Evaluating the effect of emergency department crowding on triage destination

Evaluating LLM-based generative AI tools in emergency triage: A comparative study of ChatGPT Plus, Copilot Pro, and triage nurses

BACKGROUND

The number of emergency department (ED) visits has been on steady increase globally. Artificial Intelligence (AI) technologies, including Large Language Model (LLMs)-based generative AI models, have shown promise in improving triage accuracy. This study evaluates the performance of ChatGPT and Copilot in triage at a high-volume urban hospital, hypothesizing that these tools can match trained physicians' accuracy and reduce human bias amidst ED crowding challenges.

METHODS

This single-center, prospective observational study was conducted in an urban ED over one week. Adult patients were enrolled through random 24-h intervals. Exclusions included minors, trauma cases, and incomplete data. Triage nurses assessed patients while an emergency medicine (EM) physician documented clinical vignettes and assigned emergency severity index (ESI) levels. These vignettes were then introduced to ChatGPT and Copilot for comparison with the triage nurse's decision.

RESULTS

The overall triage accuracy was 65.2 % for nurses, 66.5 % for ChatGPT, and 61.8 % for Copilot, with no significant difference (p = 0.000). Moderate agreement was observed between the EM physician and ChatGPT, triage nurses, and Copilot (Cohen's Kappa = 0.537, 0.477, and 0.472, respectively). In recognizing high-acuity patients, ChatGPT and Copilot outperformed triage nurses (87.8 % and 85.7 % versus 32.7 %, respectively). Compared to ChatGPT and Copilot, nurses significantly under-triaged patients (p < 0.05). The analysis of predictive performance for ChatGPT, Copilot, and triage nurses demonstrated varying discrimination abilities across ESI levels, all of which were statistically significant (p < 0.05). ChatGPT and Copilot exhibited consistent accuracy across age, gender, and admission time, whereas triage nurses were more likely to mistriage patients under 45 years old.

CONCLUSION

ChatGPT and Copilot outperform traditional nurse triage in identifying high-acuity patients, but real-time ED capacity data is crucial to prevent overcrowding and ensure high-quality of emergency care.

Evaluation of problems arising in emergency services from the perspectives of medical and criminal law: The example of Türkiye

Introduction

In recent years, the field of medical malpractice has attracted growing attention, and despite the long history of research in this area, aspects of this phenomenon remain unexplored. In this paper, we aimed to explore the issue of medical malpractice, focusing on cases involving healthcare professionals working in emergency services in Türkiye. We examine the surge in medical malpractice lawsuits, the consequences of such cases, and the prevalence of criminal liability faced by healthcare professionals.

Materials and methods

A comprehensive analysis of healthcare-related cases from 2017 to 2022 was carried out using the electronic decision database "LEGALBANK." We scrutinized these cases from both medical and criminal law perspectives, aiming to shed light on the complex dynamics of medical malpractice in emergency services.

Results

The findings reveal that professionals in emergency services are confronted with a considerable number of criminal cases. Among these cases, doctors are the most frequently implicated, followed by nurses, midwives, ambulance drivers, and other healthcare professionals. The crimes attributed to these professionals vary but primarily include involuntary manslaughter, misuse of public duty, forgery of documents, and reckless injury.

Discussion

In Türkiye, there is a notable prevalence of investigations conducted in emergency services and criminal cases involving healthcare professionals in this field. This dual prominence underscores the unique significance of examining medical malpractice from the perspectives of both criminal law and medicine within the Turkish context. This study categorizes the multifaceted challenges of medical malpractice as human-related, system-related, and legal, offering valuable insights into the intricate landscape of this phenomenon in Türkiye's emergency services.

Conclusion

This research contributes to a deeper understanding of medical malpractice, particularly its criminal dimensions in the Turkish context, and thereby calls for improved healthcare, enhanced patient safety, and error prevention in emergency settings.

The Need for a New Approach to MCI Readiness in the Era of Emergency Department and Hospital Crowding

Emergency department (ED) visit volumes have increased since 2007, with crowding in the United States reaching its highest levels in 2022. During this same period, mass casualty incidents (MCIs) have increased dramatically, both in frequency and severity, across the United States. Resuscitation of trauma patients is a time-sensitive process that requires immediate patient assessment by coordinated clinical teams in order to successfully diagnose and manage life-threatening injuries. To make resuscitation spaces immediately available for incoming patients, typical MCI plans call for rapidly relocating ED patients from their rooms into hallways or transferring them to open inpatient areas. With current levels of crowding, however, such alternate care spaces are often already in use and traditional MCI plans are increasingly unrealistic. With ED crowding worsening and the frequency of MCIs rising, there is a worrisome risk that EDs could fail in their efforts to save patients due to insufficient resources and spaces to meet the demands of critically injured patients. Hospitals must use innovative, novel response strategies to ensure sufficient patient care spaces in a short timeframe to save the most lives possible. In this commentary, we describe the use of buffer zones to help EDs mobilize an effective response to MCIs in the current context of severe hospital crowding.

Evaluation of Emergency Severity Index (ESI) triage quality by nurses and associated factors in Iran

INTRODUCTION

The triage process of patients in emergency departments is done by nurses in Iran. it is necessary to pay attention to the ability of nurses in patients' triage in order to have a correct picture of the status of the emergency department, so the aims of this study is to investigate the quality of nurses' triage using the Emergency Severity Index (ESI) method and related factors.

MATERIALS AND METHODS

This is a descriptive study which was performed on all 900 patients referring to the emergency department during 12 months from 2019 to 2020 in the Triage unit of two trauma center hospitals affiliated to Isfahan university of medical sciences. Data collection tools included patients' demographic, nurses' demographic and occupational checklist, and ESI Triage Form. To analyze the data, SPSS software was used, descriptive and analytic statistics were used, P < 0.05 was considered statistically significant.

RESULTS

No significant difference was observed between the quality level of triage by nurses and physicians (P > 0.05), the results of independent t-test showed that nurses in the over triage group have a higher average age and work experience. In the under triage level, the frequency of female nurses was significantly higher than male nurses (P < 0/05).

CONCLUSION

Accurate and fast triage of patients is the key to successful performance in the emergency department. Therefore correct implementation of triage and identifying the need for nurses for training and identifying existing deficiencies are of utmost importance.

Validation of the Korean Version of the Clinical Frailty Scale-Adjusted Korean Triage and Acuity Scale for Older Patients in the Emergency Department

Background and Objectives: The Clinical Frailty Scale (CFS), used to screen for prehospital frailty in patients aged >65 years, is simple, time-efficient, and has been validated in emergency departments (EDs). In this study, we analyzed whether the Korean Triage and Acuity Scale (KTAS) classification by level in older patients determined to have frailty based on the Korean version of the CFS increases the triage performance of the current KTAS. Materials and Methods: The primary outcome was 30-day in-hospital mortality, and secondary outcomes were hospital and intensive care unit (ICU) admissions. This study retrospectively analyzed prospectively collected data from three ED centers. Patients with a CFS score ranging from five (mildly frail) to nine (terminally ill) were categorized into the frailty group. We upgraded the KTAS classification of the frailty group by one level of urgency and defined this as the CFS-KTAS. Results: The cutoff values for predicting admission were three and two for the KTAS and CFS-KTAS, respectively. A significant difference was observed in the area under the receiver operating characteristic (AUROC) curve between the KTAS and CFS-KTAS. To predict ICU admission, the cutoff score was two for both scales. A significant difference was observed in the AUROC curve between the KTAS and CFS-KTAS. For predicting in-hospital mortality, the cutoff score was two for both scales. A significant difference was observed in the AUROC curve between the KTAS and CFS-KTAS. Conclusions: This study showed that the CFS-adjusted KTAS has a more useful prognostic value than the KTAS alone for predicting hospital outcomes in older patients.

Estimation of racial and language disparities in pediatric emergency department triage using statistical modeling and natural language processing

OBJECTIVES

The study aims to assess racial and language disparities in pediatric emergency department (ED) triage using analytical techniques and provide insights into the extent and nature of the disparities in the ED setting.

MATERIALS AND METHODS

The study analyzed a cross-sectional dataset encompassing ED visits from January 2019 to April 2021. The study utilized analytical techniques, including K-mean clustering (KNN), multivariate adaptive regression splines (MARS), and natural language processing (NLP) embedding. NLP embedding and KNN were employed to handle the chief complaints and categorize them into clusters, while the MARS was used to identify significant interactions among the clinical features. The study also explored important variables, including age-adjusted vital signs. Multiple logistic regression models with varying specifications were developed to assess the robustness of analysis results.

RESULTS

The study consistently found that non-White children, especially African American (AA) and Hispanic, were often under-triaged, with AA children having >2 times higher odds of receiving lower acuity scores compared to White children. While the results are generally consistent, incorporating relevant variables modified the results for specific patient groups (eg, Asians).

DISCUSSION

By employing a comprehensive analysis methodology, the study checked the robustness of the analysis results on racial and language disparities in pediatric ED triage. The study also recognized the significance of analytical techniques in assessing pediatric health conditions and analyzing disparities.

CONCLUSION

The study's findings highlight the significant need for equal and fair assessment and treatment in the pediatric ED, regardless of their patients' race and language.

Electrocardiogram interpretation during nurse triage improves the performance of the triage system in patients with cardiovascular symptoms - A prospective observational study

BACKGROUND

An immediate ECG on arrival of a patient with cardiovascular symptoms in the ED may anticipate the need for life-saving intervention. The aim was to evaluate whether ECG interpretation during nurse triage can improve triage system performance in patients with cardiovascular symptoms.

METHODS

All patients who required an assessment for cardiovascular symptoms were considered for this observational study. During triage assessment, the nurses assessed the patient's level of urgency applying the MTS, then again after this evaluation (confirming or modifying the level of urgency based on personal clinical experience) and after interpretation of the patient's ECG. The main study outcome was the diagnosis of an acute cardiovascular event.

RESULTS

Of the 1211 patients in the study, 10.5% presented the main study outcome. ECG interpretation in triage exhibited a nurse-physician agreement of 92.9% (p<0.001). increased patient priority in 7.5% of cases and reduced it in 39.6%. The discriminatory ability of the triage system had an area under the ROC of 0.712and 0.845 after ECG interpretation. ECG interpretation improved the baseline assessment of priority, with an NRI of 60.1% (p<0.001).

CONCLUSIONS

ECG interpretation in triage can be a simple and safe tool that improves the assessment of patient priority.

Reducing Nonemergent Visits to the Emergency Department in a Veterans Affairs Multistate System

STUDY OBJECTIVE

The purpose of this quality improvement study was to reduce nonemergent visits to the emergency department attendance within a multistate Veterans Health Affairs network.

METHODS

Telephone triage protocols were developed and implemented for registered nurse staff to triage selected calls to a same-day telephonic or video virtual visit with a provider (physician or nurse practitioner). Calls, registered nurse triage dispositions, and provider visit dispositions were tracked for 3 months.

RESULTS

There were 1606 calls referred by registered nurses for provider visits. Of these, 192 were initially triaged as emergency department dispositions. Of these, 57.3% of calls that would have been referred to the emergency department were resolved via the virtual visit. Thirty-eight percent fewer calls were referred to the emergency department following licensed independent provider visit compared to the registered nurse triage.

CONCLUSION

Telephone triage services augmented by virtual provider visits may reduce emergency department disposition rates, resulting in fewer nonemergent patient presentations to the emergency department and reducing unnecessary emergency department overcrowding. Reducing nonemergent attendance to emergency departments can improve outcomes for patients with emergent dispositions.

Queueing Problems in Emergency Departments: A Review of Practical Approaches and Research Methodologies

Problems related to patient scheduling and queueing in emergency departments are gaining increasing attention in theory, in the fields of operations research and emergency and healthcare services, and in practice. This paper aims to provide an extensive review of studies addressing queueing-related problems explicitly related to emergency departments. We have reviewed 229 articles and books spanning seven decades and have sought to organize the information they contain in a manner that is accessible and useful to researchers seeking to gain knowledge on specific aspects of such problems. We begin by presenting a historical overview of applications of queueing theory to healthcare-related problems. We subsequently elaborate on managerial approaches used to enhance efficiency in emergency departments. These approaches include bed management, fast-track, dynamic resource allocation, grouping/prioritization of patients, and triage approaches. Finally, we discuss scientific methodologies used to analyze and optimize these approaches: algorithms, priority models, queueing models, simulation, and statistical approaches.

The Efficacy of Lavender Aromatherapy in Reducing the Overcrowding-Related Anxiety in Health Care Workers

In general, emergency departments (EDs) are stressful workplaces with excessive workloads and time pressures. Crowding, which is an important problem worldwide disrupting ED functions, leads further increases in the stressors which health care workers are exposed to. Long-term exposure to stressors can lead to anxiety in health care workers. The aim of this study was to determine the effect of aromatherapy on crowding-related anxiety in ED health care workers. Crowding was measured simultaneously with the National Emergency Department Overcrowding Scale objectively and the Health Care Workers' Crowding Perception Evaluation Form subjectively. The state-trait anxiety level was measured at each crowding level according to the health care workers' perception. When perceived crowding was at severely overcrowding level, lavender oil aromatherapy was applied. Anxiety level was measured before and after aromatherapy. Aromatherapy was repeated 3 times on different days. A significant positive correlation was found between state anxiety level and perceived crowding (r = 0.415, p < 0.001). Aromatherapy was found to have a significant correlation in reducing the overcrowding-related anxiety in health care workers (p < 0.05). This study showed that there is a significant correlation between anxiety level and perceived crowding, and aromatherapy is related to a decrease in overcrowding-related anxiety. In EDs, lavender oil aromatherapy can be used as a complementary method in reducing the overcrowding-related anxiety. But further researches are needed to verify that aromatherapy has a causative effect on reducing overcrowding-related anxiety.

Estrategias para la medición y el manejo de la sobreocupación de los servicios de urgencias de adultos en instituciones de alta complejidad con altos volúmenes de consulta. Revisión de la literatura

La sobreocupación de los servicios de urgencias es un problema global que cada vez afecta más las instituciones de salud que atienden pacientes de mediana y alta complejidad, haciendo que estos permanezcan más tiempo en una sala de espera con la consiguiente demora en los tiempos de atención, bajo nivel de satisfacción de los usuarios, retraso en la toma de ayudas diagnósticas, retrasos al definir altas del servicio y favorecimiento de complicaciones médicas, entre otros. Para mejorar esta situación se han desarrollado estrategias como la creación de unidades de observación, unidades fast track o asignación de citas prioritarias para los pacientes que no requieren una atención urgente, de modo adicional el triaje, los exámenes point of care y la vinculación de especialistas en medicina de urgencias. Todo esto con el fin de mejorar la calidad de la atención de los pacientes, evitar que se presenten eventos adversos durante su proceso y disminuir la sobreocupación del servicio.

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.

Challenges and Barriers Affecting the Quality of Triage in Emergency Departments: A Qualitative Study

Background

Correct and fast triage is the key to successful performance in emergency departments. Various factors can affect the quality of triage; therefore, the present study was conducted to identify and explore the existing challenges in triage units in emergency departments.

Materials and Methods

The present study was a qualitative exploratory work conducted via the content analysis approach. Data were collected using in-depth, semi-structured interviews, and focus group interviews. Accordingly, 22 in-depth, semi-structured interviews were conducted in with 18 triage nurses and four emergency medicine specialists on a face-to-face basis.

Results

The challenges related to triage nurses fall into two subcategories; lack of clinical competency and psychological capabilities. The challenges related to emergency management consist of challenges in human resources management, structural, and performance.

Conclusion

The challenges existing in triage units are influenced by factors related to triage nurses and emergency management. Emergency administrators can improve the effectiveness and quality of triaging patients by empowering triage nurses and removing structural problems in triage units.

Outcomes of Crowding in Emergency Departments; a Systematic Review

INTRODUCTION

Emergency Department (ED) crowding is a global public health phenomenon affecting access and quality of care. In this study, we seek to conduct a systematic review concerning the challenges and outcomes of ED crowding.

METHODS

This systematic review utilized original research articles published from 1st January 2007, to 1st January 2019. Relevant articles from the PubMed (MEDLINE), EMBASE, and Google scholar databases were extracted using predesigned keywords. Following the PRISMA guidelines, two reviewers independently evaluated the quality of the studies using Critical Appraisal Skills Programme for cohort studies and qualitative studies, and Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument for studies.

RESULTS

Out of the total of 73 articles in the final record, we excluded 15 of them because of poor quality. This systematic review synthesized the reports of 58 original articles. The outcomes of multiple individual patients and healthcare-related challenges are comprehensively assessed.

CONCLUSIONS

ED crowding affects individual patients, healthcare systems and communities at large. The negative influences of crowding on healthcare service delivery result in delayed service delivery, poor quality care, and inefficiency; all negatively affecting the emergency patients' healthcare outcomes, in turn.

Characterizing Potentially Preventable Admissions: A Mixed Methods Study of Rates, Associated Factors, Outcomes, and Physician Decision-Making

BACKGROUND

Potentially preventable admissions are a target for healthcare cost containment.

OBJECTIVE

To identify rates of, characterize associations with, and explore physician decision-making around potentially preventable admissions.

DESIGN

A comparative cohort study was used to determine rates of potentially preventable admissions and to identify associated factors and patient outcomes. A qualitative case study was used to explore physicians' clinical decision-making.

PARTICIPANTS

Patients admitted from the emergency department (ED) to the general medicine (GM) service over a total of 4 weeks were included as cases (N = 401). Physicians from both emergency medicine (EM) and GM that were involved in the cases were included (N = 82).

APPROACH

Physicians categorized admissions as potentially preventable. We examined differences in patient characteristics, admission characteristics, and patient outcomes between potentially preventable and control admissions. Interviews with participating physicians were conducted and transcribed. Transcriptions were systematically analyzed for key concepts regarding potentially preventable admissions.

KEY RESULTS

EM and GM physicians categorized 22.2% (90/401) of admissions as potentially preventable. There were no significant differences between potentially preventable and control admissions in patient or admission characteristics. Potentially preventable admissions had shorter length of stay (2.1 vs. 3.6 days, p < 0.001). There was no difference in other patient outcomes. Physicians discussed several provider, system, and patient factors that affected clinical decision-making around potentially preventable admissions, particularly in the "gray zone," including risk of deterioration at home, the risk of hospitalization, the cost to the patient, and the presence of outpatient resources. Differences in provider training, risk assessment, and provider understanding of outpatient access accounted for differences in decisions between EM and GM physicians.

CONCLUSIONS

Collaboration between EM and GM physicians around patients in the gray zone, focusing on patient risk, cost, and outpatient resources, may provide an avenues for reducing potentially preventable admissions and lowering healthcare spending.

Effect of emergency medical service use on time interval from symptom onset to hospital admission for definitive care among patients with intracerebral hemorrhage: a multicenter observational study

Objective

This study evaluated whether emergency medical service (EMS) use was associated with early arrival and admission for definitive care among intracerebral hemorrhage (ICH) patients.

Methods

Patients with ICH were enrolled from 29 hospitals between November 2007 and December 2012, excluding those patients with subarachnoid hemorrhage, traumatic ICH, and missing information. The patients were divided into four groups based on visit type to the definitive hospital emergency department (ED): direct visit by EMS (EMS-direct), direct visit without EMS (non-EMS-direct), transferred from a primary hospital by EMS (EMS-transfer), and transferred from a primary hospital without EMS (non-EMS-transfer). The outcomes were the proportions of participants within early (<1 hr) definitive hospital ED arrival from symptom onset (pS2ED) and those within early (<4 hr) admission from symptom onset (pS2AD). Adjusted odds ratios were calculated to determine the association between EMS use and outcomes with and without inter-hospital transfer.

Results

A total of 6,564 patients were enrolled. The adjusted odds ratios (95% confidence intervals) for pS2ED were 22.95 (17.73–29.72), 1.11 (0.67–1.84), and 7.95 (6.04–10.46) and those for pS2AD were 5.56 (4.70–6.56), 0.96 (0.71–1.30), and 2.35 (1.94–2.84) for the EMS-direct, EMS-transfer, and non-EMS-direct groups compared with the non-EMS-transfer group, respectively. Through the interaction model, EMS use was significantly associated with early arrival and admission among direct visiting patients but not with transferred patients.

Conclusion

EMS use was significantly associated with shorter time intervals from symptom onset to arrival and admission at a definitive care hospital. However, the effect disappeared when patients were transferred from a primary hospital.

Implementing evidence-based practices in an emergency department: contradictions exposed when prioritising a flow culture

Background

An emergency department is typically a place of high activity where practitioners care for unanticipated presentations, which yields a flow culture so that actions that secure available beds are prioritised by the practitioners.

Objectives

How does the flow culture in an emergency department influence nurses’ use of a research‐based clinical guideline and a nutrition screening routine.

Methods

Ethnographic fieldwork was carried out over three months. The first author followed nurses, medical secretaries and doctors in the emergency department. Data were also collected by means of semi‐structured interviews. An activity system analysis, as described in the Cultural Historical Activity Theory, was conducted to identify various contradictions that could exist between different parts of the activity system.

Results

The main contradiction identified was that guidelines and screening routines provided a flow stop. Four associated contradictions were identified: insufficient time to implement guidelines; guilty conscience due to perceived nonadherence to evidence‐based practices; newcomers having different priorities; and conflicting views of what constituted being a professional.

Conclusion

We found that research‐supported guidelines and screening routines were not used if they were perceived to stop the patient flow, suggesting that the practice was not fully evidence based.

Canadian Triage and Acuity Scale: testing the mental health categories

PURPOSE

The study tested the inter-rater reliability and accuracy of triage nurses' assignment of urgency ratings for mental health patient scenarios based on the 2008 Canadian Triage and Acuity Scale (CTAS) guidelines, using a standardized triage tool. The influence of triage experience, educational preparation, and comfort level with mental health presentations on the accuracy of urgency ratings was also explored.

METHODS

Study participants assigned urgency ratings to 20 mental health patient scenarios in randomized order using the CTAS. The scenarios were developed using actual triage notes and were reviewed by an expert panel of emergency and mental health clinicians for face and content validity.

RESULTS

The overall Fleiss' kappa, the measure of inter-rater reliability for this sample of triage nurses (n=18), was 0.312, representing only fair albeit statistically significant (P<0.0001) agreement. Kendall's coefficient of concordance for the sample was calculated to be 0.680 (P<0.0001), which signifies moderate agreement. Although the sample reported high levels of education, comfort with mental health presentations, and experience, accuracy in urgency ratings measured by the percentage of correct responses ranged from 0.05% to 94% (mean: 54%). Greater accuracy in urgency ratings was recorded for triage nurses who used second-order modifiers and avoided the use of override.

CONCLUSION

Specific focus on the use of second-order modifiers in orientation and ongoing education of triage nurses may improve the reliability and validity of the CTAS when used to assign urgency ratings to mental health presentations.

ED crowding is associated with inpatient mortality among critically ill patients admitted via the ED: post hoc analysis from a retrospective study

BACKGROUND

Adverse effects of emergency department (ED) crowding among critically ill patients are not well known.

OBJECTIVES

We evaluated the association between ED crowding and inpatient mortality among critically ill patients admitted via the ED, and analyzed subsets of patients according to admission diagnosis.

METHODS

We performed a post hoc analysis using data from a previous retrospective study. We enrolled admitted patients via the ED with an initial systolic blood pressure of 90 mm Hg or lower when presenting to the ED. The ED occupancy ratio was used as a measure of crowding. The primary outcome was inpatient mortality. Multivariable logistic regression models adjusted for potential confounding variables were constructed for the entire cohort and for subsets according to admission diagnosis (infection, cardiac and vascular disease, trauma, gastrointestinal bleeding, and other factors).

RESULTS

A total of 1801 patients were enrolled, with a mortality rate of 14.6% (262 patients). The mortality rate by ED occupancy ratio quartile was 9.7% for the first quartile, 15.9% for the second quartile, 18.2% for the third quartile, and 14.4% for the fourth quartile. This resulted in adjusted odds ratios of 1.95, 2.51, and 1.93 and corresponding 95% confidence intervals of 1.23-3.12, 1.58-3.99, and 1.21-3.09 for the second, third, and fourth quartiles, respectively, compared with the first quartile. The effect of ED crowding was highest in the trauma subset, followed by the infection subset, whereas ED crowding did not appear to have any effect on the cardiac and vascular disease subsets.

CONCLUSION

Emergency department crowding was associated with increased inpatient mortality among critically ill patients admitted via the ED.

Emergency department crowding and the performance of damage control resuscitation in major trauma patients with hemorrhagic shock

OBJECTIVES

Uncontrolled hemorrhagic shock is the leading cause of potentially preventable death in major trauma patients. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, hemostatic resuscitation, and damage control surgery, has been highly recommended for trauma patients. This study investigated whether emergency department (ED) crowding was associated with poor performance of the DCR strategies in treating hemorrhagic shock trauma patients.

METHODS

This was a retrospective cohort study in an urban tertiary hospital conducted from January 2010 to December 2013. Major trauma patients who presented to the ED with hemorrhagic shock were included. ED crowding, measured by ED occupancy rate, was categorized into three groups (low, medium, and high). The performance of DCR and inpatient outcomes were analyzed using multivariate logistic analysis.

RESULTS

Of the 3,037 major trauma patients assessed, 852 met the inclusion criteria and were enrolled in the study. Patients in the high-crowding group had delayed initiation of transfusion (high vs. medium and low, 2.5 hours vs. 2.1 hours and 1.0 hours, respectively, p = 0.01), received less blood products in the ED (both comparisons p < 0.01), and experienced delays in procedures (4.5 hours vs. 3.3 hours and 2.4 hours, p < 0.01). However, the amount of crystalloid solution was similar among patients in all three groups (p = 0.17). In multivariate analysis, more patients from the high-crowding group developed traumatic coagulopathy in the intensive care unit (29.7% vs. 24.1% and 16.3%, p < 0.01), while no clear relationship was found between ED crowding and 30-day mortality or early lactate clearance rate (p > 0.05).

CONCLUSIONS

ED crowding was associated with poor performance of DCR for major trauma patients in the ED. New strategies should be implemented to ameliorate crowded conditions and potential adverse outcomes.

The association of physical access with the interval between attending the hospital and receiving service in emergency department

BACKGROUND

The relation between physical access in emergency department ‎(ED) and the time patients have to wait before being served is unknown.

OBJECTIVES

Our objective was to discover the associations between the physical access in ED and the time patients had to wait before receiving services.

MATERIALS AND METHODS

In this cross-sectional study, statistical society comprised two portions, namely, public hospitals' EDs and referred patients to the ward. Data on waiting time for 240 patients in six public and private hospitals were gathered. In addition, physical condition of EDs was inspected by visiting these hospitals. A designed checklist, based on the introduced physical space, was filled for each hospital. Results of the checklist were scored using Likert's five-points scale and Spearman and Pearson's correlation coefficient were applied to determine the relationship between physical access and waiting time.

RESULTS

The correlation between the waiting time beginning from the very moment of stepping into the ward until first examination and physical condition at the triage wards in private (P < 0.001) and public hospitals (P > 0.05) was not significant. The waiting interval, beginning from the very moment of stepping into the ward until first examination and access to physical space of ED, was significant for private hospitals (P < 0.001) and insignificant for public hospitals (P > 0.05).

CONCLUSIONS

According to the results, there was a direct correlation between access to physical space in ED and waiting time. In addition, improving the physical access did not necessarily result in shorter waiting time. Therefore, to improve triage process, improvement of waiting time indices, and modifying forms of work process in ED are recommended.