Evaluation of emergency department performance - a systematic review on recommended performance and quality-in-care measures

Characteristics and outcomes of patients with COVID-19 who return to the emergency department: a multicentre observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN)

OBJECTIVE

Unplanned return emergency department (ED) visits can reflect clinical deterioration or unmet need from the original visit. We determined the characteristics and outcomes of patients with COVID-19 who return to the ED for COVID-19-related revisits.

METHODS

This retrospective observational study used data for all adult patients visiting 47 Canadian EDs with COVID-19 between 1 March 2020 and 31 March 2022. Multivariable logistic regression assessed the characteristics associated with having a no return visit (SV=single visit group) versus at least one return visit (MV=return visit group) after being discharged alive at the first ED visit.

RESULTS

39 809 patients with COVID-19 had 44 862 COVID-19-related ED visits: 35 468 patients (89%) had one visit (SV group) and 4341 (11%) returned to the ED (MV group) within 30 days (mean 2.2, SD=0.5 ED visit). 40% of SV patients and 16% of MV patients were admitted at their first visit, and 41% of MV patients not admitted at their first ED visit were admitted on their second visit. In the MV group, the median time to return was 4 days, 49% returned within 72 hours. In multivariable modelling, a repeat visit was associated with a variety of factors including older age (OR=1.25 per 10 years, 95% CI (1.22 to 1.28)), pregnancy (1.86 (1.46 to 2.36)) and presence of comorbidities (eg, 1.72 (1.40 to 2.10) for cancer, 2.01 (1.52 to 2.66) for obesity, 2.18 (1.42 to 3.36) for organ transplant), current/prior substance use, higher temperature or WHO severe disease (1.41 (1.29 to 1.54)). Return was less likely for females (0.82 (0.77 to 0.88)) and those boosted or fully vaccinated (0.48 (0.34 to 0.70)).

CONCLUSIONS

Return ED visits by patients with COVID-19 within 30 days were common during the first two pandemic years and were associated with multiple factors, many of which reflect known risk for worse outcomes. Future studies should assess reasons for revisit and opportunities to improve ED care and reduce resource use.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, NCT04702945.

Strategies to Measure and Improve Emergency Department Performance: A Review

Emergency Departments (EDs) globally face escalating challenges such as overcrowding, resource limitations, and increased patient demand. This study aims to identify and analyze strategies to enhance the structural performance of EDs, with a focus on reducing overcrowding, optimizing resource allocation, and improving patient outcomes. Through a comprehensive review of the literature and observational studies, the research highlights the effectiveness of various approaches, including triage optimization, dynamic staffing, technological integration, and strategic resource management. Key findings indicate that tailored strategies, such as implementing advanced triage protocols and leveraging telemedicine, can significantly reduce wait times and enhance patient throughput. Furthermore, evidence suggests that dynamic staffing models and the integration of cutting-edge diagnostic tools contribute to operational efficiency and improved quality of care. These strategies, when combined, offer a multifaceted solution to the complex challenges faced by EDs, promising better patient care and satisfaction. The study underscores the need for a comprehensive approach, incorporating both organizational and technological innovations, to address the evolving needs of emergency healthcare.

[Indicators to measure the performance of emergency trauma care]

The objective of this paper was to identify the main indicators used to measure the performance in emergency trauma care. A literature review was carried out in the electronic databases: PubMEd, LILACS and Epistemónikos, including publications between January 2011 and December 31, 2021, in Spanish, English and Portuguese. A total of 962 publications were identified. When reviewing the full text, 48 articles were included. The indicators were classified in the dimensions of process and results. 100 different indicators were identified to analyze the performance of emergency trauma care. 71% were process indicators, including service time and triage. In the results dimension 29 indicators were identified; mortality was the indicator most analyzed as well as length of stay. Six indicators on the disability of injured people and 14 indicators related to satisfaction were identified, the most frequent being complaints. Various indicators have been used to assess the performance of emergency trauma care. In the results dimension, the indicators related to satisfaction and disability after injuries have been little explored. Decision-makers and those responsible for emergency care must promote performance evaluation exercises to learn about their current situation using appropriate and sensitive indicators with the available data.

Emergency department performance assessment using administrative data: A managerial framework

Administrative data play an important role in performance monitoring of healthcare providers. Nonetheless, little attention has been given so far to the emergency department (ED) evaluation. In addition, most of existing research focuses on a single core ED function, such as treatment or triage, thus providing a limited picture of performance. The goal of this study is to harness the value of routinely produced records proposing a framework for multidimensional performance evaluation of EDs able to support internal decision stakeholders in managing operations. Starting with the overview of administrative data, and the definition of the desired framework's characteristics from the perspective of decision stakeholders, a review of the academic literature on ED performance measures and indicators is conducted. A performance measurement framework is designed using 224 ED performance metrics (measures and indicators) satisfying established selection criteria. Real-world feedback on the framework is obtained through expert interviews. Metrics in the proposed ED performance measurement framework are arranged along three dimensions: performance (quality of care, time-efficiency, throughput), analysis unit (physician, disease etc.), and time-period (quarter, year, etc.). The framework has been judged as "clear and intuitive", "useful for planning", able to "reveal inefficiencies in care process" and "transform existing data into decision support information" by the key ED decision stakeholders of a teaching hospital. Administrative data can be a new cornerstone for health care operation management. A framework of ED-specific indicators based on administrative data enables multi-dimensional performance assessment in a timely and cost-effective manner, an essential requirement for nowadays resource-constrained hospitals. Moreover, such a framework can support different stakeholders' decision making as it allows the creation of a customized metrics sets for performance analysis with the desired granularity.

Systemic emergency department performance in a low resource tertiary health facility in central Kenya: Micro level emergency care system evaluation

Emergency care system (ECS) performance is a proxy indicator of emergency care (EC) response and health systems resilience. The Emergency Care and System Assessment tool (ECSA) provides a structure for measuring emergency department (ED) systemic performance, using high quality ECS metrics. These metrics aligned with WHO targeted priority action areas facilitate synergies in supporting ECS evaluation at the micro level. Retrospective file reviews and anecdotal evidence from a low resource tertiary health facility between 1st January 2020 - 31st May 2021 showed that: - the governance structure had administrative and financial autonomy from the public healthcare system, healthcare financing was mostly out of pocket (OPP) and the human resource ecosystem was structured in operations, enforcement and training to drive EC quality improvement. More than two thirds of the patients were high acuity but only 2% of the patients died. Most sentinel ED functions were available at the facility however the facility does not have a developed prehospital care, neurosurgical nor a burns unit. Micro ECS framework derived from ECSA objectively interrogates performance of the healthcare system that supports EC in a tertiary facility.

Factors associated with longer wait times, admission and reattendances in older patients attending emergency departments: an analysis of linked healthcare data

BACKGROUND AND OBJECTIVE

Care for older patients in the ED is an increasingly important issue with the ageing society. To better assess the quality of care in this patient group, we assessed predictors for three outcomes related to ED care: being seen and discharged within 4 hours of ED arrival; being admitted from ED to hospital and reattending the ED within 30 days. We also used these outcomes to identify better-performing EDs.

METHODS

The CUREd Research Database was used for a retrospective observational study of all 1 039 251 attendances by 368 754 patients aged 75+ years in 18 type 1 EDs in the Yorkshire and the Humber region of England between April 2012 and March 2017. We estimated multilevel logit models, accounting for patients' characteristics and contact with emergency services prior to ED arrival, time variables and the ED itself.

RESULTS

Patients in the oldest category (95+ years vs 75-80 years) were more likely to have a long ED wait (OR=1.13 (95% CI=1.10 to 1.15)), hospital admission (OR=1.26 (95% CI=1.23 to 1.29)) and ED reattendance (OR=1.09 (95% CI=1.06 to 1.12)). Those who had previously attended (3+ vs 0 previous attendances) were more likely to have long wait (OR=1.07 (95% CI=1.06 to 1.08)), hospital admission (OR=1.10 (95% CI=1.09 to 1.12)) and ED attendance (OR=3.13 (95% CI=3.09 to 3.17)). Those who attended out of hours (vs not out of hours) were more likely to have a long ED wait (OR=1.33 (95% CI=1.32 to 1.34)), be admitted to hospital (OR=1.19 (95% CI=1.18 to 1.21)) and have ED reattendance (OR=1.07 (95% CI=1.05 to 1.08)). Those living in less deprived decile (vs most deprived decile) were less likely to have any of these three outcomes: OR=0.93 (95% CI=0.92 to 0.95), 0.92 (95% CI=0.90 to 0.94), 0.86 (95% CI=0.84 to 0.88). These characteristics were not strongly associated with long waits for those who arrived by ambulance. Emergency call handler designation was the strongest predictor of long ED waits and hospital admission: compared with those who did not arrive by ambulance; ORs for these outcomes were 1.18 (95% CI=1.16 to 1.20) and 1.85 (95% CI=1.81 to 1.89) for those designated less urgent; 1.37 (95% CI=1.33 to 1.40) and 2.13 (95% CI=2.07 to 2.18) for urgent attendees; 1.26 (95% CI=1.23 to 1.28) and 2.40 (95% CI=2.36 to 2.45) for emergency attendees; and 1.37 (95% CI=1.28 to 1.45) and 2.42 (95% CI=2.26 to 2.59) for those with life-threatening conditions. We identified two EDs whose patients were less likely to have a long ED, hospital admission or ED reattendance than other EDs in the region.

CONCLUSIONS

Age, previous attendance and attending out of hours were all associated with an increased likelihood of exceeding 4 hours in the ED, hospital admission and reattendance among patients over 75 years. These differences were less pronounced among those arriving by ambulance. Emergency call handler designation could be used to identify those at the highest risk of long ED waits, hospital admission and ED reattendance.

Predictors of Death From Physical Illness or Accidental/Intentional Causes Among Patients With Substance-Related Disorders

OBJECTIVE

This study identified patient clinical and sociodemographic characteristics, and, more originally, service use patterns as predictors of death from physical illness or accidental/intentional causes.

METHODS

A cohort of 19,015 patients with substance-related disorders (SRD) from 14 addiction treatment centers was investigated using Quebec (Canada) health administrative databases. Death was studied over a 3-year period (April 1, 2013, to March 31, 2016), and most predictors from 4 years to 12 months prior to the time of death, using multinomial logistic regression.

RESULTS

Frequent emergency department (ED) use strongly predicted both causes of death, suggesting that outpatient care responded inadequately to patient needs. Only receipt of specialized SRD and psychiatric care significantly decreased the risk of death from physical illness, with trends toward significance for accidental/intentional death. Hospitalization, greater material deprivation and having SRD-chronic physical illnesses or alcohol-related disorders most strongly predicted risk of death from physical illness. Sociodemographic characteristics, mainly social deprivation, were more likely to predict accidental/intentional death.

CONCLUSIONS

Outpatient services could be improved by increasing outreach and motivational interventions and, for ED and hospital units, better screening, brief intervention, and referral to treatment, particularly for men and socially deprived patients at high risk of accidental/intentional death. Patients with more severe health conditions, notably older or materially deprived men at higher risk of death from physical illness, could benefit from programs like assertive community treatment or intensive case management that respond well to diverse and continuous patient needs. Collaborative care between SRD and health services could also be improved.

The preanalytical process in the emergency department, a European survey

OBJECTIVES

Clinical decision-making in emergency medicine is under constant pressure from demand and performance requirements, with blood tests being a fundamental part of this. However, the preanalytical process has received little attention. Therefore, this study aimed to investigate the quality of preanalytical phase processes in European emergency departments (EDs) from the perspectives of the three main providers: clinicians, nurses, and laboratory specialists.

METHODS

This online survey, distributed among European EDs and laboratories, was supported by the European Society for Emergency Nursing (EUSEN), European Society for Emergency Medicine (EuSEM), and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM). The size of the centres, the European region, the responder's profession and the country's economic condition were used as co-variables.

RESULTS

We included 376 responses from all ED-related professions from 306 European centres. In 66.9% of all ED visits, at least one blood test was performed. Tests were requested mostly by nurses (44.6%) using electronic Order/Entry systems (65.4%). Only a minority (19%) reported not using laboratory quality indicators (QIs). Most responders defined the TAT starting point "when the laboratory receives the sample" (66.1%), defining the goal to be "less than 60 min" (69.9%), but only 42.4% of the centres estimated achieving this goal.

CONCLUSIONS

Our survey illustrates the current situation on preanalytical blood sample processing in European EDs from the clinical and laboratory perspectives. The results emphasise the importance of the IT infrastructure and QI usage in this process and highlight some differences between European regions.

Emergency Department Use, Hospitalization, and Their Sociodemographic Determinants among Patients with Substance-Related Disorders: A Worldwide Systematic Review and Meta-Analysis

Background: Identifying the determinants of emergency department (ED) use and hospitalization among patients with substance-related disorders (SRD) can help inform healthcare services and case management regarding their unmet health needs and strategies to reduce their acute care. Objectives: The present study aimed to identify sociodemographic characteristics, type of used drug, and risky behaviors associated with ED use and hospitalization among patients with SRD. Methods: Studies in English published from January 1st, 1995 to April 30th, 2022 were searched from PubMed, Scopus, Cochrane Library, and Web of Science to identify primary studies on ED use and hospitalization among patients with SRD. Results: Of the 17,348 outputs found, a total of 39 studies met the eligibility criteria. Higher ED use and hospitalization among patients with SRD were associated with a history of homelessness (ED use: OR = 1.93, 95%CI = 1.32-2.83; hospitalization: OR = 1.53, 95%CI = 1.36-1.73) or of injection drug use (ED use: OR = 1.34, 95%CI = 1.13-1.59; hospitalization: OR = 1.42, 95%CI = 1.20-1.69). Being female (OR = 1.24, 95%CI = 1.14-1.35), using methamphetamine (OR = 1.99, 95%CI = 1.24-3.21) and tobacco (OR = 1.25, 95%CI = 1.11-1.42), having HIV (OR = 1.70, 95%CI = 1.47-1.96), a history of incarceration (OR = 1.90, 95%CI = 1.27-2.85) and injury (OR = 2.62, 95%CI = 1.08-6.35) increased ED use only, while having age over 30  years (OR = 1.40, 95%CI = 1.08-1.81) and using cocaine (OR = 1.60, 95%CI = 1.32-1.95) increased hospitalization only among patients with SRD. Conclusions: The finding outline the necessity of developing outreach program and primary care referral for patients with SRD. Establishing a harm reduction program, incorporating needle/syringe exchange programs, and safe injection training with the aim of declining ED use and hospitalization, is likely be another beneficial strategy for patients with SRD.

Is in situ simulation in emergency medicine safe? A scoping review

OBJECTIVES

To provide an overview of the available evidence regarding the safety of in situ simulation (ISS) in the emergency department (ED).

DESIGN

Scoping review.

METHODS

Original articles published before March 2021 were included if they investigated the use of ISS in the field of emergency medicine.

INFORMATION SOURCES

MEDLINE, EMBASE, Cochrane and Web of Science.

RESULTS

A total of 4077 records were identified by our search strategy and 2476 abstracts were screened. One hundred and thirty full articles were reviewed and 81 full articles were included. Only 33 studies (40%) assessed safety-related issues, among which 11 chose a safety-related primary outcome. Latent safety threats (LSTs) assessment was conducted in 24 studies (30%) and the cancellation rate was described in 9 studies (11%). The possible negative impact of ISS on real ED patients was assessed in two studies (2.5%), through a questionnaire and not through patient outcomes.

CONCLUSION

Most studies use ISS for systems-based or education-based applications. Patient safety during ISS is often evaluated in the context of identifying or mitigating LSTs and rarely on the potential impact and risks to patients simultaneously receiving care in the ED. Our scoping review identified knowledge gaps related to the safe conduct of ISS in the ED, which may warrant further investigation.

EFFECT OF THE INTRODUCTION OF EMERGENCY MEDICINE SPECIALISTS ON THE EMERGENCY DEPARTMENT PERFORMANCE INDICATORS: A RETROSPECTIVE DATA ANALYSIS

Patient management in the emergency department (ED) is evaluated by performance indicators, such as wait times (time to be seen by a physician), length of stay (LOS) and the number of diagnostic tests per patient. To improve the quality of care, dedicated emergency medicine (EM) specialists are employed to work in the ED. The aim of this study is to evaluate three performance indicators of patient management in the ED compared by specialty, internal medicine (IM) versus EM. Research was conducted in the ED of a large tertiary teaching hospital. A retrospective data analysis of the hospital information system was conducted for the period when only IM specialists were working as attendants, versus a period when two EM specialists joined the ED team. We calculated the percentage of patients seen within the recommended time per Australasian Triage system (AST) category and compared the average LOS and the average number of tests per patient, using data from June 2017 to January 2020. Means, standard deviation, standard error, 95% confidence interval were calculated, and the independent t-test was used to compare means. With the introduction of the EM specialists, the percentage of patients examined within the recommended time frame per AST category was higher. There was a significant reduction in LOS in the ED when comparing only IM specialists to IM specialists with two EM specialists (p<0.001). The IM physicians on average do more tests than EM specialists, which was statistically significant (p<0.05). There was a significant improvement in efficiency in the ED with the introduction of EM specialists which was manifested by shorter patient wait times and shorter length of stay in the Emergency Department and fewer diagnostic test orders.

Patterns in emergency department unscheduled return visits during the COVID-19 pandemic

Introduction

Fear surrounding nosocomial infections, expanded telehealth, and decreases in ED (emergency department) utilization altered the way patients sought emergency care during the COVID pandemic. This study aims to evaluate COVID-19's impact on the frequency and characteristics of unscheduled return visits (URVs) to the adult and pediatric ED.

Methods

In this retrospective cohort study, the electronic medical record was used to identify ≤9-day URVs at a tertiary adult and pediatric ED from 4/16/19–2/29/20 (control) and 4/16/20–2/28/21 (COVID). The primary outcome, proportion of total ED visits made up by URVs, and secondary outcomes, patient characteristics (age), illness acuity (emergency severity index (ESI)), disposition, and mortality were compared between the cohorts. Pediatric and adult data were analyzed separately. A sub-analysis was performed to exclude patients with suspected respiratory infections.

Results

For adults, n = 4265, there was no significant difference between the proportion of ED census made up by URVs (4.56% (control) vs 4.76% (COVID), p = 0.17), mean patient age (46.33 (control) vs 46.18 (COVID), p = 0.80), ESI acuity (2.95 (control) vs 2.95 (COVID), p = 0.83), disposition (admission 0.32% (control) vs 0.39% (COVID), p = 0.69), and mortality (0.23% (control) and 0.49% (COVID), p = 0.15). When excluding possible respiratory infections comparisons remained insignificant.

For pediatrics, n = 1214, there was a significant difference in the proportion of ED census made up by URVs (4.83% (control) to 3.55% (COVID), p < 0.01), age (5.52 (control) vs 6.43 (COVID), p = 0.01), and ESI acuity (3.31 (control) vs 3.17 (COVID), p < 0.01). There was no difference in disposition (admission 0.12% (control) vs 0% (COVID), p = 1). When excluding possible respiratory infections acuity (p = 0.03) remained significant.

Conclusion

In the adult population, COVID did not significantly alter any of our outcomes. For pediatric patients, a decrease in the proportion of URVs and increase in acuity during COVID suggests that patients may have had other means of accessing care, avoided the ED, received more adequate care at initial presentation, or represented when more acutely ill.

A new approach for emergency department performance positioning: The quality-efficiency matrix

BACKGROUND

The crowding of emergency departments (EDs) is one of the major poor-quality factors for patients. Because of this, measuring ED performance in Healthcare Systems is a difficult but an important task needed to enhance quality and efficiency.

PURPOSE

(i) Development of a tool to observe and evaluate performance measurement, analysing two critical variables (quality and efficiency), verifying the change in performance due to the implementation of a new organizational model; (ii) the implementation of the tool in two EDs with comparable annual volumes of activity in the Italian context.

METHODS

A literature review on ED performance was conducted in order to identify acknowledged performance measurements used in this context that can be used in the development of a tool for the evaluation of EDs' performance. The goal is to have a matrix that is easily understood and that shows a simple relationship between quality and efficiency. This was possible by setting up a method that translates the ED annual performance data (in this case the data related to year 2018) into a graph with benchmarking purposes, also including an actual situation (AS-IS) view as compared to a TO-BE situation (i.e., before and after an organizational change occurred).

RESULTS

Two real EDs were compared and their results depicted; they can be easily related with each other to benchmark healthcare organisations. More precisely, a comparison can be used for two main tasks: - identifying different strategic areas and observing the positioning of a health organization at any given moment in time, seeing where it stands among its competitors in a matrix; - knowing how to best allocate available resources and where to divert investment. Results show that the tool depicts the situation of EDs, with a clear indication of how performance increases or decreases in the case of AS-IS and TO-BE evaluation, and also offers a quick understanding of the benchmarked EDs' situations.

PRACTICE IMPLICATIONS

The results can be shown on a graph that summarises the performance change for the AS-IS versus TO-BE conditions. This can be a useful tool for the ED and for the hospital decision makers, as it allows for an observation of performance by analysing two critical variables: the quality and the efficiency of the service provided. The former represents customer satisfaction, which in this work is the combination of two factors (i.e., appropriateness of assigning the triage code and patient satisfaction), and the latter represents the ED's efficiency in providing emergency care. The tool also helps the organizational changes to be easily evaluated.

Patients who leave the Emergency Department without being seen. Has COVID-19 affected this phenomenon?

BACKGROUND AND AIM

Patients who present to an Emergency Department (ED) and leave without being seen by a physician represent a safety concern because they may become severely ill and experience adverse events as a result of lacking or delayed ED treatment. Prior to the COVID-19 outbreak, the increasing number of patients accessing care through the ED in Italy and throughout the world has had implications for health policies.

METHODS

A retrospective cohort study that included all ED visits from 1st January 2013 to 31st December 2018 in the Perugia University Hospital has been carried out.

RESULTS

During the 5 years investigated 26,344 out of 300,372 (8.77%) patients who attended the ED left the triage area before being seen with an average of 439 patients per month. The same phenomenon has been analysed from February to October 2020. During these 9 months there were a total of 1,824 out of 30,990 (5.88%) patients who left the ED without being seen with an average of 202 per month. The latter value is one third lower than the one related to the period investigated prior to the COVID-19 outbreak.

CONCLUSIONS

Such investigation could help to differentiate actual essential demand from non-essential demand within the ED, which could inform quality-improvement policies. Several strategies could be implemented to lower the proportion of patients who leave the department without being seen. Reorganising the activities in the ED with different paths should be implemented with the aim of reducing waiting times and in turn patients' satisfaction.

Frequencies of emergency department use and hospitalization comparing patients with different types of substance or polysubstance-related disorders

Background

This study measured emergency department (ED) use and hospitalization for medical reasons among patients with substance-related disorders (SRD), comparing four subgroups: cannabis-related disorders, drug-related disorders other than cannabis, alcohol-related disorders and polysubstance-related disorders, controlling for various clinical, sociodemographic and service use variables.

Methods

Clinical administrative data for a cohort of 22,484 patients registered in Quebec (Canada) addiction treatment centers in 2012-13 were extracted for the years 2009-10 to 2015-16. Using negative binomial models, risks of frequent ED use and hospitalization were calculated for a 12-month period (2015-16).

Results

Patients with polysubstance-related disorders used ED more frequently than other groups with SRD. They were hospitalized more frequently than patients with cannabis or other drug-related disorders, but less frequently than those with alcohol-related disorders. Patients with alcohol-related disorders used ED more frequently than those with cannabis-related disorders and underwent more hospitalizations than both patients with cannabis-related and other drug-related disorders. Co-occurring SRD-mental disorders or SRD-chronic physical illnesses, more years with SRD, being women, living in rural territories, more frequent consultations with usual general practitioner or outpatient psychiatrist, and receiving more interventions in community healthcare centers increased frequency of ED use and hospitalization, whereas both adverse outcomes decreased with high continuity of physician care. Behavioral addiction, age less than 45 years, living in more materially deprived areas, and receiving 1-3 interventions in addiction treatment centers increased risk of frequent ED use, whereas living in semi-urban areas decreased ED use. Patients 25-44 years old receiving 4+ interventions in addiction treatment centers experienced less frequent hospitalization.

Conclusion

Findings showed higher risk of ED use among patients with polysubstance-related disorders, and higher hospitalization risk among patients with alcohol-related disorders, compared with patients affected by cannabis and other drug-related disorders. However, other variables contributed substantially more to the frequency of ED use and hospitalization, particularly clinical variables regarding complexity and severity of health conditions, followed by service use variables. Another important finding was that high continuity of physician care helped decrease the use of acute care services. Strategies like integrated care and outreach interventions may enhance SRD services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00421-7.

Impact of Viral Seasonal Outbreaks on Crowding and Health Care Quality in Pediatric Emergency Departments

ABSTRACT

In pediatric emergency departments (PEDs), seasonal viral outbreaks are believed to be associated with an increase of workload, but no quantification of this impact has been published. A retrospective cross-sectional study aimed to measure this impact on crowding and health care quality in PED. The study was performed in 1 PED for 3 years. Visits related to bronchiolitis, influenza, and gastroenteritis were defined using discharge diagnoses. The daily epidemic load (DEL) was the proportion of visits related to one of these diagnoses. The daily mean of 8 crowding indicators (selected in a published Delphi study) was used. A total of 93,976 children were admitted (bronchiolitis, 2253; influenza, 1277; gastroenteritis, 7678). The mean DEL was 10.4% (maximum, 33.6%). The correlation between the DEL and each indicator was significant. The correlation was stronger for bronchiolitis (Pearson R from 0.171 for number of hospitalization to 0.358 for length of stay). Between the first and fourth quartiles of the DEL, a significant increase, between 50% (patients left without being seen) and 8% (patient physician ratio), of all the indicators was observed. In conclusion, seasonal viral outbreaks have a strong impact on crowding and quality of care. The evolution of "patients left without being seen" between the first and fourth quartiles of DEL could be used as an indicator reflecting the capacity of adaptation of an emergency department to outbreaks.

Emergency Department Quality Dashboard; a Systematic Review of Performance Indicators, Functionalities, and Challenges

Introduction:

Effective information management in the emergency department (ED) can improve the control and management of ED processes. Dashboards, known as data management tools, efficiently provide information and contribute greatly to control and management of ED. This study aimed to identify performance indicators quality dashboard functionalities, and analyze the challenges associated with dashboard implementation in the ED.

Methods:

This systematic review began with a search in four databases (Web of Science, PubMed, Embase, and Scopus) from 2000 to May 30, 2020, when the final search for papers was conducted. The data were collected using a data extraction form and the contents of the extracted papers were analyzed through ED performance indicators, dashboard functionalities, and implementation challenges.

Results:

Performance indicators reported in the reviewed papers were classified as the quality of care, patient flow, timeliness, costs, and resources. The main dashboard functionalities noted in the papers included reporting, customization, alert creation, resource management, and real-time information display. The dashboard implementation challenges included data sources, data quality, integration with other systems, adaptability of dashboard functionalities to user needs, and selection of appropriate performance indicators.

Conclusions:

Quality dashboards facilitate processes, communication, and situation awareness in the ED; hence, they can improve care provision in this department. To enhance the effectiveness and efficiency of ED dashboards, officials should set performance indicators and consider the conformity of dashboard functionalities with user needs. They should also integrate dashboards with other relevant systems at the departmental and hospital levels.

Interventions for the discharge of older people to their home from the emergency department: a systematic review

BACKGROUND

Clinicians have limited evidence on which to base their practice to effectively discharge older people from emergency. The aim of the review was to assess the effectiveness of interventions used for the discharge of older people from the emergency department to their home in the community by emergency clinicians.

METHODS

The PRISMA guidelines were followed. The search comprised seven databases including CINAHL Complete, Medline and EMBASE, and additionally unpublished literature sources including trial registries and theses databases. The results were presented for three outcomes: mortality; emergency department representation after the index visit; and physical function. A narrative analysis was performed.

RESULTS

Twenty-five studies met the inclusion criteria; 13 RCTs and 12 quasi-experimental. Risk of bias was moderate to high. There was a trend towards reduced probability of representing to the emergency department within 3 months of the index visit for individualised focussed elder discharge health interventions. Results were equivocal for other outcomes.

CONCLUSIONS

Greater clarity and consensus is needed to determine the most appropriate discharge measures, screening tools, information sources and discharge roles for the emergency setting. Rigorous multicentre trials to improve the evidence on which to base this aspect of emergency care are required.

Preventing SARS-CoV-2 transmission in the emergency department by implementing a separate pathway for patients with respiratory conditions

OBJECTIVES

This study aimed to describe the development and implementation of a separated pathway to check and treat patients with a suspected/confirmed coronavirus disease 2019 (COVID-19) in the emergency department (ED) at King Abdullah bin Abdulaziz University Hospital in Riyadh.

METHODS

We conducted a retrospective, descriptive longitudinal study from March to July 2020 by analyzing data of all confirmed cases of COVID-19 among ED visitors and healthcare workers in King Abdullah bin Abdulaziz University Hospital.

RESULTS

During the study period, a total of 1,182 swab samples were collected for testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), of which 285 (24.1%) tested positive. Of the 285 cases of confirmed SARS-CoV-2 infection, 18 were healthcare workers and 267 were patients. As a result of using the respiratory pathway for COVID-19 patients, the hospital managed to limit transmission of SARS-CoV-2 not only between patients but also between patients and healthcare workers, while also containing the pandemic. There were no cases of nosocomial SARS-CoV-2 infection recorded among the patients who visited the ED or the flu clinic. All confirmed cases were community acquired and patients were cared for under constrained measures.

CONCLUSIONS

Implementing infection control measures and restricting those with respiratory symptoms to the ED pathway prevented nosocomial spread of SARS-CoV-2 infection in the ED.

Discharge against medical advice from the emergency department in a university hospital

Background

Patients discharged against medical advice (DAMA) act as a high-risk population for the Emergency Department (ED), regardless of their presentations, and can pose a serious burden for the hospital. This study examines the prevalence, demographic and clinical characteristics, reasons, and clinical outcomes of a small sample of DAMA patients in a teaching university hospital, including readmission, morbidity, and mortality.

Methods

A prospective, descriptive cross-sectional study was conducted in the ED of King Hamad University Hospital (KHUH) with 98,992 patient visits during a 1-year period from June 2018 to June 2019. Consenting DAMA patients were asked to complete a data collection form.

Results

Patients (n = 413) had a mean age of 44.1 years with a female majority (57.1%). The majority were categorized as triage level-3 (87.7%). The main reasons for DAMA included refusal of the procedure/operation (23.2%), long ED waiting time (22.2%), subjective improvement with treatment (17.7%), and children at home (14.8%), whereas the least selected reason was dissatisfaction with medical care (1.2%). Follow-up of DAMA patients revealed that 86 cases (20.8%) were readmitted to the ED within 72 h of which 41 (47.7%) cases were morbidity and 2 (2.3%) were mortality. Marital status was a predictor of DAMA patients who revisit the ED within 72 h.

Conclusion

The results act as a pilot study to examine a small sample of DAMA patients’ characteristics, diagnosis, and ED revisits. Hospitals should investigate further the DAMA population on a larger scale, reasons for refusing procedures, and utilize this knowledge to improve the healthcare process.

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study

BACKGROUND

In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal.

OBJECTIVE

The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease.

METHODS

A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness.

RESULTS

Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025.

CONCLUSIONS

The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/25619.

Context is Key: Using the Audit Log to Capture Contextual Factors Affecting Stroke Care Processes

High quality patient care through timely, precise and efficacious management depends not only on the clinical presentation of a patient, but the context of the care environment to which they present. Understanding and improving factors that affect streamlined workflow, such as provider or department busyness or experience, are essential to improving these care processes, but have been difficult to measure with traditional approaches and clinical data sources. In this exploratory data analysis, we aim to determine whether such contextual factors can be captured for important clinical processes by taking advantage of non-traditional data sources like EHR audit logs which passively track the electronic behavior of clinical teams. Our results illustrate the potential of defining multiple measures of contextual factors and their correlation with key care processes. We illustrate this using thrombolytic (tPA) treatment for ischemic stroke as an example process, but the measurement approaches can be generalized to multiple scenarios.

Pilot assessment of an on-demand telehealth 'left without being seen' follow-up programme

INTRODUCTION

On-demand telehealth can have a high rate of patients requesting visits and dropping off without being seen by a provider, especially during the COVID-19 pandemic.

METHODS

On-demand telehealth requests made to a large healthcare system in the USA between 15 March 2020 and 31 May 2020 were included for analysis with a focus on patients who were defined as left without being seen (LWBS). As part of a pilot program a registered nurse attempted to call LWBS patients within 24 hours of their telehealth request and asked if they were ok, if they sought care for their original visit reason, what that care was, or if they still needed guidance. This information and patient demographics were analyzed.

RESULTS

During the study period there were 21,610 completed on-demand telehealth visits and 1852 patients for whom there were LWBS attempted follow-ups. Most patients LWBS for a reason that originated from the patient and not associated with the provider or telehealth platform. The mean wait time for LWBS patients was 12.4 min compared to patients waiting 15.1 min before engaging with a provider to complete a visit. Of the 1852 total LWBS patients in the follow-up programme, 819 (44.2%) were successfully contacted with a follow-up phone call. Most of these patients (63.2%) already completed or planned to complete a telehealth visit, 13.6% indicated they no longer needed to see a provider, and 12.8% planned or already completed an in-person visit. Only 2.2% went to an emergency department.

DISCUSSION

Results suggest patients can effectively self-manage their care needs.

Increasing consultant-level staffing as a proportion of overall physician coverage improves emergency department length of stay targets

Objectives

One goal of Emergency Department (ED) operations is achieving an overall length of stay (LOS) that is less than four hours. The goal of the current study was to assess for association between increasing number of on-duty EM Consultants and LOS, while adjusting for overall (all-grade) on-duty emergency doctors’ numbers and other operational factors.

Methods

This was a retrospective analysis of three years (2016–2019) of data, employing a unit of analysis of 3276 eight-hour ED shifts. The study was conducted using a prospectively populated ED database in a busy (annual census 420,000) Middle Eastern ED with staffing by Consultants and multiple non-Consultant grades (Specialists, fellows, and residents). Using logistic regression, the main predictor variable of “on-duty Consultant n” was assessed for association with the study’s primary (dichotomous) endpoint: whether a shift’s median LOS met the target of < 240 min. Linear regression was used to assess for association between on-duty Consultant n and the study’s secondary (continuous) endpoint: median LOS for the ED shift.

Results

Multivariate logistic regression adjusting for a number of operations factors (including total EP on-duty complement) identified an association between increasing n of on-duty Consultants and the likelihood of a shift’s meeting the 4-h ED LOS target (OR 1.27, 95% CI 1.20 to 1.34, p < .0001). Multiple linear regression, which also adjusted for total on-duty EP n and other operational factors, also indicated LOS benefit from more on-duty Consultants: each additional on-duty Consultant was associated with a shift’s median LOS improving by 5.4 min (95% CI 4.3 to 6.5, p < .0001).

Conclusions

At the study site, in models that adjusted for overall on-duty EP numbers as well as myriad other operational factors, increasing numbers of on-duty Consultants was associated with a statistically and operationally significant reduction in ED LOS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-020-00399-8.

Impact of Co-occurring Mental Disorders and Chronic Physical Illnesses on Frequency of Emergency Department Use and Hospitalization for Mental Health Reasons

Background: Patients with mental disorders (MD) are at high risk for a wide range of chronic physical illnesses (CPI), often resulting in greater use of acute care services. This study estimated risk of emergency department (ED) use and hospitalization for mental health (MH) reasons among 678 patients with MD and CPI compared to 1,999 patients with MD only. Methods: Patients visiting one of six Quebec (Canada) ED for MH reasons and at onset of a MD in 2014-15 (index year) were included. Negative binomial models comparing the two groups estimated risk of ED use and hospitalization at 12-month follow-up to index ED visit, controlling for clinical, sociodemographic, and service use variables. Results: Patients with MD, more severe overall clinical conditions and those who received more intensive specialized MH care had higher risks of frequent ED use and hospitalization. Continuity of medical care protected against both ED use and hospitalization, while general practitioner (GP) consultations protected against hospitalization only. Patients aged 65+ had lower risk of ED use, whereas risk of hospitalization was higher for the 45-64- vs. 12-24-year age groups, and for men vs. women. Conclusion: Strategies including assertive community treatment, intensive case management, integrated co-occurring treatment, home treatment, and shared care may improve adequacy of care for patients with MD-CPI, as well as those with MD only whose clinical profiles were severe. Prevention and outreach strategies may also be promoted, especially among men and older age groups.

Long emergency department length of stay: A concept analysis

INTRODUCTION

Emergency Department (ED) Length of stay (LOS) has been associated with poor patient outcomes, which has led to the implementation of time targets designed to keep EDLOS below a specific limit. The cut-offs defining long EDLOS varies across settings and seem to be arbitrarily chosen. This study aimed to clarify the meaning of long EDLOS.

METHODS

A concept analysis using the Walker and Avant approach was conducted. It included a literature search aiming to identify all uses of the concept, resulting in a set of defining attributes and a way of measuring the concept empirically.

RESULTS

Long EDLOS was primarily used as proxy for other phenomena, e.g. boarding or crowding. The definitions had cut-offs ranging between 4 and 48 h. The attributes defining long EDLOS was waiting, a crowded ED environment and an inefficient organization.

DISCUSSION

Time targets are probably more suitable when directed towards and tailored for specific sub-groups of the ED population.

Evaluation of outcome relevance of quality indicators in the emergency department (ENQuIRE): study protocol for a prospective multicentre cohort study

INTRODUCTION

Quality of emergency department (ED) care affects patient outcomes substantially. Quality indicators (QIs) for ED care are a major challenge due to the heterogeneity of patient populations, health care structures and processes in Germany. Although a number of quality measures are already in use, there is a paucity of data on the importance of these QIs on medium-term and long-term outcomes. The evaluation of outcome relevance of quality indicators in the emergency department study (ENQuIRE) aims to identify and investigate the relevance of QIs in the ED on patient outcomes in a 12-month follow-up.

METHODS AND ANALYSIS

The study is a prospective non-interventional multicentre cohort study conducted in 15 EDs throughout Germany. Included are all patients in 2019, who were ≥18 years of age, insured at the Techniker Krankenkasse (statutory health insurance (SHI)) and gave their written informed consent to the study.The primary objective of the study is to assess the effect of selected quality measures on patient outcome. The data collected for this purpose comprise medical records from the ED treatment, discharge (claims) data from hospitalised patients, a patient questionnaire to be answered 6-8 weeks after emergency admission, and outcome measures in a 12-month follow-up obtained as claims data from the SHI.Descriptive and analytical statistics will be applied to provide summaries about the characteristics of QIs and associations between quality measures and patient outcomes.

ETHICS AND DISSEMINATION

Approval of the leading ethics committee at the Medical Faculty of the University of Magdeburg (reference number 163/18 from 19 November 2018) has been obtained and adapted by responsible local ethics committees.The findings of this work will be disseminated by publication of peer-reviewed manuscripts and presentations as conference contributions (abstracts, poster or oral presentations).Moreover, results will be discussed with clinical experts and medical associations before being proposed for implementation into the quality management of EDs.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00015203); Pre-results.

Emergency Key Performance Indicators in the Italian region Friuli Venezia Giulia

Key Performance Indicators (KPI) regard key areas of a particular service which needs to be evaluated. Within the health system, they represent specific and measurable elements and are based on standards generally set by the scientific literature. KPI can be used to assess performances in different areas and achievement of goals. To develop and calculate a set of KPI in the Italian Region Friuli Venezia Giulia (1 million inhabitants) as an audit tool for the regional Emergency healthcare system, with a focus on three timedependent conditions: trauma, acute myocardial infarction, and stroke. To develop the set, a modified Delphi process was applied among Emergency care experts in Friuli Venezia Giulia. Then, the indicators were calculated from anonymous administrative health databases (Emergency Medical System, Emergency Department, hospital discharge, cardiac catheterization laboratory). Databases could be linked with each other at the individual level through a univocal stochastic key. Sensitivity analyses were conducted where different results were expected using different databases. Sixty-one indicators were calculated for the year 2018. Five indicators were summary descriptive measures, 10 were outcome measures, the others were process indicators; 20 were specific on acute myocardial infarction, 12 on trauma, 4 on stroke. Values for some indicators varied depending on the data source. These KPI provided new and interesting information and are used for periodic audit purposes in Friuli Venezia Giulia. Higher quality, completeness and richness of the administrative databases should be promoted to further increase the value of the indicators.

Physician-related factors associated with unscheduled revisits to the emergency department and admission to the intensive care unit within 72 h

Investigation of physician-related causes of unscheduled revisits to the emergency department (ED) within 72 h with subsequent admission to the intensive care unit (ICU) is an important parameter of emergency care quality. Between 2012 and 2017, medical records of all adult patients who visited the ED and returned within 72 h with subsequent ICU admission were retrospectively reviewed by three experienced emergency physicians. Study parameters were categorized into "input" (Patient characteristics), "throughput" (Time spent on first ED visit and seniority of emergency physicians, and "output" (Charlson Comorbidity Index). Of the 147 patients reviewed for the causes of ICU admission, 35 were physician-related (23.8%). Eight belonged to more urgent categories, whereas the majority (n = 27) were less urgent. Patients who spent less time on their first ED visits before discharge (< 2 h) were significantly associated with physician-related causes of ICU admission, whereas there was no significant difference in other "input," "throughput," and "output" parameters between the "physician-related" and "non-physician-related" groups. Short initial management time was associated with physician-related causes of ICU admission in patients with initial less urgent presentations, highlighting failure of the conventional triage system to identify potentially life-threatening conditions and possibility of misjudgement because of the patients' apparently minor initial presentations.

Strategies to measure and improve emergency department performance: a scoping review

Background

Over the last two decades, Emergency Department (ED) crowding has become an increasingly common occurrence worldwide. Crowding is a complex and challenging issue that affects EDs’ capacity to provide safe, timely and quality care. This review aims to map the research evidence provided by reviews to improve ED performance.

Methods and findings

We performed a scoping review, searching Cochrane Database of Systematic Reviews, Scopus, EMBASE, CINAHL and PubMed (from inception to July 9, 2019; prospectively registered in Open Science Framework https://osf.io/gkq4t/). Eligibility criteria were: (1) review of primary research studies, published in English; (2) discusses a) how performance is measured in the ED, b) interventions used to improve ED performance and their characteristics, c) the role(s) of patients in improving ED performance, and d) the outcomes attributed to interventions used to improve ED performance; (3) focuses on a hospital ED context in any country or healthcare system. Pairs of reviewers independently screened studies’ titles, abstracts, and full-texts for inclusion according to pre-established criteria. Discrepancies were resolved via discussion. Independent reviewers extracted data using a tool specifically designed for the review. Pairs of independent reviewers explored the quality of included reviews using the Risk of Bias in Systematic Reviews tool. Narrative synthesis was performed on the 77 included reviews. Three reviews identified 202 individual indicators of ED performance. Seventy-four reviews reported 38 different interventions to improve ED performance: 27 interventions describing changes to practice and process (e.g., triage, care transitions, technology), and a further nine interventions describing changes to team composition (e.g., advanced nursing roles, scribes, pharmacy). Two reviews reported on two interventions addressing the role of patients in ED performance, supporting patients’ decisions and providing education. The outcomes attributed to interventions used to improve ED performance were categorised into five key domains: time, proportion, process, cost, and clinical outcomes. Few interventions reported outcomes across all five outcome domains.

Conclusions

ED performance measurement is complex, involving automated information technology mechanisms and manual data collection, reflecting the multifaceted nature of ED care. Interventions to improve ED performance address a broad range of ED processes and disciplines.

Assessing healthcare service quality using routinely collected data: Linking information systems in emergency care

Emergency departments need to continuously calculate quality indicators in order to perform structural improvements, improvements in the daily routine, and ad-hoc improvements in everyday life. However, many different actors across multiple disciplines collaborate to provide emergency care. Hence, patient-related data is stored in several information systems, which in turn makes the calculation of quality indicators more difficult. To address this issue, we aim to link and use routinely collected data of the different actors within the emergency care continuum. In order to assess the feasibility of linking and using routinely collected data for quality indicators and whether this approach adds value to the assessment of emergency care quality, we conducted a single case study in a German academic teaching hospital. We analyzed the available data of the existing information systems in the emergency continuum and linked and pre-processed the data. Based on this, we then calculated four quality indicators (Left Without Been Seen, Unplanned Reattendance, Diagnostic Efficiency, and Overload Closure). Lessons learned from the calculation and results of the discussions with staff members that had multiple years of work experience in the emergency department provide a better understanding of the quality of the emergency department, the related challenges during the calculation, and the added value of linking routinely collected data.

The Impact of On-duty Emergency Medicine Trainees on Left-Without-Being-Seen Rates in an Academic Emergency Department

Objectives: One of the endpoints for assessing the emergency department (ED) performance is the left-without-being-seen (LWBS) proportion. This study aimed to evaluate the impact of increasing proportions of on-duty emergency medicine (EM) trainees on LWBS rates in clinical shifts. Methods: The study was conducted at an urban-academic-ED (annual census: 452,757) over a period of one year. We employed multivariate linear regression (p < 0.05) defining significance to identify and adjust for multiple LWBS influencers related to patient care. Results: After analyzing over 1098 shifts, the median LWBS rate was 8.9% (interquartile range 5.3% to 13.5%). The increasing number of EM trainees in the ED did not adversely impact the LWBS; the opposite was noted. In univariate analysis, the increasing proportion of on-duty EM trainee physicians was significantly (p < 0.001) associated with a decrease in the LWBS rates. The multivariate model adjusted for the statistically significant and confounding LWBS influencers, with an absolute increase of 1% in trainees’ proportion of overall on-duty physician coverage, was associated with an absolute decrease of 2.1% in LWBS rates (95% confidence interval 0.43% to 3.8%, p = 0.014). Conclusions: At the study site, there was a statistically and operationally significant improvement in LWBS associated with partial replacement of board-certified specialist-grade EM physicians with EM residents and fellow trainees.

Template for uniform reporting of emergency department measures, consensus according to the Utstein method

OBJECTIVE

To develop a template for uniform reporting of standardized measuring and describing of care provided in the emergency department (ED).

METHODS

An international group of experts in emergency medicine, with broad experience from different clinical settings, met in Utstein, Norway. Through a consensus process, a limited number of measures that would accurately describe an ED were chosen and a template was developed.

RESULTS

The final measures to be reported and their definitions were grouped into six categories: Structure, Staffing and governance, Population, Process times, Hospital and healthcare system and Outcomes. The template for Utstein-style uniform reporting is presented.

CONCLUSION

The suggested template is intended for use in studies carried out in EDs to improve comparability and knowledge translation.

A Review of Various Methods of Management of Risk in the Field of Emergency Medicine

BACKGROUND:

The main concept of risk management in the emergency department (ED) contains a broader meaning, so that; it’s known as a sudden event or situation which would happen at an uncertain future that has some negative or positive impacts which could be called threat or opportunity respectively. However, the knowledge of risk management could cover the overall procedures involved with administering the planning of risk management, identification, investigation, monitoring and also step by step clinical examination. One of the main tools for preventing adversities is evaluating and management of possible risks.

AIM:

One of the main objectives of the present study is recognising the most frequent types of the risk happening in the EDs. Moreover, the present study is trying to evaluate the possible risks which could happen among various ED sections.

METHODS:

Six databases of EMBASE, HubMed, Cochrane Library, MEDLINE, PubMed, CHBD and Goggle scholar were chosen for discovering much-related articles from the year 2005 to 2019. A total number of 68 were chosen finally to be reviewed more precisely based on the main objective of the present study.

RESULTS:

Precise planning, preparing sufficiently and conducting the process of continuous monitoring are needed for ensuring the fact that any possible risks could be managed through these planned strategies. On the other hand, by modifying the patients’ beliefs, anticipations and the available social culture about the importance of risk management issue, the overall objective of the present study could be achieved at higher rates.

CONCLUSION:

Moreover, because the potential of occurrence of risk in EDs is high and approximately more than half of them are fatal, more precise adequate systematic plans for management of them should result.

Preferences for centralised emergency medical services: discrete choice experiment

OBJECTIVES

It is desirable that public preferences are established and incorporated in emergency healthcare reforms. The aim of this study was to investigate preferences for local versus centralised provision of all emergency medical services (EMS) and explore what individuals think are important considerations for EMS delivery.

DESIGN

A discrete choice experiment was conducted. The attributes used in the choice scenarios were: travel time to the hospital, waiting time to be seen, length of stay in the hospital, risks of dying, readmission and opportunity for outpatient care after emergency treatment at a local hospital.

SETTING

North East England.

PARTICIPANTS

Participants were a randomly sampled general population, aged 16 years or above recruited from Healthwatch Northumberland network database of lay members and from clinical contact with Northumbria Healthcare National Health Service Foundation Trust via Patient Experience Team.

PRIMARY AND SECONDARY OUTCOME MEASURES

Analysis used logistic regression modelling techniques to determine the preference of each attribute. Marginal rates of substitution between attributes were estimated to understand the trade-offs individuals were willing to make.

RESULTS

Responses were obtained from 148 people (62 completed a web and 86 a postal version). Respondents preferred shorter travel time to hospital, shorter waiting time, fewer number of days in hospital, low risk of death, low risk of readmission and outpatient follow-up care in their local hospital. However, individuals were willing to trade off increased travel time and waiting time for high-quality centralised care. Individuals were willing to travel 9 min more for a 1-day reduction in length of stay in the hospital, 38 min for a 1% reduction in risk of death and 112 min for having outpatient follow-up care at their local hospital.

CONCLUSIONS

People value centralised EMS if it provides higher quality care and are willing to travel further and wait longer.

Establishment of a Unified Quality Indicators System to Increase the Effectiveness of Emergency Departments

The overall quality of an emergency department (ED) can be measured by its ability to provide fast, efficient yet high-quality medical treatments to its patients. The objective of the present study was to derive a common set of key indicators that could be used to assess the quality of the performance of EDs. A modified Delphi process was employed to achieve this. This consisted of a detailed literature review followed by a three-round expert panel interaction, which was used to reduce and refine the list of indicators. The members of the panel comprised ED physicians, ED nurses and hospital and ED administrators drawn from six EDs. This process yielded 47 essential performance indicators and 12 recommended indicators. The performance indicators were classified into 7 main groups according to their characteristics. The chosen indicators comprise a core set that will be used in an ongoing study on a representative sample of EDs.

Impact of Emergency Department Phlebotomists on Left-Before-Treatment-Completion Rates

Introduction

The emergency department (ED) serves as the primary access point to the healthcare system. ED throughput efficiency is critical. The percentage of patients who leave before treatment completion (LBTC) is an important marker of department efficiency. Our study aimed to assess the impact of an ED phlebotomist, dedicated to obtaining blood specimen collection on waiting patients, on LBTC rates.

Methods

This study was conducted as a retrospective observational analysis over approximately 18 months (October 5, 2015–March 31, 2017) for patients evaluated by a triage provider with a door-to-room (DtR) time of > 20 minutes (min). LBTC rates were compared in 10-min DtR increments for when the ED phlebotomist collected the patient’s specimen vs not.

Results

Of 71,942 patient encounters occurring during the study period, 17,349 (24.1%) met study inclusion criteria. Of these, 1842 (10.6%) had blood specimen collection performed by ED phlebotomy. The overall LBTC rate for encounters included in the analysis was 5.26% (95% confidence interval [CI], 4.94%–5.60%). Weighting the LBTC rates for each 10-min DtR interval using the fixed effects model led to an overall LBTC rate of 2.74% (95% CI, 2.09%–3.59%) for patient encounters with ED phlebotomist collection vs 5.31% (95% CI, 4.97%–5.67%) in those which did not, yielding a relative reduction of 48% (95% CI, 34%–63%). The effect of the phlebotomist on LBTC rates increased as DtR times increased. The difference in the rate of the rise of LBTC percentages, per 10-min interval, was 0.50% (95% CI, 0.19%–0.81%) higher for non-ED phlebotomist encounters vs phlebotomist encounters.

Conclusion

ED phlebotomy demonstrated a significant reduction in ED LBTC rates. Further, as DtR times increased, the impact of ED phlebotomy became increasingly significant. Adult EDs with increased rates of LBTC patient encounters may want to consider the implementation of ED phlebotomy.

SurgeCon: Priming a Community Emergency Department for Patient Flow Management

Introduction

Canadian emergency departments (ED) are struggling to provide timely emergency care. Very few studies have assessed attempts to improve ED patient flow in the rural context. We assessed the impact of SurgeCon, an ED patient-management protocol, on total patient visits, patients who left without being seen (LWBS), length of stay for departed patients (LOSDep), and physician initial assessment time (PIA) in a rural community hospital ED.

Methods

We implemented a set of commonly used methods for increasing ED efficiency with an innovative approach over 45 months. Our intervention involved seven parts comprised of an external review, Lean training, fast track implementation, patient-centeredness approach, door-to-doctor approach, performance reporting, and an action-based surge capacity protocol. We measured key performance indicators including total patient visits (count), PIA (minutes), LWBS (percentage), and LOSDep (minutes) before and after the SurgeCon intervention. We also performed an interrupted time series (ITS) analysis.

Results

During the study period, 80,709 people visited the ED. PIA decreased from 104.3 (±9.9) minutes to 42.2 (±8.1) minutes, LOSDep decreased from 199.4 (±16.8) minutes to 134.4(±14.5) minutes, and LWBS decreased from 12.1% (±2.2) to 4.6% (±1.7) despite a 25.7% increase in patient volume between pre-intervention and post-intervention stages. The ITS analysis revealed a significant level change in PIA - 19.8 minutes (p<0.01), and LWBS - 3.8% (0.02), respectively. The change over time decreased by 2.7 minutes/month (p< 0.001), 3.0 minutes/month (p<0.001) and 0.4%/month (p<0.001) for PIA, LOSDep, and LWBS, after the intervention.

Conclusion

SurgeCon improved the key wait-time metrics in a rural ED in a country where average wait times continue to rise. The SurgeCon platform has the potential to improve ED efficiency in community hospitals with limited resources.

Modeling operational quality metrics and costs of long-acting antibiotics for acute bacterial skin and skin structure infection treatment in the emergency department

Aims: To model implementation of a new treatment pathway leveraging long-acting antibiotics (LAs) for treatment of acute bacterial skin and skin structure infections (ABSSSIs) in a hospital emergency department (ED) with an observation unit, and to quantify health resource utilization and economic outcomes versus standard care (intravenous vancomycin). Materials and methods: Discrete-event simulation was used to model implementation of the LA treatment pathway in the ED versus standard care from the US Medicare perspective. Model inputs were derived from published sources to simulate a real-world hospital ED with an observation unit. Outcomes included key ED metrics such as patient throughput rate and length of stay (LOS) and cost (estimated through reimbursed amounts in 2017 USD). Results: Implementation of an LA pathway in the ED improved ABSSSI patient throughput rate by 350% (+5.8 dispositions/ED and observation unit day) and reduced LOS by 68% (-7.2 h/patient). These improvements in patient outcomes are driven by the reduced infusion time required for LA antibiotics and are greater for dalbavancin than oritavancin owing to the shorter infusion duration (30 min vs. 3 h). Limitations: External validity of the model was not assessed. The model was limited to care received in EDs; therefore, certain clinical variables outside the ED were not captured for this analysis. Conclusions: LA pathway implementation for ABSSSI treatment in the ED supported improved efficiency, which may translate to economic value. As EDs continue to focus on improving key metrics such as throughput rate and LOS, LA pathway implementation should be considered as a potential approach for abbreviated ABSSSI treatment in the ED.

The crowd-out effect of a mass casualty incident: Experience from a dust explosion with multiple burn injuries

A mass casualty incident (MCI) can have an enormous impact on an already crowded emergency department (ED), affecting the quality of health care provided to non-MCI ED patients. On June 26, 2015, a burn MCI (BMCI) occurred due to a cornstarch explosion at a party at a water park. The competing needs of the BMCI patients might have crowded out the needs of the non-BMCI patients. Although crowd-out effects have been previously documented in a variety of health care situations, they have not been extensively evaluated during MCIs. We aimed to determine whether the outcomes of the non-MCI patients were compromised during this incident.We conducted a retrospective observational study comparing several health care parameters and outcomes between non-BMCI patients and historical controls during the designated period using institutional electronic records and the National Health Insurance Research Database.On the night of the incident, 53 patients were sent to our ED; most of them arrived within 3 hours after the BMCI. There was a significant increase in the wait time for ICU beds among non-BMCI patients compared to the wait times during the corresponding week of the previous year (8.09 ± 4.21 hours vs 3.77 ± 2.15 hours, P = .008). At the hospital level, there was a significantly increased length of hospital stay (LOS) in the ICU after the MCI compared with the LOS in the ICU in the same week of the preceding year (median days: 15 vs 8, P ≤ .001). At the regional level, there were no significant differences between the 2 periods in the LOS in acute care, LOS in the ICU or mortality rates at the involved medical centers.Crowd-out effects from the MCI occurred in the ED and at the institutional level. Although there was an increased wait time for admission to the ICU and a longer LOS in the ICU, the LOS in acute care beds, treatment of time-sensitive diseases, and mortality rates were not compromised by the current MCI protocol at either the institutional or regional levels.

Association between adopting emergency department crowding interventions and emergency departments' core performance measures

OBJECTIVES

To estimate the association between adopting emergency department (ED) crowding interventions and emergency departments' core performance measures.

METHODS

We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2007 to 2015. The outcome variables are ED length of stay for discharged and admitted patients, boarding time, wait time and percentage of patients who left ED before being seen (LWBS). The independent variables are whether or not a hospital adopted each of the 20 crowding interventions. Controlling for patient-level, hospital level and temporal confounders we analyze and report results using multivariable logit model.

RESULTS

Between 2007 and 2015, NHAMCS collected data for 269,721 ED visit encounters, representing a nationwide of about 1.18 billion separate ED visits. Of 20 crowding interventions we tested, using adopting bedside registration (OR = 0.89, 95% CI = 0.75-0.98, P < .05), electronic dashboard (OR = 0.86, 95% CI = 0.76-0.98, P < .05), kiosk check-in technology (OR = 0.56, 95% CI = 0.41-0.83, P < .001), physician based triage (OR = 0.86, 95% CI = 0.73-0.99, P < .05) full capacity protocol (OR = 0.91, 95% CI = 0.79-0.99, P < .05) are associated with decrease in the odds of prolonged wait time. Adopting kiosk check-in (OR = 0.55, 95% CI = 0.35-0.85, P < .05) is associated with a decrease in the odds of prolonged boarding time. Using wireless communication devices (OR = 0.77, 95% CI = 0.57-0.97, P < .05), bedside registration (OR = 0.77, 95% CI = 0.64-0.094, P < .05) and pooled nursing (OR = 0.84, 95% CI = 0.72-0.98, P < .05) are associated with decrease in the odds of a patient LWBS.

CONCLUSIONS

Majority of interventions did not significantly associated with ED' core performance measures.

Performance Analysis of Emergency Room Episodes Through Process Mining

The performance analysis of Emergency Room episodes is aimed at providing decision makers with knowledge that allows them to decrease waiting times, reduce patient congestion, and improve the quality of care provided. In this case study, Process Mining is used to determine which activities, sub-processes, interactions, and characteristics of episodes explain why some episodes have a longer duration. The employed method and the results obtained are described in detail to serve as a guide for future performance analysis in this domain. It was discovered that the main cause of the increment in the episode duration is the occurrence of a loop between the Examination and Treatment sub-processes. It was also found out that as the episode severity increases, the number of repetitions of the Examination-Treatment loop increases as well. Moreover, the episodes in which this loop is more common are those that lead to Hospitalization as discharge destination. These findings might help to reduce the occurrence of this loop, in turn lowering the episode duration and, consequently, providing faster attention to more patients.

Assessing quality indicators related to mental health emergency room utilization

Background

This descriptive study compared 2014–15 to 2005–06 data on the quality of mental health services (MHS) in relation to emergency room (ER) use to assess the impact of the 2005 Quebec MH reform regarding access, continuity and appropriateness of care for patients with mental illnesses (PMI).

Methods

Data emanated from the Quebec Integrated Chronic Disease Surveillance System (Quebec/Canada). Participants (865,255 for 2014–15; 817,395 for 2005–06) were age 12 or over, with at least one MI, including substance use disorders (SUD), diagnosed during an ER visit, outpatient treatment or hospitalization. Variables included: access (ER use/frequency, hospitalization rates, outpatient consultations preceding an ER visit), care continuity (outpatient consultations following an ER visit/hospitalization, consecutive returns to the ERs), and care appropriateness (high ER use, recurrence of yearly ER visits, length of hospitalization). Frequency distributions were calculated on sex, age and geographic area for ER visits/hospitalizations in 2014–15, and between 2014 and 15 and 2005–06.

Results

PMI accounted for 12 % of the Quebec population in 2014–15 (n = 865,255), of whom 39% visited an ER for any reason. Amount and frequency of ER use and number/length of hospitalizations were almost twice as high for PMI versus patients without MI; 17% of PMI were also high/very high ER users and were frequently hospitalized. Among PMI, ER users were also frequent users of outpatient services despite a lack of follow-up appointments after ER visits or hospitalizations. Findings revealed some positive changes over time, such as decreased ER and hospitalization rates; yet overall access, continuity and appropriateness of care, as measured in this study, remained low.

Conclusions

This study demonstrated that the Quebec reform did not produce a substantial impact on ER use or substantially improved care, as hypothesized. Better access and continuity of care should be promoted to reduce the high prevalence of ER use among PMI. Quality improvement in MHS may be realized if ERs are supported by substantial and well-integrated community MH networks.

Staff Perceptions of Improving Emergency Care for Children: A Qualitative Study

The objective of this study was to identify staff perceptions of a service improvement for pediatric emergency care at a university teaching hospital. Semistructured qualitative interviews of stakeholders were conducted, and grounded theory approach was used for analysis. Forty-one interviews were conducted with physicians, nurses, managers, and health care workers. Major themes emerging from the analysis included the physical space of and flow within the pediatric emergency department (ED), impact of technology, staffing in the ED, the effects of frontline pediatricians and emergency physicians managing children in the ED, and the need for and expectations of a pediatric emergency medicine (PEM) consultant. Human interactions among health care providers, leadership, and teaching are considered as equally important as providing the appropriate environment and qualified professionals for improving care for children in the ED. Appointment of a PEM consultant was suggested to provide leadership and education to manage relationships and implement changes. Subsequent to the study, the model of care for PEM was changed, the pediatric care delivery became more integrated with the main ED, and two PEM consultants were appointed to the institution.

Characteristics of ED crowding in the Lazio Region (Italy) and short-term health outcomes

The effect of emergency department (ED) crowding on patient care has been studied for several years in the scientific literature. We evaluate the association between ED crowding and short-term mortality and hospitalization in the Lazio region (Italy) using two different measures. A cohort of visits in the Lazio region ED during 2012-2014 was enrolled. Only discharged patients were selected. ED crowding was estimated using two measures, length of stay (LOS), and Emergency Department volume (EDV). LOS was defined as the interval of time from entrance to discharge; EDV was defined at the time of each new entrance in ED. The outcomes under study were mortality and hospitalization within 7 days from ED discharge. A multivariate logistic model was performed (Odds Ratios, ORs, 95% CI). The cohort includes 2,344,572 visits. ED crowding is associated with an increased risk of short-term hospitalization using both LOS and EDV as exposures (LOS 1-2 h: OR = 1.71, 95% CI 1.66-1.76, LOS 2-5 h: OR = 1.38, 95% CI 1.34-1.43, LOS > 5 h OR = 1.45 95% CI 1.40-1.50 compared to patients with 1 h of LOS; EDV 75°-95° percentile: OR = 1.02, 95% CI 0.99-1.05 and EDV > 95° percentile: OR = 1.06, 95% CI 1.01-1.11 compared to patients with a EDV < 75° percentile upon arrival). Increased risk of short-term mortality is found with increasing level of LOS. High levels of EDV at the time of patients' arrival and longer LOS in ED are associated with greater risks of hospitalization for patients discharged 7 days before. LOS in ED is also associated with an increased risk of mortality.

Linking the severity of illness and the weekend effect: a cohort study examining emergency department visits

BACKGROUND

Despite extensive research on the "weekend effect" i.e., the increased mortality associated with hospital admission during weekend, knowledge about disease severity in previous studies is limited. The aim of this study is to examine patient characteristics, including disease severity, 30-day mortality, and length of stay (LOS), according to time of admission to an emergency department.

METHODS

Our study encompassed all patients admitted to a Danish emergency department in 2014-2015. Using data from electronic patient records, this study examines patient characteristics including age, gender, Charlson Comorbidity Index score, triage score, and primary diagnosis. Triage score and transfer to intensive care unit (ICU) were used as indicators of disease severity. LOS within the department and within the hospital was examined. Age- and sex-standardized 30-day mortality rates comparing patients with the same triage score admitted at daytime, evening, and nighttime on weekdays and on weekends were computed. To test differences, a Cox regression analysis was added.

RESULTS

We included 35,459 patient visits, of which 10,435 (32%) started on a weekend. There were no large differences in baseline characteristics between patients admitted on weekdays and those admitted on weekends. The relative risk (RR) for being triaged orange or red was 1.16 (95% confidence interval (CI) 1.06-1.28, P = 0.0017) for weekend admissions as compared with weekday admissions. Weekend admissions were twice as likely as weekday admissions to be transferred to the ICU (RR, 1.96; 95% CI 1.53-2.52, P = 0.0000). No significant changes were found in LOS. The 30-day mortality rate increased with disease severity regardless of time of admission. When comparing the 30-day mortality rate for patients with the same triage score, the trend was toward a higher mortality when admission occurred during the weekend. Increasing mortality rate was significant for patients admitted at evening on weekends with a hazard ratio of 1.32 (95% CI 1.03-1.70, P = 0.027) when compared with patients admitted on daytime on weekdays.

CONCLUSIONS

When comparing weekday and weekend admissions, the 30-day mortality rate increased for patients admitted at evening on weekends after adjusting for comorbidity and triage score, indicating that the weekend effect was independent of changes in illness severity.

Maintaining Safety and Improving the Care of Pediatric Behavioral Health Patients in the Emergency Department

Pediatric emergency visits for behavioral health complaints have been increasing for more than a decade. There are currently no best practices or ideal models of care. However, the evidence base for existing emergency department operational concepts can be used to implement modifications to workflow, care model, staffing, and physical environment to address patient needs. Rapid assessment, split flow, blended care model, multidisciplinary team development, mental health nursing triage, and staff training can all positively affect length of stay, staff safety, and patient satisfaction.