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Momesso T, Gokpinar B, Ibrahim R, Boyle AA. Effect of removing the 4-hour access standard in the ED: a retrospective observational study. Emerg Med J 2023; 40:630-635. [PMID: 37369563 DOI: 10.1136/emermed-2023-213142] [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: 02/06/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Time-based targets are used to improve patient flow and quality of care within EDs. While previous research often highlighted the benefits of these targets, some studies found negative consequences of their implementation. We study the consequences of removing the 4-hour access standard. METHODS We conducted a before and after, retrospective, observational study using anonymised, routinely collected, patient-level data from a single English NHS ED between April 2018 and December 2019. The primary outcomes of interest were the proportion of admitted patients, that is, the admission rate, the length of stay in the ED and ambulance handover times. We used interrupted time series models to study and estimate the impact of removing the 4-hour access standard. RESULTS A total of 169 916 attendances were included in the analysis. The interrupted time series models for the average daily admission rate indicate a drop from an estimated 35% to an estimated 31% (95% CI -4.1 to -3.9). This drop is only statistically significant for Majors (Ambulant) patients (from an estimated 38.3% to an estimated 31.4%) and, particularly, for short-stay admissions (from an estimated 18.1% to an estimated 12.8%). The models also show an increase in the average daily length of stay for admitted patients from an estimated 316 min to an estimated 387 min (95% CI 33.5 to 108.9), and an increase in the average daily length of stay for discharged patients from an estimated 222 min to an estimated 262 min (95% CI 6.9 to 40.4). CONCLUSION Lifting the 4-hour access standard reporting was associated with a drop in short-stay admissions to the hospital. However, it was also associated with an increase in the average length of stay in the ED. Our study also suggests that the removal of the 4-hour standard does not impact all patients equally. While certain patient groups such as those Majors (Ambulant) patients with less severe issues might have benefited from the removal of the 4-hour access standard by avoiding short-stay hospital admissions, the average length of stay in the ED seemed to have increased across all groups, particularly for older and admitted patients.
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Affiliation(s)
- Tomas Momesso
- UCL School of Management, University College London, London, UK
| | - Bilal Gokpinar
- UCL School of Management, University College London, London, UK
| | - Rouba Ibrahim
- UCL School of Management, University College London, London, UK
| | - Adrian A Boyle
- Emergency Department, Addenbrooke's Hospital Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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2
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Miazgowski B, Pakulski C, Miazgowski T. Length of Stay in Emergency Department by ICD-10 Specific and Non-Specific Diagnoses: A Single-Centre Retrospective Study. J Clin Med 2023; 12:4679. [PMID: 37510793 PMCID: PMC10380588 DOI: 10.3390/jcm12144679] [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: 06/04/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
The definition of non-specific presentation at a hospital emergency department (ED) has not yet been formally established. The purpose of this study was to assess the relationships between primary ED diagnoses identified by ICD-10 codes and ED length of stay (LOS). Over the course of three years, we examined 134,675 visits at a tertiary hospital. LOS was examined in groups with specific (internal, surgical, neurological, and traumatic diseases) and non-specific diagnoses. Our secondary objective was to measure LOS by age, day of the week, time of day, and season. The median LOS was 182 min (interquartile range: 99-264 min). LOS was 99 min in the traumatic group, while it was 132 min in the surgical group, 141 min in the non-specific group, 228 min in the internal medicine group, and 237 min in the neurological group. Other determinants of LOS were age, revisits, day of the week, and time of arrival-but not a season of the year. In the non-specific group (21% of all diagnoses), the percentage of hospitalizations was higher than in the specific groups. Our results suggest that in clinical practice, the non-specific group should be redefined to also encompass diagnoses from ICD-10 Chapter XXI (block Z00-Z99).
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Affiliation(s)
- Bartosz Miazgowski
- Doctoral School, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Cezary Pakulski
- Department of Anesthesiology, Intensive Therapy and Emergency Medicine, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Tomasz Miazgowski
- Department of Propaedeutic of Internal Diseases and Arterial Hypertension, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
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3
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Al-Mashat H, Lindskou TA, Møller JM, Ludwig M, Christensen EF, Søvsø MB. Assessed and discharged - diagnosis, mortality and revisits in short-term emergency department contacts. BMC Health Serv Res 2022; 22:816. [PMID: 35739517 PMCID: PMC9219135 DOI: 10.1186/s12913-022-08203-y] [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: 10/26/2021] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Emergency departments (EDs) experience an increasing number of patients. High patient flow are incentives for short duration of ED stay which may pose a challenge for patient diagnostics and care implying risk of ED revisits or increased mortality. Four hours are often used as a target time to decide whether to admit or discharge a patient. Objective To investigate and compare the diagnostic pattern, risk of revisits and short-term mortality for ED patients with a length of stay of less than 4 h (visits) with 4–24 h stay (short stay visits). Methods Population-based cohort study of patients contacting three EDs in the North Denmark Region during 2014–2016, excluding injured patients. Main diagnoses, number of revisits within 72 h of the initial contact and mortality were outcomes. Data on age, sex, mortality, time of admission and ICD-10 diagnostic chapter were obtained from the Danish Civil Registration System and the regional patient administrative system. Descriptive statistics were applied and Kaplan Meier mortality estimates with 95% CI were calculated. Results Seventy-nine thousand three hundred forty-one short-term ED contacts were included, visits constituted 60%. Non-specific diagnoses (i.e. symptoms and signs and other factors) were the most frequent diagnoses among both visits and short stay visits groups (67% vs 49%). Revisits were more frequent for visits compared to short stay visits (5.8% vs 4.2%). Circulatory diseases displayed the highest 0–48-h mortality within the visits and infections in the short stay visits (11.8% (95%CI: 10.4–13.5) and (3.5% (95%CI: 2.6–4.7)). 30-day mortality were 1.3% (95%CI: 1.2–1.5) for visits and 1.8% (95%CI: 1.7–2.0) for short stay visits. The 30-day mortality of the ED revisits with an initial visit was 1.0% (0.8–1.3), vs 0.7% (0.7–0.8) for no revisits, while 30-day mortality nearly doubled for ED revisits with an initial short stay visit (2.5% (1.9–3.2)). Conclusions Most patients were within the visit group. Non-specific diagnoses constituted the majority of diagnoses given. Mortality was higher among patients with short stay visits but increased for both groups with ED revisits. This suggest that diagnostics are challenged by short time targets.
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Affiliation(s)
- Hassan Al-Mashat
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Sdr. Skovvej 15, Aalborg, Denmark
| | - Tim A Lindskou
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Sdr. Skovvej 15, Aalborg, Denmark
| | - Jørn M Møller
- Emergency Department & Trauma Centre, Aalborg University Hospital, Aalborg, Denmark
| | - Marc Ludwig
- Emergency Department Hjørring, North Denmark Regional Hospital, Hjørring, Denmark
| | - Erika F Christensen
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Sdr. Skovvej 15, Aalborg, Denmark
| | - Morten B Søvsø
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Sdr. Skovvej 15, Aalborg, Denmark.
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4
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Walker K, Honan B, Haustead D, Mountain D, Gangathimmaiah V, Forero R, Mitchell R, Martini E, Tesch G, Bissett I, Jones P. Review article: Have emergency department time-based targets influenced patient care? A systematic review of qualitative literature. Emerg Med Australas 2021; 33:202-213. [PMID: 33622021 DOI: 10.1111/1742-6723.13747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 12/01/2022]
Abstract
Time-based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time-based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time-based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets.
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Affiliation(s)
- Katie Walker
- Emergency Department, Cabrini Institute, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bridget Honan
- Central Australian Retrieval Service, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Daniel Haustead
- Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David Mountain
- Emergency Department, Sir Charles Gardner Hospital, Perth, Western Australia, Australia
| | - Vinay Gangathimmaiah
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Roberto Forero
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Rob Mitchell
- Emergency Department, Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Greg Tesch
- Nephrology Department, Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Ian Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Peter Jones
- School of Medicine, The University of Auckland, Auckland, New Zealand
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5
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Haslam MB, Jones ES. The impact of the Emergency Department target upon the discharge decision for people who self-harm. JOURNAL OF PUBLIC MENTAL HEALTH 2019. [DOI: 10.1108/jpmh-01-2019-0003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Purpose
The purpose of this paper is to consider the influence of the Emergency Department (ED) target wait time upon the discharge decision in ED, specifically for patients who have self-harmed. Pressures to discharge patients to avoid breaching the 4-h target wait time, potentially increase the risk of adverse responses from clinicians. For the patient who has self-harmed, such interactions may be experienced as invalidating and may result in adverse outcomes.
Design/methodology/approach
Secondary data analysis was applied to the retrospective referral data of a Mental Health Liaison Team (MHLT), collected over a period of 11 months from a single hospital in the North of England. In total, 734 episodes of care were referred to the team from ED, where the primary presentation was recorded as self-harm.
Findings
Over half of patients referred to the MHLT from ED having self-harmed were seen after already breaching the target and the potential for a more restrictive outcome reduced. Of those patients seen within 4 h, the potential for a more restrictive treatment option was increased.
Practical implications
Recommendations to improve the patient journey for those who have self-harmed include mental health triage and treatment in clinical areas outside of the target.
Social implications
This study challenges the concept of the target as being realistic and attainable for patients who have self-harmed.
Originality/value
This exploratory study provides a starting point from which to explore the impact of the target time upon discharge decisions and clinical outcomes specifically for those who have self-harmed.
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McCabe A, Brenner M, Larkin P, Nic An Fhailí S, Gannon B, O'Sullivan R, Wakai A. Capturing data for emergency department performance monitoring purposes. HRB Open Res 2019; 2:18. [PMID: 32968709 PMCID: PMC7490568 DOI: 10.12688/hrbopenres.12912.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Good-quality data is required for valid and reliable key performance indicators. Little is known of the facilitators and barriers of capturing the required data for emergency department key performance indicators. This study aimed to explore and understand how current emergency department data collection systems relevant to emergency department key performance indicators are integrated into routine service delivery, and to identify the resources required to capture these data elements. Methods: Following pilot testing, we conducted two focus groups with a multi-disciplinary panel of 14 emergency department stakeholders drawn from urban and rural emergency departments, respectively. Focus groups were analyzed using Attride-Stirling's framework for thematic network analysis. Results: The global theme "Understanding facilitators and barriers for emergency department data collection systems" emerged from three organizing themes: "understanding current emergency department data collection systems"; "achieving the ideal emergency department data capture system for the implementation of emergency department key performance indicators"; and "emergency department data capture systems for performance monitoring purposes within the wider context". Conclusion: The pathways to improving emergency department data capture systems for emergency department key performance indicators include upgrading emergency department information systems and investment in hardware technology and data managers. Educating stakeholders outside the emergency department regarding the importance of emergency department key performance indicators as hospital-wide performance indicators underpins the successful implementation of valid and reliable emergency department key performance indicators.
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Affiliation(s)
- Aileen McCabe
- National Children's Research Centre, Gate 5, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
- Emergency Care Research Unit (ECRU), HRB Centre for Primary Care Research, Mercer Building, Mercer Street Lower, Dublin 2, Ireland
- Department of Emergency Medicine, Tallaght University Hospital, Dublin 22, Ireland
| | - Maria Brenner
- School of Nursing, Midwifery and Health Systems, Health Sciences Centre, University College Dublin, Dublin, Ireland
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier St. Dublin 2, Ireland
| | - Philip Larkin
- School of Nursing, Midwifery and Health Systems, Health Sciences Centre, University College Dublin, Dublin, Ireland
- Palliative and Supportive Care Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Sinéad Nic An Fhailí
- National Children's Research Centre, Gate 5, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
- Clinical Development and Analytics, Novartis Ireland, Dublin, Ireland
| | - Brenda Gannon
- Centre for Business and Economics of Health, University of Queensland, Brisbane, Australia
- Manchester Centre for Health Economics (MCHE), Institute of Population Health,, The University of Manchester, Manchester, UK
| | - Ronan O'Sullivan
- Paediatric Emergency Research Unit (PERU), National Children’s Research Centre, Dublin 12, Ireland
- Bon Secours Hospital, Cork, Ireland
| | - Abel Wakai
- Emergency Care Research Unit (ECRU), HRB Centre for Primary Care Research, Mercer Building, Mercer Street Lower, Dublin 2, Ireland
- Department of Emergency Medicine, Beaumont Hospital, Dublin 9, Ireland
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7
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Brian Haslam M. How the emergency department four-hour target affects clinical outcomes for patients diagnosed with a personality disorder. Emerg Nurse 2019; 27:20-24. [PMID: 31468847 DOI: 10.7748/en.2019.e1930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2019] [Indexed: 12/12/2022]
Abstract
Emergency departments (EDs) may already be invalidating environments for patients diagnosed with a personality disorder, with negative attitudes from staff perpetuating patients' feelings of dismissal and rejection. Despite a higher prevalence of patients with personality disorder in health services, including EDs, than the general population, there is a lack of literature on how achieving ED targets may affect this patient group. This article expands on Harden's concept of destructive goal pursuit in relation to the four-hour target and uses the literature to illustrate how pressures to meet the target may distort clinical priorities and result in adverse clinical outcomes for patients. It makes recommendations for practice including using short-stay units in which patients can be treated outside of the target wait time and introducing mental health triage in EDs to improve delivery of psychosocial assessments.
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8
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Forero R, Nahidi S, de Costa J, Fatovich D, FitzGerald G, Toloo S, McCarthy S, Mountain D, Gibson N, Mohsin M, Man WN. Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: a qualitative social dynamic perspective. BMC Health Serv Res 2019; 19:82. [PMID: 30700302 PMCID: PMC6354365 DOI: 10.1186/s12913-019-3877-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 01/04/2019] [Indexed: 11/25/2022] Open
Abstract
Background The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project. Methods The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015–2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis. Results Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels. Conclusion Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff’s experiences.
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Affiliation(s)
- Roberto Forero
- Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of NSW, Liverpool BC, NSW, 1871, Australia. .,Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, NSW, Australia.
| | - Shizar Nahidi
- Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of NSW, Liverpool BC, NSW, 1871, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, NSW, Australia
| | - Josephine de Costa
- Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of NSW, Liverpool BC, NSW, 1871, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, NSW, Australia
| | - Daniel Fatovich
- Department of Emergency Medicine, Royal Perth Hospital, Perth, WA, Australia.,Discipline of Emergency Medicine, University of Western Australia, Crawley, WA, Australia
| | - Gerry FitzGerald
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Sam Toloo
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Sally McCarthy
- Emergency Department, Prince of Wales Hospital , Randwick, NSW, Australia.,Prince of Wales Clinical School, University of NSW, Kensington, NSW, Australia
| | - David Mountain
- Department of Emergency Medicine, Sir Charles Gairdner Hospital, Crawley, WA, Australia.,Discipline of Emergency Medicine, University of Western Australia, Crawley, WA, Australia
| | - Nick Gibson
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching UNit, Liverpool Hospital, NSW Health, Liverpool, NSW, Australia.,School of Psychiatry, Faculty of Medicine, University of NSW, Sydney, NSW, Australia
| | - Wing Nicola Man
- Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of NSW, Liverpool BC, NSW, 1871, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, NSW, Australia
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9
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Hunter D, McCallum J, Howes D. Compassion in emergency departments. Part 2: barriers to the provision of compassionate care. Emerg Nurse 2018; 26:e1775. [PMID: 30047712 DOI: 10.7748/en.2018.e1775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 06/08/2023]
Abstract
In the second part of this three-part series, David Hunter and colleagues discuss the barriers to the provision of compassionate care in emergency departments (EDs). Part one reported findings from doctoral-level research exploring nursing students' experiences of compassionate care in EDs. Many of the findings related to what the students considered as barriers to the provision of compassionate care in this clinical environment. Six barriers to compassionate care were identified and this article considers them in detail.
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Affiliation(s)
- David Hunter
- University of the West of Scotland, Renfrewshire, Scotland
| | | | - Dora Howes
- School of Medicine, Dentistry and Nursing, University of Glasgow, Singapore
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10
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Hughes JA, Cabilan CJ, Young C, Staib A. Effect of the 4-h target on ‘time-to-ECG’ in patients presenting with chest pain to an emergency department: a pilot retrospective observational study. AUST HEALTH REV 2018; 42:196-202. [DOI: 10.1071/ah16263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 02/01/2017] [Indexed: 12/17/2022]
Abstract
Objectives
The aim of this study was to assess the relationship between compliance with time-based Emergency Department (ED) targets (known as NEAT) and the time taken to collect an electrocardiogram (TTE) in patients presenting with chest pain.
Methods
This was a pilot descriptive retrospective cohort study completed in a large inner city tertiary ED. Patients who presented with active or recent chest pain between July 2014 and June 2015 were eligible for inclusion. Pregnant patients, inter-hospital transfers, and traumatic chest pain were excluded. A random selection of 300 patients from the eligible cohort comprised the final sample. The differences of TTE between categories of NEAT compliance were compared using Kruskal-Wallis test. Also, the factors affecting with the acquisition of ECG within ten minutes of arrival were explored using proportional hazards regression.
Results
There was a significant inverse association between the percentage of admitted patients leaving the ED within four hours (admitted NEAT) and TTE. As admitted NEAT compliance increased TTE decreased (p = 0.004). A number of variables including triage score, arrival time, total NEAT, first location, doctor wait time, and cardiac diagnosis were all significant predictors of TTE. After adjusting for other variables Admitted NEAT remained as an independent predictor of TTE.
Conclusion
There is likely to be a relationship between NEAT and TTE that is reflective of overall hospital and not just ED functioning; however the exact relationship remains uncertain. Further study in a multisite study is warranted to further explore the relationship between NEAT, TTE and other important clinical metrics of ED performance.
What is known about the topic?
The 4-h time target or National Emergency Access Target (NEAT) is implemented in Australia to ease crowding and access block. However, little is known of its effect on important clinical endpoints, particularly ‘time-to-ECG’ (TTE).
What does this paper add?
This paper demonstrates a complex relationship between measures of time-based targets, such as time to ECG. It is likely that increasing compliance with admitted NEAT shortens TTE, demonstrating the effect of hospital functioning on the ability to deliver quality care in the emergency department.
What are the implications for practitioners?
Emergency department flow has an effect on the ability of the department to deliver key assessment. There is a relationship between NEAT compliance and TTE, but the exact relationship requires further exploration in larger multicentre studies.
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11
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Assessing the impact of systems modeling in the redesign of an Emergency Department. Health Syst (Basingstoke) 2017. [DOI: 10.1057/hs.2012.15] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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13
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Pope I, Burn H, Ismail SA, Harris T, McCoy D. A qualitative study exploring the factors influencing admission to hospital from the emergency department. BMJ Open 2017; 7:e011543. [PMID: 28851767 PMCID: PMC5577896 DOI: 10.1136/bmjopen-2016-011543] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The number of emergency admissions to hospital in England and Wales has risen sharply in recent years and is a matter of concern to clinicians, policy makers and patients alike. However, the factors that influence this decision are poorly understood. We aimed to ascertain how non-clinical factors can affect hospital admission rates. METHOD We conducted semistructured interviews with 21 participants from three acute hospital trusts. Participants included 11 emergency department (ED) doctors, 3 ED nurses, 3 managers and 4 inpatient doctors. A range of seniority was represented among these roles. Interview questions were developed from key themes identified in a theoretical framework developed by the authors to explain admission decision-making. Interviews were recorded, transcribed and analysed by two independent researchers using framework analysis. FINDINGS Departmental factors such as busyness, time of day and levels of senior support were identified as non-clinical influences on a decision to admit rather than discharge patients. The 4-hour waiting time target, while overall seen as positive, was described as influencing decisions around patient admission, independent of clinical need. Factors external to the hospital such as a patient's social support and community follow-up were universally considered powerful influences on admission. Lastly, the culture within the ED was described as having a strong influence (either negatively or positively) on the decision to admit patients. CONCLUSION Multiple factors were identified which go some way to explaining marked variation in admission rates observed between different EDs. Many of these factors require further inquiry through quantitative research in order to understand their influence further.
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Affiliation(s)
- Ian Pope
- Emergency Department, Royal London Hospital, London, UK
| | - Helen Burn
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Sharif A Ismail
- Barts Health NHS Trust and Queen Mary University of London, London, UK
| | - Tim Harris
- Emergency Department, Royal London Hospital, London, UK
| | - David McCoy
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
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14
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Zhu T, Luo L, Zhang X, Shen W. Modeling the Length of Stay of Respiratory Patients in Emergency Department Using Coxian Phase-Type Distributions With Covariates. IEEE J Biomed Health Inform 2017; 22:955-965. [PMID: 28489556 DOI: 10.1109/jbhi.2017.2701779] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Variability and unpredictability are typical features of emergency departments (EDs) where patients randomly arrive with diverse conditions. Patient length of stay (LOS) represents the consumption level of hospital resources, and it is positively skewed and heterogeneous. Both accurate modeling of patient ED LOS and analysis of potential blocking causes are especially useful for patient scheduling and resource management. To tackle the uncertainty of ED LOS, this paper introduces two methods: statistical modeling and distribution fitting. The models are applied to 894 respiratory diseases patients data in the year 2014 from ED of a Chinese public tertiary hospital. Covariates recorded include patient region, gender, age, arrival time, arrival mode, triage category, and treatment area. A Coxian phase-type (PH) distribution model with covariates is proposed as an alternative method for modeling ED LOS. The expectation-maximization (EM) algorithm is used to implement parameter estimation. The results show that ED LOS data can be modeled well by the proposed models. Distributions of ED LOS differ significantly with respect to patients' gender, arrival mode, and treatment area. Using the fitted Coxian PH model will assist ED managers in identifying patients who are most likely to have an extreme ED LOS and in predicting the forthcoming workload for resources.
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15
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Grant A, Hoyle L. Print media representations of UK Accident and Emergency treatment targets: Winter 2014-2015. J Clin Nurs 2017; 26:4425-4435. [DOI: 10.1111/jocn.13772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Aimee Grant
- South East Wales Trials Unit; Centre for Trials Research; Cardiff University; Cardiff UK
| | - Louise Hoyle
- School of Health and Social Care; Edinburgh Napier University; Edinburgh UK
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Hughes JA, Cabilan CJ, Staib A. Effect of the 4-h target on time-to-analgesia in an Australian emergency department: a pilot retrospective observational study. AUST HEALTH REV 2017; 41:185-191. [DOI: 10.1071/ah16025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 04/14/2016] [Indexed: 11/23/2022]
Abstract
Objectives
The aim of the present study was to assess the relationship between and the effect of the 4-h target or National Emergency Access Target (NEAT) on the time-to-analgesia (TTA), as well as the provision of analgesia in an adult emergency department (ED).
Methods
The present study was a pilot descriptive explorative retrospective cohort study conducted in a public metropolitan ED. Eligible presentations for analysis were adults presenting with a documented pain score of ≥4 out of 10 between 1 and 14 September 2014. Triage Category 1, pregnant, chest pain and major trauma cases were excluded from the study. As a result, data for 260 patients were analysed.
Results
Of 260 patients, 176 had analgesia with a median TTA of 49 min. Increased NEAT compliance did not significantly decrease TTA. However, when the factors that affected the provision of analgesia were analysed, an association was demonstrated between Admitted and Short Stay NEAT performance and the provision of analgesia. The likelihood of receiving analgesia at all increased as Admitted and Short Stay NEAT compliance improved.
Conclusion
NEAT is a significant health policy initiative with little clinical evidence supporting its implementation. However, as the Admitted NEAT compliance increases, the probability of receiving analgesia increases, demonstrating a possible link between hospital function and clinical care provision that needs to be explored further.
What is known about the topic?
The 4-h target or NEAT is a widely used initiative in EDs to allay crowding and access block. However, little is known of its impact on clinical endpoints, such as TTA.
What does this paper add?
TTA was not significantly reduced as NEAT compliance increased. However, when the focus was on the probability of receiving analgesia, the results demonstrated that an improvement in Admitted and Short Stay NEAT compliance was associated with an increase in the likelihood of patients receiving analgesia.
What are the implications for practitioners?
NEAT is a relatively recent initiative, hence evidence of its effect on clinically orientated outcomes is limited. Nevertheless, evidence of safety and effectiveness is emerging. The results of the present pilot study provide preliminary data on the timeliness of patient-centred care as demonstrated by TTA and administration of analgesia when required. Further, the results would seem to suggest that the provision of analgesia is affected by how timely patients are moved out of the ED to the in-patient setting. As for future investigations on TTA as a result of NEAT, a wider time period should be considered so that the accurate effect of compliance thresholds (e.g. ≥90%, 81–89%, ≤80%) of NEAT can be explored.
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Basu S, Qayyum H, Mason S. Occupational stress in the ED: a systematic literature review. Emerg Med J 2016; 34:441-447. [PMID: 27729392 DOI: 10.1136/emermed-2016-205827] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 09/12/2016] [Accepted: 09/21/2016] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Occupational stress is a major modern health and safety challenges. While the ED is known to be a high-pressure environment, the specific organisational stressors which affect ED staff have not been established. METHODS We conducted a systematic review of literature examining the sources of organisational stress in the ED, their link to adverse health outcomes and interventions designed to address them. A narrative review of contextual factors that may contribute to occupational stress was also performed. All articles written in English, French or Spanish were eligible for conclusion. Study quality was graded using a modified version of the Newcastle-Ottawa Scale. RESULTS Twenty-five full-text articles were eligible for inclusion in our systematic review. Most were of moderate quality, with two low-quality and two high-quality studies, respectively. While high demand and low job control were commonly featured, other studies demonstrated the role of insufficient support at work, effort-reward imbalance and organisational injustice in the development of adverse health and occupational outcomes. We found only one intervention in a peer-reviewed journal evaluating a stress reduction programme in ED staff. CONCLUSIONS Our review provides a guide to developing interventions that target the origins of stress in the ED. It suggests that those which reduce demand and increase workers' control over their job, improve managerial support, establish better working relationships and make workers' feel more valued for their efforts could be beneficial. We have detailed examples of successful interventions from other fields which may be applicable to this setting.
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Affiliation(s)
- Subhashis Basu
- Sheffield Occupational Health Service and Emergency Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Hasan Qayyum
- Emergency Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Suzanne Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Efficiency in the emergency department - A complex relationship between throughput rates and staff perceptions. Int Emerg Nurs 2016; 29:15-20. [PMID: 27524106 DOI: 10.1016/j.ienj.2016.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/16/2016] [Accepted: 07/28/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION It is well known that emergency departments (EDs) suffer from crowding and throughput challenges, which make the ED a challenging workplace. However, the interplay between the throughput of patients and how staff experience work is seldom studied. The aim of this study was to investigate whether staff experience of work (efficiency, work-related efforts and rewards, and quantity and quality of work) differs between days with low and high patient throughput rates. METHOD Throughput times were collected from electronic medical records and staff (n=252 individuals, mainly nurses) ratings in daily questionnaires over a total of six weeks. Days were grouped into low and high throughput rate days for the orthopedic, surgical and internal medicine sections, respectively, and staff ratings were compared. RESULTS On days with low throughput rates, employees rated their efficiency, effort, reward and quantity of work significantly higher than on days with high throughput rates. There was no difference in perceived quality of work. CONCLUSIONS There is a complex relationship between ED throughput rates and staff perceptions of efficiency and efforts/rewards with work, suggesting that whereas low throughput may be troublesome from a patient and organizational perspective, working conditions may still be perceived as more favorable.
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Morrison LE, Joy JP. Secondary traumatic stress in the emergency department. J Adv Nurs 2016; 72:2894-2906. [PMID: 27221701 DOI: 10.1111/jan.13030] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 11/27/2022]
Abstract
AIM To investigate the prevalence of secondary traumatic stress among Emergency nurses in the West of Scotland and explore their experiences of this. BACKGROUND Unexpected death, trauma and violence are regular occurrences that contribute to the stressful environment nurses working in the Emergency department experience. A potential consequence of repeated exposure to such stressors can be referred to as secondary traumatic stress. DESIGN Triangulation of methods of data collection, using two distinct phases: Phase 1 - quantitative Phase 2 - qualitative METHODS: Quantitative data were collated via postal questionnaire, from a convenience sample of Emergency nurses. Qualitative data were subsequently collated from a focus group constituting of a random sample of these Emergency nurses. Descriptive statistics were computed and thematic analysis conducted. All data were collated during February 2013. RESULTS/FINDINGS 75% of the sampled Emergency nurses reported at least one secondary traumatic stress symptom in the last week. Participants said that acute occupational stressors such as resuscitation and death were the influencing factors towards this. Strategies such as formal debriefing and social support were cited as beneficial tools for the management of secondary traumatic stress; however, barriers such as time and experience were found to inhibit their common use. CONCLUSION Secondary traumatic stress is a prevalent phenomenon among Emergency nurses in the West of Scotland and if not managed appropriately, could represent a significant barrier to the mental health of this group and their capacity to provide quality care.
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Moffatt F, Timmons S, Coffey F. ED healthcare professionals and their notions of productivity. Emerg Med J 2016; 33:789-793. [PMID: 27073111 DOI: 10.1136/emermed-2015-205164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 01/07/2016] [Accepted: 03/18/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The combination of constrained resources, patient complexity and rapidly increasing demand has meant that healthcare productivity constitutes a significant problem for emergency medicine. However, healthcare productivity remains a contentious issue, with some criticising the level of professional engagement. This paper will propose that productivity improvements in healthcare could occur (and be sustained) if professionals' perceptions and views of productivity were better understood. METHODS An 8-month ethnographic study was conducted in a large UK ED, using semistructured interviews with healthcare professionals (HCPs) (n=26), a focus group and observation. Thematic analysis of the data was undertaken based on an interpretivist philosophy. RESULTS The data demonstrate that HCPs accept productivity improvement as part of their contemporary professional role. In particular, their understanding of productivity is focused around five key domains: the patient; the professional; the culture; the process of work and the economic. CONCLUSIONS By exploring how these HCPs experienced and made sense of productivity improvement and productive healthcare, the data reveals how HCPs may reconcile a culture of caring with one of efficiency. Understanding healthcare productivity from this perspective has potential implications for service improvement design and performance measurement.
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Affiliation(s)
- Fiona Moffatt
- Division of Physiotherapy Education and Rehabilitation Sciences, The University of Nottingham, Clinical Sciences Building, City Hospital Campus, Nottingham, UK
| | - Stephen Timmons
- Centre for Health Innovation, Leadership and Learning, Nottingham University Business School, Nottingham, UK
| | - Frank Coffey
- Emergency Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Hoyle L, Grant A. Treatment targets in emergency departments: nurses’ views of how they affect clinical practice. J Clin Nurs 2015; 24:2211-8. [DOI: 10.1111/jocn.12835] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Louise Hoyle
- School of Nursing Midwifery and Social Care; Edinburgh Napier University; Edinburgh UK
| | - Aimee Grant
- Institute of Primary Care and Public Health; School of Medicine; Cardiff University; Cardiff UK
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Di Somma S, Paladino L, Vaughan L, Lalle I, Magrini L, Magnanti M. Overcrowding in emergency department: an international issue. Intern Emerg Med 2015; 10:171-5. [PMID: 25446540 DOI: 10.1007/s11739-014-1154-8] [Citation(s) in RCA: 220] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 11/10/2014] [Indexed: 10/24/2022]
Abstract
Overcrowding in the emergency department (ED) has become an increasingly significant worldwide public health problem in the last decade. It is a consequence of simultaneous increasing demand for health care and a deficit in available hospital beds and ED beds, as for example it occurs in mass casualty incidents, but also in other conditions causing a shortage of hospital beds. In Italy in the last 12-15 years, there has been a huge increase in the activity of the ED, and several possible interventions, with specific organizational procedures, have been proposed. In 2004 in the United Kingdom, the rule that 98 % of ED patients should be seen and then admitted or discharged within 4 h of presentation to the ED ('4 h rule') was introduced, and it has been shown to be very effective in decreasing ED crowding, and has led to the development of further acute care clinical indicators. This manuscript represents a synopsis of the lectures on overcrowding problems in the ED of the Third Italian GREAT Network Congress, held in Rome, 15-19 October 2012, and hopefully, they may provide valuable contributions in the understanding of ED crowding solutions.
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Affiliation(s)
- Salvatore Di Somma
- Department of Emergency Medicine, Faculty of Medicine and Psychology, Medical-Surgery Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035-1039, 00189, Rome, Italy,
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Abstract
Few performance management measures create as much heat and debate as the 4-hour target for emergency departments. This article critically reviews the history, evidence and effectiveness of the 4-hour standard for patients attending emergency departments.
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Affiliation(s)
- Adrian Boyle
- Consultant Emergency Physician at the Emergency Department, Addenbrookes Hospital, Cambridge CB2 2QQ and Visiting Senior Research Fellow, Cambridge University
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Crawford K, Morphet J, Jones T, Innes K, Griffiths D, Williams A. Initiatives to reduce overcrowding and access block in Australian emergency departments: A literature review. Collegian 2014; 21:359-66. [DOI: 10.1016/j.colegn.2013.09.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Vezyridis P, Timmons S. National targets, process transformation and local consequences in an NHS emergency department (ED): a qualitative study. BMC Emerg Med 2014; 14:12. [PMID: 24927819 PMCID: PMC4065387 DOI: 10.1186/1471-227x-14-12] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 06/05/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the attempt to reduce waiting times in emergency departments, various national health services have used benchmarking and the optimisation of patient flows. The aim of this study was to examine staff attitudes and experience of providing emergency care following the introduction of a 4 hour wait target, focusing on clinical, organisational and spatial issues. METHODS A qualitative research design was used and semi-structured interviews were conducted with 28 clinical, managerial and administrative staff members working in an inner-city emergency department. A thematic analysis method was employed and NVivo 8 qualitative data analysis software was used to code and manage the emerging themes. RESULTS The wait target came to regulate the individual and collective timescales of healthcare work. It has compartmentalised the previous unitary network of emergency department clinicians and their workspace. It has also speeded up clinical performance and patient throughput. It has disturbed professional hierarchies and facilitated the development of new professional roles. A new clinical information system complemented these reconfigurations by supporting advanced patient tracking, better awareness of time, and continuous, real-time management of emergency department staff. The interviewees had concerns that this target-oriented way of working forces them to have a less personal relationship with their patients. CONCLUSIONS The imposition of a wait-target in response to a perceived "crisis" of patients' dissatisfaction led to the development of a new and sophisticated way of working in the emergency department, but with deep and unintended consequences. We show that there is a dynamic interrelation of the social and the technical in the complex environment of the ED. While the 4 hour wait target raised the profile of the emergency department in the hospital, the added pressure on clinicians has caused some concerns over the future of their relationships with their patients and colleagues. To improve the sustainability of such sudden changes in policy direction, it is important to address clinicians' experience and satisfaction.
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Affiliation(s)
| | - Stephen Timmons
- Faculty of Medicine & Health Sciences, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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Timmons S, Coffey F, Vezyridis P. Implementing lean methods in the Emergency Department. J Health Organ Manag 2014; 28:214-28. [DOI: 10.1108/jhom-10-2012-0203] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Wang Z, Eatock J, McClean S, Liu D, Liu X, Young T. Modeling Throughput of Emergency Departments via Time Series. ACM TRANSACTIONS ON MANAGEMENT INFORMATION SYSTEMS 2013. [DOI: 10.1145/2544105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In this article, the expectation maximization (EM) algorithm is applied for modeling the throughput of emergency departments via available time-series data. The dynamics of emergency department throughput is developed and evaluated, for the first time, as a stochastic dynamic model that consists of the noisy measurement and first-order autoregressive (AR) stochastic dynamic process. By using the EM algorithm, the model parameters, the actual throughput, as well as the noise intensity, can be identified simultaneously. Four real-world time series collected from an emergency department in West London are employed to demonstrate the effectiveness of the introduced algorithm. Several quantitative indices are proposed to evaluate the inferred models. The simulation shows that the identified model fits the data very well.
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Affiliation(s)
| | | | | | - Dongmei Liu
- Nanjing University of Science and Technology, China
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28
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Mitra B, Cameron PA, Archer P, Bailey M, Pielage P, Mele G, Smit DV, Newnham H. The association between time to disposition plan in the emergency department and in-hospital mortality of general medical patients. Intern Med J 2013; 42:444-50. [PMID: 21470357 DOI: 10.1111/j.1445-5994.2011.02502.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND A perceived risk of time-limited emergency department (ED) assessment of patients is inadequate workup leading to inappropriate disposition. The aim of this study was to examine the association of time to disposition plan (TDP) on ED length of stay (LOS) and correlate this to mortality. METHODS A retrospective review of data collected from ED information systems at three hospitals was conducted between June 2008 and October 2009. Included patients were admitted to a general medical unit. Patients were excluded if admitted to intensive care, coronary care, a cardiac monitored bed or required surgery in first 24 h or had an expected LOS of <48 h. Multivariate regression analysis was used to identify independent associations with mortality. RESULTS A total of 10,107 patient episodes was analysed, of which 6768 patients (67.0%) had an ED LOS of ≥8 h. There was significant effect modification by ED LOS in the association of TDP and mortality. In the setting of longer ED LOS, a TDP of <4 h was associated with significantly higher mortality (OR 1.57, 95% CI: 1.28-1.92, P < 0.001), corrected for age, gender and triage category. This association was not significant when ED LOS was <8 h (OR 0.88, 95% CI: 0.60-1.27, P = 0.49). CONCLUSIONS In the setting of prolonged ED LOS, completing ED assessment and management within 4 h of presentation was associated with significantly higher mortality. Further prospective studies are required to understand the relationship between rapid decision making in the ED and patient safety.
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Affiliation(s)
- B Mitra
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.
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Muntlin Athlin Å, von Thiele Schwarz U, Farrohknia N. Effects of multidisciplinary teamwork on lead times and patient flow in the emergency department: a longitudinal interventional cohort study. Scand J Trauma Resusc Emerg Med 2013; 21:76. [PMID: 24180367 PMCID: PMC3843597 DOI: 10.1186/1757-7241-21-76] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 10/27/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long waiting times for emergency care are claimed to be caused by overcrowded emergency departments and non-effective working routines. Teamwork has been suggested as a promising solution to these issues. The aim of the present study was to investigate the effects of teamwork in a Swedish emergency department on lead times and patient flow. METHODS The study was set in an emergency department of a university hospital where teamwork, a multi-professional team responsible for the whole care process for a group of patients, was introduced. The study has a longitudinal non-randomized intervention study design. Data were collected for five two-week periods during a period of 1.5 years. The first part of the data collection used an ABAB design whereby standard procedure (A) was altered weekly with teamwork (B). Then, three follow-ups were conducted. At last follow-up, teamwork was permanently implemented. The outcome measures were: number of patients handled within teamwork time, time to physician, total visit time and number of patients handled within the 4-hour target. RESULTS A total of 1,838 patient visits were studied. The effect on lead times was only evident at the last follow-up. Findings showed that the number of patients handled within teamwork time was almost equal between the different study periods. At the last follow-up, the median time to physician was significantly decreased by 11 minutes (p = 0.0005) compared to the control phase and the total visit time was significantly shorter at last follow-up compared to control phase (p = <0.0001; 39 minutes shorter on average). Finally, the 4-hour target was met in 71% in the last follow-up compared to 59% in the control phase (p = 0.0005). CONCLUSIONS Teamwork seems to contribute to the quality improvement of emergency care in terms of small but significant decreases in lead times. However, although efficient work processes such as teamwork are necessary to ensure safe patient care, it is likely not sufficient for bringing about larger decreases in lead times or for meeting the 4-hour target in the emergency department.
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Affiliation(s)
- Åsa Muntlin Athlin
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, 751 85 Uppsala, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Box 564, 751 22 Uppsala, Sweden
- Department of Emergency Care, Uppsala University Hospital, 751 85 Uppsala, Sweden
- School of Nursing, University of, SA 5005 Adelaide, Australia
| | - Ulrica von Thiele Schwarz
- Department of Psychology, Stockholm University, 106 91 Stockholm, Sweden
- Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Medical Management Centre (MMC), 171 77 Stockholm, Sweden
| | - Nasim Farrohknia
- Head of Emergency Department, Södersjukhuset, Södersjukhuset AB, Sjukhusbacken 10, 118 83 Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, SE-171 77 Stockholm, Sweden
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Day A, Oldroyd C. Attempting to reduce the maximum emergency waiting time to 4 hours in England: was the initiative successful? J Emerg Nurs 2012; 38:383-5. [PMID: 22682608 DOI: 10.1016/j.jen.2012.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Alison Day
- Faculty of Health & Life Sciences, Coventry University, CV1 5FB, Coventry, England.
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Jones P, Chalmers L, Wells S, Ameratunga S, Carswell P, Ashton T, Curtis E, Reid P, Stewart J, Harper A, Tenbensel T. Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol. BMC Health Serv Res 2012; 12:45. [PMID: 22353694 PMCID: PMC3311075 DOI: 10.1186/1472-6963-12-45] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 02/21/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts? METHODS/DESIGN The study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study. DISCUSSION At the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.
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Affiliation(s)
- Peter Jones
- Adult Emergency Department, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
- Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Linda Chalmers
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Susan Wells
- Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Shanthi Ameratunga
- Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Peter Carswell
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Toni Ashton
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Elana Curtis
- Te Kupenga Hauora Māori, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Papaarangi Reid
- Te Kupenga Hauora Māori, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Joanna Stewart
- Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Alana Harper
- Adult Emergency Department, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
| | - Tim Tenbensel
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Hoskins R. Interprofessional working or role substitution? A discussion of the emerging roles in emergency care. J Adv Nurs 2011; 68:1894-903. [PMID: 22070643 DOI: 10.1111/j.1365-2648.2011.05867.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS This article presents a discussion of emerging non-medical roles in emergency care against the current policy context and the issues of role substitution and interprofessional working. BACKGROUND Non-medical roles in emergency care have grown internationally in response to an increasing demand for emergency care services and to address the growing importance of the quality healthcare agenda. The blurring of role boundaries between professional groups has become more common. Data sources. Searches were made of three electronic databases; CINAHL, Medline and EMBASE. The literature relating to interprofessional healthcare roles, and new roles in emergency care was searched from 1980 to 2010 and underpinned the discussion. DISCUSSION A theoretical framework that has emerged from the literature is that task, role substitution and interprofessional working lie on a spectrum and evolving non-medical roles can be plotted on the spectrum, usually starting at one end of the spectrum under task substitution and then potentially moving in time towards true interprofessional working. CONCLUSIONS There is still a great deal of progress to be made until non-medical roles in emergency care can truly be encompassed under the umbrella of interprofessional working and that a more robust critical mass of evidence is required to substantiate the theory that interprofessional working within teams contributes to effective, cost-effective care and better patient outcomes. RELEVANCE TO CLINICAL PRACTICE It is essential to understand the underlying motivation, policy context and key drivers for the development of new nursing and non-medical roles. This allows services to be established successfully, by understanding and addressing the key predicable barriers to implementation and change.
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Affiliation(s)
- Rebecca Hoskins
- Emergency Department, Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, UK.
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Abstract
Background: Emergency Department (ED) overcrowding is an important healthcare issue facing increasing public and regulatory scrutiny in Canada and around the world. Many approaches to alleviate excessive waiting times and lengths of stay have been studied. In theory, optimal ED patient flow may be assisted via balancing patient loads between EDs (in essence spreading patients more evenly throughout this system). This investigation utilizes simulation to explore “Crowdinforming” as a basis for a process control strategy aimed to balance patient loads between six EDs within a mid-sized Canadian city. Methods: Anonymous patient visit data comprising 120,000 ED patient visits over six months to six ED facilities were obtained from the region’s Emergency Department Information System (EDIS) to (1) determine trends in ED visits and interactions between parameters; (2) to develop a process control strategy integrating crowdinforming; and, (3) apply and evaluate the model in a simulated environment to explore the potential impact on patient self-redirection and load balancing between EDs. Results: As in reality, the data available and subsequent model demonstrated that there are many factors that impact ED patient flow. Initial results suggest that for this particular data set used, ED arrival rates were the most useful metric for ED ‘busyness’ in a process control strategy, and that Emergency Department performance may benefit from load balancing efforts. Conclusions: The simulation supports the use of crowdinforming as a potential tool when used in a process control strategy to balance the patient loads between EDs. The work also revealed that the value of several parameters intuitively expected to be meaningful metrics of ED ‘busyness’ was not evident, highlighting the importance of finding parameters meaningful within one’s particular data set. The information provided in the crowdinforming model is already available in a local context at some ED sites. The extension to a wider dissemination of information via an Internet web service accessible by smart phones is readily achievable and not a technological obstacle. Similarly, the system could be extended to help direct patients by including future estimates or predictions in the crowdinformed data. The contribution of the simulation is to allow for effective policy evaluation to better inform the public of ED ‘busyness’ as part of their decision making process in attending an emergency department. In effect, this is a means of providing additional decision support insights garnered from a simulation, prior to a real world implementation.
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Emptying the Corridors of Shame: Organizational Lessons From England's 4-Hour Emergency Throughput Target. Ann Emerg Med 2011; 57:79-88.e1. [DOI: 10.1016/j.annemergmed.2010.08.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 07/24/2010] [Accepted: 08/06/2010] [Indexed: 11/21/2022]
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Jones P, Schimanski K. The four hour target to reduce emergency department ‘waiting time’: A systematic review of clinical outcomes. Emerg Med Australas 2010; 22:391-8. [DOI: 10.1111/j.1742-6723.2010.01330.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Horwitz LI, Green J, Bradley EH. US emergency department performance on wait time and length of visit. Ann Emerg Med 2010; 55:133-41. [PMID: 19796844 PMCID: PMC2830619 DOI: 10.1016/j.annemergmed.2009.07.023] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 07/10/2009] [Accepted: 07/22/2009] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE Prolonged emergency department (ED) wait time and length of visit reduce quality of care and increase adverse events. Previous studies have not examined hospital-level performance on ED wait time and visit length in the United States. The purpose of this study is to describe hospital-level performance on ED wait time and visit length. METHODS We conducted a retrospective cross-sectional study of a stratified random sampling of 35,849 patient visits to 364 nonfederal US hospital EDs in 2006, weighted to represent 119,191,528 visits to 4,654 EDs. Measures included EDs' median wait times and visit lengths, EDs' median proportion of patients treated by a physician within the time recommended at triage, and EDs' median proportion of patients dispositioned within 4 or 6 hours. RESULTS In the median ED, 78% (interquartile range [IQR], 63% to 90%) of all patients and 67% (IQR, 52% to 82%) of patients who were triaged to be treated within 1 hour were treated by a physician within the target triage time. A total of 31% of EDs achieved the triage target for more than 90% of their patients; 14% of EDs achieved the triage target for 90% or more of patients triaged to be treated within an hour. In the median ED, 76% (IQR 54% to 94%) of patients were admitted within 6 hours. A total of 48% of EDs admitted more than 90% of their patients within 6 hours, but only 25% of EDs admitted more than 90% of their patients within 4 hours. CONCLUSION A minority of hospitals consistently achieved recommended wait times for all ED patients, and fewer than half of hospitals consistently admitted their ED patients within 6 hours.
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Affiliation(s)
- Leora I Horwitz
- Center for Outcomes Research and Evaluation, Section of General Internal Medicine, Yale-New Haven Hospital, New Haven, CT 06520, USA.
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Muntlin ÅMY, Gunningberg LAC, Carlsson MA. Different patient groups request different emergency care – A survey in a Swedish emergency department. Int Emerg Nurs 2008; 16:223-32. [DOI: 10.1016/j.ienj.2008.07.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Revised: 07/12/2008] [Accepted: 07/16/2008] [Indexed: 10/21/2022]
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Banerjee A, Mbamalu D, Hinchley G. The impact of process re-engineering on patient throughput in emergency departments in the UK. Int J Emerg Med 2008; 1:189-92. [PMID: 19384514 PMCID: PMC2657273 DOI: 10.1007/s12245-008-0055-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Accepted: 07/21/2008] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The re-engineering of emergency department (ED) processes in the UK since 2002 has produced significant reductions in waiting times. AIMS We aim to describe the generic themes contributory to this improvement in performance, which has led to progress not yet replicated elsewhere in the English-speaking world. METHODS We reviewed the Emergency Services Collaborative (ESC) set up by the National Health Service (NHS) Modernisation Agency as well as our own departmental performance in order to identify key themes for discussion. In addition, we reviewed relevant information from the UK Department of Health website. We used the 4-h target of patient passage through the ED as our primary outcome measure. RESULTS Early results from the ESC showed improvements, which have been sustained and enhanced since inception. We use our hospital performance figures to demonstrate a pattern of progressive improvement in performance, with 99.1% of all new attenders in 2007-2008 being seen, treated and discharged or admitted within 4 h of presentation to the ED. CONCLUSIONS The whole systems approach to re-engineering emergency care has led to universal improvements in patient throughput in EDs in the UK. Several of the concepts found to be useful in the NHS are worthy of consideration and adoption by other health care systems. Long waits in the ED are a thing of the past in the UK.
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Affiliation(s)
- Ashis Banerjee
- Department of Emergency Medicine, Chase Farm Hospital, The Ridgeway, Enfield, North London, UK.
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