Appropriateness, Reasons and Independent Predictors of Consultations in the Emergency Department (ED) of a Dutch Tertiary Care Center: A Prospective Cohort Study

Factors Affecting Length of Stays in the Emergency Department of a Teaching Hospital: A Retrospective Study From Najran, Saudi Arabia

BACKGROUND

 Reducing the frequency of emergency department (ED) patient visits for treatment, particularly in urgent instances, is a global healthcare objective. Additionally, a more extended stay in the ED can harm a patient's prognosis during later hospitalization. This study aims to investigate the factors affecting the length of stay in the ED in a teaching hospital.

METHODS

A retrospective chart review study was done between January 1, 2021, and February 31, 2021, involving 122 adult patients who had delayed ED visits to King Khalid Hospital in Najran, Saudi Arabia. Data on the patient's characteristics, visit time, and the causes for the delay based on the Canadian Triage and Acuity Scale (CTAS) were gathered and analyzed. Factors associated with more than six hours of delay were investigated in a univariate analysis.

RESULT

The mean age was 52.3 ±13.5 years, and 42 (34.4%) were more than 65 years of age. More than half of the study population were female (n=66; 54.1%). Most delays occurred among CTAS 4 and 5 cases (47.5%), and 22 (18.0%) occurred during holidays. The mean delay time was 6.1 ±1.8 hours. The leading delay causes were multiple consultations with further investigations (37.7%) and conflict between the teams (36.1%). In univariate analysis, ED visiting at holiday time (OR: 0.14; 95% CI: 0.04-0.40, p <0.001) and CTAS 4 and 5 (OR: 2.22; 95% CI: 0.95-5.30, p = 0.003) significantly had more delay. Factors associated with delay in univariate analysis were multiple consultations with further investigations (OR: 2.82; 95% CI: 1.32-6.26, p = 0.013), various assessments in different ED areas with a late arrival of the specialist (OR: 0.43; 95% CI: 0.20-0.91, p = 0.042), and conflict between the teams (OR: 2.50; 95% CI: 1.17-5.54, p = 0.031).

CONCLUSION

In this study, multiple assessments in different ED areas and conflict between the teams were the main factors that caused delays in ED. Implementing a timeframe monitoring system for consultations while emphasizing accelerated decision-making and disposition for patients and understanding teamwork collaboration may reduce patients' length of stay in the ED. Implementing these strategies and evaluating their impact on the length of stay in the ED requires further investigation.

Impact of the 24/7 nurse practitioner model on emergency department stay at a level 1 trauma center: A retrospective study

AIMS

The aim of the study was to assess the impact of 24/7 trauma nurse practitioner service model on the emergency department patient flow.

BACKGROUND

Seamless transition of trauma patients through the emergency department to inpatient hospital care is crucial for coordination of care, clinical safety and positive health outcomes. A level 1 trauma centre located in Southern West Virginia, USA expanded their trauma nurse practitioner service covering the emergency department 24/7.

DESIGN

Retrospective cohort study conducted in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines.

METHODS

Patients admitted to the trauma centre between March 2019 and February 2020 were divided into two groups: trauma patients managed by trauma nurse practitioners versus the hospitalist service. The hospital service group was chosen as the comparator group because any admission prior to night coverage by the trauma nurse practitioners were managed by the hospitalist service.

RESULTS

The emergency department length of stay was significantly lower in trauma nurse practitioners' patients by an average of 300 min (772.25 ± 831.91 vs. 471.44 ± 336.65, p = <.001). Similarly, time to place emergency department discharge order was shorter by 49 min (277.76 ± 159.69 vs. 228.27 ± 116.04, p = .001) for this group. Moreover, trauma nurse practitioners on an average placed one less consultation (1.06 ± 0.23 vs. 1.46 ± 0.74, p < .001).

CONCLUSION

The patient care provided by trauma nurse practitioners aided in the reduction of strain felt by their emergency department. They were able to help facilitate patient flow thus lessening the pressure of boarding in an overcrowded emergency department. The study institution hopes to sustain the current service model and continue to review outcomes and processes managed by trauma nurse practitioners to ensure consistency and quality.

RELEVANCE TO CLINICAL PRACTICE

Similar trauma centres should evaluate the structure of their trauma service that includes the role of trauma nurse practitioner service and work towards allowing them to manage patient care from the emergency department 24/7.

The association between presenting complaints and clinical outcomes in emergency department patients of different age categories

BACKGROUND AND IMPORTANCE

Although aging societies in Western Europe use presenting complaints (PCs) in emergency departments (EDs) triage systems to determine the urgency and severity of the care demand, it is unclear whether their prognostic value is age-dependent.

OBJECTIVE

To assess the frequency and association of PCs with hospitalization and mortality across age categories.

METHODS

An observational multicenter study using all consecutive visits of three EDs in the Netherlands Emergency department Evaluation Database. Patients were stratified by age category (0-18; 19-50; 51-65; 66-80; >80 years), in which the association between PCs and case-mix adjusted hospitalization and mortality was studied using multivariable logistic regression analysis (adjusting for demographics, hospital, disease severity, comorbidity and other PCs).

RESULTS

We included 172  104 ED-visits. The most frequent PCs were 'extremity problems' [range across age categories (13.5-40.8%)], 'feeling unwell' (9.5-23.4%), 'abdominal pain' (6.0-13.9%), 'dyspnea' (4.5-13.3%) and 'chest pain' (0.6-10.7%). For most PCs, the observed and the case-mix-adjusted odds for hospitalization and mortality increased the higher the age category. The most common PCs with the highest adjusted odds ratios (AORs, 95% CI) for hospitalization were 'diarrhea and vomiting' [2.30 (2.02-2.62)] and 'feeling unwell' [1.60 (1.48-1.73)]. Low hospitalization risk was found for 'chest pain' [0.58 (0.53-0.63)] and 'palpitations' [0.64 (0.58-0.71)].

CONCLUSIONS

Frequency of PCs in ED patients varies with age, but the same PCs occur in all age categories. For most PCs, (case-mix adjusted) hospitalization and mortality vary across age categories. 'Chest pain' and 'palpitations,' usually triaged 'very urgent', carry a low risk for hospitalization and mortality.

Age-adjusted interpretation of biomarkers of renal function and homeostasis, inflammation, and circulation in Emergency Department patients

Appropriate interpretation of blood tests is important for risk stratification and guidelines used in the Emergency Department (ED) (such as SIRS or CURB-65). The impact of abnormal blood test values on mortality may change with increasing age due to (patho)-physiologic changes. The aim of this study was therefore to assess the effect of age on the case-mix adjusted association between biomarkers of renal function and homeostasis, inflammation and circulation and in-hospital mortality. This observational multi-center cohort study has used the Netherlands Emergency department Evaluation Database (NEED), including all consecutive ED patients ≥ 18 years of three hospitals. A generalized additive logistic regression model was used to visualize the association between in-hospital mortality, age and five blood tests (creatinine, sodium, leukocytes, C-reactive Protein, and hemoglobin). Multivariable logistic regression analyses were used to assess the association between the number of abnormal blood test values and mortality per age category (18-50; 51-65; 66-80; > 80 years). Of the 94,974 included patients, 2550 (2.7%) patients died in-hospital. Mortality increased gradually for C-reactive Protein (CRP), and had a U-shaped association for creatinine, sodium, leukocytes, and hemoglobin. Age significantly affected the associations of all studied blood tests except in leukocytes. In addition, with increasing age categories, case-mix adjusted mortality increased with the number of abnormal blood tests. In summary, the association between blood tests and (adjusted) mortality depends on age. Mortality increases gradually or in a U-shaped manner with increasing blood test values. Age-adjusted numerical scores may improve risk stratification. Our results have implications for interpretation of blood tests and their use in risk stratification tools and acute care guidelines.Trial registration number Netherlands Trial Register (NTR) NL8422, 03/2020.

The Dynamics of Patient Visits to a Public Hospital Pediatric Emergency Department: A Time-Series Model

BACKGROUND

The overcrowding of emergency departments (EDs) is an increasingly relevant public health problem. The main aims of this study were to identify and analyze temporal periodicities of a self-referred pediatric ED (PED), correlate them with meteorological and calendar variables and build a robust forecasting model.

METHODS

An 8-year administrative data set (2010-2017) of the daily number of admissions to the PED of a public hospital in Lisbon, Portugal, was used (n = 670,379). A time-series model of the daily number of visits was built, including temporal periodicities, the Portuguese school calendar, and a meteorological comfort index (humidex).

RESULTS

Several temporal cycles were identified: 1 year (peak in January/February related to respiratory infections in younger children and infants), 6 months (peaks in May and October with an increase in the admissions of older children and adolescents with trauma, gastrointestinal infections and atopic symptoms), 4 months (related to annual school vacations), 1 week (lower admission values on Saturday), and half a week (low from Friday to Monday morning). School calendar and humidex were significantly correlated with daily admissions. The model yielded a mean absolute percentage error of 10.7% ± 1.10% when cross-validation was performed for the full data set.

CONCLUSION

Although PED visits are multifactorial, they may be predicted and explained by a relatively small number of variables. Such a model may be easily reproduced in different settings and represents a relevant tool to improve quality in EDs through correctly adapting human resources to ED demand.

Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative

INTRODUCTION

Emergency department (ED) wait time is an important health system quality indicator. Prolonged consult to decision time (CTDT), the time it takes to reach a disposition decision after receiving a specialty consultation request, can contribute to increased overall length of stay in the ED.

OBJECTIVE

To identify delays in the consultation process for general internal medicine (GIM) and trial interventions to reduce CTDT.

METHODS

The study was conducted at a large tertiary teaching hospital with GIM inpatient wards at two campuses. Four interventions were trialed over sequential Plan-Do-Study-Act cycles: (1) process mapping, (2) resident education sessions, (3) audit and feedback of CTDT, and (4) adding a swing shift during peak consult volume.

MEASUREMENTS

The primary outcome measures were mean CTDT for patients admitted to GIM and the proportion of admitted patients with CTDT of less than 3 hours.

RESULTS

Mean CTDT decreased from 4.61 hours before intervention to 4.18 hours after intervention (p < .0001). The proportion of GIM patients with CTDT less than 3 hours increased from 25% to 33% (p < .0001).

CONCLUSIONS

The interventions trialed led to a sustained reduction in CTDT over a 12-month period and demonstrated the effectiveness of education in influencing physician performance.

Admission Decisions Made by Emergency Physicians Can Reduce the Emergency Department Length of Stay for Medical Patients

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.

Independent determinants of prolonged emergency department length of stay in a tertiary care centre: a prospective cohort study

BACKGROUND

Emergency department (ED) overcrowding is a potential threat for patient safety. We searched for independent determinants of prolonged ED length of stay (LOS) with the aim to identify factors which can be targeted to reduce ED LOS, which may help in preventing overcrowding.

METHODS

This prospective cohort study included consecutive ED patients in a Dutch tertiary care centre. Multivariable logistic regression analysis was used to identify independent determinants of ED LOS > 4 h, including patient characteristics (demographics, referral type, acuity, (number of) presenting complaints and comorbidity), treating specialty, diagnostic testing, consultations, number of patients in the ED and disposition. Furthermore, we quantified the absolute time delays (measured in real-time) associated with the most important independent determinants of prolonged ED LOS.

RESULTS

In 1434 included patients independent determinants of prolonged ED LOS were number and type of presenting complaints, specialty, laboratory/radiology testing and consultations, and ICU admission. Modifiable determinants with the largest impact were blood testing; Adjusted odds ratio (AOR (95%-CI)); 3.45 (1.95-6.11), urine testing; 1.79 (1.21-2.63), radiology imaging; 3.02 (2.13-4.30), and consultation; 5.90 (4.08-8.54). Combined with the laboratory/radiology testing and/or consultations (requested in 1123 (78%) patients) the decision-making and discharge process consumed between 74 (42%) and 117 (66%) minutes of the total ED LOS of 177 (IQR: 129-225) minutes.

CONCLUSIONS

In tertiary care EDs, ED LOS can be reduced if the process of laboratory/radiology testing and consulting is optimized and the decision-making and discharge procedures are accelerated.