Door-to-Imaging Time for Acute Stroke Patients Is Adversely Affected by Emergency Department Crowding

The Capacitated Maximal Covering Location Problem Improves Access to Stroke Treatment: A Cross-Sectional Simulation Study

Disparities in accessing advanced stroke treatment have been recognized as a policy challenge in multiple countries, including Japan, necessitating priority solutions. Nevertheless, more practical healthcare policies must be implemented due to the limited availability of healthcare staff and financial resources in most nations. This study aimed to evaluate the supply and demand balance of mechanical thrombectomy (MT) and identify areas with high priority for enhancing stroke centers. The target area of this study was Hokkaido, Japan. We adopted the capacitated maximal covering location problem (CMCLP) to propose an optimal allocation without increasing the number of medical facilities. Four realistic scenarios with varying levels of total MT supply capacity for Primary stroke centers and assuming a range of 90 minutes by car from the center were created and simulated. From scenarios 1 to 4, the coverage increased by approximately 53% to 85%, scenarios 2 and 3 had 5% oversupply, and scenario 4 had an oversupply of approximately 20%. When the supply capacity cap was eliminated and 8 PSCs received 31 or more patients, they became priority enhancement targets. The CMCLP estimates demand coverage considering the supply and demand balance and indicates areas and facilities where MT supply capacity enhancement is a priority.

Factors Associated With Head and Neck Polytrauma Presentation and Admissions at Emergency Departments of Varying Sizes

Timely diagnosis of acute head and neck polytrauma presenting to emergency departments (EDs) optimizes outcomes. Since ED capacity influences triage and admission, the authors utilized the National Electronic Injury Surveillance System database to understand how ED size and trauma characteristics affect head and neck polytrauma presentation and admissions. Demographics and injury characteristics from the National Electronic Injury Surveillance System database from 2018 to 2021 were analyzed to delineate factors contributing to polytrauma presence and admission through multivariable logistic regressions. The authors' 207,951-patient cohort was primarily females (48.6%), non-Hispanic (62.4%), and white (51.4%) people who averaged 57.2 years old. Nonspecific head injuries were predominant (59.7%), followed by facial trauma (22.6%) with rare substance involvement (alcohol, 6.3%; drugs, 4.1%) presenting to high-volume EDs (48.5%). Of the patients, 20% were admitted, whereas 31.1% sustained polytrauma. Substance use [alcohol, odds ratio (OR) = 4.44; drugs, OR = 2.90] increased polytrauma likelihood; neck (OR = 1.35), face (OR = 1.14), and eye (OR = 1.26) associated with polytrauma more than head injuries. Burns (OR = 1.38) increased polytrauma likelihood more than internal organ injuries. Black patients sustained higher polytrauma when presented to non-small EDs (OR = 1.41-1.90) than white patients showed to small EDs. Admissions were higher for males (OR = 1.51). Relative to small EDs, large EDs demonstrated a higher increase in admissions (OR = 2.42). Neck traumas were more likely admitted than head traumas (OR = 1.71). Fractures (OR = 2.21) and burns (OR = 2.71) demonstrated an increased admission likelihood than internal organ injuries. Polytrauma presence and admissions likelihood are site, injury, and substance dependent. Understanding the impact of factors influencing polytrauma presence or admission will enhance triage to optimize outcomes.

Neurocritical Care for Patients With Ischemic Stroke

OBJECTIVE

Management of stroke due to large vessel occlusion (LVO) has undergone unprecedented change in the past decade. Effective treatment with thrombectomy has galvanized the field and led to advancements in all aspects of care. This article provides a comprehensive examination of neurologic intensive care unit (ICU) management of patients with stroke due to LVO. The role of the neurocritical care team in stroke systems of care and the importance of prompt diagnosis, initiation of treatment, and continued monitoring of patients with stroke due to LVO is highlighted.

LATEST DEVELOPMENTS

The management of complications commonly associated with stroke due to LVO, including malignant cerebral edema and respiratory failure, are addressed, stressing the importance of early identification and aggressive treatment in mitigating negative effects on patients' prognoses. In the realm of medical management, this article discusses various medical therapies, including antithrombotic therapy, blood pressure management, and glucose control, outlining evidence-based strategies for optimizing patient outcomes. It further emphasizes the importance of a multidisciplinary approach to provide a comprehensive care model. Lastly, the critical aspect of family communication and prognostication in the neurologic ICU is addressed.

ESSENTIAL POINTS

This article emphasizes the multidimensional aspects of neurocritical care in treating patients with stroke due to LVO.

Influencing factors on the time to CT in suspected pulmonary embolism: an explorative investigation

Pulmonary embolism is a potentially fatal condition with increased mortality if anticoagulation is delayed. This study aimed to find influencing factors on the duration from requesting a computed tomography (CT) pulmonary angiography (CTPA) to performing a CTPA in suspected acute pulmonary embolism. In 1849 cases, automatically generated time data were extracted from the radiological information system. The impact of the distance to the scanner, case-related features (sector of patient care, triage), and workload (demand for CTs, performed CTs, available staff, hospital occupancy) were investigated retrospectively using multiple regression. The time to CTPA was shorter in cases from the emergency room (ER) than in inpatients and outpatients at distances below 160 m and 240 m, respectively. While requests from the ER were also performed faster than cases from regular wards (< 180 m), no difference was found between the ER and intensive care units. Compared to "not urgent" cases, the workflow was shorter in "urgent" (- 17%) and "life-threatening" (- 67%) situations. The process was prolonged with increasing demand (+ 5%/10 CTs). The presented analysis identified relevant in-hospital influences on the CTPA workflow, including the distance to the CT together with the sector of patient care, the case triage, and the demand for imaging.

An Effective Methodology for Scoring to Assist Emergency Physicians in Identifying Overcrowding in an Academic Emergency Department in Thailand

BACKGROUND

Emergency Department (ED) overcrowding is a global concern, with tools like NEDOCS, READI, and Work Score used as predictors. These tools aid healthcare professionals in identifying overcrowding and preventing negative patient outcomes. However, there's no agreed-upon method to define ED overcrowding. Most studies on this topic are U.S.-based, limiting their applicability in EDs without waiting rooms or ambulance diversion roles. Additionally, the intricate calculations required for these scores, with multiple variables, make them impractical for use in developing nations.

OBJECTIVE

This study sought to examine the relationship between prevalent ED overcrowding scores such as EDWIN, occupancy rate, and Work Score, and a modified version of EDWIN newly introduced by the authors, in comparison to the real-time perspectives of emergency physicians. Additionally, the study explored the links between these overcrowding scores and adverse events related to ED code activations as secondary outcomes.

METHOD

The method described in the provided text is a correlational study. The study aims to examine the relationship between various Emergency Department (ED) overcrowding scores and the real-time perceptions of emergency physicians in every two-hour period. Additionally, it seeks to explore the associations between these scores and adverse events related to ED code activations.

RESULTS

The study analyzed 459 periods, with 5.2% having Likert scores of 5-6. EDOR had the highest correlation coefficient (0.69, p < 0.001) and an AUC of 0.864. Only EDOR significantly correlated with adverse events (p = 0.033).

CONCLUSION

EDOR shows the most robust link with 'emergency physicians' views on overcrowding. Additionally, elevated EDOR scores correlate with a rise in adverse events. Emergency physicians' perceptionof overcrowding could hint at possible adverse events. Notably, all overcrowding scores have high negative predictive values, efficiently negating the likelihood of adverse incidents.

Direct oral anticoagulants or vitamin K antagonists in emergencies: comparison of management in an observational study

Background

Restoring hemostasis in patients on oral anticoagulants presenting with major hemorrhage (MH) or before surgical intervention has changed, with the replacement of vitamin K antagonist (VKA) with direct oral anticoagulants (DOACs).

Objectives

To observe the difference in urgent hemostatic management between patients on VKA and those on DOACs.

Methods

A multicenter observational study evaluated the variation in laboratory testing, hemostatic management, mortality, and hospital length of stay (LOS) in patients on VKA or DOACs presenting with MH or urgent hemostatic restoration.

Results

Of the 1194 patients analyzed, 783 had MH (61% VKA) and 411 required urgent hemostatic restoration before surgery (56% VKA). Compared to the international normalized ratio (97.6%), plasma DOAC levels were measured less frequently (<45%), and the time taken from admission for the coagulation sample to reach the laboratory varied widely (median, 52.3 minutes; IQR, 24.8-206.7). No significant plasma DOAC level (<50 ng/mL) was found in up to 19% of patients. There was a poor relationship between plasma DOAC level and the usage of a hemostatic agent. When compared with patients receiving VKA (96.5%) or dabigatran (93.7%), fewer patients prescribed a factor Xa inhibitor (75.5%) received a prohemostatic reversal agent. The overall 30-day mortality for MH (mean: 17.8%) and length of stay (LOS) (median: 8.7 days) was similar between VKA and DOAC patients.

Conclusion

In DOAC patients, when compared to those receiving VKA, plasma DOAC levels were measured less frequently than the international normalized ratio and had a poor relationship with administering a hemostatic reversal agent. In addition, following MH, mortality and LOS were similar between VKA and DOAC patients.

The quality disparity of stroke care over time: An analysis based on the national dataset from 2011 to 2017

BACKGROUND

Adherence to evidence-based hospital stroke care is variable and may change over time. It is important to determine which process measures are associated with variation in outcome. In a large dataset, we analyzed the association between process and outcome and the fluctuations of indicators over time, and identified quality indicators (QIs) that should be prioritized for improving the quality of stroke care.

METHODS

We analyzed data from 123,259 patients diagnosed with acute ischemic stroke (AIS) who were treated at 109 large tertiary hospitals in China between January 2011 and May 2017. In total, 12 stroke treatment indicators were selected to calculate the hospital process composite performance (HPCP). Hospitals were divided into subgroups according to the time trend of HPCP estimated by the Group-Based Model. We analyzed the influence of hospital subgroups on the patient outcomes using a multi-level model and explored the QIs that led to variation.

RESULTS

The HPCP trends for stroke indicators of 109 hospitals over 7 years were divided into two groups (Group 1, low-HPCP; Group 2, high-HPCP). After adjusting for patient age, medical insurance, comorbidities, patterns of admission, and NIHSS-scores, patients in the high-HPCP group presented higher rate of independence and longer length of stay compared to the low-HPCP group. The multi-level model showed that there was a statistically significant difference in the utilization rate between the two groups, with most marked differences seen in emergency assessment and function evaluation indicators.

CONCLUSION

Variation in the quality of stroke care exists across hospitals, and better adherence to guideline-based care is associated with improved outcomes. We found that QIs related to emergency examination and functional assessment were the main factors differing between good and poor adherers to stroke indicators, suggesting that quality improvement in stroke care could prioritize these QIs.

A Novel Multidisciplinary Team Activation for Patients with Severe Gastrointestinal Bleeding: Creation of the Code GI Bleed Protocol

Patients with gastrointestinal (GI) bleeding present to the emergency department (ED) with a wide spectrum of illness severity. Among the most critically ill patients, comorbidities and other risk factors, such as liver disease and anticoagulation, can complicate their management. These patients are resource-intensive to stabilize and resuscitate, often requiring the continuous attention of multiple ED staff members along with rapid mobilization of specialty care. At a tertiary care hospital with the ability to provide definitive care for the most critically ill patients with GI bleeding, we introduced a multi-disciplinary team activation pathway to bring together specialists to immediately respond to the ED. We designed a Code GI Bleed pathway to expedite hemodynamic stabilization, diagnostics, source control, and timely disposition out of the ED to the intensive care unit or relevant procedural area of the hospital.

Team is brain: leveraging EHR audit log data for new insights into acute care processes

OBJECTIVE

To determine whether novel measures of contextual factors from multi-site electronic health record (EHR) audit log data can explain variation in clinical process outcomes.

MATERIALS AND METHODS

We selected one widely-used process outcome: emergency department (ED)-based team time to deliver tissue plasminogen activator (tPA) to patients with acute ischemic stroke (AIS). We evaluated Epic audit log data (that tracks EHR user-interactions) for 3052 AIS patients aged 18+ who received tPA after presenting to an ED at three Northern California health systems (Stanford Health Care, UCSF Health, and Kaiser Permanente Northern California). Our primary outcome was door-to-needle time (DNT) and we assessed bivariate and multivariate relationships with six audit log-derived measures of treatment team busyness and prior team experience.

RESULTS

Prior team experience was consistently associated with shorter DNT; teams with greater prior experience specifically on AIS cases had shorter DNT (minutes) across all sites: (Site 1: -94.73, 95% CI: -129.53 to 59.92; Site 2: -80.93, 95% CI: -130.43 to 31.43; Site 3: -42.95, 95% CI: -62.73 to 23.17). Teams with greater prior experience across all types of cases also had shorter DNT at two sites: (Site 1: -6.96, 95% CI: -14.56 to 0.65; Site 2: -19.16, 95% CI: -36.15 to 2.16; Site 3: -11.07, 95% CI: -17.39 to 4.74). Team busyness was not consistently associated with DNT across study sites.

CONCLUSIONS

EHR audit log data offers a novel, scalable approach to measure key contextual factors relevant to clinical process outcomes across multiple sites. Audit log-based measures of team experience were associated with better process outcomes for AIS care, suggesting opportunities to study underlying mechanisms and improve care through deliberate training, team-building, and scheduling to maximize team experience.

Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review

BACKGROUND

After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS.

METHODOLOGY

Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

RESULTS

A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART.

CONCLUSIONS

Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.

Advancement of door-to-needle times in acute stroke treatment after repetitive process analysis: never give up!

Background:

In acute ischemic stroke, timely treatment is of utmost relevance. Identification of delaying factors and knowledge about challenges concerning hospital structures are crucial for continuous improvement of process times in stroke care.

Objective:

In this study, we report on our experience in optimizing the door-to-needle time (DNT) at our tertiary care center by continuous quality improvement.

Methods:

Five hundred forty patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) at Hannover Medical School were consecutively analyzed in two phases. In study phase I, including 292 patients, process times and delaying factors were collected prospectively from May 2015 until September 2017. In study phase II, process times of 248 patients were obtained from January 2019 until February 2021. In each study phase, a new clinical standard operation procedure (SOP) was implemented, considering previously identified delaying factors. Pre- and post-SOP treatment times and delaying factors were analyzed to evaluate the new protocols.

Results:

In study phase I, SOP I reduced the median DNT by 15 min. The probability to receive treatment within 30 min after admission increased by factor 5.35 [95% confidence interval (CI): 2.46–11.66]. Further development of the SOP with implementation of a mobile thrombolysis kit led to a further decrease of DNT by 5 min in median in study phase II. The median DNT was 29 (25th–75th percentiles: 18–44) min, and the probability to undergo IVT within 15 min after admission increased by factor 4.2 (95% CI: 1.63–10.83) compared with study phase I.

Conclusion:

Continuous process analysis and subsequent development of targeted workflow adjustments led to a substantial improvement of DNT. These results illustrate that with appropriate vigilance, there is constantly an opportunity for improvement in stroke care.

Reducing Crowding in Emergency Departments With Early Prediction of Hospital Admission of Adult Patients Using Biomarkers Collected at Triage: Retrospective Cohort Study

BACKGROUND

Emergency department crowding continues to threaten patient safety and cause poor patient outcomes. Prior models designed to predict hospital admission have had biases. Predictive models that successfully estimate the probability of patient hospital admission would be useful in reducing or preventing emergency department "boarding" and hospital "exit block" and would reduce emergency department crowding by initiating earlier hospital admission and avoiding protracted bed procurement processes.

OBJECTIVE

To develop a model to predict imminent adult patient hospital admission from the emergency department early in the patient visit by utilizing existing clinical descriptors (ie, patient biomarkers) that are routinely collected at triage and captured in the hospital's electronic medical records. Biomarkers are advantageous for modeling due to their early and routine collection at triage; instantaneous availability; standardized definition, measurement, and interpretation; and their freedom from the confines of patient histories (ie, they are not affected by inaccurate patient reports on medical history, unavailable reports, or delayed report retrieval).

METHODS

This retrospective cohort study evaluated 1 year of consecutive data events among adult patients admitted to the emergency department and developed an algorithm that predicted which patients would require imminent hospital admission. Eight predictor variables were evaluated for their roles in the outcome of the patient emergency department visit. Logistic regression was used to model the study data.

RESULTS

The 8-predictor model included the following biomarkers: age, systolic blood pressure, diastolic blood pressure, heart rate, respiration rate, temperature, gender, and acuity level. The model used these biomarkers to identify emergency department patients who required hospital admission. Our model performed well, with good agreement between observed and predicted admissions, indicating a well-fitting and well-calibrated model that showed good ability to discriminate between patients who would and would not be admitted.

CONCLUSIONS

This prediction model based on primary data identified emergency department patients with an increased risk of hospital admission. This actionable information can be used to improve patient care and hospital operations, especially by reducing emergency department crowding by looking ahead to predict which patients are likely to be admitted following triage, thereby providing needed information to initiate the complex admission and bed assignment processes much earlier in the care continuum.

Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States

Importance

Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant.

Objective

To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities.

Design, Setting, and Participants

This study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022.

Main Outcomes and Measures

Hospitals' likelihood of adopting stroke care certification.

Results

A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51).

Conclusions and Relevance

In this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.

Waiting for Care: Length of Stay for ED Mental Health Patients by Disposition, Diagnosis, and Region (2009–2015)

Objective

Emergency departments (EDs) face increasing mental health visits on a backdrop of insufficient mental health resources. We study ED length of stay (LOS) and disposition by 1) mental health vs. medical visits; 2) psychiatric vs. substance use visits; and 3) the four regions of the United States. 

Methods

We used weighted data from the National Hospital Ambulatory Medical Care Survey (2009-2015). Visits by patients ages 18-64 were categorized into mental health and medical groups. The mental health group was then subdivided into psychiatric, substance use, and co-occurring disorders. The LOS was compared by disposition. Mental health vs. medical LOS and disposition were examined across four regions of the US.

Results

An estimated 28 million mental health and 526 million medical visits were included in the study. Mental health visits had a median (interquartile range [IQR]) of 3.7 (4.7) hours while medical visits had a median (IQR) of 2.6 (2.7) hours. Mental health compared to medical visits were more likely to result in admission or transfer and to last >6 and >12 hours. Mental health visits resulting in transfer had the longest LOS with a median (IQR) of 6.23 (7.7) hours. Of mental health visit types, co-occurring disorders visits were more likely to be >6 and >12 hours regardless of disposition. Across US regions, there was significant variation in disposition patterns for mental health vs. medical visits. The odds of mental health visits lasting >6 and >12 hours were greatest in the Northeast and the least in the South with a median (IQR) of 4.6 (5.8) hours and 3.3 (4.0) hours, respectively.

Conclusions

Metal health compared to medical visits had longer LOS, especially when the patient had co-occurring disorders or required transfer. Regionally, there is a large variation in disposition for mental health vs. medical visits. This study makes it clear that there are no standards for managing psychiatric emergencies.

Effect of resident complement on timeliness of stroke team activation in an academic emergency department

OBJECTIVES

Investigations of the impact of residents on emergency department (ED) timeliness of care typically focus only on global ED flow metrics. We sought to describe the association between resident complement/supervisory ratios and timeliness of ED care of a specific time-sensitive condition, acute stroke.

METHODS

We matched ED stroke patient arrivals at 1 academic stroke center against resident and attending staffing and constructed a Cox proportional hazards model of door-to-activation (DTA) time (ie, ED arrival ["door"] to stroke team activation). We considered multiple predictors, including calculated ratios of residents supervised by each attending physician.

RESULTS

Among 462 stroke activation patients in 2014-2015, DTA ranged from 1 to 217 minutes, 72% within 15 minutes. The median number of emergency and off-service residents supervised per attending were 1.7 (interquartile range [IQR], 1.3-2.3) and 0.7 (IQR, 0-1), respectively. A 1-resident increase in off-service residents was associated with a 24% decrease (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.64-0.90) in the probability of stroke team activation at any given time. An independent 1-resident increase in the number of emergency residents was associated with a 13% increase (HR, 1.13; 95% CI, 1.01-1.25) in timely activation.

CONCLUSION

Timeliness of care for acute stroke may be impacted by how academic EDs configure the complement and supervisory structures of residents. Higher supervisory demands imposed by increasing the proportion of rotating off-service residents may be associated with slower stroke recognition and DTA times, but this effect may be offset when more emergency residents are present.

Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List

Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.

Models Predicting Hospital Admission of Adult Patients Utilizing Prehospital Data: Systematic Review Using PROBAST and CHARMS

Background

Emergency department boarding and hospital exit block are primary causes of emergency department crowding and have been conclusively associated with poor patient outcomes and major threats to patient safety. Boarding occurs when a patient is delayed or blocked from transitioning out of the emergency department because of dysfunctional transition or bed assignment processes. Predictive models for estimating the probability of an occurrence of this type could be useful in reducing or preventing emergency department boarding and hospital exit block, to reduce emergency department crowding.

Objective

The aim of this study was to identify and appraise the predictive performance, predictor utility, model application, and model utility of hospital admission prediction models that utilized prehospital, adult patient data and aimed to address emergency department crowding.

Methods

We searched multiple databases for studies, from inception to September 30, 2019, that evaluated models predicting adult patients’ imminent hospital admission, with prehospital patient data and regression analysis. We used PROBAST (Prediction Model Risk of Bias Assessment Tool) and CHARMS (Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies) to critically assess studies.

Results

Potential biases were found in most studies, which suggested that each model’s predictive performance required further investigation. We found that select prehospital patient data contribute to the identification of patients requiring hospital admission. Biomarker predictors may add superior value and advantages to models. It is, however, important to note that no models had been integrated with an information system or workflow, operated independently as electronic devices, or operated in real time within the care environment. Several models could be used at the site-of-care in real time without digital devices, which would make them suitable for low-technology or no-electricity environments.

Conclusions

There is incredible potential for prehospital admission prediction models to improve patient care and hospital operations. Patient data can be utilized to act as predictors and as data-driven, actionable tools to identify patients likely to require imminent hospital admission and reduce patient boarding and crowding in emergency departments. Prediction models can be used to justify earlier patient admission and care, to lower morbidity and mortality, and models that utilize biomarker predictors offer additional advantages.

A systematic review of next-generation point-of-care stroke diagnostic technologies

OBJECTIVE

Stroke is a leading cause of morbidity and mortality. Current diagnostic modalities include CT and MRI. Over the last decade, novel technologies to facilitate stroke diagnosis, with the hope of shortening time to treatment and reducing rates of morbidity and mortality, have been developed. The authors conducted a systematic review to identify studies reporting on next-generation point-of-care stroke diagnostic technologies described within the last decade.

METHODS

A systematic review was performed according to PRISMA guidelines to identify studies reporting noninvasive stroke diagnostics. The QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool was utilized to assess risk of bias. PubMed, Web of Science, and Scopus databases were utilized. Primary outcomes assessed included accuracy and timing compared with standard imaging, potential risks or complications, potential limitations, cost of the technology, size/portability, and range/size of detection.

RESULTS

Of the 2646 reviewed articles, 19 studies met the inclusion criteria and included the following modalities of noninvasive stoke detection: microwave technology (6 studies, 31.6%), electroencephalography (EEG; 4 studies, 21.1%), ultrasonography (3 studies, 15.8%), near-infrared spectroscopy (NIRS; 2 studies, 10.5%), portable MRI devices (2 studies, 10.5%), volumetric impedance phase-shift spectroscopy (VIPS; 1 study, 5.3%), and eddy current damping (1 study, 5.3%). Notable medical devices that accurately predicted stroke in this review were EEG-based diagnosis, with a maximum sensitivity of 91.7% for predicting a stroke, microwave-based diagnosis, with an area under the receiver operating characteristic curve (AUC) of 0.88 for differentiating ischemic stroke and intracerebral hemorrhage (ICH), ultrasound with an AUC of 0.92, VIPS with an AUC of 0.93, and portable MRI with a diagnostic accuracy similar to that of traditional MRI. NIRS offers significant potential for more superficially located hemorrhage but is limited in detecting deep-seated ICH (2.5-cm scanning depth).

CONCLUSIONS

As technology and computational resources have advanced, several novel point-of-care medical devices show promise in facilitating rapid stroke diagnosis, with the potential for improving time to treatment and informing prehospital stroke triage.

CTA Protocols in a Telestroke Network Improve Efficiency for Both Spoke and Hub Hospitals

BACKGROUND AND PURPOSE

Telestroke networks support screening for patients with emergent large-vessel occlusions who are eligible for endovascular thrombectomy. Ideal triage processes within telestroke networks remain uncertain. We characterize the impact of implementing a routine spoke hospital CTA protocol in our integrated telestroke network on transfer and thrombectomy patterns.

MATERIALS AND METHODS

A protocol-driven CTA process was introduced at 22 spoke hospitals in November 2017. We retrospectively identified prospectively collected patients who presented to a spoke hospital with National Institutes of Health Stroke Scale scores ≥6 between March 1, 2016 and March 1, 2017 (pre-CTA), and March 1, 2018 and March 1, 2019 (post-CTA). We describe the demographics, CTA utilization, spoke hospital retention rates, emergent large-vessel occlusion identification, and rates of endovascular thrombectomy.

RESULTS

There were 167 patients pre-CTA and 207 post-CTA. The rate of CTA at spoke hospitals increased from 15% to 70% (P < .001). Despite increased endovascular thrombectomy screening in the extended window, the overall rates of transfer out of spoke hospitals remained similar (56% versus 54%; P = .83). There was a nonsignificant increase in transfers to our hub hospital for endovascular thrombectomy (26% versus 35%; P = .12), but patients transferred >4.5 hours from last known well increased nearly 5-fold (7% versus 34%; P < .001). The rate of endovascular thrombectomy performed on patients transferred for possible endovascular thrombectomy more than doubled (22% versus 47%; P = .011).

CONCLUSIONS

Implementation of CTA at spoke hospitals in our telestroke network was feasible and improved the efficiency of stroke triage. Rates of patients retained at spoke hospitals remained stable despite higher numbers of patients screened. Emergent large-vessel occlusion confirmation at the spoke hospital lead to a more than 2-fold increase in thrombectomy rates among transferred patients at the hub.

Team triage increases discharges and decreases time to discharge without increasing test ordering

OBJECTIVES

Emergency department (ED) crowding is detrimental to patients and staff. During traditional triage, nurses evaluate patients and identify their level of emergency. During team triage, physicians and/or nurse practitioners (NPs) and physician assistants (PAs) place orders, laboratory results, intravenous lines (IVs), and imaging in triage. Team triage improves access to testing and decreases length of stay. However, ordering practices in team triage may lead to overtesting.

METHODS

This is a retrospective review of patients seen before and after a team triage process was established. Percentage of patients receiving testing and the diagnostic yields of troponins, lactates, international normalized ratios (INRs), blood cultures, glomerular filtration rates (GFR), and head computed tomography (CT) images were studied.

RESULTS

A total of 704 traditionally triaged patients and 862 team triaged patients met inclusion criteria. Comparing traditional versus team triaged patients, the proportion of patients discharged was 0.44 versus 0.53 (P < 0.001), and the length of stay to discharge was 417 versus 375 minutes (P = 0.003). Comparing traditional versus team triage, a head CT was obtained 12.5% versus 5.7% (P < 0.001) of the time with diagnostic yield 45.5% versus 52% (not significant), troponin was obtained 51.3% versus 45.9% (not significant) of the time with diagnostic yield 14.9% versus 13.9% (not significant), lactate was obtained 41.6% versus 32.1% (P = 0.011) of the time with diagnostic yield 18.4% versus 12.3% (not significant), INR was obtained 70.2% versus 55.8% (P = 0.007) of the time with diagnostic yield 15.8% versus 10.5% (P = 0. 042), GFR was obtained 99.3% versus 98.4% (not significant) of the time with diagnostic yield 18.9% versus 13.7% (P = 0.02), and blood cultures were obtained 23.4% versus 7.3% (P < 0.001) of the time with diagnostic yield 7.3% versus 9.3% (not significant).

CONCLUSION

Compared with traditional triage, the team triage process increased discharges and decreased time to discharge, but did not lead to increased testing or decreased diagnostic yield.

Direct admission to improve timely access to care for patients requiring transfer to a level 1 trauma center

Background

Emergency departments (EDs) at level 1 trauma centers are often overcrowded and deny ED-to-ED transfers from lower-tiered centers. Lack of access to timely level 1 care is associated with increased mortality. We evaluated the feasibility of a direct admission (DA) protocol as a method to increase timely access to a level 1 trauma center during periods of ED overcrowding.

Methods

During periods of ED overcrowding between 1 May and 31 December 2019, we admitted patients from referring EDs directly to the intensive care unit (ICU) or inpatient ward using the DA protocol. In a prospective comparative study design, we compared their outcomes to patients during the same period who were admitted through the ED when the ED was not overcrowded.

Results

During periods of ED overcrowding, transfer was requested and clinically accepted for 28 patients, of which 23 (82.1%, age 63±20.3 years, men 52.2% men) were successfully admitted via the DA protocol. Five (17.9%) were not successfully transferred due to lack of available inpatient beds. During periods when the ED was not overcrowded, 106 patients (age 62.8±23.1 years, men 52.8%) were admitted via the ED. There were no morbidity or mortality events attributed to the DA process. Time to patient arrival was 2.7 hours (95% CI 2.3 to 3.1) in the DA cohort and 1.9 hours (95% CI 1.5 to 2.4) in the ED-to-ED cohort (p=0.104). Up-triage to the ICU within 24 hours was performed in only one patient (4.3%). In-hospital mortality did not differ (3 (13%) vs. 8 (7.6%), p=0.392).

Discussion

The DA pathway is a feasible method to safely transfer patients from a referring ED to a higher-care trauma center when its ED is overcrowded.

Level of evidence

Level III, care management.

Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care

Background: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients’ characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient’s clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients’ management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusions: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.

Impact of Emergency Department Crowding on Delays in Acute Stroke Care

Introduction

Delays in identification and treatment of acute stroke contribute to significant morbidity and mortality. Multiple clinical factors have been associated with delays in acute stroke care. We aimed to determine the relationship between emergency department (ED) crowding and the delivery of timely emergency stroke care.

Methods

We used prospectively collected data from our institutional Get with the Guidelines-Stroke registry to identify consecutive acute ischemic stroke patients presenting to our urban academic ED from July 2016–August 2018. We used capacity logs to determine the degree of ED crowding at the time of patients’ presentation and classified them as ordinal variables (normal, high, and severe capacity constraints). Outcomes of interest were door-to-imaging time (DIT) among patients potentially eligible for alteplase or endovascular therapy on presentation, door-to-needle time (DTN) for alteplase delivery, and door-to-groin puncture (DTP) times for endovascular therapy. Bivariate comparisons were made using t-tests, chi-square, and Wilcoxon rank-sum tests as appropriate. We used regression models to examine the relationship after accounting for patient demographics, transfer status, arrival mode, and initial stroke severity by the National Institutes of Health Stroke Scale.

Results

Of the 1379 patients with ischemic stroke presenting during the study period, 1081 (78%) presented at times of normal capacity, 203 (15%) during high ED crowding, and 94 (7%) during severe crowding. Median DIT was 26 minutes (interquartile range [IQR] 17–52); DTN time was 43 minutes (IQR 31–59); and median DTP was 58.5 minutes (IQR 56.5–100). Treatment times were not significantly different during periods of higher ED utilization in bivariate or in multivariable testing.

Conclusion

In our single institution analysis, we found no significant delays in stroke care delivery associated with increased ED crowding. This finding suggests that robust processes of care may enable continued high-quality acute care delivery, even during times with an increased capacity burden.

Effect of Delayed Admission to Intensive Care Units from the Emergency Department on the Mortality of Critically Ill Patients

Background: Increasing in emergency department need to critical care, the number of intensive care unit bed worldwide is inadequate to meet these applies. Objectives: The aim of this study was to investigate the effect of waiting for admission to the Intensive Care Unit (ICU) in the Emergency Department (ED) on the length of stay in the ICU and the mortality of critically ill patients. Methods: This retrospective cohort study carried out between January 2012 - 2019 patients admitted to the ICU of a training and research hospital. The data of 1297 adult patients were obtained by searching the Clinical Decision Support System. Results: The data of the patients were evaluated in two groups as those considered to be delayed and non-delayed. It was determined that the delay of two hours increased the risk of mortality 1.5 times. Hazard Ratios (HR) was 1.548 (1.077 - 2.224). Patients whose ICU admission was delayed by 5 - 6 hours were found to have the highest risk in terms of mortality (HR = 2.291 [1.503 - 3.493]). A statistically significant difference was found in the ICU mortality, 28-day and, 90-day mortality between the two groups. ICU mortality for all patients’ general was 25.2% (327/1297). This rate was 11.4% (55/481) in the non-delayed group and 33.3% (272/816) in the delayed group (P < 0.001). The 28-day mortality rate for all patients’ general was 26.9% (349/1297). This rate was found to be 13.5% (65/481) in the non-delayed group and 34.8% (284/816) in the delayed group (P < 0.001). The 90-day mortality for all patients’ general was 28.4% (368/1297). This rate was 14.1% (68/481) in the non-delayed group and 36.8% (300/816) in the delayed group (P < 0.001). Conclusions: Prolonged stay in the ED before admission to the ICU is associated with worse consequences, and increased mortality.

One-way-street revisited: Streamlined admission of critically-ill trauma patients

INTRODUCTION

Emergency department (ED) crowding is associated with increased mortality and delays in care. We developed a rapid admission pathway targeting critically-ill trauma patients in the ED. This study investigates the sustainability of the pathway, as well as its effectiveness in times of increased ED crowding.

MATERIALS & METHODS

This was a retrospective cohort study assessing the admission of critically-ill trauma patients with and without the use of a rapid admission pathway from 2013 to 2018. We accessed demographic and clinical data from trauma registry data and ED capacity logs. Statistical analyses included univariate and multivariate testing.

RESULTS

A total of 1700 patients were included. Of this cohort, 434 patients were admitted using the rapid admission pathway, whereas 1266 were admitted using the traditional pathway. In bivariate analysis, mean ED LOS was 1.54 h (95% Confidence Interval [CI]: 1.41, 1.66) with the rapid pathway, compared with 5.88 h (95% CI: 5.64, 6.12) with the traditional pathway (p < 0.01). We found no statistically significant relationship between rapid admission pathway use and survival to hospital discharge. During times of increased crowding, rapid pathway use continued to be associated with reduction in ED LOS (p < 0.01). The reduction in ED LOS was sustained when comparing initial results (2013-2014) to recent data (2015-2018).

CONCLUSION

This study found that a streamlined process to admit critically-ill trauma patients is sustainable and associated with reduction in ED LOS. As ED crowding remains pervasive, these findings support restructured care processes to limit prolonged ED boarding times for critically-ill patients.

Who Consult an Adult Psychiatric Emergency Department? Pertinence of Admissions and Opportunities for Telepsychiatry

Background and Objectives: Psychiatric disorders constitute frequent causes of emergency department (ED) admissions and these rates are increasing. However, referring to ED a whole range of conditions that could or should be dealt with elsewhere is imposing itself as a problematic situation. We aimed: (1) to provide a descriptive picture of the socio-demographic and diagnostic characteristics of the visits among adults at the psychiatric ED; (2) to estimate the clinical pertinence of these visits. Materials and Methods: Retrospective analysis of diagnostic/socio-demographic characteristics and clinical trajectories of patients admitted for a psychiatric condition at the adult psychiatric ED of the University Hospital of Geneva (HUG), Switzerland, during a 6-week timespan. Results: In our sample (n = 763 total admissions for psychiatric conditions; n = 702 for inclusion of patients having received a medical evaluation), depression/anxiety, suicidal behavior (SB), psychotic episode, and substance use disorder (SUD), in descending order, were the most common diagnoses for referral. Patients belonged to younger age groups (≤65 years), had a familial status other than married/in couple, and did not present an unfavorable socio-demographic profile. Concerning the pertinence for a psychiatric ED, primary diagnosis of depression/anxiety is the only variable significantly associated with different grade of degree. By the examination of the patients’ trajectory from admission to discharge, the clinical pertinence for a psychiatric ED admission existed for cases assigned to the Echelle Suisse du Tri (EST^®) scale degree 1 (corresponding to most urgent and severe conditions), particularly for diagnoses of depression/anxiety associated with SB, SB as primary or comorbid diagnosis, and psychotic and manic/hypomanic episode. However, diagnoses of depression/anxiety without urgent and severe features (degrees 2, 3, 4) constituted the most frequent mode of presentation. Conclusions: Ambulatory and community-integrated settings could be more appropriate for the majority of patients admitted to adult psychiatric EDs. Moreover, the implementation of telepsychiatry strategies represents a very promising opportunity to offer these patients care continuity, reduce costs and filter the demand for psychiatric ED.

Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature

BACKGROUND/AIMS

This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery.

METHODS

A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy.

RESULTS

One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model.

CONCLUSION

Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.

'See and Treat' Clinic Service Evaluation at a Tertiary Care Hospital in Abu Dhabi

Objectives

We sought to evaluate the performance provided at a ‘See and Treat’ (ST) clinic at a tertiary hospital emergency department (ED) in Abu Dhabi, UAE, and to assess its impact on ED crowding.

Methods

We conducted a retrospective electronic medical chart review and database analyses. We included patients triaged as triage level 4 (T4) and triage level 5 (T5) as per the Emergency Severity Index treated at ED in the ST clinic and other ED areas, including the off-site Urgent Care Centre (UCC) between 1 June 2016 and 30 June 2017. We analyzed a group of process and outcome measures at our ST clinic and compared them to the same measures in other areas of our ED and the co-located UCC. The process measure analyzed was the door-to-doctor time. In addition, the outcome measures analyzed were the door-to-door time, unplanned return within 72 hours, and feedback from T4 and T5 triaged patients treated at the clinic.

Results

The number of patients enrolled in the study was 43 109. Of these, 11 329 (26.3%) patients were treated at the ST clinic, 6328 (14.7%) were treated at the UCC, and 25 452 (59.0%) were treated at the main ED. The door-to-doctor time was within 30 minutes for 89.0% of ST clinic patients, and 94.0% of patients experienced a door-to-door time of within two hours; 2.1% of these patients returned within 72 hours. Among these, 78.7% returned for an issue related to their first visit. However, none of the patients were admitted on their return visit. For patients presenting to UCC and other parts of our ED, we recorded a door-to-doctor time of within 30 minutes for 80.5% of patients and a door-to-door time of within two hours for 73.0% of patients. We found the difference in waiting times (i.e., door-to-doctor times between ST clinic patients and the rest of ED) to be statistically significant (p < 0.001, 95% confidence interval (CI): 0.56–0.63). However, on comparing door-to-door times, we found the difference between ST clinic patients and the rest of ED patients was not statistically significant.

Conclusions

Door-to-doctor times were shorter in ST clinics compared to other parts of our ED, but there was no statistically significant difference in door-to-door times when comparing ST clinics to the rest of the ED. ST clinic patients had a lower rate of unplanned return within 72 hours, of which, none required admission on the return attendance. We believe ST clinics have a positive impact on reducing ED crowding but acknowledge they are one of the many plausible solutions attributing to optimized patient flow in the ED.

National trends in mental health-related emergency department visits by children and adults, 2009-2015

OBJECTIVES

Examine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits.

METHODS

Retrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis.

RESULTS

Mental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15-64 year-olds and nearly 9% by 10-14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6-5.3) of all pediatric and 11.1% (95% CI 11.0-11.3) of adult ED treatment hours.

CONCLUSIONS

Mental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.

Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study

Background

Emergency Department (ED) overcrowding adversely affects patients’ health, accessibility, and quality of healthcare systems for communities. Several studies have addressed this issue. This study aimed to conduct a systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals.

Methods

Original research articles on crowding of emergencies at hospitals published from 1st January 2007, and 1st August 2018 were utilized. Relevant studies from the PubMed and EMBASE databases were assessed using suitable keywords. Two reviewers independently screened the titles, abstracts and the methodological validity of the records using data extraction format before their inclusion in the final review. Discussions with the senior faculty member were used to resolve any disagreements among the reviewers during the assessment phase.

Results

Out of the total 117 articles in the final record, we excluded 11 of them because of poor quality. Thus, this systematic review synthesized the reports of 106 original articles. Overall 14, 55 and 29 of the reviewed refer to causes, effects, and solutions of ED crowding, respectively. The review also included four articles on both causes and effects and another four on causes and solutions. Multiple individual patients and healthcare system related challenges, experiences and responses to crowding and its consequences are comprehensively synthesized.

Conclusion

ED overcrowding is a multi-facet issue which affects by patient-related factors and emergency service delivery. Crowding of the EDs adversely affected individual patients, healthcare delivery systems and communities. The identified issues concern organizational managers, leadership, and operational level actions to reduce crowding and improve emergency healthcare outcomes efficiently.

Discontinuing involuntary mental health holds for children: Does psychiatrist specialty matter? A pilot study

BACKGROUND

Involuntary mental health detainments should only be utilized when less restrictive alternatives are unavailable and should be discontinued as soon as safety can be ensured. The study objective was to determine if child and adolescent psychiatrists discontinue a greater proportion of involuntary holds than general psychiatrists for similar pediatric patients.

METHODS

Retrospective analysis of consecutive patients under 18 years placed on an involuntary hold in the prehospital setting presenting over a 1-year period to one high-volume emergency department (ED) where youth on involuntary holds are seen by child and adolescent psychiatrists when available and general psychiatrists otherwise. The primary outcome of interest was hold discontinuation after initial psychiatric consultation. The key predictor of interest was psychiatrist specialty (child and adolescent vs. general). We conducted multivariate logistic regression modeling adjusting for patient characteristics and time of arrival.

RESULTS

Child and adolescent psychiatrists discontinued 27.4% (51/186) of prehospital holds while general psychiatrists discontinued only 10.6% (22/207). After adjusting for observable confounders, holds were over 3 times as likely to be discontinued in patients evaluated by child and adolescent psychiatrists rather than general emergency psychiatrists (adjusted OR 3.2, 95% CI 1.7-5.9, p < 0.001).

CONCLUSIONS

Child and adolescent psychiatrists are much more likely to discontinue prehospital involuntary mental health holds compared with general emergency psychiatrists. While inappropriate hold discontinuation places patients at risk of harm, prolonged hold continuation limits patients' rights and potentially increases psychiatric boarding in EDs. Earlier access to child and adolescent psychiatry may facilitate early hold discontinuation and standardize patient care.

The effect of emergency department crowding on lung-protective ventilation utilization for critically ill patients

OBJECTIVE

To measure effects of ED crowding on lung-protective ventilation (LPV) utilization in critically ill ED patients.

METHODS

This is a retrospective cohort study of adult mechanically ventilated ED patients admitted to the medical intensive care unit (MICU), over a 3.5-year period at a single academic tertiary care hospital. Clinical data, including reason for intubation, severity of illness (MPM₀-III), acute respiratory distress syndrome (ARDS) risk score (EDLIPS), and ventilator settings were extracted via electronic query of electronic health record and standardized chart abstraction. Crowding metrics were obtained at 5-min intervals and averaged over the ED stay, stratified by acuity and disposition. Multivariate logistic regression was used to predict likelihood of LPV prior to ED departure.

RESULTS

Mechanical ventilation was used in 446 patients for a median ED duration of 3.7 h (interquartile ratio, IQR, 2.3, 5.6). Mean MPM₀-III score was 32.5 ± 22.7, with high risk for ARDS (EDLIPS ≥5) seen in 373 (82%) patients. Initial and final ED ventilator settings differed in 134 (30.0%) patients, of which only 47 (35.1%) involved tidal volume changes. Higher percentages of active ED patients (workup in-progress) and those requiring eventual admission were associated with lower odds of LPV utilization by ED departure (OR 0.97, 95%CI 0.94-1.00; OR 0.97, 95%CI 0.94-1.00, respectively). In periods of high volume, ventilator adjustments to settings other than the tidal volume were associated with higher odds of LPV utilization. Reason for intubation, MPM₀-III, and EDLIPS were not associated with LPV utilization, with no interactions detected in times of crowding.

CONCLUSIONS

ED patients remain on suboptimal tidal volume settings with infrequent ventilator adjustments during the ED stay. Hospitals should focus on both systemic factors and bedside physician and/or respiratory therapist interventions to increase LPV utilization in times of ED boarding and crowding for all patients.

Association of sudden in-hospital cardiac arrest with emergency department crowding

BACKGROUND

In Taiwan, emergency department (ED) crowding is inevitable; many studies have investigated the various negative effects of ER crowding on patients. In general, ED crowding reduces patient satisfaction, delays treatment, and increases mortality. However, most studies have focused on the relationship between ED crowding and delay mortality rather than sudden mortality. This study investigates the association of ED crowding with sudden unexpected in-hospital cardiac arrest (IHCA).

METHODS

The retrospective observational study recruited patients with sudden IHCA in an ED from February 2016 to September 2017. Exclusion criteria included (1) out-of-hospital cardiac arrest, (2) patient with signed do-not-resuscitate consent, (3) pediatric patient, and (4) trauma patient. ED crowding parameters, including ED bed occupancy rates (EDBORs), number of boarding patients, and patients with boarding time to general ward or intensive care unit of >24 and >48 h, all were recorded every 2 h.

RESULTS

Significant increments were noted in IHCA incidence when EDBOR was >260%, with a rate ratio of 1.50 (95% confidence interval [CI], 1.03-2.17). However, the number of boarding patients was not associated with IHCA incidence (P > 0.05). Prolonged boarding time to general ward and ICU of >24 and >48 h both increased the IHCA incidence.

CONCLUSION

This first study investigating the relationship between ED crowding and sudden IHCA found EDBORs and prolonged boarding to general wards or ICUs were associated with increased sudden IHCA incidence.

Delayed Recognition of Acute Stroke by Emergency Department Staff Following Failure to Activate Stroke by Emergency Medical Services

Introduction

Early recognition and pre-notification by emergency medical services (EMS) improves the timeliness of emergency department (ED) stroke care; however, little is known regarding the effects on care should EMS providers fail to pre-notify. We sought to determine if potential stroke patients transported by EMS, but for whom EMS did not provide pre-notification, suffer delays in ED door-to-stroke-team activation (DTA) as compared to the other available cohort of patients for whom the ED is not pre-notified–those arriving by private vehicle.

Methods

We queried our prospective stroke registry to identify consecutive stroke team activation patients over 12 months and retrospectively reviewed the electronic health record for each patient to validate registry data and abstract other clinical and operational data. We compared patients arriving by private vehicle to those arriving by EMS without pre-notification, and we employed a multivariable, penalized regression model to assess the probability of meeting the national DTA goal of ≤15 minutes, controlling for a variety of clinical factors.

Results

Our inclusion criteria were met by 200 patients. Overall performance of the regression model was excellent (area under the curve 0.929). Arrival via EMS without pre-notification, compared to arrival by private vehicle, was associated with an adjusted risk ratio of 0.55 (95% confidence interval, 0.27–0.96) for achieving DTA ≤ 15 minutes.

Conclusion

Our single-center data demonstrate that potential stroke patients arriving via EMS without pre-notification are less likely to meet the national DTA goal than patients arriving via other means. These data suggest a negative, unintended consequence of otherwise highly successful EMS efforts to improve stroke care, the root of which may be ED staff over-reliance on EMS for stroke recognition.

Emergency department crowding: A systematic review of causes, consequences and solutions

BACKGROUND

Emergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions.

AIM

The aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A structured search of four databases (Medline, CINAHL, EMBASE and Web of Science) was undertaken to identify peer-reviewed research publications aimed at investigating the causes or consequences of, or solutions to, emergency department crowding, published between January 2000 and June 2018. Two reviewers used validated critical appraisal tools to independently assess the quality of the studies. The study protocol was registered with the International prospective register of systematic reviews (PROSPERO 2017: CRD42017073439).

RESULTS

From 4,131 identified studies and 162 full text reviews, 102 studies met the inclusion criteria. The majority were retrospective cohort studies, with the greatest proportion (51%) trialling or modelling potential solutions to emergency department crowding. Fourteen studies examined causes and 40 investigated consequences. Two studies looked at both causes and consequences, and two investigated causes and solutions.

CONCLUSIONS

The negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. This review identified a mismatch between causes and solutions. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Solutions aimed at the introduction of whole-of-system initiatives to meet timed patient disposition targets, as well as extended hours of primary care, demonstrated promising outcomes. While the review identified increased presentations by the elderly with complex and chronic conditions as an emerging and widespread driver of crowding, more research is required to isolate the precise local factors leading to ED crowding, with system-wide solutions tailored to address identified causes.

A Retrospective Study Investigating: Factors associated with mode of arrival and emergency department management for patients with acute stroke

BACKGROUND

Presentation by ambulance to the emergency department is critical for stroke patients to receive time dependent treatments. However, little is known of the factors that influence presentation by ambulance.

METHODS

Retrospective analysis of all patients with an emergency department medical diagnosis of stroke who presented to one of three Victorian emergency departments over a three-year period (2011-2013). A multivariable model was used to investigate demographic characteristics (including triage assessment category, triage identified as stroke, time to CT, and time to diagnosis within the emergency department) as predictors of arrival by ambulance.

RESULTS

3548 stroke patients were identified; mean age was 70 years, 53% were males, and 92% had an ischemic stroke. Arrival by ambulance occurred in 71% (n=2509) with arrival by private transport accounting for 29% (n=1039) of patients. Factors significantly associated with arrival by ambulance were older age (p=<0.001), being born in Australia (p=<0.001), and speaking English in the home (p=0.003). Arrival by ambulance was independently associated with rapid stroke care in the emergency department, arrival within 2h from symptom onset, attending an advanced stroke service (access to thrombolysis), triaged for stroke, medical assessment within 25min and referral for CT within 45min.

CONCLUSION

In this Australian multicenter study, it was identified that patients who arrived by ambulance received faster acute stroke care within the emergency department. Public health education which targets patients who are younger and from a non-English speaking background is needed as these demographics were not associated with timely arrival by ambulance to the emergency department.

Real-Time Surveys Reveal Important Safety Risks During Interhospital Care Transitions for Neurologic Emergencies

Critically ill patients may be exposed to unique safety threats as a result of the complexity of interhospital and intrahospital transitions involving the emergency department (ED). Real-time surveys were administered to clinicians in the ED and neuroscience intensive care unit of a tertiary health care system to assess perceptions of handoff safety and quality in transitions involving critically ill neurologic patients. In all, 115 clinical surveys were conducted among 26 patient transfers. Among all clinician types, 1 in 5 respondents felt the handoff process was inadequate. Risks to patient safety during the transfer process were reported by 1 in 3 of respondents. Perceived risks were reported more frequently by nurses (44%) than physicians/advanced practice providers (28%). Real-time survey methodology appears to be a feasible and valuable, albeit resource intensive, tool to identify safety risks, expose barriers to communication, and reveal challenges not captured by traditional approaches to inform multidisciplinary quality improvement efforts.

Interfacility Transfer Directly to the Neuroangiography Suite in Acute Ischemic Stroke Patients Undergoing Thrombectomy

BACKGROUND AND PURPOSE

In patients identified at referring facilities with acute ischemic stroke caused by a large vessel occlusion, bypassing the emergency department (ED) with direct transport to the neuroangiography suite may safely shorten reperfusion times.

METHODS

We conducted a single-center retrospective review of consecutive patients transferred to our facility for consideration of endovascular therapy. Patients were identified as admitted directly to the neuroangiography suite (DAN), transferred to the ED before intra-arterial therapy (ED-IA), and transferred to the ED but did not receive IA therapy (ED-IV).

RESULTS

A retrospective review of a prospectively maintained database of transfer patients between January 2013 and October 2016 with large vessel occlusions identified 108 ED-IV patients and 261 patients who underwent mechanical thrombectomy (DAN=111 patients and ED-IA=150 patients). There were no differences in baseline characteristics among the 3 groups. The median computed tomography ASPECTS (Alberta Stroke Program Early CT Score) was lower in the ED-IV group versus the ED-IA and DAN groups (8 versus 9; P=0.001). In the DAN versus ED-IA cohort, there were comparable rates of TICI2b/3 recanalization and access to recanalization time. There was significantly faster hospital arrival to groin access time in the DAN cohort (81 minutes versus 22 minutes; P=0.001). Functional independence at 90 days was comparable in the DAN versus ED-IA cohorts but worse in the ED-IV group (43% versus 44% versus 22%; P=0.001).

CONCLUSIONS

DAN is safe, feasible, and associated with faster times of hospital arrival to recanalization. The clinical benefit of this approach should be assessed in a prospective randomized trial.