Who breaches the four-hour emergency department wait time target? A retrospective analysis of 374,000 emergency department attendances between 2008 and 2013 at a type 1 emergency department in England

Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation

Background

People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care.

Objectives

The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration.

Design

This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach.

Setting

The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust.

Participants

Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19).

Outcomes

Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes.

Results

Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support.

Limitations

The availability and quality of data imposed limitations on the reliability of some analyses.

Future work

Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department.

Study registration

The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.

Impact of primary to secondary care data sharing on care quality in NHS England hospitals

Health information exchange (HIE) is seen as a key component of effective care but remains poorly evidenced at a health system level. In the UK National Health Service (NHS), the ability to share primary care data with secondary care clinicians is a focus of continued digital investment. In this study, we report the evolution of interoperable technology across a period of rapid digital transformation in NHS England from 2015 to 2019, and test association of primary to secondary care data-sharing capabilities with clinical care quality indicators across all acute secondary care providers (n = 135 NHS Trusts). In multivariable analyses, data-sharing capabilities are associated with reduction in patients breaching an Accident & Emergency (A&E) 4-h decision time threshold, and better patient-reported experience of acute hospital care quality. Using synthetic control analyses, we estimate mean 2.271% (STD+/-3.371) absolute reduction in A&E 4-h decision time breach, 12 months following introduction of data-sharing capabilities. Our findings support current digital transformation programmes for developing regional HIE networks but highlight the need to focus on implementation factors in addition to technological procurement.

Initial Development of a Patient Reported Experience Measure for Older Adults Attending the Emergency Department: Part I-Interviews with Service Users

Older adults are a major Emergency Department (ED) user group who may be especially vulnerable to the consequences of crowding and sub-optimal care. Patient experience is a critical component of high-quality ED care and has previously been conceptualised using a framework focusing on patients' needs. This study aimed to explore the experiences of older adults attending the ED in relation to the existing needs-based framework. Semi-structured interviews were conducted during an emergency care episode with 24 participants aged over 65 years in a United Kingdom ED with an annual census ~100,000. Questions exploring patient experiences of care confirmed that meeting the communication, care, waiting, physical, and environmental needs were prominent determinants of experience for older adults. A further analytical theme emerged which did not align to the existing framework, focused on 'team attitudes and values'. This study builds on existing knowledge relating to the experience of older adults in the ED. In addition, data will also contribute to the generation of candidate items for the development of a patient reported experience measure for older adults attending the ED.

Normal high-sensitivity cardiac troponin for ruling-out inpatient mortality in acute COVID-19

INTRODUCTION

Assessment of inpatient mortality risk in COVID-19 patients is important for guiding clinical decision-making. High sensitivity cardiac troponin T (hs-cTnT) is a biomarker of cardiac injury associated with a worse prognosis in COVID-19. We explored how hs-cTnT could potentially be used in clinical practice for ruling in and ruling out mortality in COVID-19.

METHOD

We tested the diagnostic value of hs-cTnT in laboratory-confirmed COVID-19 patients (≥18 years old) admitted to the Royal Berkshire Hospital (UK) between 1st March and 10th May 2020. A normal hs-cTnT was defined as a value within the 99th percentile of healthy individuals (≤14 ng/L), and an elevated hs-cTnT was defined as >14 ng/L. Adverse clinical outcome was defined as inpatient mortality related to COVID-19.

RESULTS

A total of 191 COVID-19 patients (62% male; age 66±16 years) had hs-cTnT measured on admission. Of these patients, 124 (65%) had elevated hs-cTnT and 67 (35%) had normal hs-cTnT. On a group level, patients with elevated hs-cTnT had worse inpatient survival (p = 0.0014; Kaplan-Meier analysis) and higher risk of inpatient mortality (HR 5.84 [95% CI 1.29-26.4]; p = 0.02; Cox multivariate regression) compared to patients with normal hs-cTnT. On a per-patient level, a normal hs-cTnT had a negative predictive value of 94% (95% CI: 85-98%) for ruling out mortality, whilst an elevated hs-cTnT had a low positive predictive value of 38% (95% CI: 39-47%) for ruling in mortality.

CONCLUSIONS

In this study cohort of COVID-19 patients, the potential clinical utility of hs-cTnT appears to rest in ruling out inpatient mortality. This finding, if prospectively validated in a larger study, may allow hs-cTnT to become an important biomarker to facilitate admission-avoidance and early safe discharge.

Impact of Socio-demographic Characteristics on Time in Outpatient Cardiology Clinics: A Retrospective Analysis

Inequitable access to health services influences health outcomes. Some studies have found patients of lower socio-economic status (SES) wait longer for surgery, but little data exist on access to outpatient services. This study analyzed patient-level data from outpatient public cardiology clinics and assessed whether low SES patients spend longer accessing ambulatory services. Retrospective analysis of cardiology clinic encounters across 3 public hospitals between 2014 and 2019 was undertaken. Data were linked to age, gender, Indigenous status, country of birth, language spoken at home, number of comorbidities, and postcode. A cox proportional hazards model was applied adjusting for visit type (new/follow up), clinic, and referral source. Higher hazard ratio (HR) indicates shorter clinic time. Overall, 22 367 patients were included (mean [SD] age 61.4 [15.2], 14 925 (66.7%) male). Only 7823 (35.0%) were born in Australia and 8452 (37.8%) were in the lowest SES quintile. Median total clinic time was 84 min (IQR 58-130). Visit type, clinic, and referral source were associated with clinic time (R² = 0.23, 0.35, 0.20). After adjusting for these variables, older patients spent longer in clinic (HR 0.94 [0.90-0.97]), though there was no difference according to SES (HR 1.02 [0.99-1.06]) or other variables of interest. Time spent attending an outpatient clinic is substantial, amplifying an already significant time burden faced by patients with chronic health conditions. SES was not associated with longer clinic time in our analysis. Time spent in clinics could be used more productively to optimize care, improve health outcomes and patient experience.

Impact of the 24-hour time target policy for emergency departments in South Korea: a mixed method study in a single medical center

BACKGROUND

In South Korea, after the spread of the Middle East Respiratory Syndrome epidemic was aggravated by long stays in crowded emergency departments (EDs), a 24-hour target policy for EDs was introduced to prevent crowding and reduce patients' length of stay (LOS). The policy requires at least 95% of all patients to be admitted, discharged or transferred from an ED within 24 hours of arrival. This study analyzes the effects of the 24-hour target policy on ED LOS and compliance rates and describes the consequences of the policy.

METHODS

A mixed-methods approach was applied to a retrospective observational study of ED visits combined with a survey of medical professionals. The primary measure was ED LOS, and the secondary measure was policy compliance rate which refers to the proportion of patient visits with a LOS shorter than 24 hours. Patient flow, quality of care, patient safety, staff workload, and staff satisfaction were also investigated through surveys. Mann-Whitney U and χ2 tests were used to compare variables before and after the introduction of the policy.

RESULTS

The median ED LOS increased from 3.9 hours (interquartile range [IQR] = 2.1-7.6) to 4.5 hours (IQR = 2.5-8.5) after the policy was introduced. This was likely influenced by the average monthly number of patients, which greatly increased from 4819 (SD = 340) to 5870 (SD = 462) during the same period. The proportion of patients with ED LOS greater than 24 hours remained below5% only after 6 months of policy implementation, but the number of patients whose disposition was decided at 23 hours increased by 4.84 times. Survey results suggested that patient flow and quality of care improved slightly, while the workload of medical staff worsened.

CONCLUSIONS

After implementing the 24-hour target policy, the proportion of patients whose ED LOS exceeded 24 hours decreased, even though the median ED LOS increased. However, the unintended consequences of the policy were observed such as increased medical professional workload and abrupt expulsion of patients before 24 hours.

Determinants of time-to-disposition in patients who underwent CT for pulmonary embolism: a retrospective study

Background

Pulmonary embolism (PE) is a common life-threatening medical emergency that needs prompt diagnosis and management. Providing urgent care is a key determinant of quality in the emergency department (ED) and time-based targets have been implemented to reduce length of stay and overcrowding. The study aimed to determine factors that are associated with having a time-to-disposition of less than 4 h in patients with suspected PE who underwent computed tomography pulmonary angiography (CT-PA) to confirm the diagnosis.

Methods

After obtaining approval from the ethics committee, we conducted a retrospective observational study by examining CT-PA scans that was performed to rule out PE in all adult patients presenting at the ED between January 2018 and December 2019. Demographic information and clinical information, as well as arrival and disposition times were collected from electronic health records. Multivariable regression analysis was used to identify the independent factors associated with meeting the 4-h target in the ED.

Results

In total, the study involved 232 patients (76 men and 156 women). The median length of stay in the ED was 5.2 h and the 4-h target was achieved in 37% of patients. Multivariable logistic regression analysis revealed that a positive CT-PA scan for PE was independently associated with meeting the four-hour target in the ED (odds ratio [OR]: 2.2; 95% CI: 1.1–4.8). Furthermore, Hemoptysis was the only clinical symptom that served as an independent factor associated with meeting the 4-h target in the ED (OR: 10.4; 95% CI: 1.2–90.8).

Conclusion

Despite the lower number of staff and higher volume of patients on weekends, patients who presented on weekends had shorter stays and were more likely to meet the 4-h target. Careful clinical assessment, prior to requesting a CT-PA scan, is crucial, since negative CT-PA scans may be associated with failure to meet the 4-h target.

A Comparison of the Time Spent in Emergency Departments by Older Adults With and Without Mental Health Needs

Older adults present to emergency medical services with a multitude of clinical and functional needs due to polypharmacy and multipathology. Older adults with mental health needs require additional time for the more comprehensive assessment required as a result of their underlying mental health condition. This article compares the time spent in emergency departments by older adults who have a mental health need with those who do not. Information on how they access prehospital and inhospital care is examined alongside key factors that impact on time spent in emergency departments. Data were collected from hospital records of older adults presenting at emergency departments in 3 large Health and Social Care Trusts in the United Kingdom using a retrospective, secondary, official personal information database source over 1 year. A total sample of 74,766 attendance records of older adults older than 65 years were examined. adults who presented with or had a mental health condition in their diagnosis or history, which made up a subsample of 1,818 people, were found to have significant differences in the time spent in emergency departments and some notable differences in trends and admission patterns. They wait longer than the older person without mental health needs, are more likely to breach the 4-hr waiting time target, are admitted in higher numbers, and rely heavily on the ambulance service. Health and social care systems and services need to undergo transformations to ensure that all people who access services are treated fairly and effectively.

The psychiatric decision unit as an emerging model in mental health crisis care: a national survey in England

Psychiatric decision units have been developed in many countries internationally to address the pressure on inpatient services and dissatisfactory, long waits people in mental health crisis can experience in emergency departments. Research into these units lags behind their development, as they are implemented by healthcare providers to address these problems. This is the first-ever national survey to identify their prevalence, structure, activities, and contextual setting within health services, in order to provide a robust basis for future research. The response rate was high (94%), and six PDUs in England were identified. The results indicated that PDUs open 24/7, accept only voluntary patients, provide recliner chairs for sleeping rather than beds, and limit stays to 12-72 hours. PDUs are predominantly staffed by senior, qualified mental health nurses and healthcare assistants, with psychiatry input. Staff:patient ratios are high (1:2.1 during the day shift). Differences in PDU structure and activities (including referral pathway, length of stay, and staff:patient ratios) were identified, suggesting the optimal configuration for PDUs has not yet been established. Further research into the efficacy of this innovation is needed; PDUs potentially have a role in an integrated crisis care pathway which provides a variety of care options to service users.

Applying health-six-sigma principles helps reducing the variability of length of stay in the emergency department

BACKGROUND

Reducing length of stay (LOS) is one of the urgent problems in healthcare systems worldwide. Popular methods that are used to reduce LOS are the Lean and the 6 Sigma, which in practice result in limited improvements. In this paper, we introduce and test a tailored method for implementing the 6 Sigma principles in healthcare (we call H-6S).

OBJECTIVE

To reduce the variability in the time between admission and discharge of patients in the emergency department.

METHODS

The study took place within the emergency department (ED) of Josephtal Medical Center in Eilat, Israel. Our analysis focused on the processes of examining and treating patients from admission to ED until discharge home. The analysis was done during the second quarter of 2018. The implementation of the recommendations took place during Q3 2018. The reported results are from Q3 2018 to Q2 2019, compared to the corresponding period in 2017 (experienced team).

RESULTS

In Q2 2017, LOS was 2.42 ± 2.07 h (experienced team, n = 9928). In Q2 2018, the LOS was 2.62 ± 7.04 h (before the H-6S, inexperienced team, n = 9484). In Q2 2019 following the intervention, it reached 2.3 ± 1.74 h (n = 7647). The differences between the standard deviations of the three periods are significant.

CONCLUSION

Implementing H-6S dropped the variance of LOS within 3 months and remained low for the whole year. Each new team of physicians who enter the ED should be thoroughly instructed as to the routines and expectations of the system from them, which should narrow the differences of previous education between them.

Factors associated with emergency department length of stay of internal medicine patients

Emergency Department (ED) Length Of Stay (ED-LOS) is associated with quality of care, patient safety and treatment outcome. The aim of this study is to identify factors associated with ED-LOS of internal medicine patients and provide recommendations to shorten ED-LOS. A retrospective cohort study was conducted in a single center in the Netherlands. Anonymised data of 7,380 ED attendances from January 2016 to January 2018 were analyzed. Data included time of ED arrival and departure, sex, age, source of referral, triage category, first or consecutive visit and number of radiological examinations. Univariate analyses were used. Mean ED-LOS was 220 minutes. Factors which significantly prolonged ED-LOS were older age, source of referral, triage category, need for admission, first visit, number of radiological examinations, presentation in winter or spring and time of arrival (day and evening). Several patient and circumstantial factors are associated with ED-LOS. To shorten ED-LOS, we recommend to anticipate need for admission for older patients who arrive by ambulance and to create time slots in the radiology program and to restructure the morning report.

Staff perceptions of how changes occur in an emergency department: a qualitative study

Introduction

Changes in healthcare organisations often incur significant financial costs and disrupt of normal operations. The objective of this research was to explore staff perceptions of changes at a university teaching hospital in the UK.

Methods

Grounded theory methodology was used to perform a secondary analysis of 41 interview transcripts from participants consisting of 20 physicians, 13 nurses, 2 support workers and 6 managers involved in paediatric emergency care at the hospital.

Results

Four major themes identified from the analysis were types of changes, change readiness, change triggers and challenges to implementing changes. Both planned and emergent changes can occur simultaneously, and emergency department staff are ready to manage them although external pressures seem to be the main trigger for changes, emergent changes appear to occur as initiatives to improve performance or improve services. Emergent changes at a systemic level have an inclusive planning, implementation and evaluation process. They have to be implemented at minimal cost and show the value of changes.

Discussion and conclusion

These results suggest that emergent changes that were to be implemented at a system level had higher scrutiny of their value and to occur with zero or minimum financial cost. Planned changes implemented by senior management as top–down process should have similar procedures and scrutiny to emergent changes arising from staff, to ensure value for cost. Policy makers and senior managers should encourage and evaluate group or system level changes that arise as a bottom–up process and assess associated financial cost.

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.

Door-To-Triage Time in a Canadian Tertiary-Care Center

BACKGROUND

The interval from patient arrival to triage is arguably the most dangerous time a patient spends in the emergency department (ED), as they are an unknown entity until assessed by a health care professional.

OBJECTIVE

We sought to quantify door-to-triage time (DTT), an important factor in patient safety that has not yet been quantified in Canada.

METHODS

Data were collected from all ambulatory patients presenting to a tertiary-care ED during a consecutive 7-day period. Demographic information, arrival time (door time), triage time, and Canadian Triage and Acuity Score (CTAS) were collected. DTT was compared across variables using Kruskal-Wallis one-way analysis of variance.

RESULTS

Seven hundred and seventy-five patients were included in the study, representing 82.9% of ambulatory patients. DTT was variable (1-86 min) with a median of 12 min (interquartile range [IQR] 6-21 min). Patients in the 5^th percentile with the longest DTT waited a median of 54 min (IQR 48-63 min). DTT varied across days of the week (p < 0.01); the longest wait was on Monday (median 22 [IQR 11-43] min) and the shortest on Sunday (median 8 [IQR 5-12] min). There was no relationship between DTT and CTAS (p = 0.12).

CONCLUSIONS

DTT is an important variable affecting patient safety. Given site-specific factors, replication across additional centers is necessary. Additional research evaluating factors affecting DTT, different triage paradigms, and quality improvement interventions should be undertaken.

In-vitro diagnostic point-of-care tests in paediatric ambulatory care: A systematic review and meta-analysis

INTRODUCTION

Paediatric consultations form a significant proportion of all consultations in ambulatory care. Point-of-care tests (POCTs) may offer a potential solution to improve clinical outcomes for children by reducing diagnostic uncertainty in acute illness, and streamlining management of chronic diseases. However, their clinical impact in paediatric ambulatory care is unknown. We aimed to describe the clinical impact of all in-vitro diagnostic POCTs on patient outcomes and healthcare processes in paediatric ambulatory care.

METHODS

We searched MEDLINE, EMBASE, Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science from inception to 29 January 2020 without language restrictions. We included studies of children presenting to ambulatory care settings (general practice, hospital outpatient clinics, or emergency departments, walk-in centres, registered drug shops delivering healthcare) where in-vitro diagnostic POCTs were compared to usual care. We included all quantitative clinical outcome data across all conditions or infection syndromes reporting on the impact of POCTs on clinical care and healthcare processes. Where feasible, we calculated risk ratios (RR) with 95% confidence intervals (CI) by performing meta-analysis using random effects models.

RESULTS

We included 35 studies. Data relating to at least one outcome were available for 89,439 children of whom 45,283 had a POCT across six conditions or infection syndromes: malaria (n = 14); non-specific acute fever 'illness' (n = 7); sore throat (n = 5); acute respiratory tract infections (n = 5); HIV (n = 3); and diabetes (n = 1). Outcomes centred around decision-making such as prescription of medications or hospital referral. Pooled estimates showed that malarial-POCTs (Plasmodium falciparum) better targeted antimalarial treatment by reducing over-treatment by a third compared to usual care (RR 0.67; 95% CI [0.58 to 0.77], n = 36,949). HIV-POCTs improved initiating earlier antiretroviral therapy compared to usual care (RR, 3.11; 95% CI [1.55 to 6.25], n = 912). Across the other four conditions, there was limited evidence for the benefit of POCTs in paediatric ambulatory care except for acute respiratory tract infections (RTI) in low-and-middle-income countries (LMICs), where POCT C-Reactive Protein (CRP) may reduce immediate antibiotic prescribing by a third (risk difference, -0.29 [-0.47, -0.11], n = 2,747). This difference was shown in randomised controlled trials in LMICs which included guidance on interpretation of POCT-CRP, specific training or employed a diagnostic algorithm prior to POC testing.

CONCLUSION

Overall, there is a paucity of evidence for the use of POCTs in paediatric ambulatory care. POCTs help to target prescribing for children with malaria and HIV. There is emerging evidence that POCT-CRP may better target antibiotic prescribing for children with acute RTIs in LMIC, but not in high-income countries. Research is urgently needed to understand where POCTs are likely to improve clinical outcomes in paediatric settings worldwide.

Why are there long waits at English emergency departments?

A core performance target for the English National Health Service (NHS) concerns waiting times at Emergency Departments (EDs), with the aim of minimising long waits. We investigate the drivers of long waits. We analyse weekly data for all major EDs in England from April 2011 to March 2016. A Poisson model with ED fixed effects is used to explore the impact on long (> 4 h) waits of variations in demand (population need and patient case-mix) and supply (emergency physicians, introduction of a Minor Injury Unit (MIU), inpatient bed occupancy, delayed discharges and long-term care). We assess overall ED waits and waits on a trolley (gurney) before admission. We also investigate variation in performance among EDs. The rate of long overall waits is higher in EDs serving older patients (4.2%), where a higher proportion of attendees leave without being treated (15.1%), in EDs with a higher death rate (3.3%) and in those located in hospitals with greater bed occupancy (1.5%). These factors are also significantly associated with higher rates of long trolley waits. The introduction of a co-located MIU is significantly and positively associated with long overall waits, but not with trolley waits. There is substantial variation in waits among EDs that cannot be explained by observed demand and supply characteristics. The drivers of long waits are only partially understood but addressing them is likely to require a multi-faceted approach. EDs with high rates of unexplained long waits would repay further investigation to ascertain how they might improve.

"Me First, Others Later" A focused ethnography of ongoing cultural features of waiting in an Iranian emergency department

BACKGROUND

Waiting is an inevitable experience in all emergency departments (EDs). This waiting time may negatively influence the patients and their relatives' satisfaction, healthcare professionals' (HCPs) performance, and the quality of care provided. This study aims to explore, gain understanding of and describe what it is like to wait in an Iranian emergency department (ED) with particular focus on cultural features.

METHOD

A focused ethnographic approach based on Spradley's (1980) developmental research sequence was conducted in the ED of a tertiary academic medical center in northwest Iran over a 9-month study period from July 2017 to March 2018. Participant observation, ethnographic interviews and examination of related documents and artefacts were used to collect data. All the data were recorded in either field notes or verbatim transcripts and were analysed using Spradley's ethnographic data analysis method concurrently.

RESULTS

The overarching theme of "Me first, others later" emerged. Within this overarching theme there were seven sub-themes as follows: human-related factors, system-related factors, patients and their relatives' beliefs and behaviors, HCPs' beliefs and behaviors, consequences for patients and their relatives, consequences for HCPs, and consequences for ED environment and care process.

CONCLUSION

The mentality 'me first, others later' as the main cultural barrier to emergency care, strenuously undermined our positive practice environment. An accountable patient/relative support liaison, a clearly-delineated process of ED care delivery, guidelines for providing culturally competent ED care, and public awareness programs are needed to address the concerns and conflicts which establish a mutual trust and rapport.

Exploring the characteristics, acuity and management of adult ED patients at night-time

Objectives

ED care is required for acutely unwell and injured patients 24 hours a day, 7 days a week. The aim of this study was to compare characteristics and activity of type 1 ED attendances according to whether their time of arrival was during the day (08:00–18:00) or at night (18:00–08:00).

Methods

Hospital Episode Statistics (HES) data from NHS Digital for all A&E and admitted patient care activity provided by all acute (not mental health or primary care) NHS hospital trusts in Yorkshire and Humber (1 April 2011 to 31 March 2014) for adult patients were analysed. Adjusted linear and logistic regression was used to model the data.

Results

Adjusted regression analysis results show that patients who attended ED at night waited an extra 18.76 (95% CI 18.62 to 18.89) min to be seen by a clinician. They also spent an additional 13.64 (95% CI 13.47 to 13.81) min total in ED. Patients who attended at night were OR 2.20 (95% CI 2.17 to 2.23) times more likely to leave without being seen. They were also OR 1.26 (95% CI 1.25 to 1.27) times more likely to re-attend the ED and were OR 1.20 (95% CI 1.19 to 1.21) times more likely to present with non-urgent conditions. Overnight patients were more likely to be admitted to hospital, OR 1.09 (95% CI 1.09 to 1.10) times, however, those admitted were more likely to have a short-stay admission.

Conclusion

There is an ‘overnight effect’ of patients attending EDs. Patients wait longer, leave without being seen, attend with non-urgent problems and are more likely to be admitted for a short stay. Further work is required to identify the potential underlying causes of these differences.

Multistate model of the patient flow process in the pediatric emergency department

Objectives

The main purpose of this paper was to model the process by which patients enter the ED, are seen by physicians, and discharged from the Emergency Department at Nationwide Children’s Hospital, as well as identify modifiable factors that are associated with ED lengths of stay through use of multistate modeling.

Methods

In this study, 75,591 patients admitted to the ED from March 1^st, 2016 to February 28^th, 2017 were analyzed using a multistate model of the ED process. Cox proportional hazards models with transition-specific covariates were used to model each transition in the multistate model and the Aalen-Johansen estimator was used to obtain transition probabilities and state occupation probabilities in the ED process.

Results

Acuity level, season, time of day and number of ED physicians had significant and varying associations with the six transitions in the multistate model. Race and ethnicity were significantly associated with transition to left without being seen, but not with the other transitions. Conversely, age and gender were significantly associated with registration to room and subsequent transitions in the model, though the magnitude of association was not strong.

Conclusions

The multistate model presented in this paper decomposes the overall ED length of stay into constituent transitions for modeling covariate-specific effects on each transition. This allows physicians to understand the ED process and identify which potentially modifiable covariates would have the greatest impact on reducing the waiting times in each state in the model.

Delirium Assessment in Older People in Emergency Departments. A Literature Review

Delirium is a neuropsychiatric syndrome often manifesting in acute disease conditions, and with a greater prevalence in the older generation. Delirium in the Emergency Department (ED) is a highly prevalent problem that typically goes unnoticed by healthcare providers. The onset of a delirium episode in the ED is associated with an increase in morbidity and mortality. Because delirium is a preventable syndrome, these statistics are unacceptable. Emergency Department staff therefore should strive to perform systematic screening in order to detect delirium. Different tools have been developed for the assessment of delirium by healthcare professionals other than psychiatrists or geriatricians. Emergency Departments require delirium assessment scales of high sensitivity and specificity, suited to the characteristics of the Department, since the time available is scarce. In addition, the presence of dementia in the assessment of delirium may induce sensitivity bias. Despite the existence of numerous delirium rating scales, scales taking less than three minutes to complete are recommended. The choice of the tool depends on the characteristics of the ED. The only scale affording high sensitivity and specificity in older people with and without dementia is the Four "A"s Test (4AT); it requires no training on the part of the rater, and can be performed in under two minutes.

Improving the use of treatment escalation plans: a quality-improvement study

Objectives

Treatment escalation plans (TEPs) are vital in communicating a ceiling of care. However, many patients still deteriorate and die without a pre-established ceiling of care for attending clinicians to rely on. We aimed to increase the proportion of suitable patients that have TEPs in place in a rural district general hospital.

Methods

We undertook three ‘Plan-Do-Study-Act’ (PDSA) cycles between 1 December 2016 and 9 June 2017. These cycles aimed to assess the problem, implement a solution and monitor its sustainability. We sampled all acute medical admissions at different time points, focusing on the acute medical unit. We identified patients requiring TEP forms using SupportiveandPalliative Care Indicators Tool. Stakeholders were surveyed during the project, and a process communication map was developed to understand the human interfaces that occur when producing a TEP.

Results

We sampled a total of 323 patients (PDSA 1, n=128; PDSA 2, n=95; PDSA 3, n=100). Following implementation of a ‘talking to your doctor about treatment’ leaflet, the proportion of patients who did not have a TEP but required one fell from 43% (n=38, PDSA 1) to 27% (n=20, PDSA 3) then to 23% (n=77, PDSA 3) (CI 0.6631 to 39.917, p=0.028).

Conclusions

This study highlights the challenges of TEP form completion. The impact of our intervention appeared to raise awareness of advanced care planning. The information contained in our leaflet could be distributed in more innovative ways to ensure patients unable to access textual information are able to receive this message.