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Momesso T, Gokpinar B, Ibrahim R, Boyle AA. Effect of removing the 4-hour access standard in the ED: a retrospective observational study. Emerg Med J 2023; 40:630-635. [PMID: 37369563 DOI: 10.1136/emermed-2023-213142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Time-based targets are used to improve patient flow and quality of care within EDs. While previous research often highlighted the benefits of these targets, some studies found negative consequences of their implementation. We study the consequences of removing the 4-hour access standard. METHODS We conducted a before and after, retrospective, observational study using anonymised, routinely collected, patient-level data from a single English NHS ED between April 2018 and December 2019. The primary outcomes of interest were the proportion of admitted patients, that is, the admission rate, the length of stay in the ED and ambulance handover times. We used interrupted time series models to study and estimate the impact of removing the 4-hour access standard. RESULTS A total of 169 916 attendances were included in the analysis. The interrupted time series models for the average daily admission rate indicate a drop from an estimated 35% to an estimated 31% (95% CI -4.1 to -3.9). This drop is only statistically significant for Majors (Ambulant) patients (from an estimated 38.3% to an estimated 31.4%) and, particularly, for short-stay admissions (from an estimated 18.1% to an estimated 12.8%). The models also show an increase in the average daily length of stay for admitted patients from an estimated 316 min to an estimated 387 min (95% CI 33.5 to 108.9), and an increase in the average daily length of stay for discharged patients from an estimated 222 min to an estimated 262 min (95% CI 6.9 to 40.4). CONCLUSION Lifting the 4-hour access standard reporting was associated with a drop in short-stay admissions to the hospital. However, it was also associated with an increase in the average length of stay in the ED. Our study also suggests that the removal of the 4-hour standard does not impact all patients equally. While certain patient groups such as those Majors (Ambulant) patients with less severe issues might have benefited from the removal of the 4-hour access standard by avoiding short-stay hospital admissions, the average length of stay in the ED seemed to have increased across all groups, particularly for older and admitted patients.
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Affiliation(s)
- Tomas Momesso
- UCL School of Management, University College London, London, UK
| | - Bilal Gokpinar
- UCL School of Management, University College London, London, UK
| | - Rouba Ibrahim
- UCL School of Management, University College London, London, UK
| | - Adrian A Boyle
- Emergency Department, Addenbrooke's Hospital Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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2
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Miazgowski B, Pakulski C, Miazgowski T. Length of Stay in Emergency Department by ICD-10 Specific and Non-Specific Diagnoses: A Single-Centre Retrospective Study. J Clin Med 2023; 12:4679. [PMID: 37510793 PMCID: PMC10380588 DOI: 10.3390/jcm12144679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
The definition of non-specific presentation at a hospital emergency department (ED) has not yet been formally established. The purpose of this study was to assess the relationships between primary ED diagnoses identified by ICD-10 codes and ED length of stay (LOS). Over the course of three years, we examined 134,675 visits at a tertiary hospital. LOS was examined in groups with specific (internal, surgical, neurological, and traumatic diseases) and non-specific diagnoses. Our secondary objective was to measure LOS by age, day of the week, time of day, and season. The median LOS was 182 min (interquartile range: 99-264 min). LOS was 99 min in the traumatic group, while it was 132 min in the surgical group, 141 min in the non-specific group, 228 min in the internal medicine group, and 237 min in the neurological group. Other determinants of LOS were age, revisits, day of the week, and time of arrival-but not a season of the year. In the non-specific group (21% of all diagnoses), the percentage of hospitalizations was higher than in the specific groups. Our results suggest that in clinical practice, the non-specific group should be redefined to also encompass diagnoses from ICD-10 Chapter XXI (block Z00-Z99).
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Affiliation(s)
- Bartosz Miazgowski
- Doctoral School, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Cezary Pakulski
- Department of Anesthesiology, Intensive Therapy and Emergency Medicine, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Tomasz Miazgowski
- Department of Propaedeutic of Internal Diseases and Arterial Hypertension, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
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3
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Shaw V, Yu A, Parsons M, Olsen T, Walker C. Acute assessment services for patient flow assistance in hospital emergency departments. Cochrane Database Syst Rev 2023; 7:CD014553. [PMID: 37439227 PMCID: PMC10334694 DOI: 10.1002/14651858.cd014553.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
BACKGROUND Emergency departments (EDs) are facing serious and significant issues in the delivery of effective and efficient care to patients. Acute assessment services have been implemented at many hospitals internationally to assist in maintaining patient flow for identified groups of patients attending the ED. Identifying the risks and benefits, and optimal configurations of these services may be beneficial to those wishing to utilise an acute assessment service to improve patient flow. OBJECTIVES To assess the effects of acute assessment services on patient flow following attendance at a hospital ED. SEARCH METHODS We searched MEDLINE, CENTRAL, Embase and two trials registers on 24 September 2022 to identify studies. No restrictions were imposed on publication year, publication type, or publication language. SELECTION CRITERIA Studies eligible for inclusion were randomised trials and cluster-randomised trials with at least two intervention and two control sites. Participants were adults (as defined by study authors) receiving care either in the ED or the acute assessment service, where both were based in the hospital setting. The comparison was hospital-based acute assessment services with usual, ED-only care. The outcomes of this review were mortality at time point closest to 30 days, length of stay in the service (in minutes), and waiting time to see a doctor (in minutes). DATA COLLECTION AND ANALYSIS We followed the standard procedures of Cochrane Effective Practice and Organisation of Care for this review (https://epoc.cochrane.org/resources). MAIN RESULTS We identified a total of 5754 records in the search. Following assessment of 3609 de-duplicated records, none were found to be eligible for inclusion in this review. AUTHORS' CONCLUSIONS At present there are no randomised controlled trials exploring the effects of acute assessment services on patient flow in hospital-based emergency departments compared to usual, ED-only care.
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Affiliation(s)
- Victoria Shaw
- Department of Nursing, Toi Ohomai Institute of Technology, Rotorua, New Zealand
| | - An Yu
- Infrastructure and investment, Te Whatu Ora, Wellington, New Zealand
| | - Matthew Parsons
- Faculty of Health, The University of Waikato, Hamilton, New Zealand
| | - Tava Olsen
- Melbourne Business School, The University of Melbourne, Melbourne, Australia
| | - Cameron Walker
- Engineering Science, The University of Auckland, Auckland, New Zealand
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4
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Impact of the 24-hour time target policy for emergency departments in South Korea: a mixed method study in a single medical center. BMC Health Serv Res 2022; 22:1510. [PMID: 36510204 PMCID: PMC9742653 DOI: 10.1186/s12913-022-08861-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022] Open
Abstract
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.
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5
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Marsilio M, Roldan ET, Salmasi L, Villa S. Operations management solutions to improve ED patient flows: evidence from the Italian NHS. BMC Health Serv Res 2022; 22:974. [PMID: 35908053 PMCID: PMC9338603 DOI: 10.1186/s12913-022-08339-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/11/2022] [Indexed: 11/26/2022] Open
Abstract
Background Overcrowding occurs when the identified need for emergency services outweighs the available resources in the emergency department (ED). Literature shows that ED overcrowding impacts the overall quality of the entire hospital production system, as confirmed by the recent COVID-19 pandemic. This study aims to identify the most relevant variables that cause ED overcrowding using the input-process-output model with the aim of providing managers and policy makers with useful hints for how to effectively redesign ED operations. Methods A mixed-method approach is used, blending qualitative inquiry with quantitative investigation in order to: i) identifying and operationalizing the main components of the model that can be addressed by hospital operation management teams and ii) testing and measuring how these components can influence ED LOS. Results With a dashboard of indicators developed following the input-process-output model, the analysis identifies the most significant variables that have an impact on ED overcrowding: the type (age and complexity) and volume of patients (input), the actual ED structural capacity (in terms of both people and technology) and the ED physician-to-nurse ratio (process), and the hospital discharging process (output). Conclusions The present paper represents an original contribution regarding two different aspects. First, this study combines different research methodologies with the aim of capturing relevant information that by relying on just one research method, may otherwise be missed. Second, this study adopts a hospitalwide approach, adding to our understanding of ED overcrowding, which has thus far focused mainly on single aspects of ED operations.
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Affiliation(s)
- Marta Marsilio
- Department of Economics, Management and Quantitative Methods (DEMM), Università degli Studi di Milano, Milano, Italy.
| | - Eugenia Tomas Roldan
- CERISMAS (Research Centre in Health Care Management), Università Cattolica del Sacro Cuore, Milano, Italy
| | - Luca Salmasi
- Department of Economics and Finance, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Stefano Villa
- Department of Management, Università Cattolica del Sacro Cuore, Milano, Italy
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Silwal PR, Exeter D, Tenbensel T, Lee A. Understanding geographical variations in health system performance: a population-based study on preventable childhood hospitalisations. BMJ Open 2022; 12:e052209. [PMID: 35649589 PMCID: PMC9161092 DOI: 10.1136/bmjopen-2021-052209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To investigate interdistrict variations in childhood ambulatory sensitive hospitalisation (ASH) over the years. DESIGN Observational population-based study over 2008-2018 using the Primary Health Organisation Enrolment Collection (PHO) and the National Minimum Dataset hospital events databases. SETTING New Zealand primary and secondary care. PARTICIPANTS All children aged 0-4 years enrolled in the PHO Enrolment Collection from 2008 to 2018. MAIN OUTCOME MEASURE ASH. RESULTS Only 1.4% of the variability in the risk of having childhood ASH (intracluster correlation coefficient=0.014) is explained at the level of District Health Board (DHB), with the median OR of 1.23. No consistent time trend was observed for the adjusted childhood ASH at the national level, but the DHBs demonstrated different trajectories over the years. Ethnicity (being a Pacific child) followed by deprivation demonstrated stronger relationships with childhood ASH than the geography and the health system input variables. CONCLUSION The variation in childhood ASH is explained only minimal at the DHB level. The sociodemographic variables also only partly explained the variations. Unlike the general ASH measure, the childhood ASH used in this analysis provides insights into the acute conditions sensitive to primary care services. However, further information would be required to conclude this as the DHB-level performance variations.
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Affiliation(s)
- Pushkar Raj Silwal
- Health Systems Department, The University of Auckland, Auckland, New Zealand
| | - Daniel Exeter
- Section of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Tim Tenbensel
- Health Systems Department, The University of Auckland, Auckland, New Zealand
| | - Arier Lee
- Section of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
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7
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Hospital Access Block: A Scoping Review. J Emerg Nurs 2022; 48:430-454. [DOI: 10.1016/j.jen.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/17/2022] [Accepted: 03/02/2022] [Indexed: 11/30/2022]
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Towns CR, Rowley N, Woods L. Mixed gender accommodation: prevalence, trend over time and vulnerability of older adults. Intern Med J 2022; 52:474-478. [DOI: 10.1111/imj.15712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/19/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Cindy R. Towns
- Department of General Medicine Wellington Hospital Wellington New Zealand
- Department of Medicine Wellington School of Medicine Wellington New Zealand
| | - Natalie Rowley
- Department of General Medicine Wellington Hospital Wellington New Zealand
| | - Lisa Woods
- School of Mathematics and Statistics Victoria University Wellington New Zealand
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9
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Yang CF, Chang KL, Phan CS, Lin FY, Wang YD, Ho SW. Pre- and Post-Implementation of One-Hour Rule for the Boarding of Referral of Critically Ill Patients in the Emergency Department. J Acute Med 2021; 11:141-145. [PMID: 35155090 PMCID: PMC8743190 DOI: 10.6705/j.jacme.202112_11(4).0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/24/2020] [Accepted: 09/29/2020] [Indexed: 06/14/2023]
Abstract
In 2017, the Taiwan Ministry of Health and Welfare established a regional electronic referral system in Central Taiwan to streamline transfers of critically ill patients from the intensive care unit (ICU) of a regional hospital to a medical hospital center. Moreover, in 2018, a one-hour rule for the boarding of referral of critically ill patients from emergency department (ED) to ICU was implemented. This pre- and post-implementation study enrolled consecutive critically ill referral patients from a single academic medical center hospital from January 1, 2017 to December 31, 2018. After implementation of the one-hour rule, two interventions, namely, active bed management before patient arrival and no requirement for laboratory test results to be completed before ICU admissions, were used to improve patient flow in the ED. After implementation of one-hour rule, the proportion of patients transferred to the ICU within 1 hour increased from 3.1% to 65.9% (p < 0.001). Median ED length of stay (LOS) reduced from 129.5 minutes to 52.0 minutes (p < 0.001). The overall mortality rate decreased from 34.4% to 26.8%, without a significant difference. In conclusion, the implementation of the one-hour rule for the boarding of referral of critically ill patients in the ED is safe and possible. Achieving the target significantly reduced ED LOS by 77.5 minutes without an increase in patient mortality rate.
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Affiliation(s)
- Chia-Fen Yang
- Chung Shan Medical University Hospital Department of Emergency Medicine Taichung Taiwan
- Chung Shan Medical University Department of Emergency Medicine Taichung Taiwan
| | - Kuang-Leei Chang
- Chung Shan Medical University Hospital Department of Emergency Medicine Taichung Taiwan
- Chung Shan Medical University Department of Emergency Medicine Taichung Taiwan
| | - Chee-Seong Phan
- Chung Shan Medical University Hospital Department of Emergency Medicine Taichung Taiwan
- Chung Shan Medical University Department of Emergency Medicine Taichung Taiwan
| | - Fei-Yi Lin
- Chung Shan Medical University Hospital Department of Nursing Taichung Taiwan
- Chung Shan Medical University Department of Nursing Taichung Taiwan
| | - Yao-Dong Wang
- Chung Shan Medical University Hospital Division of Chest, Department of Internal Medicine Taichung Taiwan
| | - Sai-Wai Ho
- Chung Shan Medical University Hospital Department of Emergency Medicine Taichung Taiwan
- Chung Shan Medical University Department of Emergency Medicine Taichung Taiwan
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10
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Strobel S, Ren KY, Dragoman A, Pettit C, Stancati A, Kallergis D, Smith M, Sidhu K, Rutledge G, Mondoux S. Do Patients Respond to Posted Emergency Department Wait Times: Time-Series Evidence From the Implementation of a Wait Time Publication System in Hamilton, Canada. Ann Emerg Med 2021; 78:465-473. [PMID: 34148660 DOI: 10.1016/j.annemergmed.2021.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/15/2021] [Accepted: 03/31/2021] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE One proposed solution to prolonged emergency department (ED) wait times is a publicly available website that displays estimated ED wait times. This could provide information to patients so that they may choose sites with low wait times, which has the potential to smooth the overall wait times in EDs across a health system. We describe the effect of a novel city-wide ED wait time website on patient volume distributions throughout the city of Hamilton, Ontario, Canada. METHODS We compared the number of new patients arriving every 15 minutes during 2 separate time periods-before and after a publicly viewable wait time website was made available. For each ED site, the effect of the posted wait time was measured by assessing its association with the total number of patient arrivals in the subsequent hour at the same site and at all other sites in Hamilton. RESULTS Linear models showed clinically modest changes in patient volumes when wait times changed. However, nonlinear models showed that a 60-minute increase in wait time at a site was associated with 10% fewer patients presenting over the next hour. Larger negative associations were observed at community hospitals and urgent care centers. Increases in wait times at a given site were also associated with increased patient volumes at other sites in the system. CONCLUSION After the implementation of a public wait time website, elevated wait times led to fewer patients at the same site but more patient visits at other sites. This may be consistent with the wait time tracker inducing patients to avoid sites with high wait times and instead visit alternate sites in Hamilton, but only when wait times were very high.
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Affiliation(s)
- Stephenson Strobel
- Department of Economics, Cornell University, Ithaca, NY; Department of Emergency Medicine, Niagara Health System, Niagara Falls, Ontario, Canada
| | - Kevin Y Ren
- MD Program, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Alexandru Dragoman
- MD Program, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Calyn Pettit
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | - Matthew Smith
- St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Kuldeep Sidhu
- Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gregory Rutledge
- St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada; Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shawn Mondoux
- St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada; Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.
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11
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Jones P, Haustead D, Walker K, Honan B, Gangathimmaiah V, Mitchell R, Bissett I, Forero R, Martini E, Mountain D. Review article: Has the implementation of time-based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature. Emerg Med Australas 2021; 33:398-408. [PMID: 33724685 DOI: 10.1111/1742-6723.13760] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 11/30/2022]
Abstract
Time-based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000-2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty-three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short-stay admissions were excluded, and when pre-target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re-presented to EDs. Short-stay admissions and re-admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians.
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Affiliation(s)
- Peter Jones
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Daniel Haustead
- Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Katie Walker
- Emergency Department, Cabrini Health, Melbourne, Victoria, Australia
| | - Bridget Honan
- Central Australian Retrieval Service, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Vinay Gangathimmaiah
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Robert Mitchell
- Emergency and Trauma Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ian Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Roberto Forero
- Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | | | - David Mountain
- Emergency Department, Sir Charles Gardner Hospital, Perth, Western Australia, Australia
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12
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Shaw VM, Yu A, Parsons M, Olsen T, Walker C. Acute assessment services for patient flow assistance in hospital emergency departments. Hippokratia 2021. [DOI: 10.1002/14651858.cd014553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Victoria M Shaw
- School of Nursing; The University of Auckland; Auckland New Zealand
| | - An Yu
- School of Nursing; The University of Auckland; Auckland New Zealand
| | - Matthew Parsons
- Faculty of Health; The University of Waikato; Hamilton New Zealand
| | - Tava Olsen
- Information Systems and Operations Management; The University of Auckland; Auckland New Zealand
| | - Cameron Walker
- Engineering Science; The University of Auckland; Auckland New Zealand
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13
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Trivedy M. If I were minister for health, I would … review the four-hour waiting time in the emergency department. J R Soc Med 2021; 114:218-221. [PMID: 33325759 PMCID: PMC8091571 DOI: 10.1177/0141076820975363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Mihir Trivedy
- Aintree University Hospitals NHS Foundation Trust, Liverpool L9 7AL, UK
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14
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Lines LM. Games People Play: Lessons on Performance Measure Gaming from New Zealand Comment on "Gaming New Zealand's Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?". Int J Health Policy Manag 2021; 10:225-227. [PMID: 32610791 PMCID: PMC8167274 DOI: 10.34172/ijhpm.2020.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/05/2020] [Indexed: 11/18/2022] Open
Abstract
For decades, observers have noted that gaming of performance measurement appears to be both endemic and endlessly creative. A recent study by Tenbensel and colleagues provides a detailed look at gaming of a health system performance measure—emergency department (ED) wait times—within four hospitals in New Zealand. Combined, these four hospitals handled more than 25% of the ED visits in the country each year. Tenbensel and colleagues examine whether the New Zealand ED wait time target was set appropriately and whether we can trust any performance measure statistics that are not independently verified or audited. Their thoughtprovoking examination is relevant to anyone working in quality improvement and provides a valuable set of tools for detecting gaming in performance measurement.
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Affiliation(s)
- Lisa M Lines
- Center for Advanced Methods Development, RTI International, Durham, NC, USA.,Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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15
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Walker K, Honan B, Haustead D, Mountain D, Gangathimmaiah V, Forero R, Mitchell R, Martini E, Tesch G, Bissett I, Jones P. Review article: Have emergency department time-based targets influenced patient care? A systematic review of qualitative literature. Emerg Med Australas 2021; 33:202-213. [PMID: 33622021 DOI: 10.1111/1742-6723.13747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 12/01/2022]
Abstract
Time-based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time-based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time-based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets.
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Affiliation(s)
- Katie Walker
- Emergency Department, Cabrini Institute, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bridget Honan
- Central Australian Retrieval Service, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Daniel Haustead
- Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David Mountain
- Emergency Department, Sir Charles Gardner Hospital, Perth, Western Australia, Australia
| | - Vinay Gangathimmaiah
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Roberto Forero
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Rob Mitchell
- Emergency Department, Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Greg Tesch
- Nephrology Department, Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Ian Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Peter Jones
- School of Medicine, The University of Auckland, Auckland, New Zealand
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Todd VF, Swain A, Howie G, Tunnage B, Smith T, Dicker B. Factors Associated with Emergency Medical Service Reattendance in Low Acuity Patients Not Transported by Ambulance. PREHOSP EMERG CARE 2021:1-17. [PMID: 33320722 DOI: 10.1080/10903127.2020.1862943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/03/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
Background: The decision for emergency medical services (EMS) personnel not to transport a patient is challenging: there is a risk of subsequent deterioration but transportation of all patients to hospital would overburden emergency departments. The aim of this large-scale EMS study was to identify factors associated with an increased likelihood of ambulance reattendance within 48 hours in low acuity patients who were not transported by ambulance.Methods: We conducted a 2-year retrospective cohort study using data from the St John New Zealand EMS between 1 July 2016 and 30 June 2018 to investigate demographic and clinical associations with ambulance reattendance.Results: In total, 83,171 low acuity patients not transported by ambulance were included, of whom 4,512 (5.4%) had an EMS ambulance reattend within 48 hours. There were significant associations between EMS reattendance and patient age, sex, ethnicity, deprivation, and event location. Patients aged 60-74 years old had the highest likelihood of ambulance recall (OR 2.87, 95% CI: 2.51-3.28). Males were more likely to have an EMS ambulance reattend within 48 hours (OR 1.17, 95% CI: 1.09-1.25). Māori and Pacific Peoples had a similar likelihood of EMS recall to European/Others; however, the Asian cohort showed a reduced likelihood of reattendance (OR 0.76, 95% CI: 0.62-0.93).There were significant associations between EMS reattendance and non-transport reason, time spent on scene, event type, clinical acuity level (status), and pain score. Shorter (<30 minutes) on scene times were associated with a decreased likelihood of ambulance reattendance, whereas longer scene times (>45 minutes) were associated with an increased likelihood. Medical events were more likely to require reattendance than accident-related events (OR 1.22, 95% CI: 1.13-1.32). Non-transported patients with a severe pain score (7-10/10) were at increased likelihood of requiring reattendance (OR 1.60, 95% CI: 1.33-1.92).Discussion: The overall low rate of EMS reattendance is encouraging. Further research is needed into the clinical presentation of patients requiring ambulance reattendance within 48 hours to determine if there are early warning signs indicative of subsequent deterioration.
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Affiliation(s)
- Verity F Todd
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
| | - Andy Swain
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
| | - Graham Howie
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
| | - Bronwyn Tunnage
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
| | - Tony Smith
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
| | - Bridget Dicker
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
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17
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Jones PG, van der Werf B. Emergency department crowding and mortality for patients presenting to emergency departments in New Zealand. Emerg Med Australas 2020; 33:655-664. [PMID: 33300257 DOI: 10.1111/1742-6723.13699] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The association between ED crowding and mortality has been established internationally, but not in New Zealand. The aim was to determine which measures of crowding were associated with mortality for new patients presenting to New Zealand EDs. The primary outcome was mortality for patients within 7 days of arrival in the ED. METHODS This was a retrospective cohort study, using administrative data from 2006 to 2012. The crowding conditions at the time of presentation of each patient were recreated. Multivariable Cox proportional hazard modelling was used to determine the probability of death within 7 days of the presentation to ED. Each crowding measure was added independently to the optimum mortality model to determine how each crowding metric influenced the model. RESULTS Twenty-five of 28 (89%) eligible acute hospitals in New Zealand were included, with 5 793 767 ED visits by 2 214 865 individuals. Seven-day mortality was higher for patients arriving at times when there was more than 10% hospital access block (hazard ratio [HR] 1.10, 95% confidence interval [CI] 1.05, 1.17) or non-compliance with the 4-h emergency access target (HR 1.07, 95% CI 1.01, 1.12). ED occupancy did not influence the model importantly, while the number of arrivals in the previous 6 h was associated with lower mortality (HR 0.90, 95% CI 0.84, 0.97). CONCLUSION Access block had the strongest association with 7-day mortality. That ED occupancy and the number of arrivals were not associated with increased mortality suggests that system issues related to long ED stays may be most important in the link between ED crowding and mortality.
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Affiliation(s)
- Peter G Jones
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Bert van der Werf
- Epidemiology and Biostatistics, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Tenbensel T, Jones P, Chalmers LM, Ameratunga S, Carswell P. Gaming New Zealand's Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations? Int J Health Policy Manag 2020; 9:152-162. [PMID: 32331495 PMCID: PMC7182144 DOI: 10.15171/ijhpm.2019.98] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 10/18/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Gaming is a potentially dysfunctional consequence of performance measurement and management systems in the health sector and more generally. In 2009, the New Zealand government initiated a Shorter Stays in Emergency Department (SSED) target in which 95% of patients would be admitted, discharged or transferred from an emergency department (ED) within 6 hours. The implementation of similar targets in England led to well-documented practices of gaming. Our research into ED target implementation sought to answer how and why gaming varies over time and between organisations. METHODS We developed a mixed-methods approach. Four organisation case study sites were selected. ED lengths of stay (ED LOS) were collected over a 6-year period (2007-2012) from all sites and indicators of target gaming were developed. Two rounds of surveys with managers and clinicians were conducted. Interviews (n=68) were conducted with clinicians and managers in EDs and the wider hospital in two phases across all sites. The interview data was used to develop explanations of the patterns of variation across time and across sites detected in the ED LOS data. RESULTS Our research established that gaming behaviour - in the form of 'clock-stopping' and decanting patients to short-stay units (SSUs) or observation beds to avoid target breaches - was common across all 4 case study sites. The opportunity to game was due to the absence of independent verification of ED LOS data. Gaming increased significantly over time (2009-2012) as the means to game became more available, usually through the addition or expansion of short-stay facilities attached to EDs. Gaming varied between sites, but those with the highest levels of gaming differed substantially in terms of organisational dynamics and motives. In each case, however, high levels of gaming could be attributed to the strategies of senior management more than to the individual motivations of frontline staff. CONCLUSION Gaming of New Zealand's ED target increased after the real benefits (in terms of process improvement) of the target were achieved. Gaming of ED targets could be minimised by eliminating opportunities to game through independent verification, or by monitoring and limiting the means and motivations to game.
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Affiliation(s)
- Tim Tenbensel
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Peter Jones
- Auckland District Health Board Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - Shanthi Ameratunga
- School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Peter Carswell
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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d'Etienne JP, Zhou Y, Kan C, Shaikh S, Ho AF, Suley E, Blustein EC, Schrader CD, Zenarosa NR, Wang H. Two-step predictive model for early detection of emergency department patients with prolonged stay and its management implications. Am J Emerg Med 2020; 40:148-158. [PMID: 32063427 DOI: 10.1016/j.ajem.2020.01.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To develop a novel model for predicting Emergency Department (ED) prolonged length of stay (LOS) patients upon triage completion, and further investigate the benefit of a targeted intervention for patients with prolonged ED LOS. MATERIALS AND METHODS A two-step model to predict patients with prolonged ED LOS (>16 h) was constructed. This model was initially used to predict ED resource usage and was subsequently adapted to predict patient ED LOS based on the number of ED resources using binary logistic regressions and was validated internally with accuracy. Finally, a discrete event simulation was used to move patients with predicted prolonged ED LOS directly to a virtual Clinical Decision Unit (CDU). The changes of ED crowding status (Overcrowding, Crowding, and Not-Crowding) and savings of ED bed-hour equivalents were estimated as the measures of the efficacy of this intervention. RESULTS We screened a total of 123,975 patient visits with final enrollment of 110,471 patient visits. The overall accuracy of the final model predicting prolonged patient LOS was 67.8%. The C-index of this model ranges from 0.72 to 0.82. By implementing the proposed intervention, the simulation showed a 12% (1044/8760) reduction of ED overcrowded status - an equivalent savings of 129.3 ED bed-hours per day. CONCLUSIONS Early prediction of prolonged ED LOS patients and subsequent (simulated) early CDU transfer could lead to more efficiently utilization of ED resources and improved efficacy of ED operations. This study provides evidence to support the implementation of this novel intervention into real healthcare practice.
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Affiliation(s)
- James P d'Etienne
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Yuan Zhou
- Department of Industrial, Manufacturing, and Systems Engineering, The University of Texas at Arlington, 701 S. Nedderman Dr., Arlington, TX 760199, USA.
| | - Chen Kan
- Department of Industrial, Manufacturing, and Systems Engineering, The University of Texas at Arlington, 701 S. Nedderman Dr., Arlington, TX 760199, USA.
| | - Sajid Shaikh
- Department of Information Technology, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Amy F Ho
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Eniola Suley
- Department of Industrial, Manufacturing, and Systems Engineering, The University of Texas at Arlington, 701 S. Nedderman Dr., Arlington, TX 760199, USA.
| | - Erica C Blustein
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA.
| | - Chet D Schrader
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA; Integrative Emergency Services, 4835 LBJ Fwy Suite 900, Dallas, TX 75244, USA.
| | - Nestor R Zenarosa
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA; Integrative Emergency Services, 4835 LBJ Fwy Suite 900, Dallas, TX 75244, USA.
| | - Hao Wang
- Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA; Integrative Emergency Services, 4835 LBJ Fwy Suite 900, Dallas, TX 75244, USA.
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20
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Admission Decisions Made by Emergency Physicians Can Reduce the Emergency Department Length of Stay for Medical Patients. Emerg Med Int 2020; 2020:8392832. [PMID: 32104606 PMCID: PMC7036127 DOI: 10.1155/2020/8392832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/08/2020] [Accepted: 01/20/2020] [Indexed: 11/17/2022] Open
Abstract
Background Emergency department (ED) overcrowding is a worldwide problem that poses a threat to patient safety by causing treatment delays and increasing mortality. Consultations are common and important in the emergency medicine profession and are associated with longer ED length of stay (LOS). The purpose of this study was to evaluate the impact of admission decisions by emergency physicians without consultations on the ED LOS and other quality indicators. Methods The study was a retrospective observational study comparing the ED LOS of patients admitted to the internal medicine (IM) department before and after the policy change regarding admission decisions that was implemented in October 2016. During and after the policy change, emergency physicians decided how to arrange for and treat medical patients by processing their admission and providing follow-up care without consultations. The ED LOS and other indicators of patients admitted to the IM department were compared between the study period (January to June 2017) and the control period (January to June 2016). Results The median ED LOS of patients admitted to the IM department decreased from 673 (IQR: 347-1,369) minutes in the control period to 237 (IQR: 166-364) minutes in the study period. There were no significant differences in the interdepartmental transfer rate or in-hospital mortality between the two periods. Conclusions The admission decisions regarding medical patients made by emergency physicians without specialty consultations reduced the ED LOS without a significant negative effect on mortality or hospital LOS.
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Prang KH, Canaway R, Bismark M, Dunt D, Kelaher M. The impact of Australian healthcare reforms on emergency department time-based process outcomes: An interrupted time series study. PLoS One 2018; 13:e0209043. [PMID: 30540856 PMCID: PMC6291126 DOI: 10.1371/journal.pone.0209043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/27/2018] [Indexed: 12/01/2022] Open
Abstract
Background In 2011, the Australian government introduced national healthcare reforms aimed at increasing the timeliness and quality of hospital care. The healthcare reforms included, but were not limited to, emergency department (ED) time-based targets, financial incentives, and public performance reporting of hospital data. We sought to evaluate the impact of the national healthcare reforms on ED time-based process outcomes. Methods A quasi-experimental study of ED presentations from 2006 to 2016 in the state of Victoria, Australia. Uncontrolled, interrupted time-series analyses were used to evaluate, by hospital peer groups, the effect of national healthcare reforms on: patient wait times for treatment; treatment within recommended time; and patient departure within four hours of arrival in ED. Results There were small improvements in ED time-based process outcomes following the introduction of the national healthcare reforms. These occurred in most hospital peer groups immediately and over the longer term, across the various triage categories. The largest improvements occurred in small hospitals and smallest improvements in medium sized hospitals. ED time-based targets, now abolished by the Australian government, were not achieved in any hospital peer groups. Conclusions Our findings suggest that national healthcare reforms had the potential to prompt fundamental changes in ED processes leading to significant improvements in ED performances across most hospital peer groups but were generally unable to reach the ED targets imposed nationally. ED performances also varied by hospital peer groups. Attention to ED time-based process outcomes within hospital peer groups may provide insights into hospital practices that could improve the quality and efficiency of ED care.
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Affiliation(s)
- Khic-Houy Prang
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rachel Canaway
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marie Bismark
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Dunt
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Margaret Kelaher
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- * E-mail:
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Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS One 2018; 13:e0203316. [PMID: 30161242 PMCID: PMC6117060 DOI: 10.1371/journal.pone.0203316] [Citation(s) in RCA: 542] [Impact Index Per Article: 90.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/17/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Emergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions. AIM The aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding. METHOD The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A structured search of four databases (Medline, CINAHL, EMBASE and Web of Science) was undertaken to identify peer-reviewed research publications aimed at investigating the causes or consequences of, or solutions to, emergency department crowding, published between January 2000 and June 2018. Two reviewers used validated critical appraisal tools to independently assess the quality of the studies. The study protocol was registered with the International prospective register of systematic reviews (PROSPERO 2017: CRD42017073439). RESULTS From 4,131 identified studies and 162 full text reviews, 102 studies met the inclusion criteria. The majority were retrospective cohort studies, with the greatest proportion (51%) trialling or modelling potential solutions to emergency department crowding. Fourteen studies examined causes and 40 investigated consequences. Two studies looked at both causes and consequences, and two investigated causes and solutions. CONCLUSIONS The negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. This review identified a mismatch between causes and solutions. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Solutions aimed at the introduction of whole-of-system initiatives to meet timed patient disposition targets, as well as extended hours of primary care, demonstrated promising outcomes. While the review identified increased presentations by the elderly with complex and chronic conditions as an emerging and widespread driver of crowding, more research is required to isolate the precise local factors leading to ED crowding, with system-wide solutions tailored to address identified causes.
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Affiliation(s)
- Claire Morley
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Maria Unwin
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
| | - Gregory M. Peterson
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Jim Stankovich
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
| | - Leigh Kinsman
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
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Van Der Linden MC, Van Loon M, Feenstra NSF, Van Der Linden N. Assessing bottlenecks in Emergency Department flow of patients with abdominal pain. Int Emerg Nurs 2018; 40:1-5. [PMID: 29636284 DOI: 10.1016/j.ienj.2018.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/14/2018] [Accepted: 03/22/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Abdominal pain has a wide range of possible causes, which may lead to difficulties in diagnosing and lengthy Emergency Department (ED) stays. In this study, bottlenecks in ED processes of patients with abdominal pain were identified. METHODS Time-points of patients who presented to a Dutch ED with abdominal pain were observed and documented. The institutional review board approved the study. RESULTS In total, 3015 min of patient time were observed in 54 patients. Median length of stay (LOS) was 218 min for admitted patients, and 168 min for discharged patients. For 65 patients (27.4%), LOS exceeded 4 h. Delays were found during the diagnostic process, when multiple physicians were needed in order to make a decision, and during departure. CONCLUSIONS Our study concerning individual patients' time-points provides important insight into delays in the patient journey of patients with abdominal pain. Flow improvement can be achieved by focusing on these bottlenecks, for example by minimizing diagnostic delays and by simultaneous specialists' consultations for patients who need more than one physician. The optimization of ED flow for patients with abdominal pain depends on coordinated efforts between ED staff, medical specialists, radiology and laboratory staff, staff from inpatient units, and hospital supporting services.
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Affiliation(s)
| | - Merel Van Loon
- Emergency Department, Haaglanden Medical Center, PO Box 432, 2501 CK The Hague, The Netherlands.
| | - Nienke S F Feenstra
- Erasmus University, Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, The Netherlands.
| | - Naomi Van Der Linden
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, PO Box 123, Broadway, Sydney, NSW 2007, Australia.
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