ED without nursing triage, arrived more often by ambulance, and were more likely to have private insurance than to be self-paying or to have other payment arrangements (e.g. worker's compensation or charity/no charge). CONCLUSIONS When comparing all patients who left the ED before completion of care, those who left after versus before medical provider evaluation differed in their patient, hospital, and visit characteristics and may represent a high risk patient group.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Justin Brett Belsky
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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[Not Available]. CAN J EMERG MED 2015; 18:1-9. [PMID: 26558326 DOI: 10.1017/cem.2015.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
RÉSUMÉObjectifL’objectif de cette étude rétrospective était d’identifier les facteurs associés aux décomptes quotidiens de départs avant prise en charge médicale (DAPCM) dans les deux salles d’urgence du Centre hospitalier universitaire de Sherbrooke, Fleurimont (HF) et Hôtel-Dieu (HD).MéthodeDes données cliniques et démographiques anonymisées, ainsi que des données hospitalières, ont été extraites de la banque de données du Centre Informatisé de Recherche Évaluative en Services et Soins de Santé pour la période du 1er avril 2011 au 30 juin 2012. Les variables étant corrélées au nombre de DAPCM par jour par site lors des analyses univariées ont été retenues pour l’analyse de régression linéaire multivariée.RésultatsLes analyses de régression multivariées démontrent que le nombre de DAPCM par jour diminue pour les deux sites lorsque la durée moyenne de séjour des patients non hospitalisés à l’urgence diminue (HF:b=1,17, p<0,001; HD:b=1,41, p<0,001) et lorsqu’un médecin dédié aux patients ambulatoires est présent (HF:b=-4,35, p<0,001; HD:b=-5,48, p<0,001). De plus, des facteurs reliés à l’achalandage des salles d’urgence et la raison primaire de consultation ont également eu un effet sur le nombre de DAPCM par jour.ConclusionDes efforts devraient être faits afin de diminuer la durée moyenne de séjour des patients non hospitalisés à l’urgence et d’assurer la présence d’un médecin dédié aux patients ambulatoires pour diminuer le nombre de DAPCM.
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Hess JJ, Wallenstein J, Ackerman JD, Akhter M, Ander D, Keadey MT, Capes JP. Scribe Impacts on Provider Experience, Operations, and Teaching in an Academic Emergency Medicine Practice. West J Emerg Med 2015; 16:602-10. [PMID: 26587079 PMCID: PMC4644023 DOI: 10.5811/westjem.2015.6.25432] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 06/02/2015] [Accepted: 06/16/2015] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Physicians dedicate substantial time to documentation. Scribes are sometimes used to improve efficiency by performing documentation tasks, although their impacts have not been prospectively evaluated. Our objective was to assess a scribe program's impact on emergency department (ED) throughput, physician time utilization, and job satisfaction in a large academic emergency medicine practice. METHODS We evaluated the intervention using pre- and post-intervention surveys and administrative data. All site physicians were included. Pre- and post-intervention data were collected in four-month periods one year apart. Primary outcomes included changes in monthly average ED length of stay (LOS), provider-specific average relative value units (RVUs) per hour (raw and normalized to volume), self-reported estimates of time spent teaching, self-reported estimates of time spent documenting, and job satisfaction. We analyzed data using descriptive statistics and appropriate tests for paired pre-post differences in continuous, categorical, and ranked variables. RESULTS Pre- and post-survey response rates were 76.1% and 69.0%, respectively. Most responded positively to the intervention, although 9.5% reported negative impressions. There was a 36% reduction (25%-50%; p<0.01) in time spent documenting and a 30% increase (11%-46%, p<0.01) in time spent in direct patient contact. No statistically significant changes were seen in job satisfaction or perception of time spent teaching. ED volume increased by 88 patients per day (32-146, p=0.04) pre- to post- and LOS was unchanged; rates of patients leaving against medical advice dropped, and rates of patients leaving without being seen increased. RVUs per hour increased 5.5% and per patient 5.3%; both were statistically significant. No statistically significant changes were seen in patients seen per hour. There was moderate correlation between changes in ED volume and changes in productivity metrics. CONCLUSION Scribes were well received in our practice. Documentation time was substantially reduced and redirected primarily to patient care. Despite an ED volume increase, LOS was maintained, with fewer patients leaving against medical advice but more leaving without being seen. RVUs per hour and per patient both increased.
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Affiliation(s)
- Jeremy J Hess
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Joshua Wallenstein
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Jeremy D Ackerman
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Murtaza Akhter
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Douglas Ander
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Matthew T Keadey
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - James P Capes
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
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Anderson D, Pimentel L, Golden B, Wasil E, Hirshon JM. Drivers of ED efficiency: a statistical and cluster analysis of volume, staffing, and operations. Am J Emerg Med 2015; 34:155-61. [PMID: 26508583 DOI: 10.1016/j.ajem.2015.09.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 09/18/2015] [Accepted: 09/30/2015] [Indexed: 11/29/2022] Open
Abstract
STUDY OBJECTIVE The percentage of patients leaving before treatment is completed (LBTC) is an important indicator of emergency department performance. The objective of this study is to identify characteristics of hospital operations that correlate with LBTC rates. METHODS The Emergency Department Benchmarking Alliance 2012 and 2013 cross-sectional national data sets were analyzed using multiple regression and k-means clustering. Significant operational variables affecting LBTC including annual patient volume, percentage of high-acuity patients, percentage of patients admitted to the hospital, number of beds, academic status, waiting times to see a physician, length of stay (LOS), registered nurse (RN) staffing, and physician staffing were identified. LBTC was regressed onto these variables. Because of the strong correlation between waiting times measured as door to first provider (DTFP), we regressed DTFP onto the remaining predictors. Cluster analysis was applied to the data sets to further analyze the impact of individual predictors on LBTC and DTFP. RESULTS LOS and the time from DTFP were both strongly associated with LBTC rate (P<.001). Patient volume is not significantly associated with LBTC rate (P=.16). Cluster analysis demonstrates that physician and RN staffing ratios correlate with shorter DTFP and lower LBTC. CONCLUSION Volume is not the main driver of LBTC. DTFP and LOS are much more strongly associated. We show that operational factors including LOS and physician and RN staffing decisions, factors under the control of hospital and physician executives, correlate with waiting time and, thus, in determining the LBTC rate.
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Affiliation(s)
- David Anderson
- Zicklin School of Business, Baruch College, City University of New York, New York, NY
| | - Laura Pimentel
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD.
| | - Bruce Golden
- Robert H. Smith School of Business, University of Maryland, College Park, MD
| | - Edward Wasil
- Kogod School of Business, American University, Washington, DC
| | - Jon Mark Hirshon
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
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Affiliation(s)
- Anita Deakin
- Australian Patient Safety Foundation; University of South Australia; Adelaide South Australia Australia
| | - Kim Hansen
- The Prince Charles Hospital; Brisbane Queensland Australia
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Cost-effectiveness of a physician-nurse supplementary triage assessment team at an academic tertiary care emergency department. CAN J EMERG MED 2015; 18:191-204. [PMID: 26337026 DOI: 10.1017/cem.2015.88] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the cost-effectiveness of physician-nurse supplementary triage assistance team (MDRNSTAT) from a hospital and patient perspective. METHODS This was a cost-effectiveness evaluation of a cluster randomized control trial comparing the MDRNSTAT with nurse-only triage in the emergency department (ED) between the hours of 0800 and 1500. Cost was MDRNSTAT salary. Revenue was from Ontario's Pay-for-Results and patient volume-case mix payment programs. The incremental cost-effectiveness ratio was based on MDRNSTAT cost and three consequence assessments: 1) per additional patient-seen; 2) per physician initial assessment (PIA) hour saved; and 3) per ED length of stay (EDLOS) hour saved. Patient opportunity cost was determined. Patient satisfaction was quantified by a cost-benefit ratio. A sensitivity analysis extrapolating MDRNSTAT to different working hours, salary, and willingness-to-pay data was performed. RESULTS The added cost of the MDRNSTAT was $3,597.27 [$1,729.47 to ∞] per additional patient-seen, $75.37 [$67.99 to $105.30] per PIA hour saved, and $112.99 [$74.68 to $251.43] per EDLOS hour saved. From the hospital perspective, the cost-benefit ratio was 38.6 [19.0 to ∞] and net present value of -$447,996 [-$435,646 to -$459,900]. For patients, the cost-benefit ratio for satisfaction was 2.8 [2.3 to 4.6]. If MDRNSTAT performance were consistently implemented from noon to midnight, it would be more cost-effective. CONCLUSIONS The MDRNSTAT is not a cost-effective daytime strategy but appears to be more feasible during time periods with higher patient volume, such as late morning to evening.
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Preyde M, Crawford K, Mullins L. Patients' satisfaction and wait times at Guelph General Hospital Emergency Department before and after implementation of a process improvement project. CAN J EMERG MED 2015; 14:157-68. [DOI: 10.2310/8000.2012.110590] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTObjective:A process improvement program (PIP) was implemented in the emergency department (ED) at Guelph General Hospital in July 2009. The purpose of this study was to examine patients' satisfaction and wait times by level of Canadian Triage and Acuity Scale (CTAS) score before and 6 months after implementation of this program.Methods:Two samples were recruited: one was recruited before implementation of the PIP, January to June 2009 (T1), and one was recruited 6 months after implementation, January to June 2010 (T2). Patients were contacted by telephone to administer a survey including patient satisfaction with quality of care. Time to physician initial assessment, numbers left without being seen, and length of stay (LOS) were obtained from hospital records to compare wait times before and 6 months after implementation of the PIP.Results:Patients (n = 301) reported shorter wait times after implementation (e.g., 12% reported seeing a physician right away at T1 compared to 29% at T2). Time to physician initial assessment improved for patients with CTAS scores of III, IV, and V (average decrease from 2.1 to 1.7 hours), fewer patients (n = 425) left without being seen after implementation, and the mean and 90th percentile of LOS decreased for all patients except the mean LOS for discharged patients with a CTAS score of I. Total time spent in the ED for admitted patients decreased from 11.11 hours in the 2009 period to 9.95 in the 2010 period, and for nonadmitted patients, the total time decreased from 3.94 to 3.29 hours. The overall satisfaction score improved from a mean of 3.17 to 3.4 (of 4; p < 0.001).Conclusion:Implementation of the ED PIP corresponded with decreased wait times, increased patient satisfaction, and improved patient flow for patients with CTAS scores of III, IV, and V.
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Svoboda T. Difficult behaviors in the emergency department: a cohort study of housed, homeless and alcohol dependent individuals. PLoS One 2015; 10:e0124528. [PMID: 25919015 PMCID: PMC4412575 DOI: 10.1371/journal.pone.0124528] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 03/15/2015] [Indexed: 11/18/2022] Open
Abstract
Background This study contrasted annual rates of difficult behaviours in emergency departments among cohorts of individuals who were homeless and low-income housed and examined predictors of these events. Methods Interviews in 1999 with men who were chronically homeless with drinking problems (CHDP) (n = 50), men from the general homeless population (GH) (n = 61), and men residing in low-income housing (LIH) (n = 58) were linked to catchment area emergency department records (n = 2817) from 1994 to 1999. Interview and hospital data were linked to measures of difficult behaviours. Results Among the CHDP group, annual rates of visits with difficult behaviours were 5.46; this was 13.4 (95% CI 10.3–16.5) and 14.3 (95% CI 11.2–17.3) times higher than the GH and LIH groups. Difficult behaviour incidents included physical violence, verbal abuse, uncooperativeness, drug seeking, difficult histories and security involvement. Difficult behaviours made up 57.54% (95% CI 55.43–59.65%), 24% (95% CI 19–29%), and 20% (95% CI 16–24%) of CHDP, GH and LIH visits. Among GH and LIH groups, 87% to 95% were never involved in verbal abuse or violence. Intoxication increased all difficult behaviours while decreasing drug seeking and leaving without being seen. Verbal abuse and violence were less likely among those housed, with odds ratios of 0.24 (0.08, 0.72) and 0.32 (0.15, 0.69), respectively. Conclusions Violence and difficult behaviours are much higher among chronically homeless men with drinking problems than general homeless and low-income housed populations. They are concentrated among subgroups of individuals. Intoxication is the strongest predictor of difficult behaviour incidents.
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Affiliation(s)
- Tomislav Svoboda
- Department of Family and Community Medicine, University of Toronto, Centre for Research on Inner-City Health, Li Ka Shing Knowledge Institute—St. Michael’s Hospital, Toronto, Canada
- * E-mail:
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Wang H, Robinson RD, Cowden CD, Gorman VA, Cook CD, Gicheru EK, Schrader CD, Jayswal RD, Zenarosa NR. Use of the SONET score to evaluate Urgent Care Center overcrowding: a prospective pilot study. BMJ Open 2015; 5:e006860. [PMID: 25872940 PMCID: PMC4401867 DOI: 10.1136/bmjopen-2014-006860] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To derive a tool to determine Urgent Care Center (UCC) crowding and investigate the association between different levels of UCC overcrowding and negative patient care outcomes. DESIGN Prospective pilot study. SETTING Single centre study in the USA. PARTICIPANTS 3565 patients who registered at UCC during the 21-day study period were included. Patients who had no overcrowding statuses estimated due to incomplete collection of operational variables at the time of registration were excluded in this study. 3139 patients were enrolled in the final data analysis. PRIMARY AND SECONDARY OUTCOME MEASURES A crowding estimation tool (SONET: Severely overcrowded, Overcrowded and Not overcrowded Estimation Tool) was derived using the linear regression analysis. The average length of stay (LOS) in UCC patients and the number of left without being seen (LWBS) patients were calculated and compared under the three different levels of UCC crowding. RESULTS Four independent operational variables could affect the UCC overcrowding score including the total number of patients, the number of results pending for patients, the number of patients in the waiting room and the longest time a patient was stationed in the waiting room. In addition, UCC overcrowding was associated with longer average LOS (not overcrowded: 133±76 min, overcrowded: 169±79 min, and severely overcrowded: 196±87 min, p<0.001) and an increased number of LWBS patients (not overcrowded: 0.28±0.69 patients, overcrowded: 0.64±0.98, and severely overcrowded: 1.00±0.97). CONCLUSIONS The overcrowding estimation tool (SONET) derived in this study might be used to determine different levels of crowding in a high volume UCC setting. It also showed that UCC overcrowding might be associated with negative patient care outcomes.
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Affiliation(s)
- Hao Wang
- Department of Emergency Medicine, Integrative Emergency Services Physician Group, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Richard D Robinson
- Department of Emergency Medicine and Urgent Care Center, Integrative Emergency Services Physician Group, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Chad D Cowden
- Department of Emergency Medicine and Urgent Care Center, Integrative Emergency Services Physician Group, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Violet A Gorman
- Department of Emergency Medicine and Urgent Care Center, Integrative Emergency Services Physician Group, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Christopher D Cook
- Department of Emergency Medicine and Urgent Care Center, Integrative Emergency Services Physician Group, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Eugene K Gicheru
- Department of Emergency Medicine and Urgent Care Center, Integrative Emergency Services Physician Group, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Chet D Schrader
- Department of Emergency Medicine and Urgent Care Center, Integrative Emergency Services Physician Group, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Rani D Jayswal
- Department of Emergency Medicine and Urgent Care Center, Integrative Emergency Services Physician Group, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Nestor R Zenarosa
- Department of Emergency Medicine and Urgent Care Center, Integrative Emergency Services Physician Group, John Peter Smith Health Network, Fort Worth, Texas, USA
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Gravel J, Gouin S, Carrière B, Gaucher N, Bailey B. Unfavourable outcome for children leaving the emergency department without being seen by a physician. CAN J EMERG MED 2015; 15:289-99. [DOI: 10.2310/8000.2013.130939] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTObjective:To assess the prevalence of an unfavourable outcome among children leaving without being seen by a physician in the emergency department (ED).Method:This was a prospective cohort study conducted over a complete year in a pediatric tertiary care ED. A random sample of all children younger than 19 years of age who left without being seen by a physician was contacted by phone 4 to 6 days following the ED visit. The primary outcome was the occurrence of an unfavourable outcome prospectively defined using a Delphi method among 15 pediatric emergency physicians. An unfavourable outcome was defined as hospitalization, the need for an invasive procedure (intravenous or intramuscular medication, fracture reduction, bone casting, or surgical intervention), suicide attempt, or death in the 72 hours following leaving without being seen by a physician. As a secondary outcome, multiple potential predictors were evaluated. The first analysis evaluated the proportion of unfavourable outcomes among children who left without being seen by a physician. Then logistic regression identified predictors of unfavourable outcomes.Results:During the study period, 61,909 children presented to the ED, 7,592 (12%) left without being seen by a physician, and 1,579 were recruited. Thirty-eight (2.4%; 95% CI 1.7–3.2) patients fulfilled the criteria for an unfavourable outcome. On multiple logistic regression, chief complaints related to trauma and absence of nurse counseling had higher risks of unfavourable outcome.Conclusions:Approximately 2% of children who left without being seen by a physician at a tertiary care pediatric ED had an unfavourable outcome.
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Blake DF, Dissanayake DB, Hay RM, Brown LH. 'Did not waits': a regional Australian emergency department experience. Emerg Med Australas 2015; 26:145-52. [PMID: 24708003 DOI: 10.1111/1742-6723.12223] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Describe the characteristics, reasons for leaving and outcomes of patients who did not wait (DNW) to be seen by a health practitioner in a regional Australian ED. METHODS Prospective observational study of a convenience sample of ED DNW patients presenting to The Townsville Hospital between June 2011 and July 2012. Seven days from each month were selected, and DNW patients presenting on those days were enrolled. An investigator attempted to contact every DNW patient by telephone in the following week to elicit reasons for leaving, subsequent health contacts, outcomes and suggestions for system improvements. Additional outcome information was obtained from hospital electronic medical records. RESULTS Nearly 15 000 patients presented on the study days, with 648 (4.3%) DNWs: 415 (64.0%) adults, 193 (29.8%) children (1-16 years old) and 40 (6.2%) infants. Thirty-eight (5.9%) patients who DNW were Australasian Triage Scale (ATS) category 3, 546 (84.3%) were ATS category 4 and 64 (9.9%) were ATS category 5. Most DNW patients presented on Sundays and between 1600 and 2359. Just over half of the patients who DNW (52.9%) sought additional medical treatment, with 4.9% requiring subsequent hospital admission. Three psychiatric patients who DNW required urgent mental health interventions organised by the investigators. Frustration with perceived waiting times was the most common reason for leaving without being seen. CONCLUSIONS Regional Australia ED patients who DNW often still require medical care, with approximately 1 in 20 requiring subsequent hospital admission. Patients with psychiatric conditions who DNW might be at particular risk.
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Affiliation(s)
- Denise F Blake
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia; School of Marine and Tropical Biology, James Cook University, Townsville, Queensland, Australia
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Aksoy H, Aksoy U, Ozturk M, Ozyurt S, Acmaz G, Karadag OI, Yucel B, Aydin T. Utilization of emergency service of obstetrics and gynecology: a cross-sectional analysis of a training hospital. J Clin Med Res 2014; 7:109-14. [PMID: 25436028 PMCID: PMC4245062 DOI: 10.14740/jocmr2013w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2014] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Overutilization and inappropriate use of emergency departments (EDs) by patients with non-urgent health problems has become a major concern worldwide. This study aims to describe the characteristics of obstetric and gynecologic patients admitted to the Department of Emergency Obstetric and Gynecology. METHODS A retrospective and cross-sectional study was designed at our Emergency Service of Obstetrics and Gynecology of Kayseri Education and Research Hospital of Medicine between January 1 and December 31, 2013. A total of 30,853 patients applying to emergency service were retrospectively analyzed from the admission charts, patient files and hospital automation system. Patients were assessed in terms of demographic features, presentation times, complaints, admission type (with own facilities, with consultation or with ambulance), diagnoses (urgent or non-ergent), discharge rates, clinical admission, rejection rate of examination, and rejection rate of hospitalization. RESULTS A total of 30,853 patients were analyzed retrospectively. The mean age of patients was 27.69 ± 8.44 years; 51% of patients were between 20 and 29 years old. The categories of patients in urgent and non-urgent were 69% and 31% respectively. Most common presentation time period was between 19:00 and 21:00. Labor pain, pain and bleeding during pregnency, routine antenatal control, pelvic pain and menstrual irregularity were the most common complaints. Labor pain with the rate of 21% was the most common cause of ED admission. All patients who presented with labor pain were hospitalized. Patients hospitalized for labor constituted 56% of all hospitalized patients. Among patients, 62% were treated on an outpatient basis and 38% were hospitalized. Of patients, 3.54% refused to hospitalization. The cases using the ambulance to admission constituted 1.07% of all ED patients. Of these patients who have used ambulance 3.65% refused to the patient examination. CONCLUSIONS To improve the obstetric and gynecologic emergency medical care in Turkey, demographic properties and other characteristics of patients should be analyzed in detail. Detailed analysis of the data contributes to the further design and perspective of the EDs.
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Affiliation(s)
- Huseyin Aksoy
- Department of Obstetrics and Gynecology, Kayseri Military Hospital, Kayseri, Turkey
| | - Ulku Aksoy
- Department of Obstetrics and Gynecology, Kayseri Memorial Hospital, Kayseri, Turkey
| | - Mustafa Ozturk
- Department of Obstetrics and Gynecology, Etimesgut Military Hospital, Ankara, Turkey
| | - Sezin Ozyurt
- Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital of Medicine, Kayseri, Turkey
| | - Gokhan Acmaz
- Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital of Medicine, Kayseri, Turkey
| | - Ozge Idem Karadag
- Department of Obstetrics and Gynecology, Kayseri Acibadem Hospital, Kayseri, Turkey
| | - Burak Yucel
- Department of Obstetrics and Gynecology, Kayseri Acibadem Hospital, Kayseri, Turkey
| | - Turgut Aydin
- Department of Obstetrics and Gynecology, Kayseri Acibadem Hospital, Kayseri, Turkey
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Kim BBJ, Delbridge TR, Kendrick DB. Improving process quality for pediatric emergency department. Int J Health Care Qual Assur 2014; 27:336-46. [PMID: 25076607 DOI: 10.1108/ijhcqa-11-2012-0117] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Overcrowding in emergency departments (EDs) leads to longer waiting times and results in higher number of patients leaving the ED without being seen by a physician. EDs need to improve quality for patients' waiting time and length of stay (LoS) from the perspective of process and flow control management. The paper aims to discuss these issues. DESIGN/METHODOLOGY/APPROACH The retrospective case study was performed using the computerized ED patient time logs from arrival to discharge between July 1, 2009 and June 30, 2010. Patients were divided into two groups either adult or pediatric with a cutoff age of 18. Patients' characteristics were measured by arrival time periods, waiting times before being seen by a physician, total LoS and acuity levels. A discrete event simulation was applied to the comparison of quality performance measures. FINDINGS Statistically significant differences were found between the two groups in terms of arrival times, acuity levels, waiting time stratified for various arrival times and acuity levels. The process quality for pediatric patients could be improved by redesign of patient flow management and medical resource. RESEARCH LIMITATIONS/IMPLICATIONS The results are limited to a case of one community and ED. This study did not analyze the characteristic of leaving the ED without being seen by a physician. PRACTICAL IMPLICATIONS Separation of pediatric patients from adult patients in an ED can reduce the waiting time before being seen by a physician and the total staying time in the ED for pediatric patients. It can also lessen the chances for pediatric patients to leave the ED without being seen by a physician. ORIGINALITY/VALUE A process and flow control management scheme based on patient group characteristics may improve service quality and lead to a better patient satisfaction in ED.
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Missed opportunities: evolution of patients leaving without being seen or against medical advice during a six-year period in a Swiss tertiary hospital emergency department. BIOMED RESEARCH INTERNATIONAL 2014; 2014:690368. [PMID: 25013794 PMCID: PMC4075075 DOI: 10.1155/2014/690368] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 05/06/2014] [Accepted: 05/24/2014] [Indexed: 11/17/2022]
Abstract
Aim. The study aimed at describing the evolution over a 6-year period of patients leaving the emergency department (ED) before being seen (“left without being seen” or LWBS) or against medical advice (“left against medical advice” or LAMA) and at describing their characteristics. Methods. A retrospective database analysis of all adult patients who are admitted to the ED, between 2005 and 2010, and who left before being evaluated or against medical advice, in a tertiary university hospital. Results. During the study period, among the 307,716 patients who were registered in the ED, 1,157 LWBS (0.4%) and 1,853 LAMA (0.9%) patients were identified. These proportions remained stable over the period. The patients had an average age of 38.5 ± 15.9 years for LWBS and 41.9 ± 17.4 years for LAMA. The median time spent in the ED before leaving was 102.4 minutes for the LWBS patients and 226 minutes for LAMA patients. The most frequent reason for LAMA was related to the excessive length of stay. Conclusion. The rates of LWBS and LAMA patients were low and remained stable. The patients shared similar characteristics and reasons for leaving were largely related to the length of stay or waiting time.
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Elmqvist C, Frank C. Patients' strategies to deal with their situation at an emergency department. Scand J Caring Sci 2014; 29:145-51. [PMID: 24750520 DOI: 10.1111/scs.12143] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 03/21/2014] [Indexed: 12/30/2022]
Abstract
INTRODUCTION The care in the emergency department (ED) is often characterised by high standards of efficiency and rapid treatment and the encounter between patient and staff can be described as both short and fragmented. Research within this field has mostly been performed with quantitative measurements and patients are both satisfied and vulnerable in their care at an ED. There is a lack of qualitative studies about patient's strategies to deal with their situation. AIM The aim was to describe patient's strategies for dealing with their situation at an ED. METHODS Secondary analysis has been made of 13 qualitative interviews grounded in a lifeworld perspective. The interviews were analysed by qualitative content analysis. RESULTS The results showed that patients' strategies to deal with the situation at the ED are passive or active. The passive strategy is being patient and the active strategies varied in terms of having hidden tactics, using visible tactics and using families as support. CONCLUSION These findings increase the importance of gaining knowledge about these strategies so that the staff at the ED can support the patients so they do not have to use them.
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Affiliation(s)
- Carina Elmqvist
- Centre for Acute & Critical Care, Department of Health and Caring Sciences, Linneaus University, Växjö, Sweden
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Patient characteristics and institutional factors associated with those who “did not wait” at a South East Queensland Emergency Department. ACTA ACUST UNITED AC 2014; 17:11-8. [DOI: 10.1016/j.aenj.2013.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 10/21/2013] [Accepted: 10/22/2013] [Indexed: 11/18/2022]
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